key: cord- - u kn ge authors: huberty, mark title: awaiting the second big data revolution: from digital noise to value creation date: - - journal: nan doi: . /s - - - sha: doc_id: cord_uid: u kn ge “big data”—the collection of vast quantities of data about individual behavior via online, mobile, and other data-driven services—has been heralded as the agent of a third industrial revolution—one with raw materials measured in bits, rather than tons of steel or barrels of oil. yet the industrial revolution transformed not just how firms made things, but the fundamental approach to value creation in industrial economies. to date, big data has not achieved this distinction. instead, today’s successful big data business models largely use data to scale old modes of value creation, rather than invent new ones altogether. moreover, today’s big data cannot deliver the promised revolution. in this way, today’s big data landscape resembles the early phases of the first industrial revolution, rather than the culmination of the second a century later. realizing the second big data revolution will require fundamentally different kinds of data, different innovations, and different business models than those seen to date. that fact has profound consequences for the kinds of investments and innovations firms must seek, and the economic, political, and social consequences that those innovations portend. yet this bbig data^revolution has so far fallen short of its promise. precious few firms transmutate data into novel products. instead, most rely on data to operate, at unprecedented scale, business models with long pedigree in the media and retail sectors. big data, despite protests to the contrary, is thus an incremental change-and its revolution one of degree, not kind. the reasons for these shortcomings point to the challenges we face in realizing the promise of the big data revolution. today's advances in search, e-commerce, and social media relied on the creative application of marginal improvements in computational processing power and data storage. in contrast, tomorrow's hopes for transforming real-world outcomes in areas like health care, education, energy, and other complex phenomena pose scientific and engineering challenges of an entirely different scale. our present enthusiasm for big data stems from the confusion of data and knowledge. firms today can gather more data, at lower cost, about a wider variety of subjects, than ever before. big data's advocates claim that this data will become the raw material of a new industrial revolution. as with its th century predecessor, this revolution will alter how we govern, work, play, and live. but unlike the th century, we are told, the raw materials driving this revolution are so cheap and abundant that the horizon is bounded only by the supply of smart people capable of molding these materials into the next generation of innovations (manyika et al. ) . this utopia of data is badly flawed. those who promote it rely on a series of dubious assumptions about the origins and uses of data, none of which hold up to serious scrutiny. in aggregate, these assumptions all fail to address whether the data we have actually provides the raw materials needed for a data-driven industrial revolution we need. taken together, these failures point out the limits of a revolution built on the raw materials that today seem so abundant. four of these assumptions merit special attention: first, n = all, or the claim that our data allow a clear and unbiased study of humanity; second, that today = tomorrow, or the claim that understanding online behavior today implies that we will still understand it tomorrow; third, offline = online, the claim that understanding online behavior offers a window into economic and social phenomena in the physical world; and fourth, that complex patterns of social behavior, once understood, will remain stable enough to become the basis of new data-driven, predictive products and services in sectors well beyond social and media markets. each of these has its issues. taken together, those issues limit the future of a revolution that relies, as today's does, on the bdigital exhaust^of social networks, e-commerce, and other online services. the true revolution must lie elsewhere. gathering data via traditional methods has always been difficult. small samples were unreliable; large samples were expensive; samples might not be representative, despite researchers' best efforts; tracking the same sample over many years required organizations and budgets that few organizations outside governments could justify. none of this, moreover, was very scalable: researchers needed a new sample for every question, or had to divine in advance a battery of questions and hope that this proved adequate. no wonder social research proceeded so slowly. mayer-schönberger and cukier ( ) argue that big data will eliminate these problems. instead of having to rely on samples, online data, they claim, allows us to measure the universe of online behavior, where n (the number of people in the sample) is basically all (the entire population of people we care about). hence we no longer need worry, they claim, about the problems that have plagued researchers in the past. when n = all, large samples are cheap and representative, new data on individuals arrives constantly, monitoring data over time poses no added difficulty, and cheap storage permits us to ask new questions of the same data again and again. with this new database of what people are saying or buying, where they go and when, how their social networks change and evolve, and myriad other factors, the prior restrictions borne of the cost and complexity of sampling will melt away. but n ≠ all. most of the data that dazzles those infatuated by bbig data^-mayer-schönberger and cukier included-comes from what mckinsey & company termed bdigital exhaust^ (manyika et al. ) : the web server logs, e-commerce purchasing histories, social media relations, and other data thrown off by systems in the course of serving web pages, online shopping, or person-to-person communication. the n covered by that data concerns only those who use these services-not society at large. in practice, this distinction turns out to matter quite a lot. the demographics of any given online service usually differ dramatically from the population at large, whether we measure by age, gender, race, education, and myriad other factors. hence the uses of that data are limited. it's very relevant for understanding web search behavior, purchasing, or how people behave on social media. but the n here is skewed in ways both known and unknown-perhaps younger than average, or more tech-savvy, or wealthier than the general population. the fact that we have enormous quantities of data about these people may not prove very useful to understanding society writ large. but let's say that we truly believe this assumption-that everyone is (or soon will be) online. surely the proliferation of smart phones and other devices is bringing that world closer, at least in the developed world. this brings up the second assumption-that we know where to go find all these people. several years ago, myspace was the leading social media website, a treasure trove of new data on social relations. today, it's the punchline to a joke. the rate of change in online commerce, social media, search, and other services undermines any claim that we can actually know that our n = all sample that works today will work tomorrow. instead, we only know about new developments-and the data and populations they cover-well after they have already become big. hence our n = all sample is persistently biased in favor of the old. moreover, we have no way of systematically checking how biased the sample is, without resorting to traditional survey methods and polling-the very methods that big data is supposed to render obsolete. but let's again assume that problem away. let's assume that we have all the data, about all the people, for all the online behavior, gathered from the digital exhaust of all the relevant products and services out there. perhaps, in this context, we can make progress understanding human behavior online. but that is not the revolution that big data has promised. most of the bbig data^hype has ambitions beyond improving web search, online shopping, socializing, or other online activity. instead, big data should help cure disease, detect epidemics, monitor physical infrastructure, and aid first responders in emergencies. to satisfy these goals, we need a new assumption: that what people do online mirrors what they do offline. otherwise, all the digital exhaust in the world won't describe the actual problems we care about. there's little reason to think that offline life faithfully mirrors online behavior. research has consistently shown that individuals' online identities vary widely from their offline selves. in some cases, that means people are more cautious about revealing their true selves. danah boyd's work (boyd and marwick ) has shown that teenagers cultivate online identities very different from their offline selves-whether for creative, privacy, or other reasons. in others, it may mean that people are more vitriolic, or take more extreme positions. online political discussions-another favorite subject of big data enthusiasts-suffer from levels of vitriol and partisanship far beyond anything seen offline (conover et al. ) . of course, online and offline identity aren't entirely separate. that would invite suggestions of schizophrenia among internet users. but the problem remains-we don't know what part of a person is faithfully represented online, and what part is not. furthermore, even where online behavior may echo offline preferences or beliefs, that echo is often very weak. in statistical terms, our ability to distinguish bsignificant^from binsignificant^results improves with the sample size-but statistical significance is not actual significance. knowing, say, that a history of purchasing some basket of products is associated with an increased risk of being a criminal may be helpful. but if that association is weak-say a one-hundredth of a percent increase-it's practical import is effectively zero. big data may permit us to find these associations, but it does not promise that they will be useful. ok, but you say, surely we can determine how these distortions work, and incorporate them into our models? after all, doesn't statistics have a long history of trying to gain insight from messy, biased, or otherwise incomplete data? perhaps we could build such a map, one that allows us to connect the observed behaviors of a skewed and selective online population to offline developments writ large. this suffices only if we care primarily about describing the past. but much of the promise of big data comes from predicting the future-where and when people will get sick in an epidemic, which bridges might need the most attention next month, whether today's disgruntled high school student will become tomorrow's mass shooter. satisfying these predictive goals requires yet another assumption. it is not enough to have all the data, about all the people, and a map that connects that data to real-world behaviors and outcomes. we also have to assume that the map we have today will still describe the world we want to predict tomorrow. two obvious and unknowable sources of change stand in our way. first, people change. online behavior is a culmination of culture, language, social norms and other factors that shape both people and how they express their identity. these factors are in constant flux. the controversies and issues of yesterday are not those of tomorrow; the language we used to discuss anger, love, hatred, or envy change. the pathologies that afflict humanity may endure, but the ways we express them do not. second, technological systems change. the data we observe in the bdigital exhaust^of the internet is created by individuals acting in the context of systems with rules of their own. those rules are set, intentionally or not, by the designers and programmers that decide what we can and cannot do with them. and those rules are in constant flux. what we can and cannot buy, who we can and cannot contact on facebook, what photos we can or cannot see on flickr vary, often unpredictably. facebook alone is rumored to run up to a thousand different variants on its site at one time. hence even if culture never changed, our map from online to offline behavior would still decay as the rules of online systems continued to evolve. an anonymous reviewer pointed out, correctly, that social researchers have always faced this problem. this is certainly true but many of the features of social systems-political and cultural institutions, demography, and other factors-change on a much longer timeframe than today's data-driven internet services. for instance, us congressional elections operate very differently now compared with a century ago; but change little between any two elections. contrast that with the pace of change for major social media services, for which years may be a lifetime. a recent controversy illustrates this problem to a t. facebook recently published a study (kramer et al. ) in which they selectively manipulated the news feeds of a randomized sample of users, to determine whether they could manipulate users' emotional states. the revelation of this study prompted fury on the part of users, who found this sort of manipulation unpalatable. whether they should, of course, given that facebook routinely runs experiments on its site to determine how best to satisfy (i.e., make happier) its users, is an interesting question. but the broader point remains-someone watching the emotional state of facebook users might have concluded that overall happiness was on the rise, perhaps consequence of the improving american economy. but in fact this increase was entirely spurious, driven by facebook's successful experiment at manipulating its users. compounding this problem, we cannot know, in advance, which of the social and technological changes we do know about will matter to our map. that only becomes apparent in the aftermath, as real-world outcomes diverge from predictions cast using the exhaust of online systems. lest this come off as statistical nihilism, consider the differences in two papers that both purport to use big data to project the outcome of us elections. digrazia et al. ( ) claim that merely counting the tweets that reference a congressional candidate-with no adjustments for demography, or spam, or even name confusion-can forecast whether that candidate will win his or her election. this is a purely bdigital exhaust^approach. they speculate-but cannot know-whether this approach works because (to paraphrase their words) bone tweet equals one vote^, or ball attention on twitter is better^. moreover, it turns out that the predictive performance of this simple model provides no utility. as huberty ( ) shows, their estimates perform no better than an approach that simply guesses that the incumbent party would win-a simple and powerful predictor of success in american elections. big data provided little value. contrast this with wang et al. ( ) . they use the xbox gaming platform as a polling instrument, which they hope might help compensate for the rising non-response rates that have plagued traditional telephone polls. as with twitter, n ≠ all: the xbox user community is younger, more male, less politically involved. but the paper nevertheless succeeds in generating accurate estimates of general electoral sentiment. the key difference lies in their use of demographic data to re-weight respondents' electoral sentiments to look like the electorate at large. the xbox data were no less skewed than twitter data; but the process of data collection provided the means to compensate. the black box of twitter's digital exhaust, lacking this data, did not. the difference? digrazia et al. ( ) sought to reuse data created for one purpose in order to do something entirely different; wang et al. ( ) set out to gather data explicitly tailored to their purpose alone. . the implausibility of big data . taken together, the assumptions that we have to make to fulfill the promise of today's big data hype appear wildly implausible. to recap, we must assume that: . everyone we care about is online; . we know where to find them today, and tomorrow; . they represent themselves online consistent with how they behave offline, and; . they will continue to represent themselves online-in behavior, language, and other factors-in the same way, for long periods of time. nothing in the history of the internet suggests that even one of these statements holds true. everyone was not online in the past; and likely will not be online in the future. the constant, often wrenching changes in the speed, diversity, and capacity of online services means those who are online move around constantly. they do not, as we've seen, behave in ways necessarily consistent with their offline selves. and the choices they make about how to behave online evolve in unpredictable ways, shaped by a complex and usually opaque amalgam of social norms and algorithmic influences. but if each of these statements fall down, then how have companies like amazon, facebook, or google built such successful business models? the answer lies in two parts. first, most of what these companies do is self-referential: they use data about how people search, shop, or socialize online to improve and expand services targeted at searching, shopping, or socializing. google, by definition, has an n = all sample of google users' online search behavior. amazon knows the shopping behaviors of amazon users. of course, these populations are subject to change their behaviors, their self-representation, or their expectations at any point. but at least google or amazon can plausibly claim to have a valid sample of the primary populations they care about. second, the consequences of failure are, on the margins, very low. google relies heavily on predictive models of user behavior to sell the advertising that accounts for most of its revenue. but the consequences of errors in that model are low-google suffers little from serving the wrong ad on the margins. of course, persistent and critical errors of understanding will undermine products and lead to lost customers. but there's usually plenty of time to correct course before that happens. so long as google does better than its competitors at targeting advertising, it will continue to win the competitive fight for advertising dollars. but if we move even a little beyond these low-risk, self-referential systems, the usefulness of the data that underpin them quickly erodes. google flu provides a valuable lesson in this regard. in , google announced a new collaboration with the centers for disease control (cdc) to track and report rates of influenza infection. historically, the cdc had monitored us flu infection patterns through a network of doctors that tracked and reported binfluenza-like illness^in their clinics and hospitals. but doctors' reports took up to weeks to reach the cdc-a long time in a world confronting sars or avian flu. developing countries with weaker public health capabilities faced even greater challenges. google hypothesized that, when individuals or their family members got the flu, they went looking on the internet-via google, of course-for medical advice. in a highly cited paper, ginsberg et al. ( ) showed that they could predict region-specific influenza infection rates in the united states using google search frequency data. here was the true promise of big data-that we capitalize on virtual data to better understand, and react to, the physical world around us. the subsequent history of google flu illustrates the shortcomings of the first big data revolution. while google flu has performed well in many seasons, it has failed twice, both times in the kind of abnormal flu season during which accurate data are most valuable. the patterns of and reasons for failure speak to the limits of prediction. in , google flu underpredicted flu rates during the h n pandemic. post-hoc analysis suggested that the different viral characteristics of h n compared with garden-variety strains of influenza likely meant that individuals didn't know they had a flu strain, and thus didn't go looking for flu-related information (cook et al. ) . conversely, in , google flu over-predicted influenza infections. google has yet to discuss why, but speculation has centered on the intensive media coverage of an early-onset flu season, which may have sparked interest in the flu among healthy individuals (butler ). the problems experienced by google flu provide a particularly acute warning of the risks inherent in trying to predict what will happen in the real world based on the exhaust of the digital one. google flu relied on a map-a mathematical relationship between online behavior and real-world infection. google built that map on historic patterns of flu infection and search behavior. it assumed that such patterns would continue to hold in the future. but there was nothing fundamental about those patterns. either a change in the physical world (a new virus) or the virtual one (media coverage) were enough to render the map inaccurate. the cdc's old reporting networks out-performed big data when it mattered most. despite ostensibly free raw materials, mass-manufacturing insight from digital exhaust has thus proven far more difficult than big data's advocates would let on. it's thus unsurprising that this revolution has had similarly underwhelming effects on business models. amazon, facebook, and google are enormously successful businesses, underpinned by technologies operating at unprecedented scale. but they still rely on centuries-old business models for most of their revenue. google and amazon differ in degree, but not kind, from a newspaper or a large department store when it comes to making money. this is a weak showing from a revolution that was supposed to change the st century in the way that steam, steel, or rail changed the th. big data has so far made it easier to sell things, target ads, or stalk long-lost friends or lovers. but it hasn't yet fundamentally reworked patterns of economic life, generated entirely new occupations, or radically altered relationships with the physical world. instead, it remains oddly self-referential: we generate massive amounts of data in the process of online buying, viewing, or socializing; but find that data truly useful only for improving online sales and search. understanding how we might get from here to there requires a better understanding of how and why data-big or small-might create value in a world of better algorithms and cheap compute capacity. close examination shows that firms have largely used big data to improve on existing business models, rather than adopt new ones; and that those improvements have relied on data to describe and predict activity in worlds largely of their own making. where firms have ventured beyond these self-constructed virtual worlds, the data have proven far less useful, and products built atop data far more prone to failure. the google flu example suggests the limits to big data as a source of mass-manufactured insight about the real world. but google itself, and its fellow big-data success stories, also illustrate the shortcomings of big data as a source of fundamentally new forms of value creation. most headline big data business models have used their enhanced capacity to describe, predict, or infer in order to implement-albeit at impressive scale and complexity-centuries-old business models. those models create value not from the direct exchange between consumer and producer, but via a web of transactions several orders removed from the creation of the data itself. categorizing today's big data business models based on just how far they separate data generation from value creation quickly illustrates how isolated the monetary value of firms' data is from their primary customers. having promised a first-order world, big data has delivered a third-order reality. realizing the promise of the big data revolution will require a different approach. the same problems that greeted flu prediction have plagued other attempts to build big data applications that forecast the real world. engineering solutions to these problems that draw on the potential of cheap computation and powerful algorithms will require not different methods, but different raw materials. the data those materials require must originate from a first-order approach to studying and understanding the worlds we want to improve. such approaches will require very different models of firm organization than those exploited by google and its competitors in the first big data revolution. most headline big data business models do not make much money directly from their customers. instead, they rely on third parties-mostly advertisers-to generate profits from data. the actual creation and processing of data is only useful insofar as it's of use to those third parties. in doing so, these models have merely implemented, at impressive scale and complexity, the very old business model used by the newspapers they have largely replaced. if we reach back into the dim past when newspapers were viable businesses (rather than hobbies of the civic-minded wealthy), we will remember that their business model had three major components: . gather, filter, and analyze news; . attract readers by providing that news at far below cost, and; . profit by selling access to those readers to advertisers. the market for access matured along with the newspapers that provided it. both newspapers and advertisers realized that people who read the business pages differed from those who read the front page, or the style section. front-page ads were more visible to readers than those buried on page a . newspapers soon started pricing access to their readers accordingly. bankers paid one price to advertise in the business section, clothing designers another for the style pages. this segmentation of the ad market evolved as the ad buyers and sellers learned more about whose eyeballs were worth how much, when, and where. newspapers were thus third-order models. the news services they provided were valuable in their own right. but readers didn't pay for them. instead, news was a means of generating attention and data, which was only valuable when sold to third parties in the form of ad space. data didn't directly contribute to improving the headline product-news-except insofar as it generated revenue that could be plowed back into news gathering. the existence of a tabloid press of dubious quality but healthy revenues proved the weakness of the link between good journalism and profit. from a value creation perspective, google, yahoo, and other ad-driven big data businesses are nothing more than newspapers at scale. they too provide useful services (then news, now email or search) to users at rates far below cost. they too profit by selling access to those users to third-party advertisers. they too accumulate and use data to carve up the ad market. the scale of data they have available, of course, dwarfs that of their newsprint ancestors. this data, combined with cheap computation and powerful statistics, has enabled operational efficiency, scale, and effectiveness far beyond what newspapers could ever have managed. but the business model itself-the actual means by which these firms earn revenues-is identical. finally, that value model does not emerge, fully-formed, from the data itself. the data alone are no more valuable than the unrefined iron ore or crude oil of past industrial revolutions. rather, the data were mere inputs to a production process that depended on human insightthat what people looked for on the internet might be a good proxy for their consumer interests. big-box retail ranks as the other substantial success for big data. large retailers like amazon, wal-mart, or target have harvested very fine-grained data about customer preferences to make increasingly accurate predictions of what individual customers wish to buy, in what quantities and combinations, at what times of the year, at what price. these predictions are occasionally shocking in their accuracy-as with target's implicit identification of a pregnant teenager well before her father knew it himself, based solely on subtle changes in her purchasing habits. from this data, these retailers can, and have, built a detailed understanding of retail markets: what products are complements or substitutes for each other; exactly how much more people are willing to pay for brand names versus generics; how size, packaging, and placement in stores and on shelves matters to sales volumes. insights built on such data have prompted two significant changes in retail markets. first, they have made large retailers highly effective at optimizing supply chains, identifying retail trends in their infancy, and managing logistical difficulties to minimize the impact on sales and lost competitiveness. this has multiplied their effectiveness versus smaller retailers, who lack such capabilities and are correspondingly less able to compete on price. but it has also changed, fundamentally, the relationship of these retailers to their suppliers. big box retailers have increasingly become monopsony buyers of some goods-books for amazon, music for itunes. but they are also now monopoly sellers of information back to their suppliers. amazon, target and wal-mart have a much better understanding of their suppliers' customers than the customers themselves. they also understand these suppliers' competitors far better. hence their aggregation of information has given them substantial power over suppliers. this has had profound consequences for the suppliers. wal-mart famously squeezes suppliers on cost-either across the board, or by pitting suppliers against one another based on detailed information of their comparative cost efficiencies and customer demand. hence big data has shifted the power structure of the retail sector and its manufacturing supply chains. the scope and scale of the data owned by amazon or wal-mart about who purchases what, when, and in what combinations often means that they understand the market for a product far better than the manufacturer. big data, in this case, comes from big business-a firm that markets to the world also owns data about the world's wants, needs, and peculiarities. even as they are monopsony buyers of many goods (think e-books for amazon), they are correspondingly monopoly sellers of data. and that has made them into huge market powers on two dimensions, enabling them to squeeze suppliers to the absolute minimum price, packaging, size, and other product features that are most advantageous to them-and perhaps to their customers. but big data has not changed the fundamental means of value creation in the retail sector. whatever its distributional consequences, the basic retail transaction-of individuals buying goods from retail intermediaries, remains unchanged from earlier eras. the same economies of scale and opportunities for cross-marketing that made montgomery ward a retail powerhouse in the th century act on amazon and wal-mart in the st. big data may have exacerbated trends already present in the retail sector; but the basics of how that sector creates value for customers and generates profits for investors are by no means new. retailers have yet to build truly new products or services that rely on data itself-instead, that data is an input into a longstanding process of optimization of supply chain relations, marketing, and product placement in service of a very old value model: the final close of sale between a customer and the retailer. second-and third-order models find value in data several steps removed from the actual transaction that generates the data. however, as the google flu example illustrated, that data may have far less value when separated from its virtual context. thus while these businesses enjoy effectively free raw materials, the potential uses of those materials are in fact quite limited. digital exhaust from web browsing, shopping, or socializing has proven enormously useful in the self-referential task of improving future web browsing, shopping, and socializing. but that success has not translated success at tasks far removed from the virtual world that generated this exhaust. digital exhaust may be plentiful and convenient to collect, but it offers limited support for understanding or responding to real-world problems. first-order models, in contrast, escape the flu trap by building atop purpose-specific data, conceived and collected with the intent of solving specific problems. in doing so, they capitalize on the cheap storage, powerful algorithms, and inexpensive computing power that made the first wave of big data firms possible. but they do so in pursuit of a rather different class of problems. first order products remain in their infancy. but some nascent examples suggest what might be possible. ibm's watson famously used its natural language and pattern recognition abilities to win the jeopardy! game show. doing so constituted a major technical feat: the ability to understand unstructured, potentially obfuscated jeopardy! game show answers, and respond with properly-structured questions based on information gleaned from vast databases of unstructured information on history, popular culture, art, science, or almost any other domain. the question now is whether ibm can adapt this technology to other problems. its first attempts at improving medical diagnosis appear promising. by learning from disease and health data gathered from millions of patients, initial tests suggest that watson can improve the quality, accuracy, and efficacy of medical diagnosis and service to future patients (steadman ) . watson closes the data value loop: patient data is made valuable because it improves patient services, not because it helps with insurance underwriting or product manufacturing or logistics or some other third-party activity. premise corporation provides another example. premise has built a mobile-phone based data gathering network to measure macroeconomic aggregates like inflation and food scarcity. this network allows them to monitor economic change at a very detailed level, in regions of the world where official statistics are unavailable or unreliable. this sensor network is the foundation of the products and services that premise sells to financial services firms, development agencies, and other clients. as compared with the attenuated link between data and value in second-or third-order businesses, premise's business model links the design of the data generation process directly to the value of its final products. optimum energy (oe) provides a final example. oe monitors and aggregates data on building energy use-principally data centers-across building types, environments, and locations. that data enables it to build models for building energy use and efficiency optimization. those models, by learning building behaviors across many different kinds of inputs and buildings, can perform better than single-building models with limited scope. most importantly, oe creates value for clients by using this data to optimize energy efficiency and reduce energy costs. these first-order business models all rely on data specifically obtained for their products. this reliance on purpose-specific data contrasts with third-order models that rely on the bdigital exhaust^of conventional big data wisdom. to use the newspaper example, thirdorder models assume-but can't specifically verify-that those who read the style section are interested in purchasing new fashions. google's success stemmed from closing this information gap a bit-showing that people who viewed web pages on fashion were likely to click on fashion ads. but again, the data that supports this is data generated by processes unrelated to actual purchasing-activities like web surfing and search or email exchange. and so the gap remains. google appears to realize this, and has launched consumer surveys as an attempt to bridge that gap. in brief, it offers people the chance to skip ads in favor of providing brand feedback. we should remember the root of the claim about big data. that claim was perhaps best summarized by halevy et al. ( ) in what they termed bthe unreasonable effectiveness of data^-that, when seeking to improve the performance of predictive systems, more data appeared to yield better returns on effort than better algorithms. most appear to have taken that to mean that data-and particularly more data-are unreasonably effective everywhereand that, by extension, even noisy or skewed data could suffice to answer hard questions if we could simply get enough of it. but that misstates the authors' claims. they did not claim that more data was always better. rather, they argued that, for specific kinds of applications, history suggested that gathering more data paid better dividends than inventing better algorithms. where data are sparse or the phenomenon under measurement noisy, more data allow a more complete picture of what we are interested in. machine translation provides a very pertinent example: human speech and writing varies enormously within one language, let alone two. faced with the choice between better algorithms for understanding human language, and more data to quantify the variance in language, more data appears to work better. but for other applications, the bbigness^of data may not matter at all. if i want to know who will win an election, polling a thousand people might be enough. relying on the aggregated voices of a nation's twitter users, in contrast, will probably fail (gayo-avello et al. ; gayo-avello ; huberty ) . not only are we not, as section discussed, in the n = all world that infatuated mayer-schönberger and cukier ( ); but for most problems we likely don't care to be. having the right data-and consequently identifying the right question to ask beforehand-is far more important than having a lot of data of limited relevance to the answers we seek. big data therefore falls short of the proclamation that it represents the biggest change in technological and economic possibility since the industrial revolution. that revolution, in the span of a century or so, fundamentally transformed almost every facet of human life. someone born in , who lived to be years old, grew up in a world of horses for travel, candles for light, salting and canning for food preservation, and telegraphs for communication. the world of their passing had cars and airplanes, electric light and refrigerators, and telephones, radio, and motion pictures. having ranked big data with the industrial revolution, we find ourselves wondering why our present progress seems so paltry in comparison. but much of what we associate with the industrial revolution-the advances in automobile transport, chemistry, communication, and medicine-came much later. the businesses that produced them were fundamentally different from the small collections of tinkerers and craftsmen that built the first power looms. instead, these firms invested in huge industrial research and development operations to discover and then commercialize new scientific discoveries. these changes were expensive, complicated, and slow-so slow that john stuart mill despaired, as late as , of human progress. but in time, they produced a world inconceivable to even the industrial enthusiasts of the s. in today's revolution, we have our looms, but we envision the possibility of a model t. today, we can see glimmers of that possibility in ibm's watson, google's self-driving car, or nest's thermostats that learn the climate preferences of a home's occupants. these and other technologies are deeply embedded in, and reliant on, data generated from and around realworld phenomena. none rely on bdigital exhaust^. they do not create value by parsing customer data or optimizing ad click-through rates (though presumably they could). they are not the product of a relatively few, straightforward (if ultimately quite useful) insights. instead, ibm, google, and nest have dedicated substantial resources to studying natural language processing, large-scale machine learning, knowledge extraction, and other problems. the resulting products represent an industrial synthesis of a series of complex innovations, linking machine intelligence, real-time sensing, and industrial design. these products are thus much closer to what big data's proponents have promised-but their methods are a world away from the easy hype about mass-manufactured insights from the free raw material of digital exhaust. we're stuck in the first industrial revolution. we have the power looms and the water mills, but wonder, given all the hype, at the absence of the model ts and telephones of our dreams. the answer is a hard one. the big gains from big data will require a transformation of organizational, technological, and economic operations on par with that of the second industrial revolution. then, as now, firms had to invest heavily in industrial research and development to build the foundations of entirely new forms of value creation. those foundations permitted entirely new business models, in contrast to the marginal changes of the first industrial revolution. and the raw materials of the first revolution proved only tangentially useful to the innovations of the second. these differences portend a revolution of greater consequence and complexity. firms will likely be larger. innovation will rely less on small entrepreneurs, who lack the funds and scale for systems-level innovation. where entrepreneurs do remain, they will play far more niche roles. as rao ( ) has argued, startups will increasingly become outsourced r&d, whose innovations are acquired to become features of existing products rather than standalone products themselves. the success of systems-level innovation will threaten a range of current jobs-white collar and service sector as well as blue collar and manufacturing-as expanding algorithmic capacity widens the scope of digitizeable tasks. but unlike past revolutions, that expanding capacity also begs the question of where this revolution will find new forms of employment insulated from these technological forces; and if it does not, how we manage the social instability that will surely follow. with luck, we will resist the temptation to use those same algorithmic tools for social control. but human history on that point is not encouraging. regardless, we should resist the temptation to assume that a world of ubiquitous data means a world of cheap, abundant, and relevant raw materials for a new epoch of economic prosperity. the most abundant of those materials today turn out to have limited uses outside the narrow products and services that generate them. overcoming that hurdle requires more than just smarter statisticians, better algorithms, or faster computation. instead, it will require new business models capable of nurturing both new sources of data and new technologies into truly new products and services. social privacy in networked publics: teens' attitudes, practices, and strategies when google got flu wrong assessing google flu trends performance in the united states during the influenza virus a (h n ) pandemic more tweets, more votes: social media as a quantitative indicator of political behavior d ( ) i wanted to predict elections with twitter and all i got was this lousy paper: a balanced survey on election prediction using twitter data limits of electoral predictions using twitter detecting influenza epidemics using search engine query data the unreasonable effectiveness of data multi-cycle forecasting of congressional elections with social media experimental evidence of massive-scale emotional contagion through social networks big data: the next frontier for innovation, competition, and productivity. mckinsey global institute report mayer-schönberger v, cukier k ( ) big data: a revolution that will transform how we live, work, and think entrepreneurs are the new labor ibm's watson is better at diagnosing cancer than human doctors forecasting elections with non-representative polls acknowledgments this research is a part of the ongoing collaboration of brie, the berkeley roundtable on the international economy at the university of california at berkeley, and etla, the research institute of the finnish economy. this paper has benefited from extended discussions with cathryn carson, drew conway, chris diehl, stu feldman, david gutelius, jonathan murray, joseph reisinger, sean taylor, georg zachmann, and john zysman. all errors committed, and opinions expressed, remain solely my own.open access this article is distributed under the terms of the creative commons attribution license which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited. key: cord- -od mf f authors: capodaglio, andrea g.; callegari, arianna title: online monitoring technologies for drinking water systems security date: journal: risk management of water supply and sanitation systems doi: . / - - - - _ sha: doc_id: cord_uid: od mf f more stringent constraints placed nowadays on water companies to provide high quality drinking water, increasing water resources scarcity in many areas of the planet, forcing water companies to work on marginal water bodies for supply, and the threat of hostile actions by political extremists and terrorist groups, that may willingly and deliberately cause contamination of an otherwise safe supply, are recent issues that have spurred demand for more efficient and comprehensive online water monitoring technologies. traditionally, quality parameters associated with drinking water provision were monitored using routine grab samples followed by laboratory analysis. this approach only allowed to capture small data sets, mostly unrepresentative of the true variance at the source, and allowed potentially important events to occur undetected. this paper examines state-of-the-art technologies for online monitoring of water quality in supply water systems, and reports some recent application examples. a safe and reliable supply of drinking water is nowadays an issue that bears strategic significance worldwide. in many areas of the globe the demand for high quality freshwater far exceeds the available supply, already; it is estimated, for example (who, ) that over million deaths each year are currently caused worldwide by pathogenic bacteria during the consumption of unsanitary water: it is easily foreseeable that in the future the issue of freshwater resource ______ * to whom correspondence should be addressed. andrea g. capodaglio, department of hydraulic & environmental engineering university of pavia, via ferrata , pavia, e-mail: italy capo@unipv.it and drinking water supply scarcity will continue to escalate, driven by population growth and economic development pressure. more stringent constraints placed nowadays on water companies to provide high quality drinking water, increasing water resources scarcity in many areas of the planet, forcing water companies to work on marginal water bodies for supply, and the threat of hostile actions by political extremists and terrorist groups, that may willingly and deliberately cause contamination of an otherwise safe supply, are recent issues that have spurred demand for more efficient and comprehensive online water monitoring technologies. micro-biological contamination of drinking water has an immediate effect on the emergence of infectious diseases. availability of micro-biologically safe drinking water is probably the most effective and economical way to ensure public health. in addition to "traditional" microbiological contamination by human waste, contamination of drinking water sources with pesticides and herbicides as part of the major contaminating factors is a growing problem worldwide. during the last decades, several studies revealed the presence of hazardous contaminants in wastewater effluents, being discharged in rivers and streams due to "normal" anthropic activities, including pesticides (Öllers et al., ) , natural and synthetic hormones (kolpin et al., ) , plasticizers, personal care products and pharmaceuticals compounds (daughton and ternes, ; jones et al., ) . a recent study estimated that there are , human pathogens including viruses and prions, bacteria and ricketssiae, fungi, protozoa and helminths; about % are considered to be emerging pathogens. their number continues to grow, as evidenced by the relatively recent emergence of severe acute respiratory syndrome (sars), caused by a novel coronavirus. in the past - years, on average at least one new pathogen has been identified each year, and many more have re-emerged after periods of inactivity or by appearing in areas where they were not previously reported (cunliffe, ) . pathogens identified in recent years include a range of organisms that can be transmitted directly from water or by water-related vectors. while a high proportion of the substantial burden of water-borne disease is caused by classical by pathogens such as salmonella typhi and vibrio cholerae, the spectrum of challenges is expanding (table ) . there are many reasons why water-borne pathogens emerge. in some cases this can be due to advancements in disease diagnosis and detection of the causative organisms: for example, it is likely that cryptosporidium caused diarrhoeal illness before it was diagnosed as a human pathogen in . in other cases true emergence can be caused by factors such as new environments, new technologies and changes in human behaviour. some pathogens have emerged for a combination of reasons. legionella was first detected in following the outbreak of legionnaires' disease in philadelphia. however, increased use of water-cooled air conditioning systems and spa pools has contributed to increased incidence of legionnaires' disease. as far as deliberate human hostile actions on urban water supplies, although none has been reported to date, in january, , the fbi circulated a reserved bulletin warning water industry managers that al-qaida terrorists may have been studying american dams and water-supply systems in preparation for new attacks (ionlife, ) . traditionally, quality parameters associated with drinking water provision were monitored using routine grab samples followed by laboratory analysis. this approach only allowed to capture small data sets, mostly unrepresentative of the true variance at the source, and allowed potentially important events to occur undetected. it is clear, that, in view of what just reported, this can no longer be considered a satisfactory procedure, and that online monitoring of water supplies, for a larger number of parameters than currently available, is quickly becoming an unavoidable choice. water utilities around the world are already using some form of online monitoring to warn of contamination of drinking water, in anticipation of yetto-be specified regulations: in the united states, turbidity is currently the only quality indicator for which there is a regulatory requirement for continuous online monitoring; in europe, the eu drinking water monitoring regulations (council directive / /ec) do not specifically require online measurements (awwa, ). online monitoring is usually defined as the unattended sampling, analysis and reporting of a parameter; it produces a sequence of data at much greater frequency than that permitted by manual (grab) sampling and it also allows real-time feedback for either process control, water quality characterization for operational or regulatory purposes, and alert/alarm purposes. online monitoring can be carried out at onsite as well as remote locations and will deliver measurements at intervals of seconds-to-minutes apart. clearly, online instrumentation must be placed at representative locations in the water system and must be periodically maintained by qualified technical personnel. monitoring requirements can be defined in relationship to: • source water quality: (a) variability, in space and time (very low for groundwater, low for lakes, high for rivers); (b) vulnerability (type and location of possible contaminating activity), time-of-travel of the contaminant to the intake, effectiveness of barriers, control options after an alarm • water treatment: process optimization options and response times, sampling frequency must allow adequate process control • distribution systems: minimization of deterioration of water quality over time and distance, early detection of cross-connections and water losses in addition, it must be considered that online monitors could have different sensitivity and selectivity according to the matrix and range of concentrations analyzed. a multibarrier approach to drinking water quality protection, such as those that are commonly used by facilities worldwide, is based on the concept that contaminants must be subject to as many points of control/treatment (barriers) as possible prior to the tap. the ideal location for control of contaminants is as close to the source as possible. a source water with low vulnerability is therefore characterized by few potential contaminant activities, transit time longer than that required for laboratory analysis, and the presence of multiple physical barriers between contaminating activities and point of intake. in a source water with moderate vulnerability, online monitoring of surrogate parameters (such as toc, doc, uv , ph and conductivity) may be considered to keep track of potential pollution. in a high vulnerability water source, online monitoring of chemical-physical-biological parameters (turbidity, ph, conductivity, redox, fish toxicity) and surrogate parameters in addition to specific indicators (e.g. vocs, phenols and specific toxicity tests) may be preferred. this is summarized in table . some parameters commonly used to monitor in online mode a supply source are listed in table . parameters used to monitor online water treatment are listed in table . both tables list also parameters for which online monitoring technology may not be widely available, nor field proved at the moment, but that may be useful for the given purpose (awwa, ) . the availability of real-time analytical information is one of the key benefits of online monitoring instrumentation: this information must however be conveyed to the appropriate user by means of a data collection and transmission system which is often referred to as scada, which consists of the individual online instruments, connected to programmable logic controllers (plcs) or remote telemetry units (rtus), that convert instrument outputs to the desired units, compare them to criteria set by the user, and generate signals for alarm or control to other process equipment. a host computer, that can be used to visualize or store data, or to further utilize them for specific purposes, almost always complements these systems. generally speaking, online monitoring instrumentation can be divided in: • physical monitors (turbidity, particles, color, conductivity, tds, hardness, alkalinity, acidity, streaming current, radioactivity, temperature, redox potential) • inorganic monitors (ph and do, disinfectants, such as chlorines and ozone, metals, fluoride, nutrients, cyanide) • organic monitors (carbon and hydrocarbons, uv adsorption, vocs, pesticides, disinfection by-products) • biological monitors (nonspecific, algae, protozoa, pathogens) • hydraulic monitors (flow, level and pressure) this paper will focus on the four former classes, discussing for each basic operating principles, and evaluation of the technology for online applications in the water distributing system. a wide array of technologies can be used for monitoring physical parameters, among them: light scattering/blocking (turbidity, particles, ss), light absorbance (color), electrochemical (conductivity, hardness, redox), electrophoretic (streaming current), chemical tritration (alkalinity, acidity, hardness) and other (radioactivity, temperature) (table ) . turbidity refers to the clarity of a water sample, and can be defined as an optical property that causes light to be scattered and absorbed by suspended particulate matter (inorganic or organic) in the sample. it is one of the most commonly monitored parameters in the water industry, and the one that is most amenable to online monitoring. a turbidimeter consists of a light source, a sample cell and a photodetector; commercial instruments differ in the type of light source and the number and location of photodetectors. color is caused by the absorption of visible light by dissolved/colloidal substances or small suspended particles and can be an indication of pollution by disinfection by-products, industrial pollutants and/or metals, although it does not, by itself, represent a health risk. color is in fact regulated as an aesthetic parameter only and is seldom monitored online, except in cases where the water source is subject to industrial effluents and/or storm runoff inputs. color is measured either visually or spectrophotometrically. dissolved organic/inorganic impurities (tds) are compounds of different nature and sources, and constitute the solid residue after all the water evaporates. tds must be determined gravimetrically in the laboratory, however, since these species tend to increase the electrical conductivity of the solution, conductivity is often used as a surrogate measure for tds, especially when in online mode. hardness is defined as the sum of divalent cations in a water sample, and is relevant in drinking water systems for aesthetic reasons and for corrosion concerns. alkalinity is defined as the acid-neutralizing capacity of a solution. both can be determined by chemical tritration (hardness with edta, alkalinity with an acid solution). inorganic monitors are used in online mode to detect influent and effluent water quality, and for treatment process control; the applicable technologies are listed in table . online monitoring of inorganic constituents is still in the early phase for many elements of interest to drinking water concerns. for metals, available technology is an adaptation to automatic operation mode of complex colorimetric methods developed for laboratory applications, and therefore turns out to be expensive and/or complex to operate, nor still suitable for installation in remote or unmanned sites. also, for many metals of interest in drinking water systems (as, cd, pb, hg, se, zn), online monitoring technologies do not exist at all. some promise for future application comes from developments in optode technology, coupled with miniaturized spectrophotometry. the technology for online monitoring of organic compounds includes toc analyzers, uv absorption and differential spectroscopy; it is much more developed than that for inorganics, for this reason, although neither eu nor us regulations require online monitoring of these substances, many drinking water utilities routinely use online organics monitoring to some degree. toc methods measure the carbon content of dissolved and particulate organic matter in the water, without giving information about the nature of this organic substances. table shows the different fractions of carbon measured by an organic carbon analyzer. toc measurement is defined by well established methods and occurs generally according to a four-step process: sample treatment (filtration), inorg. c removal (acidification to ph < ), oxidation (with uv, catalyzed uv, chemical oxidation, etc.) and co determination (ndir detectors, colorimetry, or conductivity methods). detection limits depend on the specific technique's operating temperature (usually > . mg/l for low temp., > mg/l for high temp.). most organic compounds found in water absorb uv radiation: using a uv spectrometer it is therefore possible to estimate the concentration of these compounds. originally, a uv light source with the single wave length of nm was used for such measures, however, in recent years, instrumentation reading the entire uv-vis spectrum ( - nm) has been developed and marketed (s-can, ) . uv absorption is a well-defined and commonly used methodology; evidence shows strong correlation between these measurements and organic carbon concentration measured with standard methods such as toc or others (figure ). in addition, it has been shown that other parameters can be measured indirectly by correlating their concentration values to uv absorption in the full spectrum ( figure ) ; several commonly sought organic compounds have typical absorption spectra that make their identification quite easy with appropriate instrumentation (figure ) . hydrocarbons in general are probably the main class of water pollutants found in surface and ground water (i.e., source water for drinking water systems). methods for online hydrocarbon detection include: fluorometry, reflectivity, light scattering and turbidity measurement, ultrasonic methods, electrical conductivity, spectroscopy, gas-phase detection (after volatilization), resistance-based sensors; some of these methods, however, give just an indication of the presence/absence of oil on the water surface. volatile organic compounds (vocs), including, among the others, aromatic compounds, halogenates and trihalometanes, are compounds that evaporate when exposed to air and can be of health concern when found in drinking water systems (trihalometanes are disinfection by-products -dbps -that can be precursors to the formation of carcinogens). their presence in drinking water can be a symptom of accidental pollution in the source water, of treatment failure/deficiency, or of incorrect disinfection procedures. current online monitoring technologies for vocs include purge-and-trap gaschromatography with flame ionization (fid), electron capture (ecd) or photoionization detectors or mass spectrometry (ms). detection limits for different substances vary according to the detector method. pesticides, including insecticides, fungicides and herbicides comprise triazines and phenlylurea compounds; they are monitored in drinking water systems in order to: detect accidental pollution in source waters, and check the effectiveness of treatment specifically designed to remove such substances. online monitoring of pesticides can be carried out using composite techniques, such as: • high pressure liquid chromatography (hplc)/diode array (da) detection, consists of extraction and enrichment, chromatographic separation and da detection. • gas chromatography (gc), consists of extraction and enrichment, gc separation and mass spectrometer (ms) detection. • liquid chromatography/mass spectrometry, consists in extraction and enrichment, lc separation and ms, thermospray, electrospray or particle beam detection. each technique is capable to optimally detect a group of compounds, for example, hplc/da can be used to analyse; atrazine, chlortoluron, cyanazine, desethylkatrazine, diuron, hexazinone, isoproruton, linuron, metazachlor, methabenzthiszuron, metobrorumon, metolachlor, metoxuron, monolinuron, sebutylazine, simazine and terbutylazine. in theory, any analytical laboratory method can be adapted for use as online measurement, provided that the requirements for consumables and manual intervention can be minimized: current online systems are often a "robotized" adaptation of known offline laboratory procedures, however, not always this solution is the most efficient one. a series of novel technologies, such as optochemical sensors, biosensors, and microbiological sensors are being tested for organics and hydrocarbon analysis. advances already in use include differential uv spectroscopy for dbps detection and microphase solid-phase extraction (spe) for the analysis of semivolatile organics (yongtao et al., ) . there are two basic types of biological monitors currently in use: those that use biological species as indicators of the presence of contaminants of concern (e.g. toxic chemicals), and those that screen for the presence of biological species of concern (e.g. nuisance algae, pathogens). in common us terminology, the term biomonitor usually indicates the former, and is in fact used as synonymous with toxicity monitor. in eu terminology, biomonitor refers generally to all types of biologically-based systems. at the present time, many existing biological monitors are quite new and can be considered experimental/unique applications. table shows an overview of the most common types of online biological monitors. sensitivity of test organism to individual compounds must be determined initially. online biological monitors are a very active area of r&d due to increasing regulatory and public demand pressures. while bacterial-based systems show great sensitivity and ease of operation, and development in this area will likely derive from improved fingerprinting of organisms and maintenance cost reduction, most advances can be expected from protozoan monitor technology, with techniques in uv absorption/scattering analysis that may soon allow automated detection of cryptosporidium and giardia. also, molecular techniques initially applied to the recognition of the genomic sequence of specific organisms in clinical applications (bej, ) , have also shown great potential for use in the detection of pathogens in water, and are producing extremely interesting results that could lead to widespread online use in the very next future (see also section ). chemical fingerprinting describes the use of a unique chemical signature, isotopic ratio, mineral species, or pattern analysis to identify different chemicals. optical fingerprinting by uv, vis, and nir absorption spectroscopy can be effectively achieved by low-cost and compact spectrometric devices, that can also be linked to an online diagnostic system, to directly identify some compounds (e.g. benzene) present in the water or to give an indication of the possibility of the presence of related compounds. in optical fingerprinting, a wide portion of the uv, vis and nir spectrum can be monitored simultaneously at high measurement frequency (minutes or fractions thereof); figure shows the spectral fingerprint of a typical municipal wastewater, in the range - nm, together with three other spectral readings from the same source that were recorded within min from the first. these show clearly different features, indicating a pronounced change in water quality. although this alone will not, in general, indicate the compound or compounds responsible for the change (they will need to be further investigated, if a definite answer is desired), but that can nevertheless trigger an alert to the system's operator, indicating deviation from routine conditions. some relevant applications taken from recent literature, are illustrated in the following sections, as examples of the current state-of-the-art in online monitoring technology. the river trent drains the large, mainly urban, catchment of midlands, with million residents, in the uk; although traditionally it has been considered too polluted to serve as a drinking water supply source, the river has undergone marked improvements in quality until, in , it was targeted as such. water is currently withdrawn from the river into bankside storage lakes, from where is taken to a purification plant. at this point, it became necessary to identify a suitable online monitoring strategy in order to protect this planned development (kirmeyer et al., ) . in order to protect water quality and provide operational data to the treatment plant operators, a list of parameters subject to online/laboratory monitoring has been established (table ). online monitors provide an alarm when a preset warning limit is exceeded, prompting immediate additional investigation. when a second, "action" preset limit is exceeded, water extraction into storage is automatically terminated. online monitors include traditional inorganic, organic and oil monitors, as well as an automated liquid chromatography (hplc) system for monitoring organics, originally developed for analysis of triazine and phenylurea in the rhine river, and uniquelly adapted to detect other acid herbicides and phenolic compounds known to be frequently present in the trent, at levels < . μg/l. vocs are detected by means of a purge-and-trap gc analyzer. maintenance requirements are relatively high (each unit requires - h of onsite attendance twice a week, in addition to the time required to review data, prepare buffers and standards, etc.). overall, in about years of operation, the system has recorded several incidents of parameter abnormality in the river trent, including ammonia toxicity events and contamination by various herbicides. it has been confirmed that online monitoring gives a far better definition of each recorded event than otherwise available, while spot samples analyzed at the laboratory in parallel have always been in good agreement with the online results. the llobregat river, near barcelona (spain) is characterized by a highly variable flowrate; to ensure sufficient supply during drought periods, dams have been built along its course. in addition, a continuous, automatic system with ten stations along its course has been put in place to monitor critical water quality parameters; these may vary depending on the monitoring location, in order to account for different needs and conditions. there are three types of stations: basic ( , upstream), complete ( , midstream) and special ( , mid-to-downstream); these are described in table . the objectives of the monitoring network are: • to provide warning of pollution incidents, ensuring safety of the water produced by the purification plants • to control instream water quality by monitoring changes in pollution indicators • to provide information for the operators of the water systems and planners through data access with a specifically created scada user interface in the course of several years of operation the automatic water quality monitoring network has recorded various incidents of pollution, including: • repeated occurrences of salinity discharges from potash mines, caused by accidental breakage of collectors or leaching due to rainfall • an event of chromium pollution in a tributary stream, due to industrial source discharges • multiple overflows of drainage and sewer systems causing variations of turbidity, toc, ammonia, uv adsorption and do • highly significant variations of physical and chemical parameters (mainly do, ph) due to photosynthetic activity . . on-line monitoring networks for drinking water security of karst water springs in geological karstic formations are the main source for drinking water supply for about % of the austrian population. water quality from these springs shows rapid, occasional instabilities for some parameters, caused by natural events, such as heavy rainfalls. rapid fluctuations of raw water quality, especially concerning turbidity, but also elevated concentrations of dissolved organic substances, and increased bacteria counts can occur in an unpredictable way during storm weather. furthermore, anthropogenic events like accidents and spills in proximity of the springs might also affect the quality of the raw water. the raw water quality is obviously one of the most important factors determining the final quality of the drinking water, in addition, rapid changes of source quality can limit the efficient usage of treatment procedures during drinking water production. as it is impossible to predict the impact of such events, it is vital to enhance drinking water security by monitoring the composition of the raw water continuously. main springs and important locations in the trunk mains had been monitored online since the late s. buildings equipped with power supply, pipe installations and special foundations had to be built for housing cabinet analysers, for monitoring spectral absorption coefficient (uv ), toc, turbidity, electrical conductivity and ph. in year , a novel submersible uv-vis-spectrometer, introduced by s::can messtechnik gmbh, capable of measuring light absorbance in the spectral range of nm to nm, and thus turbidity, organic carbons (e.g. toc, doc) and nitrate without any sample preparation were adopted. this new monitoring equipment provided new opportunities to the waterworks by allowing to monitor the totality of springs, even those without power supply, and by eliminating pumps, filters, membranes and reagents that were used by the old instrumentation, lowering substantially the overall cost of monitoring operations (weingartner and hosftaeder, ) . at present, vienna waterworks operates a s::can-based monitoring systems in order to monitor turbidity, sac , nitrate, toc, doc, temperature and electric conductivity at locations, since monitoring just one parameter would not meet the needs of efficient and safe drinking water supply, as different types of events cause different changes in the composition of the spring water. the results of these monitoring systems are transferred in real time to an early warning system that can be accessed from four central stations. this early warning system manages the raw water sources h a day. whenever current readings exceed limits that are specific to each parameter, the water of the spring of concern will not be used for drinking water production but drained away. oxidation of organic materials for drinking water disinfection is a commonly applied treatment step. during oxidation of natural organic substances in the source water, for example using ozone, large molecules, such as humic and fulvic acids, are cracked into smaller ones. a side-effect of this procedure is the increased availability of microbiologically assimilable organic carbon (aoc): whereas the original large molecules are not readily accessible to microorganisms, the smaller oxidation products can be digested and thus can stimulate bacterial regrowth in the distribution network. aoc is an important parameter especially in drinking water networks where no residual disinfectant is present in the water; its measurement is performed using cell cultures, which is a lengthy procedure. online uv/vis spectroscopy has proven itself as a tool that allows the collection of specific information on the removal efficiency for and subsequent concentrations of (organic) substances in water. the use of two on-line spectrometer instruments, placed before and after a treatment step, and the calculation of the differential spectrum between these two sites could open up a further area in water quality monitoring and process control as it allows calculation and prediction of water quality parameters previously unavailable (van der broeke et al., ) . two on-line spectrometers probes were installed in the pilot plant of amsterdam waterworks, weesperkarspel. in this pilot plant, the full treatment train of the waterworks is represented. the source, an artificial lake with high concentrations of natural organic matter, is sequentially treated in an ozone reactor (four bubble columns), pellet softening reactor, biological activated carbon (bac) filtration reactor and finally a slow sand filter. a parallel bac reactor was fed with water from the full scale treatment plant, which uses identical raw water, to be able to verify the effects of the changes in the ozone settings on water quality. the aoc calibration obtained in this way is a surrogate parameter, in the sense that the aoc concentrations in the water are far below the concentrations that can be distinguished using a uv/vis spectrophotometer without sample pre-concentration. the developed calibration, in combination with the on-line spectrometer probe, allows for on-line, in-situ measurement of dissolved ozone concentrations. the use of two instruments simultaneously, required to perform on-line differential measurements, allowed the prediction of the changes in aoc levels in individual treatment steps in real-time. the software ana::larm, for use with online uv spectrometers in a speciallydesigned configuration ( figure ), has been developed specifically for contaminant alarm systems based on thousands of spectra, and is successfully used in several applications in europe. the training of the alarm parameters can be done by the instrument automatically, or is done manually guided by the pc software. it allows for a very simple half-or fully automatic setup and configuration of up to eight spectral alarm parameters within a few minutes. it will react on any type of figure . configuration of online monitoring station for use with the software ana::larm organic contamination that provides an absorption signal in the uv range. the alarm sensitivity for many organic contaminants is between and ppb. at the same time it is most insensitive to any fluctuation of the matrix within the natural "normal" range, and thus keeps false alarms to an unmatched minimum. the approach and methods used are absolutely new and unique, and open a completely new perspective for water monitoring beyond the trending of "classical" concentration parameters (s-can, b) . a contaminant warning system (cws) as an integrated tool that employs in-situ sensors, supervisory control and data acquisition (scada) systems, and water quality event detection systems (eds) to continuously monitor network conditions and warn operations personnel of any potential contamination events, has been studied by the us environmental protection agency (epa) and sandia national laboratories (hasan, et al., ; grayman, et al., ) . the sensor component can be comprised of various water quality sensing platforms, including contaminant-specific sensors, or existing water quality sensors (e.g., ph, cl, electrical conductivity, etc.) as currently installed in many municipal water distribution systems to provide "surrogate" data to the cws's. it has in fact been proved by experiments conducted in laboratory and pipe test loop systems, that a majority of potential contaminants will change values of at least a surrogate parameter away from normal background levels (byer and carlson, ; cook et al., ; hall et al., ) . monitoring of surrogate parameters can therefore provide information on the presence of contaminants within a distribution system and this information can be transmitted to a central processing location through the scada system. the challenge is to analyze the surrogate parameter signals to accurately identify changes in water quality that are significantly beyond the range of the ambient variability of the background water quality. the recently developed the canary eds software (hart et al., ) is an open-source software platform that gathers water quality signal inputs from scada systems and processes the data using one or more event detection algorithms, using a number of statistical models to determine the probability of an anomalous water quality event occurring for a given time step and monitoring location within the distribution network (mckenna and hart, ). the canary system has not been used in real applications, yet, and offline case studies, based on real hystorical data, have evidentiated some problems in correctly pinpointing alarm causes, as changes in the network hydraulics (such as opening and closing valves, draining/filling of storage tanks and pump operations) can cause significant changes in water quality as waters of different ages and from different sources mix within the network. the existence of escherichia coli (e.coli) in drinking water is an important indicator of faecal pathogens and potential micro biological contamination. currently available detection methods for its presence in drinking water distribution networks are inadequate, for multiple reasons: first of all, current methods are very time consuming meaning that contamination will already have reached end-users before laboratory results are available; secondly, current sampling and analysis procedures lead to detection success rates of only % to maximum % (with optimized sample taking). research by scientists from the dutch kiwa shows that by using a network of on-line sensors, the success rate can be increased to % (koerkamp and van wijlen, ) . the core of this labonline system is based on a combination of a concentrator unit and a sensor system using disposable chips, which prevent the sensor system itself from cross-contaminations and guarantee reliable and high quality measurements in time. initially designed for e.coli, the system is theoretically capable of detecting a broad group of microbiological contaminants like bacteria and viruses. industrial production is scheduled for late . the same research group developed a sensor technology for pesticides based on a combination of an integrated optic chip, a biochemical transduction layer (micro)-fluidics, electronics and data acquisition and system control software, called optiqua mobilelab. the optiqua mobilelab sensor for the detection of pesticides will have the following characteristics: low cost per analysis, easy to use, detection of five pesticides (simazine, atrazine, glyphosat, ampa, bam ( , -dichlorbenzamide), detection of additional pesticides (available in later stages), on site detection, prompt analysis results (minutes), high resolution (e.g. detection limits . μg/l with a dynamic range of . - μg/l), robust, low maintenance system. knowledge of the sequence of microbial genomes has led to the development of molecular methods for detection of microbial pathogens in clinical specimens as well as water and other environmental samples. a wide array of molecular techniques has therefore been applied to the study of microbiological water quality issues. the application of molecular techniques, such as pcr (polymerase chain reaction) has generated a great deal of valuable information on the occurrence, diversity, and biology of pathogens in water (loge et al., ) . in addition, molecular methods demonstrate rapid detection and enhanced specificity compared to other analytical methods. a micro analysis system for water pathogen monitoring consists of a micro polymerase chain reaction (pcr) chip integrated with a continuous-flow microarray that is able to reduce the analysis time from about h to within several hours as compared with the existing epa approved methods was presented by yong ( ) . pathogen samples were successfully detected by the micro analysis system through dna amplification by the micro pcr chip followed by direct transfer of the amplicons to the microarray for detection. in addition to one species monitoring, the system shows potential in direct monitoring of a range of pathogens at the same time through pcr and different probes immobilized on microarrays. comprehensive two-dimensional gas chromatography also referred to as gcxgc, is an analytical technique in which all the eluted compounds from a first column are successively submitted to a new separation in a second column with different selectivity. contrary to gas chromatography (gc) which employs only one chromatographic column, gcxgc uses two chromatographic columns, coupled in series, with a modulator at their junction. developed in , due to its principle, gcxgc offers a much better capacity of separation and a better sensitivity than conventional gas chromatography. thanks to the sensitivity of gcxgc (three-to fivefold higher than gc) some compounds can be detected at the ng/l level. semard et al. ( ) applied this technique to the screening of wastewater and effluents samples. a large range of drugs (antidepressors, antibiotics, anticoagulants…), personal care products (sunscreens, antiseptics, cosmetics…) and carcinogen compounds were found in the raw waste water samples. in addition to the above mentioned micropollutants, a wide variety of nitrogen aliphatic and aromatic structures that could act as dbp (disinfection by-products) precursors, were also uncovered. this technology does not yet have the potential for direct online application. courtois et al. ( ) also propose a molecular technique, based on polymerase chain reactions to detect pathogens. to improve pcr diagnostics for routine analysis purposes, they focus on the processing of the sample, which is crucial for the robustness and the overall performance of the method. their objectives in sample preparation are to increase the concentration of the target organisms to the practical operating range of a given pcr assay; and to produce a purified dna extract that would be representative of the initial water sample and would be free of pcr-inhibitory substances. this can be achieved by means of a twostep ultrafiltration (uf) procedure by using protoptype hollow fiber uf cartridge, and a commercial uf centrifugal concentrator. this paper has overviewed existing instrumentation applicable to water supply online monitoring, and examined a few state-of-the-art application examples. it is clear that technological development in this field is very rapid, and that astonishing advances are anticipated in several areas (fingerprinting, optochemical sensors, biosensors, molecular techniques). software applications, together with new generation sensors, are also contributing to the identification of otherwise difficultly monitored parameters. in spite of the high technology being developed, monitoring costs are bound to become a lesser and lesser part of a water utility budget due to the fact that automation and technological simplification will abate the human cost factor (maintenance and other labour forms) and reduce significantly the complexity of procedures (with those, of reagent requirements, etc.). proper interpretation and use of the growing mass of water quality data that will become available through new technologies will allow better management of water resources, and water treatment and distribution facilities. online monitoring for drinking water utilities molecular based methods for the detection of microbial pathogens in the environment real-time detection of intentional chemical contamination in decision support system for water distribution system monitoring for homeland security universal concentration for large volumes of water samples before molecular detection of waterborne pathogens emerging enteric and potentially waterborne pathogens in the region ternes ( ) pharmaceuticals and personal care products in the environment: agents of subtle change? design of early warning and predictive source water monitoring systems on-line water quality parameters as indicators of distribution system contamination canary: a water quality event detection algorithm development tool safeguarding the security of public water supplies using early warning systems: a brief review case studies of online monitoring systems next generation sensors for detection of pesticides and e.coli in water pharmaceuticals, hormones, and other organic wastewater contaminants in u.s. streams, - : a national reconnaissance how safe is our water? the threat of terrorism human pharmaceuticals in the aquatic environment pcr detection of specific pathogens in water: a risk-based analysis on-line identification of adverse water quality events from monitoring of surrogate data: canary software simultaneous quantification of neutral and acidic pharmaceuticals and pesticides at the low-ng/l level in surface waters use of on-line uv/vis-spectrometry in the measurement of dissolved ozone and aoc concentrations in drinking water treatment on-line monitoring networks for drinking water security of karst water. all about karst and water, vienna. who ( ) emerging issues in water and infectious disease. world health organization ) micro analysis system for water pathogen monitoring spe twin-pal. online in situ monitoring of semivolatile organic compounds in water key: cord- -lx ar e authors: yang, xu; li, deli; liu, xiaoqiang; tan, jianguo title: learner behaviors in synchronous online prosthodontic education during the covid- pandemic date: - - journal: j prosthet dent doi: . /j.prosdent. . . sha: doc_id: cord_uid: lx ar e statement of problem: synchronous online prosthodontic courses became a popular learning mode during the covid- pandemic crisis. nonetheless, the extent of learner participation and completion of these courses remains unknown. purpose: the purpose of this study was to assess learner behaviors in synchronous online prosthodontic continuing education lectures in china during the covid- pandemic. material and methods: all live online prosthodontic courses held by an online dental school in china from february to may were retrieved. the no-cost lectures could be accessed anonymously and viewed repeatedly on the day of broadcast. learning behavior data (teacher speaking time, audience total, timing of first visit to the online classroom, viewing time, and completion rate) were obtained. learning progress was calculated by dividing viewing time by teacher speaking time. when a learner progressed through % of a lecture, the lecture was considered completed. results: a total of learners participated in online prosthodontic courses, which had a mean duration of . ± . minutes. for each lecture, ± participants attended, with ± participants completing each session. there were participants ( . %) who viewed the lectures for less than minute. approximately half of the participants viewed the lectures for less than minutes, with their learning progress failing to pass %. the average completion rate was . %, with variation in completion rate dependent on when a learner first visited the online classroom. significant differences were found among the lecture completion rates and the timing of the first visit to the online classroom (p<. ). conclusions: synchronous online prosthodontic education courses in china had a high number of participants but low learning progress and completion rates during the covid- pandemic. learner behaviors in synchronous online prosthodontic education during the covid- pandemic since early , coronavirus disease (covid- ) has become a worldwide pandemic crisis. countries and regions have established pandemic prevention policies, which have had major impacts on social, economic, medical and dental activities, as well as lifestyles. countries have adopted social distancing policies with varying degrees of success. people are increasingly realizing that even after the pandemic dissipates, social distancing may continue long into the future. important changes have also occurred in the provision and utilization of dental care and education, [ ] [ ] [ ] with the emergence of covid- disrupting, in particular, how medical education, including dental education, is structured and provided. [ ] [ ] [ ] [ ] [ ] the covid- pandemic highlighted the need for alternative educational methods such as distance learning. [ ] [ ] [ ] [ ] [ ] in traditional dental education, high-quality practical skills training is inseparable from iterative, face-to-face guidance and communication. today, dental education methods are increasingly diverse, with distance learning becoming an important supplement to on-site education. , distance education may prove to be an effective alternative to traditional education methods, and students have been enthusiastic about online learning. [ ] [ ] [ ] [ ] synchronous online learning occurs via a live, virtual interactive classroom. in response to the covid- crisis, dental educators have converted university courses to an online format to avoid the risk of covid- transmission during in-person education. , using modern technology, students can access lectures at home, thereby avoiding on-site attendance and reducing the risk of infection. since the onset of covid- , most face-to-face academic meetings have been suspended or canceled. , synchronous online dental education courses and their participants have increased significantly, in part because of the courses' ability to overcome the geographical constraints typically found in traditional modes of education. , however, synchronous online courses are not as regulated as on-site classes. [ ] [ ] [ ] often, instructors cannot supervise learners with respect to their attendance and participation. furthermore, the current era of information overload can create a multitude of distractions and obstacles for learners when joining and completing an online course. importantly, the extent of learner participation and completion of these courses remains unknown, and the authors are unaware of research that has investigated the effectiveness of synchronous online learning during the covid- pandemic. the present observational study assessed learner behaviors in synchronous online prosthodontic continuing education lectures in china during the covid- pandemic. the primary purpose was to evaluate the participation, learning progress, and completion rate of the courses. a secondary purpose was to determine whether the completion rate was affected by the participant's first visit (fv) time to the online classroom. this study aimed to illustrate the reality of synchronous online learning and provide a reference for improving the effectiveness of distance prosthodontic education. the null hypotheses were that the completion rate of synchronous online prosthodontic education during the covid- pandemic would not be influenced by the specific lectures and the learners' first-visit time to the online classroom. this research was conducted by using lectures from a well-known dental online education institution, tsmile, based in pr china. all live online prosthodontic lectures held from february to may were retrieved. these lectures covered contemporary clinical topics in fixed prosthodontics, implant dentistry, and esthetic dentistry. each lecture consisted of to minutes of instruction, with some exceeding minutes because of interactive discussion. the no-cost lectures could be accessed anonymously from smartphones or laptop or tablet computers. each lecture could be viewed repeatedly on the day of broadcast. learning behavior data (teacher speaking time, audience total, timing of fv to the online classroom, viewing time, and completion rates) were obtained from the online platform. no demographic information was collected, so ethical approval was not required. only participants with data points for each variable were included for analysis. learning progress was calculated by dividing viewing time by teacher speaking time. when a learner progressed through % of a lecture, the lecture was considered completed. the online classrooms allowed early access to the course introduction before the course officially started, giving learners to fv the online classroom anywhere between several hours to several days before the start of the course. the participants were divided into groups as per the timing of their fv to the online classroom: early group (fv minutes before the lecture began); punctual group (fv< minutes before the lecture began); and late group (fv occurred after the lecture had started). differences in completion rates among lectures were analyzed, as well as differences among fv times. normally distributed continuous variables were presented as mean ±standard deviation. non-normal continuous variables were presented as median (interquartile range). count variables were presented as n (%). during the covid- pandemic crisis, synchronous online prosthodontic education became a popular learning mode and was highly engaged. nonetheless, the students' learning progress and completion rate remained low. when conducting synchronous online courses, course content and teaching skills must be optimized, and learners guided to visit the online classroom for the first time within hour of the start of the course to improve the completion rate. the chi-square test for significant differences between lectures and fv time was used with a statistical software program (ibm spss statistics, v . ; ibm corp) (a=. ). overall, learners participated in online prosthodontic lectures, which had a mean instruction duration of . ± . minutes (table ) . for each lecture, ± participants attended, with ± participants completing each session. the viewing time and learning progress followed skewed distributions (fig. ) . a total of participants ( . %) viewed the lectures for less than minute (fig. a) . approximately half of the participants viewed the lectures for less than minutes (fig. a) , with their learning progress failing to pass % (fig. b) . some participants viewed parts or all of the lecture repeatedly; . % of participants had learning progress values that exceeded % (fig. b) . the completion rate ranged from . % to . %, with an average completion rate of . % (table ). there were significant differences among the completion rates of the lectures (p<. ) ( table ) . learners who visited the online classroom for the first time less than minutes before the lecture began (punctual group) had the highest completion rate of . % (table ). in contrast, the learners whose fv occurred more than minutes before the lecture began (early group) had the lowest completion rate ( . %). the completion rate of those first visiting the online classroom after the lecture started (late group) was . %. there were significant differences among the completion rates of each fv group (p<. ) ( table ) . this research assessed learner behaviors in synchronous online prosthodontic education courses in china during the covid- pandemic. the participation, learning progress, and completion rates of learners and the data's relationship to the lectures and to the timing of learners' first visits to the online classroom were evaluated. the results indicated that synchronous online prosthodontic education courses were highly engaged with low learning progress. the overall completion rate was low and was affected by lectures and the fv time to the online classroom. therefore, the null hypotheses were rejected. synchronous online courses became a popular learning mode with a high number of participants in china during the covid- pandemic. different factors contributed to its recent popularity. time is an important factor restricting dentist participation in continuing education. during the pandemic, dental clinical work was greatly reduced, providing dentists with more free time for continuing education. in addition, synchronous courses are easily accessed, free from space constraints, and do not require face-to-face contact, helping to reduce the transmission risk of covid- . these attributes may contribute to a high number of participants in such courses, participation that is rarely matched by in-person classes. nevertheless, more attention must be paid to learner levels of engagement. , participant behavior in synchronous online courses has not been regulated. as a result, one third of the participants viewed lectures for less than minute, and nearly half of the participants progressed through less than % of the lecture content. only one fifth completed the online class. this may be because the focus of responsibility for the class has shifted, to some extent, from the teacher to the students. learners can enter and leave the online classroom freely and may get distracted by their surroundings, particularly as they participate in courses outside a formal classroom. distance learners may find it difficult to motivate themselves to stay engaged for long periods. in addition, deficient hardware or software infrastructure, inadequate technological abilities, and a complex learning environment are also difficulties that students may face in distance education. , nonetheless, to increase the effectiveness of online education, learning progress and completion rates need first to be increased. the learner total and completion rate was significantly related to specific lectures, perhaps because of varying interest in the lecture topics, content, and speakers. therefore, the course design needs to consider the interest of learners to increase attentiveness throughout each class. for online classes, it may be more difficult to engage in timely and effective interaction with students, which is a key component of generating interest in online education. the development of online courses requires effort from both experts and learners. when developing online lectures, attention should be paid to teaching methods and teacher abilities, experience, and presentation skills. the course must contain effective visual learning elements, as well as easy-to-express and easy-to-understand content. to achieve this goal, it is necessary to provide systematic training for teachers. learner completion rates were also related to the timing of their fv to the online classroom. audience members who visited the online classroom for the first time within minutes before the course began had the highest completion rate of . %, exceeding the average completion rate of . %. some learners entered the online classroom more than minutes before the start of the course, visiting the classroom a few hours or days previously e they may be distracted by their surrounding environment, which leads to a decline in completion rate. for learners who entered the online classroom for the first time less than minutes before the lecture began, they were less likely to be disturbed by their surroundings, which is conducive to completing the course. some learners entered the live online classroom after the lecture started. being late suggests they may not have paid enough attention to the course and could not fully comprehend the course content when entering midway through. this may explain why the completion rate was low for the late group. given the "new normal" ushered in by the pandemic, dental educators are being forced to develop innovative strategies to continue educational tasks during the crisis. dentists are willing to conduct synchronous online dental continuing education courses, indicating that this educational model may be broadly adopted in the future. it is possible to continue to teach theoretical content online. however, face-to-face classrooms are significantly more conducive to student-teacher and student-student interactions. when discussing clinical treatments, an internet-based discussion is a less effective educational method compared with in-person discussions, which involve more natural ways of communicating. therefore, when conducting synchronous online courses, the focus should be on theoretical explanations, not clinical treatment discussions. limitations of this study included that the synchronous online prosthodontic education institutions and courses evaluated were limited in scope. there may be differences between institutions and their courses, and the course quality and teaching effectiveness were not evaluated. participation and completion rates only reflect the act of viewing course content online and do not necessarily reflect effective learning. in addition, the data were derived during a unique historical period; thus, the results cannot be generalized excessively. additional studies about the effect of synchronous online education courses on learner theoretical knowledge and practical skills, in china and worldwide, are necessary. based on the findings of this survey study, the following conclusions were drawn: . synchronous online prosthodontic courses had a high number of participants but low learning progress and completion rates. . the completion rates were significantly related to individual lectures and the timing of the learners' fv to the online classroom. . the impact of the covid- pandemic may be far-reaching, including in the realm of dental education, and may forever change the way dentists are taught. world health organization. coronavirus disease (covid- ) situation reports the impact of the covid- epidemic on the utilization of emergency dental services health services provision of public tertiary dental hospitals during the covid- epidemic in china coronavirus disease (covid- ): emerging and 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the united states novel coronavirus (covid- ) and dentistryea comprehensive review of literature martelli junior h. covid- pandemic and the impact on dental education: discussing current and future perspectives a review of continuing professional development for dentists in europe comparing face-to-face, synchronous, and asynchronous learning: postgraduate dental resident preferences use of educational technology in promoting distance education suspending classes without stopping learning: china's education emergency management policy in the covid- outbreak reasons for and barriers to attending continuing education activities and priorities for different dental specialties. open access maced key: cord- - w bqrox authors: aghdam, atae rezaei; watson, jason; miah, shah j; cliff, cynthia title: towards empowering diabetic patients: a perspective on self-management in the context of a group-based education program date: - - journal: nan doi: nan sha: doc_id: cord_uid: w bqrox this paper provides a novel framework for maximizing the effectiveness of the diabetes group education program, which could be generalized in any similar problem context. diabetes is recognised as the world's fastest-growing chronic disease (australia ; lovic et al. ) . according to the international diabetes federation (idf), by one adult in ten will have diabetes ( million) (australia ). diabetes is a chronic and progressive disease, which needs continuing self-management and self-awareness for a lifestyle change (kjellsdotter et al. ) . selfmanagement is one of the most key success factors impacting the progression of type- diabetes for patients, as the decisions that they make daily considerably impact their health outcomes (funnell and anderson ) . patients play a pivotal role in their self-care as they are doing more than % of their diabetes care outside of medical centres or at home (su et al. ) . ohcs as affordable and easily accessible / services, can facilitate self-management of diabetics by offering health-related advice and stories, social and emotional support (aghdam et al. ). an ohc refers to a group of people who interact with each other in an online platform about similar health issues (wang et al. ) . due to the fact that people tend to trust others who are in a similar situation rather than organisations, businesses, or government figures and media, it stands to reason that the content shared by peers in ohcs has potential to encourage community members to engage in health-related online activities (irshad et al. ; litchman and edelman ) . participating in ohcs progressively transforms patients from passive recipients of healthcare services to active agents (bragazzi ) . as active agents, patients can access, share and integrate their resources, sharing their experiences and stories, and emotionally supporting peers to achieve their health-related goals (forouzandeh and aghdam ) (aghdam et al. ) . the empowerment of patients improves the patients' role in co-creation, co-designing, and co-delivering health services (ciasullo et al. ) . this is essentially a reality for people with chronic disease such as diabetes patients who need informational and emotional supports that allow them to be successful in their disease self-management (litchman and edelman ) . in this regard, the diabetes education program has been a focus of prior research as a specific intervention that supports diabetes self-management (findlay-white et al. ) . ohcs provide opportunities for members to exchange new ideas, knowledge and information about diabetes selfmanagement, functioning as a bridge among people with type- diabetes and healthcare professionals and providing online discussion platforms to brainstorm potential solutions (sim et al. ) . as such, this study aims to investigate the potential practices of online diabetes communities to address the following question; how can an online diabetes community empower patients in context of a diabetes group education program (dgep)? the remainder of this paper is organised as follows; the next section describes the background of the literature. the following section explains the research methodology followed by the trustworthiness process. the discussion section provides a comprehensive overview of the contributions of the study from both theoretical and practical perspectives and the final section synthesises the findings and provides avenues for future research. chronic disease is generally of long duration, slow progression, and impacts the quality of life (martz et al. ). the care for people with chronic diseases such as type- diabetes is often complex and requires self-management as an essential element of the chronic care model (wagner et al. ). self-management includes actions and behaviours to manage the psychical, emotional, and social effects of the chronic disease (adams et al. ). one of the key methods for self-management of chronic disease and improved health outcomes is patient education (ellis et al. ; mensing and norris ) . patient education is the keystone of chronic disease self-management and is significant in achieving positive health outcomes for chronic disease patients (ellis et al. ; mensing and norris ) . patients need support, education, guidance and empowerment from their healthcare providers to tackle barriers to effective self-management (diabetes ). studies contended that participation in self-management courses also improves patient confidence, self-management skills and ability to self-manage their chronic disease, and improves the quality of life (turner et al. ) . diabetes group education programs typically assist patients to achieve knowledge and skills and confidence to manage their diabetes as well as opportunities to interact with peers and healthcare providers (jonkman et al. ) . group interactions facilitate further learning and raise motivation by interacting and learning from the experience of others (odgers-jewell et al. ) . research shows that diabetes group-based education programs benefit patients who derive social and emotional support from discussion with others (steinsbekk et al. ). this type of active participation by australasian conference on information systems aghdam & watson , wellington towards empowering diabetic patients patients in their health journey leads to value co-creation (osei-frimpong et al. ) . in the healthcare context value co-creation refers to "activities centered around the individual patients or in collaboration with numbers of the service delivery network including the patient, family, friends, other patients, health professionals and the outside community" (mccoll-kennedy et al. , p. ) . value is co-created synergistically and digital health platforms such as ohcs act as a coordinating device between community members (smedlund ) . thus, digital health platforms such as ohcs are ideal places for value co-creation (aghdam et al. ; kamalpour et al. ) . because of the nature of the dgep, patients face three different stages during their health journey; ( ) prior to joining, ( ) during the program, and ( ) after the program. we adapted customer-dominant logic (cdl) to divide the customer journey into these three phases. in fact, cdl argues that customers control the service situation and control is a relevant issue in many domains, and due to progressively empowered customers (seybold ) , this direction will most likely continue in the future (heinonen and strandvik ) . accordingly, in the healthcare domain, empowering patients in ohcs can activate value co-creation behaviour among stakeholders (litchman et al. ). as diabetes self-management requires a patient-centred approach (funnell et al. ) , in particular for a demand-driven decision making (e.g. in clinical settings -miah, ) and to date, the most successful diabetes self-management group activities and classes have been evaluated based on empowerment theory (heisler ) , our study applied empowerment theory in the context of ohcs and a diabetes group education program. empowerment theory contends that actions, activities or structures might be empowering and the outcome of such process leads to being empowered (zimmerman ) . according to empowerment theory, people need opportunities to become active in community decision-making to improve their quality of life. as such, we leverage an affordable and easily accessible / digital health platform such as ohcs to facilitate the process of selfmanagement through informational, social, and emotional support. the proposed framework goes beyond the existing system-centric approaches to a new mode of conceptualisation and practice, which focuses on interactions among all stakeholders in ohcs. the proposed framework addresses diabetesrelated needs and challenges including; informational, social, and psychological needs. in this study, we selected online reddit diabetes communities as our data source. the interactions between users are mostly focused on the posts themselves and members will give the post all their attentions. there are numerous diabetes-related topics in this forum, which make it a promising source of users' interactions for this research study. reddit is a social aggregation and public discussion website. in reddit, three popular diabetes communities comprise of more than , members. in this study, we selected r/diabetes, r/type diabetes, and r/diabetes_t communities. within each community, there are a variety of threads and topics discussed by users. the total number of users in all of these communities was , in april . from each topic, the tile and the content (e.g., textual information) were extracted without the additional information of the authors. a total of topics were collected from reddit from october to april . in total threads were collected for analysis. research argued that participation in diabetes group education program has multiple benefits for patients such as social and emotional support, and sharing experiences (odgers-jewell et al. ) . the queensland university of technology (qut) offers a partnership face-to-face dgep to patients who are newly diagnosed or living with the type- diabetes long term. over the course of program, the qut dgep aims to provide a quality lifestyle intervention empowering type- diabetic patients to better manage their symptoms. the dgep runs for weeks and includes various types of activities such as; initial assessment, weekly one-hour personalized exercise session, one-hour interactive group education regarding diabetes-related topics (e.g., diet, mindfulness, foot care, living with a chronic condition, etc.), and a final assessment at the end of the program. the outcomes of this award-winning program are promising and all patients involved no longer needing to stay on the long waiting list of the hospitals. one of the most important objectives of the dgep is to keep patients connected whilst outside the program. we, therefore, aim to extend the value of the face-to-face dgep by identifying the potential practices on the online diabetes communities, proposing a diabetes ohc framework for keeping patients connected to the program after discharge from the program. aghdam & watson , wellington towards empowering diabetic patients we collected data from the three popular reddit diabetes online communities (r/diabetes, r/type diabetes, and r/diabetes_t ). reddit is a popular forum for diabetes (duggan and smith ) . there are numerous health-related topics on this website, which make it a promising source of users' interactions for this research study. in addition, reddit allows researchers to mine its data. hence, we used the python reddit application programming interface (api) wrapper (praw) to collect the data. praw is a python package that allows researchers to access, parse topics and subreddit, and extract the associated reply threads. as inclusion criteria for selecting posts and threads, we selected type- diabetes-related topics with more than replies on each topic to obtain enough information. the interactions between users are mostly focused on the posts themselves and members will give the post all their attention. demographic information about the participants was anonymized to guarantee the confidentiality and privacy of participants' data. in every stage of this research study, we followed the code of ethics for researchers of the queensland university of technology (qut). the approval number is . in this study, we conducted an inductive thematic analysis to identify emergent themes from the data. the six steps of thematic analysis provided by (clarke et al. ) , guided us to identify the salient themes. following the six steps of the thematic analysis and with the assistance of the nvivo qualitative analysis software, we manually generated an initial list of codes. during the first step, we performed an initial analysis of the relevant topics and threads and recorded our notes via memo and annotation features of nvivo . in the second step, we inductively generated nodes. in the third step, we combined codes revealing three overarching themes and nine subthemes. in the fourth step, which was reviewing and refining the themes, we reviewed all themes and subthemes to make sure that they followed a coherence pattern. during this phase, two themes were integrated because of their common content. in the fifth step, we concisely named the identified themes to reflect the story behind each theme and reflect what the themes are about. hence, we named themes that address the research questions. finally, in the sixth step, findings were synthesised to provide a concise and coherent report. in terms of testing the trustworthiness of the findings, we employed percent agreement as our method of inter-coder reliability checking. two scholars, experienced in qualitative research and thematic analysis, checked different parts from creating initial codes to naming the themes. each of them independently analysed the entire data and during the first meeting, the per cent agreement was % and after the second meeting, discussing the essence of the themes, a consensus was achieved and the overall results were %, making us confident about the reliability of our findings. after performing the thematic analysis, our analysis resulted in three emergent themes from the data. themes include ( ) exchange lifestyle-related advice, ( ) experience of commonality, and ( ) brainstorm potential solutions for daily challenges. table , summarises the thematic analysis outcomes. as evidenced in table , patient participation in diabetes online communities leads to the co-creation of value. for instance, in theme , patients shared resources such as articles, and videos with peers. another key finding is to improve patients' psychological wellbeing by participating in online activities such as story sharing and encourage other members of the community in selfmonitoring. ohcs provide an opportunity for users to enhance their knowledge about symptoms, share their experience and advice. information sharing by peers, experience and advice sharing, life-style related advice sharing, and sharing daily-basis activities are the most common activities identified by researchers in this study through thematically analysing the content of threads in the reddit diabetes online communities. these types of giving and seeking (exchanging) advice are illustrative examples of value co-creation behaviours. in the value co-creation process, stakeholders such as organizations, patients or caregivers share, integrate and renew each other's resources ). our analysis shows that diabetic users mostly shared their experience, stories, and online resources (e.g., research articles, youtube videos, and websites' urls). resource exchange is a mutual action taken by stakeholders in ohcs to access, share, and integrate resources (beirão et al. ) . in this regard, ohcs can facilitate resource exchange among stakeholder. for instance, members of the diabetes communities shared their up-to-date information and experience about using wearable devices (e.g., continues glucose monitors (cgm), dexcom and sport watches) for self-monitoring their health condition and reduce the burden of living with diabetes and improve quality of life. the experience of commonality in ohcs provides opportunities for members to feel that they are not alone. hence, the experience of commonality is associated with positive mental health, improving emotional wellbeing members of the diabetes communities perceived these online platforms as great places to tackle the feeling of loneliness and isolation. especially in the current situation of the global outbreak of covid- , these online communities are ideal places to tackle psychological distress and depression. at this particular point in time, diabetic patients need to strengthen their sense of community by connecting and supporting each other in the ohcs. because of the nature of ohcs, aghdam & watson , wellington towards empowering diabetic patients which provides access to information and coordinated social interactions, the members of these communities benefit an alternative solution and needs such as improving their wellbeing (zhao et al. ) . emotional support directly impacts on the ability to self-manage diabetes and equally selfmanagement of diabetes influences emotional wellbeing (schiøtz et al. ) . sharing the same situation and stories with other members is another aspect of emotional support. sharing the same stories creates a shared sense of meaning and community for users. in the reddit diabetes communities, a large number of users encourage peers in their self-management of diabetes. patients also reported that sharing monitoring data such as blood glucose and weight makes them feel empowered and motivated. members of these communities' support each other in coping with social and emotional barriers, staying motivated to reach their goals, and encourage better self-care habits without fear of judgement or stigma. improving the emotional wellbeing of diabetes leads to better self-care, overcoming psychological barriers, and ultimately, a better quality of life. ohcs are ideal places for brainstorming solutions by members. we identified brainstorming of potential solutions to address daily challenges as another co-creation behaviour occurred in diabetes online communities. virtual brainstorming is one of the most significant benefits of ohcs for diabetic patients. it provides an opportunity for community members to contribute new ideas to address diabetic daily challenges such as carrying medical equipment, diabetic's workplace problems, injection, and sleep problems. this was identified in many threads posted by the members of the communities. hence, ohcs are ideal places to brainstorm potential solutions to address these issues. as it can be viewed in table , reddit patient suggests a solution to another patient, who is struggling with carrying diabetes bag in public and private business areas. these types of solutions are another example of value co-creation behaviour within diabetes online communities. participating of community members in brainstorming activities, make them feel that their contributions are valuable and their ideas will help peers to tackle some daily challenges. because of the high number of demands for dgep, patients need to be in a waiting list before joining the program. while they are in a waiting list, they can communicate with discharged patients and use their experience. the resource exchange help patients reduce their stress and better prepare for the program. during the program patients, share their experiences and health-related stories with peers, encouraging each other to reach their health-related goals. during this phase, ohc can play an important role as an online interactive platform to facilitate patient-to-patient and patient-to-hcp interaction. after discharge from the program, patients still need to stick to their plans and selfmanage their diabetes. ohcs provide opportunities for them to keep connected to the program, interact with hcps and share their experience of the program with patients, who are in the "prior-tojoining" phase. figure , demonstrates the proposed framework for diabetes online communities. aghdam & watson , wellington towards empowering diabetic patients in terms of the validity and utility of the proposed framework, we conducted expert interviews. a qualitative assessment of the framework flexibility was carried out through interviews with healthcare professionals and the diabetes program coordinator at the qut clinic. two health experts, who are directly involved and organised the dgep, and have more than ten years of experience in the healthcare domain initially evaluated the framework and provided their feedback and suggestions. ohcs are proper educational platforms that lead to better health outcomes and members can learn more from others on how to better manage their health conditions (chen et al. ). information that shared by patients in ohcs benefits other patients by learning from peers, improving their self-management of disease, and ultimately, improving their health (yan and tan ) . the proposed framework focused on patients as active agents in the process of online value co-creation. patients are pivotal stakeholders in our framework that can co-create value by resource exchange and social support. in our framework, diabetic patients participate in different forms of value co-creation through informational, social, and emotional support. ohcs empower patients to actively engage in co-creation activities / especially in times of fear, isolation, and uncertainty. this research study has been conducted during the global pandemic of the covid- . during this pandemic and isolation time, patients increasingly participate in diabetes online communities to gain and offer emotional support. these easy-access and / online platforms help patients to tackle psychological issues such as depression, anxiety, and loneliness because diabetic patients have a twofold greater risk of depression (schram et al. ). shared stories and experiences in ohcs make patients feel that they are not alone, strengthening their sense of community by connecting and supporting each other. digital health platforms such as diabetes online communities have the potential to increase easy access to diabetes self-management interventions and techniques in the lower cost (rosal et al. ) . furthermore, participating in diabetes group-based education program provides opportunities for patients to meet and discuss with other members of the communities, obtaining social and emotional support (steinsbekk et al. ) . in doing so, in recent years, the queensland university of technology (qut) offer a partnership program to patients who are newly diagnosed or living with the condition long term. this program aims to provide a quality lifestyle intervention and empowering type- diabetic patients to better manage their symptoms. as type- diabetes is a self-managed disease, one of the main aims of the program is to keep patients connected to the program after discharge. we australasian conference on information systems aghdam & watson , wellington towards empowering diabetic patients adopted customer-dominant logic (cdl) as a way to explore overlaps between our findings and the dgep. cdl is focused on activities and experiences of the customer at three different stages: preservice, service, and post-service (heinonen and strandvik ) . it is used as a way to extend the customers' perceptions of the offering and to extend market interactions (heinonen and strandvik ) . following cdl, we divided the diabetic patient journey into three phases including; ( ) prior to joining the program, ( ) during the program, and ( ) after discharge from the program. in each phase, we identified value co-creation behaviours such as; resource sharing, story and advice sharing, and social and emotional support. theoretically, we extended the target body of the knowledge in the healthcare service delivery through enhancing the empowerment theory in which, patients are the central facet and healthcare professionals and healthcare organisations are facilitators of the value cocreation process (funnell and anderson ) . research studies have overlooked the nuances relationship between empowerment theory, value co-creation, and the role of ohcs as facilitators for this process. this study provides an opportunity for leveraging peer-to-peer support within digital health platforms such as ohcs to empower patients in their self-management of diabetes. practically, our findings further provide recommendations to the healthcare industry on how to effectively contribute to the online intervention by shifting from traditional dyadic interaction between healthcare professionals and the patient to online co-creation among all stakeholders. we believe that healthcare providers can potentially use our theoretical and empirical findings to extend the value of the face-toface diabetes group-based education programs by keep patients connected to the program / regardless of their geographical distance with lower cost. our study is not without limitations, yet these limitations provide interesting avenues for future research. our data were gathered from reddit diabetes online communities. we selected three popular diabetes communities on the reddit to analyse the contents and interactions among members. we might overlook some small communities related to type- diabetes. furthermore, we only used reddit as our data collection source. future studies can focus on more diabetes online communities, aiming that how can a fully functional assistive artefact be designed for diabetic patients, using the design science research guideline (miah ; miah et al. ) . although the face-to-face diabetes education program held in queensland, australia, it can be generalised to any other organisational or country context (for example, in decision support implementation (ali, miah and khan, ) ensuring empowering end users). our future study will extend the current framework by conducting interviews with the members of the communities to identifying their current level of engagement with ohc, identify benefits and challenges of using these platforms, and investigate their online value co-creation behaviour. therefore, there are some areas required for further research. another future avenue is to investigate the perspective in which healthcare organisations indirectly participate in online value cocreation. experimental design studies of ohcs to explore the behavioural and psychological aspects of social support could also be useful. in this research study, we sought to extend the current understanding of the potential of diabetes online communities in empowering self-management for diabetic patients. as such, the main aim of this study was to investigate the potential practices of online diabetes communities to empower selfmanagement of diabetic patients in their health journey. findings show that patients in diabetes online communities share information, experiences, stories, and potential solutions. they actively participate in online activities regarding offering and receiving support from peers. the vast majority of the shared contents on diabetes online communities include lifestyle-related advice such as diet, exercise and using wearable technologies to better monitor and care of diabetes. members of diabetes online communities contend that these online forums are ideal platforms to obtain social and emotional support from peers. our findings, which investigated the connection between diabetes online communities' practices and outcomes and the real-world dgep case can further assist healthcare organisations to effectively contribute to the online intervention and extend their communication channel from a traditional power balance between hco and patients to interactive platform that enables all stakeholders to actively engage in value co-creation activities. as discussed, type- diabetes is a chronic disease that needs ongoing self-care and self-manage. ohcs provide opportunities for them to encourage each other in regards to sticking to their self-monitoring and selfmanagement. this is especially true when they discharge from the dgep and have no access to faceto-face interactions. the st annual crossing the quality chasm summit: a focus on communities improving the theoretical understanding toward patient-driven health care innovation through online value cocreation: systematic review online value co-creation in the healthcare service ecosystem: a review antecedents of business intelligence implementation for addressing organizational agility in small business context, 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for healthcare decision making a metadesign theory for tailorable decision support group participants' experiences of a patient-directed group-based education program for the management of type diabetes mellitus service experiences and dyadic value co-creation in healthcare service delivery: a cit approach exploring the meaningfulness of healthcare organizations: a multiple case study a virtual world versus face-to-face intervention format to promote diabetes self-management among african american women: a pilot randomized clinical trial social support and self-management behaviour among patients with type diabetes depression and quality of life in patients with diabetes: a systematic review from the european depression in diabetes (edid) research consortium get inside the lives of your customers p- effect of diabetes self-management education (dsme) on glycemic control in patients with type diabetes digital health platform complementor motives and effectual reasoning group based diabetes self-management education compared to routine treatment for people with type diabetes mellitus. a systematic review with meta-analysis diabetes management through remote patient monitoring: the importance of patient activation and engagement with the technology an evaluation of a self-management program for patients with long-term conditions improving chronic illness care: translating evidence into action analyzing and predicting user participations in online health communities: a social support perspective feeling blue? go online: an empirical study of social support among patients patient value co-creation in online health communities: social identity effects on customer knowledge contributions and membership continuance intentions in online health communities empowerment theory this is an open-access article licensed under a creative commons attribution-noncommercial . new zealand, which permits non-commercial use, distribution, and reproduction in any medium key: cord- - ri kw k authors: håkansson, anders title: impact of covid- on online gambling – a general population survey during the pandemic date: - - journal: front psychol doi: . /fpsyg. . sha: doc_id: cord_uid: ri kw k the covid- pandemic may have severe impact on mental health, and concerns have been raised about potentially increased online behavior and possibly increased gambling problems, such as in sports bettors at risk of transfer to even riskier forms of gambling during sports lock-down. given the need for objective data about gambling behavior during the pandemic, the present analysis, from a project assessing online gambling in sweden, aimed to study past- -day gambling patterns in online gamblers in sweden. the study, carried out in may, , during the pandemic and its restrictions on society, included past-year online gamblers (n = ). past- -day gambling for several gambling types was lower compared to a previous study in online gamblers in the same setting, while online non-sports gambling remained at high levels. those reporting sports betting even during a period with decreased sports betting occasions proved to have markedly higher gambling problems. covid- may alter gambling behaviors, and online gamblers who maintain or initiate gambling types theoretically reduced by the crisis may represent a group at particular risk. the covid- pandemic has raised a number of issues related to health, beyond the most urgent and life-threatening consequences. the risk of mental health consequences has been highlighted (holmes et al., ) , and this also includes a risk of increased online behavior, such as increased video gaming (king et al., ) or addictive internet use (sun et al., ) . likewise, concerns have been raised about covid- -related consequences on gambling behavior. problem gambling and the gambling disorder represent conditions which are globally widespread; past-year problem gambling has been reported to occur in between . and . % of the general population across different countries and continents (calado and griffiths, ) . the gambling disorder is associated with severe financial, social and psychological consequences, including psychiatric comorbidity, but can be treated, primarily with cognitive-behavioral therapy and motivational interventions (potenza et al., ) . it has been documented in previous national financial crises that these may affect gambling behavior (economou et al., ) , although experiences from such crises are somewhat inconclusive (olason et al., ) . the covid- crisis, and the confinement and other restrictions associated with it, represent a previously unseen situation with both financial consequences for the population, other changes to the labor market, schooling and leisure activities. these changes include an increase in the time spent at home, possibly more time spent online, a risk of increased worry about the future, and may potentially affect gambling behavior . one specific circumstance is the substantial change in the gambling market itself, as virtually all sports typically subject to sports betting disappeared during a significant period of time . given the possible effects on other types of online behavior from covid- -related confinement (king et al., ; sun et al., ) , it may be hypothesized that some gambling types would be more favored than others, whereas others may decrease . sports betting is one of types of gambling known to increase the risk of problem gambling, and represents the second most common gambling type reported by treatment-seeking gambling disorder patients in the present setting (håkansson et al., ) . one concern is that given the large impact on sports during the pandemic, due to lockdown regulations and canceled events (radio sweden, ) , people with otherwise predominating sports betting habits would turn to gambling types with potentially even higher addictive potential, such as online casino games or other online-based gambling, due to the lack of sports events and land-based gambling opportunities . early in the pandemic, fear of such a transition within the gambling market led politicians to take legal action, such as through a limit to gambling advertising (sbc news, ) , or other proposed limits to the extent of online gambling (reuters, ) . sweden, the setting studied here, is one of the countries where the online gambling market is strong and online gambling is common among treatment-seeking patients (håkansson et al., ; håkansson and widinghoff, ) , which contributes to the perceived risk of further online gambling predominance during covid- . the fear of a transition to online gambling is supported by the general impression of online gambling being more addictive (chóliz, ) . however, so far, population data are very limited with respect to actual gambling habits during the covid- crisis. a previous general population study (including both gamblers and nongamblers) in sweden found a modest percentage reporting an increased gambling behavior during the crisis. as a response to decreased sports events, a minority reported either turning to other remaining sports events, online casino, or horse betting. in total, those reporting an increase in their gambling behavior were more likely to be problem gamblers (håkansson, ) . from a population survey in ontario, canada, it was reported that during the first weeks of lockdown of physical facilities such as landbased casinos, a substantial migration appeared to have occurred from land-based-only gambling to online gambling (price, ) . given the theoretically increased role of online behaviors (king et al., ; sun et al., ) , and the cancelation of sports activities, the present study focused on people reporting to be online gamblers. for the present study, data were derived from a population study on gambling behaviors, designed prior to the covid- crisis as a web survey which was carried out during the month of may, , i.e., during the ongoing crisis. this substudy used the past- -day data in order to describe gambling patterns during covid- . the aim of the present study was to describe past- -day use of different gambling types during the covid- pandemic in individuals defined as online gamblers, in order to enable a comparison with past- -day data reported from a previous survey in online gamblers carried out in . in particular, given the considerable changes in sports world-wide, the study also aimed to assess whether online sports bettors still reporting past- -day sports betting differed from those who did not. here, it was hypothesized that past- -day gambling in swedish online gamblers would be more common (in relation to a measure of past-year gambling behavior) for some gambling types, such as online casino or other online-based gambling types likely to be unaffected by the covid- constraints, compared to gambling types more clearly affected by the pandemic. also, it was hypothesized that people who maintained gambling during the crisis, particularly for gambling types such as sports betting believed to be reduced during covid- -related restrictions, would present other characteristics than other online gamblers. the present analysis is a partial analysis from a larger study on online gambling in sweden. this sub-analysis focuses on past- day and past-year gambling patterns in swedish online gamblers, in order to highlight the online gambling situation during the ongoing covid- crisis. the overall study was designed prior to the covid- crisis, and aimed for a larger number of analyses of the online gambling behavior in the setting. as a past- -day measure for different gambling types is available, this subset of data was used for the present analysis. the survey was carried out from may to , such that the -day period for each participant refers to a period well within the period of time when constraints due to covid- were actively ongoing, and during that whole -day period, sports betting related to major sports events, such as major soccer leagues, were completely canceled. the study data was collected using the same inclusion criteria and the same methodology as in a previous study carried out in , and which previously has reported associations between specific types of online gambling patterns and problem gambling and indebtedness (håkansson and widinghoff, ) . the study was reviewed by the swedish ethical review authority (file number - ), which expressed that the study did not formally require ethical permission according to swedish law, as it does not deal with data that can be directly or indirectly linked to a specific individual, and also expressed no ethical concerns with respect to the study. the study was opened only after a participant provided informed consent. participation in the study was paid following the credit system used by ipsos for other studies, and where a survey of the present extent and duration is rewarded with credit points corresponding to a value of around . euros within the credit system of the company. the present study took place in sweden, where gambling, since january st, , is regulated in a license-based system, with a large number of licensed operators. land-based casinos and land-based electronic gambling machines are run by a statebased monopoly, whereas betting on sports and horse racing, online casino and bingo games, as well as land-based and online lotteries, are subject to competition between a number of operators. a large percentage of the gambling advertisements seen in television promote online gambling, with online casino representing the largest share of these commercial messages (håkansson and widinghoff, ) . likewise, a majority of treatment-seeking gambling disorder patients report online casino as their predominating gambling type, with sports betting being the second most common type (håkansson et al., ) . slightly below . % of the general population are believed to be problem gamblers, with an increase reported to have occurred particularly in women, according to official general population survey data (bbc, ). during the period analyzed in the present study, sports events on competitive level in sweden were canceled, whereas land-based horse track racing continued, although without present audience but available through wagering online. likewise, the four major land-based casinos, all owned by the state monopoly, were closed. the present study aimed to include past-year online gamblers. the sample addressed were web panel members of a swedish market survey company, ipsos, i.e., individuals already enrolled with that company's web panel, and typically receiving market surveys and political opinion polls. the same methods and the same recruitment strategy were used in a previous study assessing online gamblers in sweden, recruited through the same web survey company and with the same screen-out question (håkansson and widinghoff, ) . participants of the web panel are regularly addressed with offers to participate in different surveys. in this case, they were included with the question "if you think about the past months, how often have you gambled on sports betting or online casino games?" with the options to respond "don't gamble on sports betting or online casino, " " - times, " " - times, " " times or more, " or "unsure/don't know." only individuals responding " times or more" were further considered in the study. the study had the intention to include , individuals. when closing the study, , individuals had answered the survey. for of them, at least one of the nine items of the gambling severity instrument (pgsi, see below) were missing, and therefore could not be categorized in a gambling severity category. three of them, however, had a total value already reaching above the cut-off for the highest problem level in that instrument (eight points or more) from the available items, and were accordingly categorized into that highest problem gambling category and included in the study. the remaining individuals were excluded from further analyses (based on the uncertainty of their problem gambling status), such that a final sample of individuals were included in the study. patterns of recent gambling was measured for each of the gambling types included, asking for whether that gambling types had been used ( ) during the past days, and if not ( ) at any time during the past-year (gambling types assessed were online casino, land-based casino, online horse betting, landbased horse betting, sports live betting, sports non-live betting, online poker, land-based poker, land-based electronic gambling machines, online bingo, and gambling within video games). thus, respondents endorsing the past- -day item were not asked about the period of time prior to the past days. individuals reporting any past-year gambling for a gambling type, but not past- -day gambling for that type, were compared to those reporting past- -day gambling (non-recent vs. recent gamblers). as no comparable -day period was available for comparison, the proportions of past-year gamblers who reported past- -day gambling, for each gambling type, were used as a measure of the extent to which different gambling types were affected by the covid- period. problem gambling severity was measured using the problem gambling severity index (pgsi), a nineitem scale (wynne and ferris, ) frequently used for the measure of a hazardous or problematic gambling behavior, with questions asked with a time frame of the past months. the same instrument was used, among other studies, in the preceding study on online gamblers in the present setting (håkansson and widinghoff, ) . as in previous research, respondents were categorized as having no risk gambling ( points), low risk gambling ( - points), moderate-risk gambling ( - points), or problem gambling ( points and above). gender and age (the latter in age groups) were reported, as well as living conditions (categories collapsed into living alone without children vs. not living alone) and occupation (categories collapsed into working/studying vs. unemployed/retired/sick-leave). also, it was reported whether the individual had ever self-excluded from gambling through the national self-exclusion system spelpaus , a governmental authority-based system introduced in swedish gambling legislation since january st, , and which allows a person to self-exclude for a duration of up to months (with the possibility of prolongation) from all legal (licensed) gambling operators in the country. sample characteristics and gambling patterns were reported as descriptive data. also, for each gambling type, descriptive data report the percentage of past-year gamblers for that gambling type who report having used it during the past days. past- -day gamblers-for each gambling type-were compared to non- -day past-year-gamblers for that gambling type, using chi-square analyses. seventy-five percent of respondents were men, and a majority were either working or retired. in total, % had a history of self-exclusion from the spelpaus system. fifty-two percent had no risk gambling according to the pgsi measure, % had lowrisk gambling, % were moderate-risk gamblers, and % were ( ) - ( ) and above ( ) living conditions alone with children ( ) alone without children ( ) with partner and children ( ) with partner without children ( ) with my parents ( ) occupation working ( ) studying ( ) unemployed ( ) retired ( ) other ( ) history of national self-exclusion yes ( ) no ( ) wish not to answer ( ) no risk ( ) low risk ( ) moderate risk ( ) problem gambling ( ) problem gamblers. a full description of the characteristics of the study sample is found in table . in women (n = ), % were moderate-risk gamblers and % were problem gamblers (a total of %), and in men (n = ), the corresponding percentages were and % (total %, p < . for gender difference, chi-square linear-by-linear). expressed as the percentage of past-year gamblers who gambled during the past days, for each gambling type, this ratio of past- -day gambling was the highest for online horse betting ( %), online casino ( %), online poker ( %) and online bingo ( %), as well as for the less frequent gambling within video games ( %), but lower for sports live betting ( %), non-live sports betting ( %), electronic gambling machines ( %), landbased horse gambling ( %), and land-based casino games ( %, table ). for those reporting past- -day gambling, compared to those denying that but reporting past-year gambling for the same gambling type, being a moderate-risk or problem gamblers was significantly more likely among the recent gamblers for landbased casino gambling, land-based electronic machine gambling, and for any sports betting, but less likely for online horse betting. the past- -day gamblers for online casino and land-based poker were significantly more likely to be female, whereas the recent online horse bettors were significantly more likely to be men ( table ) . the percentage of respondents in active work or studying were lower in recent gamblers for online casino ( vs. %, p < . ) and for online horse betting ( vs. %, p = . ), whereas no significant differences were seen in other gambling types (data not shown). among respondents reporting any sports betting during the pastyear (n = ), those who reported past- -day sports betting (n = ) were more likely to report past- -day online casino gambling ( vs. %, p < . ), land-based casino gambling ( vs. %, p = . ), online poker gambling ( vs. %, p < . ), land-based poker gambling ( vs. %, p = . ), land-based electronic gambling machines ( vs. %, p < . ), online bingo ( vs. %, p < . ), and gambling within video games ( vs. %, p < . ), while there were no significant differences regarding other types of gambling. those who reported past- -day sports betting were more likely to have a history of indebtedness ( vs. %, p = . ), and had higher levels of gambling problems (p < . , linear-by-linear, with the proportions of moderate-risk and problem gamblers being and % vs. and % vs., respectively). instead, they did not differ with respect to gender, age, history of self-exclusion, living alone without children, or currently in work/studies (data not shown). the present study is among the first studies reporting recent online gambling data from the covid- crisis. the present study included online gamblers, and focused on the characteristics of those reporting or not reporting recent gambling, in a situation with a changing gambling market where all major sports events had been canceled world-wide. thereby, the study attempts to shed light onto the discussion about whether the dramatic changes in the society during covid- could affect gambling among online gamblers. in summary, it can be concluded that online gambling types were more common compared to their past-year rates than were the landbased gambling types. importantly, sports bettors who did report sports betting even during this period, where such betting in the society was assumingly rare, had a very high degree of gambling problems and indebtedness, and gambled more. there was no indication that past-year sports bettors who denied betting in the recent covid- -affected period would have an increased gambling on other types of gambling. however, online horse bettors appeared to have a lower degree of gambling problems if they were recent gamblers, such that the characteristics of this group of gamblers may have been different during the pandemic than in the months prior to that. in the current study carried out during the covid- pandemic, the rates of -day gambling in the present study can be compared to the findings of a previous study with the same methods for recruitment, carried out in (håkansson and widinghoff, ) . in that study, the gender distribution was virtually the same as here ( % men in the previous study), whereas in the present study, participants tended to be older; in the previous study, % were in the youngest age group ( % here), and and % were in the two oldest age groups ( and % here). in the present study, past- -day gambling was comparable to the previous study for online casino ( vs. % in the previous study) and online bingo ( % in both studies), whereas gambling types which were lower in the present study include land-based casino gambling ( vs. % in the previous study), land-based horse betting ( vs. %), live sports betting ( vs. % in the previous study) and non-live sports betting ( vs. % in the previous study), land-based electronic gambling machine gambling ( vs. % in the previous study), and online poker ( vs. % in the previous study). instead, past- -day gambling in the present study was higher for online horse betting ( vs. % in the previous study). while respondents in the present study tended to be older, the data still describe clearly that land-based gambling types were markedly lower this time, whereas the percentages for online casino and online bingo appeared to be unchanged during the covid- situation. thus, although movements between gambling types cannot be analyzed here, the present data confirm the hypothesis that during the pandemic, some gambling types are more likely maintained than others, in line with the reported changes to the gambling market during the pandemic, whereas other types are more likely affected. for example, a low reporting of land-based casino gambling was far from surprising, as the major official casinos were closed during the study period, although smaller restaurantbased casinos may still be operating in many places in the country. this is consistent with the description of a relatively substantial migration of gamblers from land-based gambling opportunities to online gambling during casino lockdown in ontario, canada (price, ) . the higher degree of gambling problems and indebtedness in past-month gamblers were consistent with the hypothesis that in times where gambling of some types is scarce, those who still engage in that gambling type differ from those who do not. in this context; in times when sports betting is scarce, those who still bet on the reduced amount of sports are likely to have more severe gambling problems. in a recent general population study, a minority of respondents reported that the reduced sports betting opportunities made them gamble on other sports events than they usually do (håkansson, ) . in the present study, land-based gambling options, such as casino and gaming machine gambling in the land-based modality, also displayed the same pattern. thus, even though this was a sample recruited for their online gambling patterns; those who did report recent gambling on the markedly reduced land-based gambling types, had more severe gambling problems. in covid- and potential future similar crises, preventive efforts and interventions should address individuals who maintain gambling behaviors which are abandoned by a majority due to physical and legal restrictions. sports betting was far from inexistent even during the weeks when the global restrictions from covid- were the largest, such as during confinement in many countries. here, it should be borne in mind that individuals were recruited based on their past-year gambling online on occasions or more, i.e., they are likely to be a high-risk sample with respect to online involvement and intense gambling patterns, as supported by a previous study using the same recruitment strategy (håkansson and widinghoff, ) . thus, the present study may capture a group with particularly pronounced involvement in gambling and low tendencies to give up gambling completely. also, it is clear that despite the nearly total lock-down of wellestablished sports world-wide, some sports events still did occur. for example, there have been reports of low-tier soccer games receiving disproportional attention on betting sites, which has been highlighted mainly in the context of fears of fraud (match-fixing). however, besides this type of amateurlevel sports events still happening (sbc news, ), some nations' soccer leagues, otherwise unseen in the global media, continued; the belarus soccer league, for example, received some attention as it remained available for legal sports betting (the guardian,, ). therefore, again, despite a very large decrease in sports-related gambling opportunities world-wide, individuals who stick to the few gambling options left on the market may be a group presenting particularly high risk of gambling problems. it has been discussed whether specific other gambling types would attract new users because of the covid- , with the fear that some gambling types would put ex-bettors into more addictive gambling because of turning to other than the preferred gambling type. in the present study, for most gambling types, the past- -day gamblers either did not differ from past-year gamblers, or had a higher degree of gambling problems, such as for sports betting (as discussed above), landbased electronic gambling machines, or land-based casino. it is difficult to know whether the enhanced gambling problems in these recent gamblers are due to a recent increase because of the pandemic, or simply because frequent gamblers are more likely to report recent gambling compared to a person who gambles only occasionally, and therefore likely with a lower degree of problems. interestingly, however, one specific gambling type demonstrates the opposite trend; online horse bettors had significantly less gambling problems if they reported past- -day use, compared to past-year users with no recent use of that type. although this was measured in a limited sample and can be subject to confounding factors unknown here, it can be hypothesized that this specific gambling type has attracted individuals during the pandemic who have less gambling problems and who typically do not engage in horse race betting, such as if a move had happened from other more pandemic-influenced gambling types to this one. the relatively high reporting of online horse betting (and higher than in our previous study from the same setting) is in line with media reports of a sharp increase in horse wagering during the crisis (financial times, ) , and with the previous reporting from the general population in sweden that the ratio of individuals increasing/decreasing their horse wagering was unsurprisingly higher than for sports betting which was largely canceled (håkansson, ) . in contrast to the association with gambling problems (and indebtedness), it is interesting to note that employment status, or living alone, were factors unrelated to the reporting of recent sports betting; thus, this study gives no support to the idea that living conditions or a labor situation affected by the crisis may change gambling patterns. however, this issue would require more research, including more detailed and in-depth analyses including longitudinal study designs, and likely would merit from a longer time frame to study than only the weeks of crisis preceding this study. the present sub-analysis, describing sports betting and other gambling behaviors in online gamblers during a unique change to the society and to the gambling market, may have implications in immediate association with the covid- crisis. for the remainder of the acute and sub-acute phases of the pandemic, those who bet even on a scarce betting market may be more likely to have gambling problems and should be particularly approached by responsible gambling strategies. likewise, both in the short and long run, the present findings call for more research following gamblers over time during and after the pandemic, and particularly interventions research testing methods to prevent excessive gambling in the context of this crisis. such interventions may involve legal constraints on gambling types perceived to be particularly hazardous, in particular rapid online games, such as the limitation of advertisements or deposit limits suggested by policy makers in some settings (reuters, ; sbc news, ) . the actual effect of such interventions remains to be studied. interventions may also involve an increased awareness in mental health care or social support settings, where hazardous gambling patterns can be screened for in times of a financial crisis. although the world has never seen a crisis similar to the present one, study implications may also be relevant to other crises of a magnitude affecting many parts of society, including the world of sports and gambling. also, again, it puts attention to the importance to address the role of gambling in sports; for example, previous research has shown that elite athletes (grall-bronnec et al., ) may have a higher risk of being problem gamblers. in the present study, problem gambling was more common in women. while this may be a surprising finding in relation to most previous research, where a majority of problem gamblers are male (tavares et al., ; díez et al., ; calado and griffiths, ; edgren et al., ) . however, in the present setting, female problem gambling may have increased in recent years (svensson and romild, ; bbc, ) , and the gender distribution of the whole sample and the sub-sample with moderate-risk or problem gambling is consistent with the previous study using the same methodology (håkansson and widinghoff, ) . the present study has limitations; it relies on self-report data collected through a market survey company, which may limit the preciseness of reported data. the present study had the intention to include online gamblers, i.e., individuals with a certain degree of online gambling behavior (ten or more occasions during the past-year), given the high prevalence of online gambling and in order to provide a new measure to compare to a previous online gambling study carried out in the present setting (håkansson and widinghoff, ) . therefore, the present findings cannot be readily generalizable to samples of typical land-based gamblers (but also was not intended to do so), and were studied in only one country (where online gambling is common in problem gamblers, håkansson et al., ) , and may not be generalizable to settings where online gamblers represent a smaller proportion of the overall population gamblers. while some key figures were comparable to the previous study in online gamblers in sweden, the study can only claim to be representative of web panel-recruited online gamblers, and not to represent the whole population of land-based gamblers as well. while lock-down decisions due to the covid- pandemic clearly affected other types of land-based gambling that gambling related to sports, the sample assessed here was included because of their pastyear online gambling, making conclusions more difficult to draw conclusions about populations who may have had only a landbased casino gambling, for example. likewise, data rely on self-report rather than on objective measures of actual gambling, which, however, would have been difficult given the large number of gambling operators available in the area. it is also not possible to establish, from the present data, whether an individual's recent gambling represents an initiation or an increase in gambling, or even an individual's typical pattern of irregular or rare gambling which happened to occur during the past days prior to taking the survey. related to this, another limitation is the cross-sectional study design, i.e., the lack of a possibility to follow each individual's changing gambling pattern over time. however, the present analyses aimed to assess the gambling patterns in online gambling during the most acute phases of the pandemic in the present setting, but future followup studies are planned using the same type of recruitment, and can provide new measures of how gambling behaviors may alter in post-acute phases of the pandemic. overall, the results of the present study call for new data collections in this and other geographical settings, and in different pandemic phases. despite these limitations, the present sub-study from a structured web survey dataset of online gamblers, is one of the first and one of the few studies reporting gambling involvement actually happening during the covid- crisis. in conclusion, the present study has implications of relevance to stakeholders in the gambling policy area and in preventive and treatment work in problem gambling. people reporting sports betting in times when the world of sports is dramatically altered due to the pandemic may be at higher risk of problem gambling than other sports bettors, and should be a group to address for prevention and intervention. online casino and bingo gambling appear to less affected by the covid- crisis, while land-based gambling in these online gamblers appeared to be more scarce, and online horse betting was the only gambling type more commonly reported than in a corresponding previous dataset. the present findings add to the knowledge about online gambling, and to the need to address online gambling as one of the potential health hazards in the aftermath of the covid- pandemic. the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher. the studies involving human participants were reviewed and approved by the swedish ethical review authority. the patients/participants provided their written informed consent to participate in this study. ah was the sole author of the present manuscript, and the responsible of the research idea, the planning and ethics application of the study, as well as statistical analyses and writing of the manuscript. the present study does not have any specific funding. however, the study could be carried out thanks to the researcher's overall funding from the swedish state-owed gambling operator svenska spel, from the swedish alcohol monopoly, from the swedish enforcement authority, from the swedish sports federation, and from the regional hospital system of southern sweden. sweden female gambling addicts outnumber men for first time problem gambling worldwide: an update and systematic review of empirical research the challenge of online gambling: the effect of legalization on the increase in online gambling addiction male and female pathological gamblers: bet in a different way and show different mental disorders problem gambling in greece: prevalence and risk factors during the financial crisis gender comparison of online and land-based gamblers from a nationally representative sample: does gambling online pose elevated risk? gamblers bet on marbles and trotting as pandemic hits sport gambling among european professional athletes. prevalence and associated factors changes in gambling behavior during the covid- pandemic -a web survey study in sweden gambling during the covid- crisis -a cause for concern? who seeks treatment when medicine opens the door to gambling disorder patients -psychiatric comorbidity and heavy predominance of online gambling over-indebtedness and problem gambling in a general population sample of online gamblers. front television gambling advertisements: extent and content of gambling advertisements with a focus on potential highrisk commercial messages multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science problematic online gaming and the covid- pandemic gambling in the mist of economic crisis: results from three national prevalence studies from iceland gambling disorder online gambling in the midst of covid- : a nexus of mental health concerns, substance use and financial stress sweden tightens coronavirus rules to ban gatherings of more than sweden to limit online betting during coronavirus outbreak spain order 'social shield' to fast track gambling advertising window increased addictive internet and substance use behavior during the covid- pandemic in china problem gambling features and gendered gambling domains amongst regular gamblers in a swedish population-based study gender differences in gambling progression last league standing: belarusian football basks in new-found popularity the canadian problem gambling index: final report. ottawa: canadian centre on substance abuse (ccsa) conflict of interest: ah holds a position as researcher at lund university which was sponsored by the swedish state-owned gambling operator svenska spel as part of that body's responsible gambling policies, and also had funding from the research council of svenska spel as well as the research council of the swedish alcohol monopoly and from the swedish sports federation. none of these organization have been involved in or had any influence on any part of the present work.copyright © håkansson. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- -sv ha authors: penley, benjamin; chen, hui-han; eckel, stephen f.; ozawa, sachiko title: characteristics of online pharmacies selling adderall date: - - journal: j am pharm assoc ( ) doi: . /j.japh. . . sha: doc_id: cord_uid: sv ha objectives: adderall (amphetamine-dextroamphetamine) is a controlled substance with harmful adverse effects if abused or misused. we assessed the availability of adderall from common search engines, and evaluated the safety and marketing characteristics of online pharmacies selling adderall. design: cross-sectional study. setting and participants: from december to february , the phrase “buy adderall online” was queried in four search engines: google (n = ), bing (n = ), yahoo (n = ) and duckduckgo (n = ). online pharmacies that claimed to sell adderall and had unique uniform resource locators, were active, free-access, and in english language were included. outcome measures: online pharmacies were categorized as rogue, unclassified, or legitimate on the basis of legitscript classifications. safety and marketing characteristics, and costs were collected. results: of the online pharmacies found to sell adderall, were rogue or unclassified. across all rogue and unclassified online pharmacies, prescriptions were not required ( %), pharmacist services were not offered ( %), and quantity limits were not placed on the number of adderall purchases ( %). rogue and unclassified online pharmacies appealed to cost, offering price discounts ( %), bulk discounts ( %), and coupon codes ( %). contrary to their claims, cheaper prices were available for all formulations and dosages of adderall from goodrx than from these online pharmacies. rogue and unclassified online pharmacies promoted and enabled the illicit purchase of adderall, appealing to privacy ( %), offering purchase through cryptocurrency ( %), and claiming registration or accreditation of their sites ( %). conclusion: rogue online pharmacies are pervasive in search engine results, enabling the illicit purchase of adderall without a prescription. consumers are at risk of purchasing adderall, a medication with high abuse potential, from unsafe sources. law enforcement, regulatory agencies, and search engines should work to further protect consumers from unregistered and illegitimate online pharmacies selling adderall. adderall (amphetamine/dextroamphetamine [shire u.s. inc]) is a central nervous system stimulant medication commonly used to treat attention deficit hyperactivity disorder (adhd). although effective in its treatment of adhd, adderall carries a high potential for abuse and dependencedits nonmedical use among college students for neurocognitive enhancement has been well documented, with a prevalence estimated from % to %. [ ] [ ] [ ] the overall nonmedical use of prescription stimulants has been estimated at approximately % in adults. inherent to the abuse of amphetamines are risks including weight loss, cardiovascular events, psychological dependence, and morphologic brain changes. [ ] [ ] [ ] [ ] [ ] [ ] owing to its high potential for abuse, which could lead to severe psychological or physical dependence, adderall is classified by the u.s. drug enforcement administration (dea) as a schedule ii medication. online pharmacies have emerged as a popular destination for the purchase of prescription drugs. although the overall volume varies on a daily basis, , - , online pharmacy websites were found to be accessible in . online pharmacies can be defined by whether they operate as legitimate and registered pharmacies or whether they are illegitimate and in violation of u.s. pharmacy laws and practice standards. according to legitscript, a verification and monitoring service, % of the accessible online pharmacies are illegitimate, of which % are rogue, meaning that they sell drugs without a valid prescription. given the high prevalence of rogue online pharmacies, the ease of access to medications with abuse potential is of particular concern. national organizations have been combating the proliferation of illegitimate online pharmacies. the besaferx campaign of the food and drug administration (fda) and the buy safe rx campaign of the alliance for safe online pharmacies (asop) empower consumers by raising awareness of the dangers of purchasing medications from illegitimate online pharmacies, as well as providing information on the warning signs that an online pharmacy might be operating illegally. , the national association of boards of pharmacy (nabp) lists accredited digital pharmacies on its website. nabp also offers a verification service for legitimate online pharmacies through which they can receive a ".pharmacy" domain, increasing consumers' visibility of legitimate pharmacies. legitscript allows consumers to enter a uniform resource locator (url) to determine a pharmacy's legitimacy. moreover, beyond raising public awareness, regulatory and legal actions are ongoing against illegitimate online pharmacies. operation pangea, a cooperative effort led by interpol in conjunction with fda and the u.s. department of justice (doj) has led to the removal of thousands of illegitimate online pharmacies. legitscript has also partnered with the fda to identify and close illegitimate online pharmacies. still, illegitimate online pharmacies remain challenging to control because there are innumerable urls under which they can operate. despite these organizational attempts, rogue online pharmacies remain pervasive and many consumers remain unaware of the associated dangers. in choosing rogue online pharmacies, consumers opt out of medication counseling, monitoring, and drug-drug interaction checking that pharmacists and health professionals offer. the use of such resources in health care has been shown to improve patient outcomes. concerns regarding insufficient safety measures are further exacerbated by the marketing methods that illegitimate online pharmacies use to attract consumers. , although it has been shown that patients using noprescription online pharmacies are at greater risk of developing treatment-related adverse events, there is a lack of current data on how rogue online pharmacies approach patient safety and what marketing methods they employ, particularly for medications with high abuse potential. the accessibility of adderall online is a public health hazard. [ ] [ ] [ ] we investigated the availability of adderall from online pharmacies through search results of common search engines and documented the websites' safety and marketing characteristics, as well as the costs of adderall. assess the availability of adderall from common search engines, and evaluate the safety and marketing characteristics of online pharmacies selling adderall. the website selection was conducted from december to february using different search engines (google, bing, yahoo, and duckduckgo) with the phrase "buy adderall online." these search engines were chosen on the basis of user traffic, and for duckduckgo specifically, its emphasis on user privacy. search algorithms on these websites already incorporated synonyms of the search terms. the first results of google and bing, and the first of yahoo and duck-duckgo were screened, incorporating more results from the more popular search engines. websites were included if they claimed to sell adderall, were active websites, were free to access, were in english language, and had a unique url. information for websites selling either adderall immediate release (ir) or adderall extended release (xr) were collected because these products contain the same active ingredient (amphetamine/dextroamphetamine). websites that required extra click to reach the website selling the product were also included. screenshots were taken of the website pages to ensure the internal validity of results. the legitimacy of the websites was assessed using legitscript, a verification and monitoring service that has monitored more than , online pharmacies. among other criteria, legit-script classifies pharmacies depending on licensure or registration in affiliated jurisdictions, sale of controlled substances, prior discipline, requirement of valid prescriptions, protection of privacy, patient services offered, transparency, and domain name registration. the websites in this analysis were classified as legitscript defines them: rogued"these merchants engage in background: the online pharmacy marketplace is saturated with illegitimate retailers that sell prescription medications without requiring a valid prescription. ▪ no-prescription access to adderall, a schedule ii medication with a high potential for abuse, poses a threat to public health. ▪ this article is the first to investigate the safety, marketing, and cost characteristics of online pharmacies selling adderall. adderall is readily accessible with no prescription through common search engines d of online pharmacies analyzed, permitted access to adderall without a prescription. ▪ for all formulations, doses, and quantities, adderall was on average more expensive from illegitimate online pharmacies than prices advertised on goodrx, suggesting additional costs to obtain adderall without a prescription. ▪ more efforts to monitor and remove illegitimate online pharmacies are required by law enforcement, regulatory agencies, and search engines. illegal, unsafe, or misleading activities like selling prescription drugs without a prescription;" legitimated"these merchants are registered with a legitscript certification program and have passed legitscript certification criteria;" or unclassifieddno information was available from legitscript. the average monthly traffic to website domains defined as unique visits from any country was obtained using www. similarweb.com. this website aggregates information on website traffic from a variety of sources, including open exchange of first-party data and survey of public data sources. the internet protocol (ip) addresses of websites were checked using www.ip location.com, which retrieves geographic information on the basis of ip addresses. the registered geographic locations of the ip addresses were compared with the listed website locations. characteristics related to safety were selected on the basis of previous literature and obtained from each included website. , , , , the characteristics were collected as binary variables: whether the website displayed or required such characteristics or not, and were examined across rogue, unclassified, and legitimate pharmacies. the characteristics of interest included ( ) requirement of a prescription; ( ) requirement of a health-related questionnaire; ( ) offer to speak with a pharmacist; ( ) drug-related warnings and precautions on the product page; ( ) drug information on the product page, including class of medication; ( ) controls on the amount of adderall that could be ordered (e.g., restricting patients to a -day supply); and ( ) country match between website location listed vis-a-vis ip address location. characteristics related to marketing were selected on the basis of previous literature. , , , , , the following marketing characteristics were gathered from each website: ( ) claims a "discount" compared with other pharmacies; ( ) offers bulk discounts; ( ) offers a "promo code" or coupon on checkout; ( ) facilitates purchases using cryptocurrency (e.g., bitcoin); ( ) has drug-specific advertisements pertaining to adderall; ( ) displays advertisements for other products on the page advertising the sale of adderall; ( ) has a phone number or whatsapp contact information listed; ( ) includes an offer to speak with an associate; ( ) claims pharmacy registration (e.g., professional compounding centers of america [pcca] or nabp digital pharmacy accreditation); ( ) includes customer testimonies; and ( ) offers privacy reassurances (e.g., discrete packaging or protection of health-or billing-related information). the price and shipping costs of mg adderall ir and adderall xr at the most frequently sold quantities of , , , , and tablets or capsules were collected. the price per tablet or capsule of adderall ir and adderall xr was calculated after accounting for shipping costs. the shipping costs were distributed among the total quantity of pills or capsules in an order. online pharmacy prices were compared with the prices offered through goodrx, an online prescription drug coupon site, which is what a u.s. consumer might expect to pay out-of-pocket without insurance at a brick-and-mortar store. through searching google, bing, yahoo, and duckduckgo with the query "buy adderall online," we identified a total of online pharmacies claiming to sell adderall ( figure ). of these online pharmacies, legitscript classified as rogue, whereas were unclassified (i.e., no information about these sites was available through legitscript), and only site was legitimate. traffic to these websites, as determined by www. similarweb.com, differed depending on the classification as outlined in figure . the traffic to rogue and unclassified websites was low, with most receiving fewer than unique monthly visits. the monthly traffic of the legitimate website was comparatively much larger at - million unique monthly visits. online pharmacies selling adderall the safety characteristics of all online pharmacies selling adderall are described in table . among rogue and unclassified pharmacies, prescriptions and health-related questionnaires were not required ( %), none offered pharmacist services ( %), and none placed a quantity limit on the number of adderall tablets or capsules that could be ordered ( %). rogue and unclassified pharmacies commonly offered some form of drug warnings and precautions ( %), and nearly uniformly provided some form of drug information ( %). the locations of rogue and unclassified online pharmacies were not listed on nearly half ( %) of their websites. overall, the locations listed on rogue and unclassified online pharmacy websites were not consistent with the locations of their servers as determined by www.iplocation.net ( %). server locations and the respective website-listed locations of online pharmacies in our sample are depicted in figure . the marketing characteristics of all online pharmacies selling adderall are described in table . rogue and unclassified online pharmacies often made cost arguments by claiming a price discount compared with other pharmacies ( %), providing bulk discounts ( %), and offering coupon or promotional codes ( %). other marketing characteristics included the use of advertisements in various forms: customer testimonies ( %); adderall-specific ads ( %); and ads for other products on the product page ( %). rogue and unclassified online pharmacies stressed their accessibility by offering a phone number or whatsapp contact information ( %), and nearly uniformly offered customers the opportunity to speak with an associate through a "contact us" page or chat feature ( %). privacy was stresseddrogue and unclassified online pharmacies provided privacy assurances on either patient information or "discreet package delivery" ( %). privacy was also offered by accepting cryptocurrency such as bitcoin ( %). rogue and unclassified online pharmacies often declared some form of registration or verification through varied accrediting bodies and agencies such as the pcca or nabp digital pharmacy accreditation, in turn suggesting product quality and safety ( %). for rogue and unclassified online pharmacies, the cost per tablet of mg adderall ir and cost per capsule of mg adderall xr at quantities of , , , , and tablets or capsules are displayed in figure . at all dosages and quantities, the prices for adderall ir and adderall xr online were higher than the price offered through the coupon site goodrx. the single legitimate website (www.humanapharmacy.com) required a prescription, offered pharmacist services, and placed a limit on the quantity of adderall that could be sold, as determined by the quantity written on the prescription. drug warnings and precautions, drug information, and the price for adderall could not be observed on this site because consumers were unable to advance without a member identification and prescription. the marketing characteristics of the legitimate website did not place an emphasis on price (there were no listed price or bulk discounts) but did promote accessibility with a the legitimate website offered privacy assurances and advertised its registration and accreditation with nabp, the utilization review accreditation commission, and the accreditation commission for health care. we found that most online pharmacies selling adderall were rogue or unclassified by legitscript. of online pharmacies claiming to sell adderall, only was a legitimate seller. by not requiring a prescription, rogue pharmacies allow the purchase of medications that could be abused, enabling the illadvised practice of adderall use without concurrent therapeutic monitoring. with high doses and repeated use of adderall, the development of psychological amphetamine dependence and adverse events such as weight loss, psychosis, seizures, and cardiovascular events can occur. , although data are sparse, morphologic brain changes and related behavioral alterationsdparticularly in adolescents with prolonged amphetamine usedare also a concern. - in addition, although we did not conduct an analysis on drug quality, it is documented that rogue online pharmacies frequently sell substandard and falsified medications. consumers with and without valid prescriptions face risks when purchasing from rogue online pharmacies. those with a valid prescription might receive poor quality medication and be harmed by impurities, fail to achieve therapeutic goals, and suffer from a lack of therapeutic monitoring. those without a valid prescription, who might be more inclined to abuse adderall and take more than the necessary dose, are predisposed to the same known risks as those with a prescription, in addition to the potential for an increased frequency of dose-dependent adverse effects. concerns related to the purchase of adderall from rogue online pharmacies are amplified by the marketing characteristics that these pharmacies employ. as evinced in these pharmacies not placing quantity limits on the amount of adderall for purchase, rogue online pharmacies intend to sell as much of these products as possible. the sale of adderall is achieved through varied sales argumentsdthe appeal to costsavings, constant customer support, and privacydthat are perhaps the most important for consumers who intend to purchase controlled substances without a prescription. rogue online pharmacies appeal to discrete package delivery, protection of patient information, and the use of de-identified forms of payments involving cryptocurrency. these sales arguments, which are designed to lure consumers into purchasing more medications, run counter to reasonable patient care and sensible legislation that aims to protect the public from drugs with abuse and misuse potential. previous studies comparing prescription drug prices between online and brick-and-mortar pharmacies have had mixed results depending primarily on the drug studied, with several finding lower costs online. , our investigation into the cost of mg adderall ir and adderall xr from rogue online pharmacies revealed that the marketing language detailing "affordability" was not necessarily true for the purchase of adderall without a prescription. compared with prices listed on goodrx, a popular coupon site for patients purchasing medications without insurance, rogue online pharmacy prices, including shipping costs for adderall ir and adderall xr, were nearly -fold more expensive per unit. the steep price differential is suggestive of the illegal nature of adderall purchase without a prescription online. simply from a cost standpoint, patients with a valid prescription have little incentive to purchase adderall from a rogue online pharmacy. this result supports existing literature that among online pharmacies there is a price markup for the purchase of medications online pharmacies selling adderall science and practice without a prescription. our results demonstrate that the noprescription price differential extends to brick-and-mortar pharmacies, which offer cheaper medications. organizations that offer registration and accreditation for online pharmacies, such as nabp's digital pharmacy accreditation and legitscript, enable consumers to confidently identify legitimate online pharmacies. our research showed, however, that rogue online pharmacies often inauthentically claimed registration. rogue online pharmacies are creative in their methods to bolster reputability. on their websites' "home" and "about us" pages, some claimed registration with nabp, pcca, or dea; some claimed to only sell u.s. food and drug administration (fda)-approved medications (e.g., " % fda approved"); some claimed that the world health organization recommends their site; and some had seal icons with phrases such as "verified seller." claims such as these might mislead consumers into feeling safe in their purchase of medications. although some of these claims are difficult to act on, accrediting agencies such as nabp and pcca should move to improve their online screening and surveillance to ( ) ensure that rogue online pharmacies are not falsely registered or accredited, and ( ) prevent rogue online pharmacies from misusing the accrediting organizations' logos and names. although nabp sets the standard in transparency with its list of accredited pharmacies and the promotion of ".pharmacy" domains for verified websites, the screening of individual online pharmacies is important because consumers might not be aware of nabp's running list of accredited pharmacies. although there have been numerous efforts to control the groundswell of rogue online pharmacies, our results suggest that these efforts have not been altogether successful. operation pangea, a cooperative effort led by interpol in conjunction with fda and doj, has led to the removal of thousands of illegitimate online pharmacies. fda regularly issues warning letters to online pharmacies engaged in illegal activity, and also operates the besaferx campaign, which is a public awareness effort that empowers consumers to recognize and use legitimate online pharmacies. , numerous nongovernmental efforts also exist to quell the use of illegal online pharmacies, including asop global foundation, which conducts research into illegal online pharmacies and informs consumers and policymakers of associated harms. the center for safe internet pharmacies is another nonprofit organization, founded by internet service providers and technology companies, with the goal to raise public awareness and, in partnering with legitscript, provide a platform for patients to verify their online pharmacy with the "verify before you buy" initiative. , beyond verification services, legitscript identifies and notifies registrars to close rogue online pharmacies. legitscript reported helping to close , rogue pharmacies in alone. however, illegitimate online pharmacies are challenging to control because they regularly re-emerge. although the overall web traffic to rogue online pharmacies in our results was relatively low (figure ), this could be suggestive of the methods that rogue online pharmacies use to avoid detection, regularly closing and opening new websites under unique urls. this is supported by our finding that the geographic country locations listed on rogue and unclassified online pharmacy websites were largely ( %) not consistent with the locations of their servers. these results demonstrate that search engines are not effectively screening for, and removing, rogue online pharmacies from their search results at present. in the absence of efficient methods to regulate and remove rogue online pharmacies, it is imperative that search engines acknowledge the pervasiveness of rogue online pharmacies within their search results and take additional measures of control. search engines should help lead the effort to create a safer online pharmacy landscape through the generation of search algorithms that select for legitimate online pharmacies. there were several limitations to our study. we limited our screening to websites owing to feasibility. given this limitation, numerous online pharmacies remained undetected. this limited screening yielded only legitimate pharmacy, precluding an in-depth analysis comparing the characteristics of rogue pharmacies with those of legitimate pharmacies. however, we believe that our methodology accurately replicates the behavior of a typical u.s. consumer who would only view the first few pages of search results. although we were able to assess how many unique visits each online pharmacy received from www.similarweb.com, it is not possible to determine how frequently adderall products were viewed or purchased on each website. we did not attempt to purchase adderall from any of the included online pharmacies. it is therefore unclear whether an order placed with an online pharmacy included in this sample would have resulted in the delivery of adderall. without purchasing the product, we also could not test the quality of the medication. however, we believe that the purchase of prescription drugs from rogue online pharmacies is in itself ethically tenuous. although we believe that our results are generally applicable to the online pharmacy landscape, given the transient nature of online pharmacies, our resultsdin terms of particular sites analyzeddare a slice in time, analyzing the sites listed on search engines in the united states from december to february . our study also failed to capture the prevalence of adderall advertising on social media platforms, which is an emerging market for the advertising and person-to-person sale of controlled substances. , still, we hold that common search engines remain a relevant and easy access point for consumers to find websites selling controlled substances. finally, data collection for our study was conducted before the novel coronavirus disease (covid- ) pandemic, which saw an increase in rogue online pharmacies peddling noprescription medications, particularly for treatment of covid- . our results remain relevant and even more important now because online consumption of goods and prescription medications is becoming commonplace, putting more consumers at risk as they purchase from rogue online pharmacies. adderall, a controlled substance with high potential for abuse, is readily accessible online without a prescription. while doing little to ensure patient safety, rogue online pharmacies treat patients as consumers with aggressive marketing tactics. in addition to concerted law enforcement and regulatory efforts to remove these websites, common search engines should make efforts to better select for legitimate online pharmacies, deterring the illegal purchase of adderall and improving the safety of consumers in the online pharmacy marketplace. in the meantime, organizations should continue to offer and support efforts to warn consumers of the dangers of illegitimate online pharmacies. prescription stimulant medication misuse: where are we and where do we go from here? misuse of stimulant medication among college students: a comprehensive review and meta-analysis trends in medical use, diversion, and nonmedical use of prescription medications among college students from to : connecting the dots nonmedical use and diversion of adhd stimulants among u.s. adults ages - : a national internet survey prescription stimulants in individuals with and without attention deficit hyperactivity disorder: misuse, cognitive impact, and adverse effects cardiovascular complications of acute amphetamine abuse: cross-sectional study potential adverse effects of amphetamine treatment on brain and behavior: a review misuse of prescription stimulants among college students: a review of the literature and implications for morphological and cognitive effects on brain functioning adolescent drug exposure: a review of evidence for the development of persistent changes in brain function prescription drugs: abuse and addiction us drug enforcement administration. drug scheduling center for safe internet pharmacies. legitscript: the internet pharmacy market in . available at digital danger: a review of the global public health, patient safety and cybersecurity threats posed by illicit online pharmacies alliance for safe online pharmacies. the alliance for safe online pharmacies is dedicated to combatting illegal online pharmacies and counterfeit medicines to make the internet safer for consumers worldwide united states food and drug administration national association of boards of pharmacy. digital pharmacy accreditation operation pangea -shining a light on pharmaceutical crime a detailed analysis of online pharmacy characteristics to inform safe usage by patients improving medication adherence and health care outcomes in a commercial population through a community pharmacy online pharmacies and the enhancement of peripheral thinking in consumers marketing and pricing strategies of online pharmacies health outcomes in patients using no-prescription online pharmacies to purchase prescription drugs uppers' keep going up nonmedical prescription psychiatric drug use and the darknet: a cryptomarket analysis search engines continue to advertise rogue online pharmacies legitscript international healthcare merchant standards legitscript merchant and website classification guide quality of online pharmacies and websites selling prescription drugs: a systematic review you've got m@il: fluoxetine coming soon!': accessibility and quality of a prescription drug sold on the web over-the-internet availability of hormonal contraceptives regardless of risk factors prescription drug price paradox: cost analysis of canadian online pharmacies versus us medicare beneficiaries for the top drugs united states food and drug administration keeping families safe when purchasing prescription online verify your online pharmacy before you buy legitscript helps shut down , rogue internet pharmacies in a machine learning approach for the detection and characterization of illicit drug dealers on instagram: model evaluation study solution to detect, classify, and report illicit online marketing and sales of controlled substances via twitter: using machine learning and web forensics to combat digital opioid access rogue online pharmacies in the time of pandemic: capitalizing on misinformation and fear we thank the directors and coordinators of the research and scholarship in pharmacy (rasp) pathway at unc eshelman school of pharmacy for their guidance and support. we also thank colleen higgins on the global health economics for pharmacy team for her contributions. key: cord- - v weno authors: sauter, marian; draschkow, dejan; mack, wolfgang title: building, hosting and recruiting: a brief introduction to running behavioral experiments online date: - - journal: brain sci doi: . /brainsci sha: doc_id: cord_uid: v weno researchers have ample reasons to take their experimental studies out of the lab and into the online wilderness. for some, it is out of necessity, due to an unforeseen laboratory closure or difficulties in recruiting on-site participants. others want to benefit from the large and diverse online population. however, the transition from in-lab to online data acquisition is not trivial and might seem overwhelming at first. to facilitate this transition, we present an overview of actively maintained solutions for the critical components of successful online data acquisition: creating, hosting and recruiting. our aim is to provide a brief introductory resource and discuss important considerations for researchers who are taking their first steps towards online experimentation. in midst of the covid- pandemic [ ], many researchers are bound to rethink lab-based behavioral experiments [ ] . there is an emerging need for online testing solutions (for a flowchart, see figure ) for day-to-day research activities, thesis work and experimental practical courses alike. even without a forced shutdown of physical labs, online experiments have gained popularity [ ] in the last decade [ ] [ ] [ ] [ ] [ ] . they offer great advantages in terms of participant diversity (in terms of age, gender, origin, culture and social status) [ , ] , time and resource efficiency [ ] . a big strength of online studies is that they scale very well, as recruiting larger samples does not require a higher workload and particularly hard-to-reach populations become more readily accessible (e.g., [ ] [ ] [ ] [ ] [ ] ; see also figure ). this can be especially useful for reaching clinical samples or for conducting experimental cross-cultural studies. this article is mainly aimed at cognitive psychology and behavioral neuroscience researchers who have none or limited prior experience in conducting behavioral experiments within an online ecosystem. our focus is on providing a conceptual overview of the critical components of online experimentation. we further summarize the most well-established tools for implementing these components and provide information about good starting points on the road to online studies. finally, we offer some considerations and rules of thumb for succeeding with online acquisition, mainly focusing on feasibility and data quality. the critical procedural pillars of any behavioral study are: ( ) programming an experiment in the preferred software (e.g., e-prime, psychopy, psychtoolbox, etc.); ( ) setting-up the testing machine (e.g., lab-computer, multi-unit testing facility, etc.) and ( ) recruiting participants to conduct the study. the process of bringing experiments online requires the same pipeline but can be more demanding in terms of harmonizing these steps to ensure that each part of the pipeline is compatible with the other parts ( figure ). for comprehensibility, we will outline each of these three steps in the next section. this will include a conceptual overview, but also specific examples of solutions (providers, software) which enable the corresponding step in the pipeline. the features and pricing are subject to change. for this reason, in this overview we discuss the main integrative possibilities, which we believe, will not change as quickly (for an up-to-date description of the detailed offerings, one should consult the respective websites). some of the described solutions are quite modular and specialized (table : b, c, d) in solving only individual steps of the process, whereas other providers offer a more holistic integrated-service ecosystem (table : a). in section . . we will discuss the considerations one should make when picking an ecosystem, but we will abstain for making strong recommendations and claims at this point. notably, we limited this overview to software that appears to be under active development to ensure steady security updates (with updates in ). brain sci. , , x for peer review of machine (e.g., lab-computer, multi-unit testing facility, etc.) and ( ) recruiting participants to conduct the study. the process of bringing experiments online requires the same pipeline but can be more demanding in terms of harmonizing these steps to ensure that each part of the pipeline is compatible with the other parts ( figure ). for comprehensibility, we will outline each of these three steps in the next section. this will include a conceptual overview, but also specific examples of solutions (providers, software) which enable the corresponding step in the pipeline. the features and pricing are subject to change. for this reason, in this overview we discuss the main integrative possibilities, which we believe, will not change as quickly (for an up-to-date description of the detailed offerings, one should consult the respective websites). some of the described solutions are quite modular and specialized (table : b, c, d) in solving only individual steps of the process, whereas other providers offer a more holistic integrated-service ecosystem (table : a). in section . . we will discuss the considerations one should make when picking an ecosystem, but we will abstain for making strong recommendations and claims at this point. notably, we limited this overview to software that appears to be under active development to ensure steady security updates (with updates in ). the compiled experimental files are then uploaded to an online host, which generates a link, making the study accessible online (potentially with the aid of a study management system). participants are recruited through recruitment platforms and access the online experiments on the host. the data is stored on the hosting server. equivalently to studies designed for in-lab testing, the first step in online experimentation is the programming of the experiment (table : b). in comparison to the hegemony of java, python, c++ and matlab libraries for experimental programming of lab-based studies, javascript (js) is the language of choice for online experiments. even though it is usually ranked as the most popular programming language in the world, js has not been a hallmark in behavioral testing. current solutions for online-experimental generation often provide a graphical user interface (gui), enabling users to drag-and-drop modular components into an experimental sequence. as this rather simplistic, general solution is sometimes insufficiently flexible for more complex experimental designs, a good experimental environment should provide the possibility to extend these modular components with scripts and code-based solutions. arguably, the easiest transition from in-lab to online testing is granted by psychopy builder [ ] [ ] [ ] [ ] and opensesame [ , ] . both environments are very popular for traditional testing and allow for a rather straight-forward restructuring towards their online counterparts (psychojs and osweb), if only their drag-and-drop modules were used to create experiments. all sections in which scripting was used (e.g., python inserts) will need to be rewritten into javascript by the experimenter. fortunately, python (especially its 'object-based' subset) and javascript generally only differ in terms of syntax and not programming logic [ ] , so the rewriting is comparably easy. additionally, psychopy auto-translates base-python to js (but not functions from specific libraries). there are the compiled experimental files are then uploaded to an online host, which generates a link, making the study accessible online (potentially with the aid of a study management system). participants are recruited through recruitment platforms and access the online experiments on the host. the data is stored on the hosting server. equivalently to studies designed for in-lab testing, the first step in online experimentation is the programming of the experiment (table : b). in comparison to the hegemony of java, python, c++ and matlab libraries for experimental programming of lab-based studies, javascript (js) is the language of choice for online experiments. even though it is usually ranked as the most popular programming language in the world, js has not been a hallmark in behavioral testing. current solutions for online-experimental generation often provide a graphical user interface (gui), enabling users to drag-and-drop modular components into an experimental sequence. as this rather simplistic, general solution is sometimes insufficiently flexible for more complex experimental designs, a good experimental environment should provide the possibility to extend these modular components with scripts and code-based solutions. arguably, the easiest transition from in-lab to online testing is granted by psychopy builder [ ] [ ] [ ] [ ] and opensesame [ , ] . both environments are very popular for traditional testing and allow for a rather straight-forward restructuring towards their online counterparts (psychojs and osweb), if only their drag-and-drop modules were used to create experiments. all sections in which scripting was used (e.g., python inserts) will need to be rewritten into javascript by the experimenter. fortunately, python (especially its 'object-based' subset) and javascript generally only differ in terms of syntax and not programming logic [ ] , so the rewriting is comparably easy. additionally, psychopy auto-translates base-python to js (but not functions from specific libraries). there are plenty other experiment builders available: gorilla [ ] , inquisit web [ ] , labvanced [ ] and testable [ ] , from the integrated-service providers (see table : a) and lab.js [ , ] , jspsych [ , ] , psytoolkit [ ] [ ] [ ] , tatool web [ ] from the function-specific solutions (see table : b). their advantages and shortcomings should be evaluated on a lab's basis depending on individual needs. generally, as all experiment builders (except for inquisit) operate on a javascript backend, they offer similar flexibility. they differ in available features (example tasks or modules), but as all builders have online documentations, often with demonstration tasks available, researchers can quickly see whether they fit their specific needs. we see the most difficulties in transferring experiments online for psychtoolbox [ ] users, as matlab ® 's compile-to-javascript approach offers no trivial translation of experiments to browser-based software [ ] . [ ] links can be shared to any platform or social media but extensive documentation is not available; [ ] no active participant pool; [ ] testable offers a mixed payment model; testable is also free for all departments in [ ] ; [ ] up to participants and one study; [ ] only available upon request. in lab-based studies, the final resting place of the finished experiment is the testing machine. for online studies, the experiment needs to be made available for online distribution by hosting it on a server (table : c). this is potentially the most confusing step in the pipeline of creating an online study. some labs with a lot of experience in online experimentation host their studies on their own servers. this comes with the advantages of low maintenance costs, full control and flexibility. on the downside, it requires some expertise for setup and continued maintenance. the more feasible alternative is centralized hosting providers. here, hosting and study management is a service, and as such, all providers require a fee. the general idea behind study management systems is to simplify the hosting and participant handling process, like user management, automated data storage or creation of unique participation links. the whole range of features offered by different providers can be evaluated by visiting their websites. for example, one of the easier but not especially flexible hosting services is offered by open lab [ ] . it takes all studies created with lab.js and tests some participants for free. their unique selling point is arguably its integration with open science framework (osf) [ ] . participant data are directly uploaded to osf, which could make it potentially interesting for multi-lab open science initiatives (it should be noted that there is neither a documentation, nor a privacy policy nor information about the responsible person or company publicly available.) another interesting example is pavlovia [ ]. you can upload html /javascript studies and there is documentation for importing studies created with lab.js, jspsych and the psychopy builder (psychojs). it offers easy integration with recruitment tools and a gitlab platform [ ] where experimenters can share their complete code. an example for more easily setting up one's own hosting platform is just another tool for online studies (jatos) [ , ] . jatos similarly takes html /javascript studies and documents how to import studies created via lab.js, jspsych and opensesame web. it offers a wide range of options and is a very comprehensive study management tool. finally, we want to highlight how important experiment-server compatibility is. in the examples above, we pointed out that a specific hosting service supports studies programmed by specific experimental builders. no host supports all experimental builds and no experimental build is compatible with all hosts. thus, a decision should always be made on the level of the overall ecosystem and not on the individual components of the pipeline (building vs. hosting vs. recruiting). the dominant advantage of running experimental studies online lies in its efficiency. it is feasible to collect responses from hundreds of participants within hours. thanks to the possibility of world-wide sampling, data collection can literally be completed over night. once the experiment is created and accessible online (usually with a link), participants can be recruited. due to higher participant numbers compared to most lab-based studies, handling this process manually is not advisable (for tools see table : d). orsee [ , ] and sona [ ] are participant pool management systems, which offer comprehensive automation tools. however, both require researchers to maintain their own (usually limited in size) participant pool. additionally, only a limited number of participants can be recruited from the local university, via social media and (institutional) mailing lists. maintaining an active pool of potential participants is the main advantage of amazon mechanical turk (mturk) [ ] [ ] [ ] , prolific academic [ , ] and qualtrics panel [ ] . all three providers offer participant recruitment and payment handling services. note that there is also cloudresearch [ ] , which is a recruitment service that uses the mturk platform, but unlike mturk itself, is specifically directed at researchers and offers better participant handling and targeting tools. as one essentially only needs a link to the study, they integrate well with the study management systems and experiment builders mentioned above (see table for details). while differences in their features are too narrow for the scope of this article, we will discuss some important points on data quality in section . generally speaking, what researchers need for online experimentation is the same as what they need for lab-based studies (figure ) : ( ) a programmed experiment, ( ) a server to host the study and ( ) a recruiting platform which advertises to participants. as outlined in the previous sections, there are many solutions for each of these steps. some solutions provide a single and holistic framework for all three aspects (table : a), whereas other solutions are specifically tailored to one of the aspects and need to be integrated into an ecosystem by the experimenter. here, the benefits and drawbacks mirror what we already know from software solutions in other domains. integrated-service providers enable time savings by reducing compatibility issues, providing customer support, and reducing administrative load. on the flip side, they sometimes lack transparency, lack flexibility (minimal compatibility with other solutions), and are generally expensive. non-profit and open-source solutions usually require more integration considerations and some of them lack direct customer support. instead, they provide forums and community feedback, low or no costs, and more peer-reviewed benchmarks. ideally, the decision on which online ecosystem to use, should be made in accordance to the lab's capabilities and needs as well as criteria of quality (see section ). as all platforms are javascript-based, they offer similar functionality and most experimental paradigms should theoretically be realizable on all platforms. in principal, a wide range of in-lab research questions can be targeted with online task implementations. the individual journey of a task from in-lab to online, however, can be quite different, as some tasks might need little adjustment, while others would require a major overhaul in order to provide informative results. general recommendations about which tasks are suitable for online testing and which platforms are best for the respective tasks are hard to make, as labs' use cases are too diverse. it will ultimately be a question of money, the labs' know-how and specific institutional infrastructure. of note, switching from other software packages to an integrated-service provider has often the drawback that previously programmed experiments cannot be run anymore and even slight adaptations to the experiments (for example control studies that reviewer asked for) are impossible without completely reprogramming the experiment. therefore, when deciding how to transfer experiments to the online world, researchers should not only consider what the provider offers, but also how they can adapt their research to the new environment. from an open science perspective, it should also be considered, that not all platforms allow experimental scripts to be exported. the authors personally had good experiences with osweb (for building) combined with jatos (for hosting) as well as psychopy (for building) with pavlovia (for hosting) [ ] and prolific (for recruitment). similarly, the authors would not recommend setting up experimental studies on self-maintained webservers without the aid of a study management system (e.g., jatos) because of the need to account for everything that can go wrong, such as handling data storage, assigning participant codes, assuring participants do not participate more than once, handling payment and so on. the dominant concern with running experiments online is data quality. while the most obvious concerns (e.g., motivation, distractions, stimulus timing) can be dealt with an appropriate design and incentive strategy, we would like to stress the importance of recording and analyzing dropouts [ ] . unlike laboratory studies, participants may drop out at rates of up to %. in a dropout analysis of local studies, zhou and fishbach [ ] found that % had a dropout rate of over %. alarmingly, the authors of the analyzed studies were unaware of these dropouts. they also found that out of published mturk studies, only six disclosed dropout rates. crucially, dropout rates can interact with the experimental condition [ , ] . to arrive at sound conclusions, it is therefore obligatory to report and analyze dropout rates. further, it is imaginable that stimulus presentation times or response times are unreliable because of variations in internet speed or display settings throughout the experiment. however, almost all online solutions operate by downloading (pre-buffering) the entire experiment onto the participant's machine. additionally, modern screen refresh rates are almost exclusively set to hz (de facto standard), making certain specifications of online studies a bit more predictable. among others [ ] [ ] [ ] , two recent large studies [ , ] investigated timing precision (unintended variability in stimulus presentation) of several online and offline solutions. the online-based comparison found good overall precision for gorilla ( ms), jspsych ( ms), psychojs (− ms) and lab.js ( ms). notably, these means are inflated by particularly bad performance using the safari browser and mac os x. the offline-based comparison, psychopy and opensesame achieved precisions of ms to ms, with only minor exceptions [ , ] , most notably with audio playback. a study investigating response timing, for example, found an additive timing offset of ms (similar across conditions) in online recordings compared to lab studies, while reproducing all expected task-based effects in various tasks (stroop, flanker, visual search, attentional blink) [ ] . in addition to timing, there could be concerns that participants might be less committed when they sit at home and are not directly observed by the experimenter. several studies have shown that decreased attention to the task is not necessarily found [ , ] and data quality is comparable to lab-based studies [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . for example, in a recent study, participants completed several attention checks (in between outcome measures) and there was no difference between lab participants and online participants in any of the measures. however, the study showed that online participants had higher self-reported distraction (use of cell phone, talking to another person, etc). in any case, experimenters should adjust their experiment to account for the sample diversity (see the following section) and participants' motivations [ ] . crump et al. [ ] recommend that the latter can be accomplished by giving accuracy as feedback following each trial; giving prompts to encourage speeded responding when participants do not meet deadlines; and by giving summary assessments of performance after blocks of trials. there are some aspects researchers should consider when starting out with running online studies or transferring lab-based experiments to online systems [ , , ] (see figure ). to a certain extent, creating successful online experiments is similar to app development: one needs to think of a coherent framework and constantly worry about what the users are doing with the 'product' and whether they are using it as intended-without many opportunities for direct feedback. experimental instructions should be easy enough to be understood by a more diverse sample that is not necessarily used to behavioral testing. further, measures need to be taken to detect and discourage poor performance, that is 'fake' participation. finally, online studies need to be shorter than classical lab-based studies. lab-based studies typically attract young psychology students who are weird (western, educated, and from industrialized, rich, and democratic countries) [ ] . the samples drawn from online recruitment platforms are more representative of the general (online) population [ , ] . study participants have potentially never participated in a behavioral response time experiment. for this reason, experimenters need to be more thorough when creating experimental instructions and ascertain that they can stand on their own without verbal explanations (note: this is also a good recommendation for lab-based studies). it is crucial that the instructions are comprehensible by people of a wider age range representing many cultures and socio-economic backgrounds [ ] . in the authors' experience, a pictorial step-by-step instruction leads to less misunderstandings or even dropouts compared to a single page of text. it is advisable that instructions are forced to stay on the screen for some time before continuation is allowed or an instruction check is added ( [ ] , experiment ). in order to check whether participants have truly understood the instructions, a test run and online evaluation before beginning the main experiment is advised. additionally, study management systems also incorporate some monitoring functions to check that participants stayed on track. for example, it is possible to monitor how often the browser tab running the experiment was minimized during the experiment and viewing distance can be controlled [ ] . notably, on some platforms, explicit measures need to be taken to prevent participants from completing a study twice [ ] . the interaction between experimenter and participant is comparably indirect in online experiments. therefore, participants might be less inclined to be attentive simply for the sake of helping the experimenter with their research. it should therefore be considered to state the relevance of the research explicitly. it was shown that mturk participants perform better, when the task is presented as meaningful [ ] . for many participants drawn from recruitment services, the dominant motivation for participation is monetary compensation. while the amount of payment should be similar to lab-based studies for ethical reasons, the data quality is not necessarily affected by higher monetary incentives. in a category learning experiment by crump et al. [ ] (see experiment ), participants were paid either $ . (low incentive group) or a base amount of $ and a bonus of up to $ . depending on their performance (high incentive group). they found that the incentive structure had no effect on learning or error rates. however, they found that they could collect data more quickly and had fewer dropouts when payment was higher. typically, participants are paid a fixed amount after successful completion of the study-regardless of how long it takes them to complete it. this is why some participants try to complete the experiment as fast as possible without sticking to the instructions ('fake' participation). in order to ensure good data quality, the experimenters might need to adapt the experimental design to discourage such behavior. this implies that the best experiments to run online include a validation mechanism. generally, forced-choice paradigms (both rt and accuracy types), in which one of the alternatives is the correct choice, are especially suitable because the experimenter can evaluate the participants' performance during runtime, while judgment studies (e.g., moral dilemma tasks) are harder to evaluate and objective performance or attention checks might need to be included into the design. in the authors experience, an easy option for alternative-forced-choice tasks is to repeat the trial each time participants answered incorrectly. the authors also experienced less dropouts when a progress bar (comparable to surveys) was added. gamification of the study in general promises to yield better results [ ] . the interaction between experimenter and participant is comparably indirect in online experiments. therefore, participants might be less inclined to be attentive simply for the sake of helping the experimenter with their research. it should therefore be considered to state the relevance of the research explicitly. it was shown that mturk participants perform better, when the task is presented as meaningful [ ] . for many participants drawn from recruitment services, the dominant motivation for participation is monetary compensation. while the amount of payment should be similar to lab-based studies for ethical reasons, the data quality is not necessarily affected by higher monetary incentives. in a category learning experiment by crump et al. [ ] (see experiment ), participants were paid either $ . (low incentive group) or a base amount of $ and a bonus of up to $ . depending on their performance (high incentive group). they found that the incentive structure had no effect on learning or error rates. however, they found that they could collect data finally, online experimental studies should be short. participants would possibly not sit min in front of their screen and produce quality data. since structured investigations are still missing, we asked germans through appinio [ ] at which time they would abort an online experiment that offered minimum wage. most respondents said 'after minutes' ( %), followed by 'after minutes' ( %), 'after minutes' ( %) and 'after min or never' ( %). keeping these considerations in mind, for a certain subset of investigations (certainly not all), carefully developed online studies have a huge potential. many of the noise factors can be combated with a large sample size and intelligent preparatory work. taking behavioral experiments online is facilitated by numerous steadily maintained tools ranging from simple libraries to complex ecosystems. researchers need to wisely choose the software based on their own prior experience, the lab's resources and the requirements of the general area of study. colleges and universities across the us are canceling in-person classes due to coronavirus-cnn introduction to behavioral research on the internet economic games on the internet: the effect of stakes quantifying the web browser ecosystem psychological experiments on the internet. section iii: computer techniques for internet experimentation the online laboratory: conducting experiments in a real labor market running behavioral operations experiments using amazon's mechanical turk evaluating online labor markets for experimental research: amazon.com's mechanical turk. political anal amazon's mechanical turk: a new source of inexpensive, yet high-quality, data? conducting behavioral research on amazon's mechanical turk a league of their own: demographics, motivations and patterns of use of , male adult non-medical anabolic steroid users in the united states should we trust web-based studies? a comparative analysis of six preconceptions about internet questionnaires the bbc internet study: general methodology does the shape of a cup influence coffee taste expectations? a cross-cultural, online study. food qual standards for internet-based experimenting builder-psychopy v experiments in behavior made easy psychopy-psychophysics software in python building experiments in psychopy opensesame: an open-source, graphical experiment builder for the social sciences comparing python to other languages gorilla in our midst: an online behavioral experiment builder labvanced-online experiments made easy lab.js: a free, open, online study builder a javascript library for creating behavioral experiments in a web browser psytoolkit: a software package for programming psychological experiments using linux a novel web-based method for running online questionnaires and reaction-time experiments what's new in psychtoolbox- . perception switching to online experiments for their projects. therefore, we decided to make testable available to all, waiving all our fees until the end of this academic year open science framework (osf) the first single application for the entire devops lifecycle-gitlab | gitlab just another tool for online studies" (jatos): an easy solution for setup and management of web servers supporting online studies another tool for online studies subject pool recruitment procedures: organizing experiments with orsee sona systems: cloud-based subject pool software for universities running experiments on amazon mechanical turk evaluating amazon's mechanical turk as a tool for experimental behavioral research prolific | online participant recruitment for surveys and market research prolific.ac-a subject pool for online experiments panel management software-recruit, target, & save money | 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comparison between web-based (psytoolkit) and lab-based (e-prime . ) measurements of response choice and response time in a complex psycholinguistic task types of motivation affect study selection, attention, and dropouts in online experiments lessons learned in adapting a lab-based measure of working memory capacity for the web tapped out or barely tapped? recommendations for how to harness the vast and largely unused potential of the mechanical turk participant pool most people are not weird controlling for participants' viewing distance in large-scale, psychophysical online experiments using a virtual chinrest nonnaïveté among amazon mechanical turk workers: consequences and solutions for behavioral researchers breaking monotony with meaning: motivation in crowdsourcing markets does gamification work?-a literature review of empirical studies on gamification appinio-marktforschung in minuten this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord- -jkscwdjh authors: adarkwah, michael agyemang title: “i’m not against online teaching, but what about us?”: ict in ghana post covid- date: - - journal: educ inf technol (dordr) doi: . /s - - -z sha: doc_id: cord_uid: jkscwdjh globally, information and communication technology (ict) is regarded as a dependable vehicle for facilitating educational reform and development, a platform for communication, and as a means to achieve the sustainable development goal four (sdg ). since the enactment of the no child left behind act (nclb) and declaration of the sdg , many countries have opted to embrace the lifelong education for all by integrating ict in teaching and learning at all school levels. the ghanaian government’s initiative to ensure “education anytime anywhere for everyone” by revolutionizing teaching and learning through ict has faced a lot of challenges and criticisms. the main mission of the ghana ict for accelerated development (ict ad) in was to transform ghana into an information and technology-driven high-income economy through education, but this goal is yet to be realized. in the wake of the covid- which has forced many countries and educational sectors to adopt online learning, there is a need to discuss the effectiveness of online learning and barriers to online learning in the developing contexts, and how to successfully integrate ict in schools for online learning, especially rural schools where students’ educational careers are in jeopardy because they benefit less from online learning. the paper identifies critical factors that affect online learning, recommends post covid- strategies to promote e-learning for policymakers in education and the government, and concludes with a conceptual model for emergency transition to e-learning. online learning is hailed as an essential force in democratizing education (jones ) . it is a way of opening education to populations who had restricted access because of geography, status or physical handicap (carr-chellman ) . khan ( ) defines it as an innovative method to instruct students in remote areas, which involves all types of learning that is done using the computer or other ict resources. since the term was first introduced in , it is used as an overlapping concept with blended learning, elearning, online courses, and online or distance education (singh and thurman ) . the advancement of ict has called for online learning as a feasible and economically appropriate means of extending quality higher education (asunka ) . the role of ict in education, specifically higher education, cannot be downplayed, it is beneficial for teachers and students (aljaraideh and bataineh ) . however, the challenge associated with online learning is the access to ict resources because online learning thrives on the availability of ict facilities (arthur-nyarko and kariuki, , b) . there is an uneven spread of access to ict among different populations, households, and spaces because network is not the same everywhere (lembani, gunter, breines, tapiwa, & dalu, ) . the significant role ict plays in the development of any nation has called for countries to produce ict literate citizens (crisolo, ) . ict has gained a solid reputation in the education systems of both developed and developing countries (law, pelgrum, & plomp, ) . ict in education can provide the twenty-firstcentury skills needed to adapt and compete in this knowledge and information society (haji, moluayonge, & park, ) . according to the authors, ict in education enhances student learning, provides education to students with no or limited access to education, aid in facilitating the training of teachers, and enhances the skilled workforce and promote social mobility. ict is also considered as essential for quality higher education (liebenberg, chetty, & prinsloo, ) . ict has the ability to enhance learning, make a subject appealing, facilitate problem-solving, communication, research skills, and decision-making process (hong, ) . waluyo ( ) adds that ict is a positive predictor of the academic achievement of students in mathematics, science, and reading. ict also facilitates teaching and e-learning, which ultimately have a positive effect on teaching, learning, and research activities. a general assumption is that for ghana to meet economic, social, and political global demands, ict should be prioritized. in light of this, the ministry of education of ghana introduced the "one laptop, one student" policy where , laptops were dispensed to schools (three schools in each region) across the country (education sector performance report, ). another , laptops were also purchased to be distributed to junior high schools (education sector performance report, ) . according to amanortsu, dzandu, & asabere ( ) , most of the government initiatives to ensure quality and accessible ict education for all in ghana has failed to achieve its goals. for example, agyemang & dadzie ( ) found in their study that a policy statement for supplying ict based-support for distance education (de) learners were available but were yet to be implemented. the integration of ict in teaching and learning is still at the early stage in the education systems of most developing countries (antwi, bansah, & franklin, ) . over a decade ago, ghana introduced de as a means to provide learners with access to quality education and promote human resource development (addah, kpebu, & kwapong, ) . one of the major challenges in the ghanaian education system is the inequality of educational resources which includes usage of computers and other ict materials (buabeng-andoh, ) . antwi et al. ( ) mentioned that the provision of ict in secondary schools for learning is skewed towards schools categorized as premier ("a") schools and located in urban areas. also, at the primary level, provision of ict is also skewed towards private schools (ayebi-arthur, aidoo, & wilson, ) . governments should fund ict projects that emphasizes on the needs, capacities, perspectives, and aspirations of the greater number of people living in rural areas (david, ) . the main objective of the study is to provide possible solutions for successful transitioning, implementation and sustenance of e-learning programs. the paper first identifies the e-learning challenges in the ghanaian context based on respondent's views and then provide strategies for smooth delivery of e-learning derived from extant literature the research questions leading this investigation are; what are the perceived effectiveness of the online learning, what are the perceived barriers to online learning and what are the perceived strategies for a successful ict integration in education for students who are unable to partake in e-learning process because of environmental and contextual factors related to ict in lieu of the covid- crisis. there are limited studies that thoroughly examines the effectiveness of and barriers to the online learning, and identify critical contextualized factors to enhance online learning in developing countries like ghana since the inception of the covid- . the government of ghana has invested several resources and initiated many promulgated policies to ensure ict is accessible to every student in ghana because of its pivotal role in education. the first governmental policy on ict was the ict for accelerated development (ict ad) in which outlined a framework that sought to transform ghana into an information and knowledge-driven ict literate nation (ministry of education, ) . this policy was reviewed twice (in and ) until a revised policy document was made available in . the main goal of the revised version was to facilitate the integration, utilization, and modernization of ict in schools in ghana. it was proposed that ict should be integrated as a core subject, an elective subject, and as a teaching tool for all other subject areas. the policy highlighted that ict access and literacy is low in ghana. one of the main goals of the educational reforms is to ensure that all students in ghana in the pre-tertiary institutions acquire basic ict literary skills (which also include the use of internet), and apply the skills in their studies and in their daily activities (mereku, yidana, hordzi, tete-mensah, & williams, ) . a survey of lecturers and students in accra polytechnic revealed that access to ict facilities was inadequate, time to access ict was inadequate, and there was little use of ict software (amanortsu, dzandu, & asabere, ) . another study in ghana found that % of the respondents teaching ict in the early years of school had knowledge about ict, and % of the teachers did not integrate ict in their teaching (asante, ) . boni ( ) in his study concluded that both teachers and students in ghana lacked the efficacy and creativity in using ict for teaching and learning. mubashir-ahmed ( ) attributes the the challenges associated with ict integration in ghanaian schools to lack of internet access, lack of quality teachers, insufficient number of computers, high cost of ict gadgets, and lack of electric power in some communities. another study in ghana revealed that access to electricity is a major factor affecting online learning in the country (arthur-nyarko and kariuki, , b) . despite the unprecedented efforts by successive governments to ensure ict is integrated in teaching and learning, the process have been fraught with a lot of challenges in ghana, especially in the rural areas. ghana ranked th among countries in the global ict development index in after being ranked rd in (international telecommunication union, ; international telecommunication union, ) . in lieu of the covid- crisis, the government of ghana announced the suspension of all school operations both pre-tertiary and tertiary on march , , as parts of the efforts to stop the spread of the virus (cromwell, ) . the closure of universities and schools have disrupted the learning of students and have deprived students opportunities for growth and development (unesco, ) . digital learning emerged as an ultimate response to the disruption in education due to the covid- lockdown of schools. since the lockdown, the government of ghana has considered the possibility of initiating online courses for students. instead of been proactive in ensuring rigorous implementation of online teaching and learning, the education system was stagnant until it was prompted by the covid- crisis. the minister of education, matthew opoku prempah announced that the center for national distance learning and open schooling (cndlos) has rolled out an online platform that will make core content accessible to all students in the senior high school (shs) level. he further declared that the ministry had plans in place to broadcast more contents to the junior high school (jhs) and upper primary students. however, the national union of ghana students (nugs) has petitioned the government to halt all online academic activities launched in the universities across the country (anyorigya, ) . the nugs referred to the online learning as "challenge-ridden online learning". the association cited inadequate bundle incentives for schools (lecturers and students), lack of properly laid framework for the implementation of online learning, and the plight of needy students who have been left out of the online learning platforms because of their inability to settle school bills. another concern raised by the nugs is the possibility of compulsory exams and assignments on e-learning platforms that will disadvantage students who are unable to participate in the online learning because of factors beyond their control. online learning in sub-saharan africa is a great challenge because it relies on the availability of ict facilities (asunka, ) . according to the unesco ( ), there is a gap between the availability of ict infrastructure and the capability of agrarian communities to integrate ict to boost the economy. also, the report mentioned that african universities and teacher education institutions do not have the adequate ability to help integrate ict in schools. with the limited access to ict resources and institutional challenges in its implementation in sub-saharan countries such as ghana, there is a need for the government and education sectors across the country to address contextual and environmental difficulties faced by needy and rural school students who are excluded from the e-learning platforms which are no fault of theirs. e-learning is beneficial (arthur-nyarko and kariuki, , b), but its effectiveness is contextualized (lembani, gunter, breines, tapiwa, & dalu, ) . students from developing countries score lower in online learning and are likely to withdraw from the online courses compared to their colleagues in developed countries (kizilcec & halawa, ) . in the us, a meta-analysis of existing data revealed that students engaged in online learning performed better than those in face-to-face sessions while students who blended online and traditional learning performed the best of all (the council of independent colleges, ). a student may be part of the online learning but may not actively use the service or follow the tutor (bean, et al., ) . barriers identified in literature include; high cost, inadequate infrastructure, lack of ict skills, rejection of e-learning by faculty members, and lack of accessibility to quality internet connection and electricity. start-up cost for online learning may be expensive (queiros & de villiers, ) . the high cost of purchasing ict equipment affect the adoption of online learning (sinha & bagarukayo, ) . technology and gadgets needed to make learning effective may not be cheap, affecting the online process negatively (srichanyachon, ) . limited funding can affect institutions from hosting online learning (bean, et al., ) . online education may cost more to develop and deliver than face-to-face courses (turk & cherney, ) . in tanzania, % of teachers declared they lacked access to computer, while % revealed they experienced low internet bandwidth (mtebe & raisamo, ) . teaching and learning can take place at anywhere and at anytime with the help of ict tools (cradler & bridgforth, ) . inadequate access to technology, studying materials and computers can leave students marginalized and anxious, which affect the online learning process (queiros & de villiers, ) . asunka ( ) , he concluded that only out of students had access to computer and internet connectivity at home. lack of technology skills and inadequate background experience with online learning are constraints to online education (olesova, yang, & richardson, ) . tutors ought to have required advanced technological skills which sometimes require schools to hire tutors from outside companies who already have the skills (bean, et al., ) . lack of experience with online teaching is a barrier to organizing online education (luongo, ) . students who do not have prior knowledge and experience in online learning sometimes also lack technical assistance and support systems (srichanyachon, ) . according to mtebe & raisamo ( ) , % of teachers engaged in online learning in tanzania lacked the skills needed to create or use online educational resources. most faculty members reject online learning as alien to them and are skeptical about it (bacow, bowen, guthrie, lack, & long, ) . some faculty members also consider developing online courses as time consuming in comparison to traditional methods of teaching (the council of independent colleges, ). hesitance by faculty members to teach online courses and their lack of acceptance of online instruction is a perceived barrier to online learning (turk & cherney, ) . slow and unreliable network connections affect the quality of online learning (bean, et al., ) . instructions can be delayed as a result of poor internet connections (srichanyachon, ) . in the study. limited internet access which includes poor internet connection and low speed demotivate institutions for pursuing online education (sinha & bagarukayo, ) . rural communities involved in online learning find it difficult to fund and attract qualified teachers to instruct advanced courses (de la varre, keane, & irvin, ). lack of internet access and computers in homes in rural areas affect the progress of online learning (depaul, ). lack of constant supply of electricity and internet access in rural communities also makes it difficult to assimilate the online education process (ivala, ) . in education, ict integration involves many interrelated factors such as curriculum, teacher characteristics, training and development, infrastructure, organisational factors like school leadership, school culture and supportive framework (judge, ) . ict integration concerns with the application of technology to aid student learn traditional academic subjects (grabe & grabe, ) . according to the authors, successful ict integration has transformed communities and shaped their lives and thoughts. in , the british columbia ministry of education announced the integration of ict in kindergarten to grade throughout the country to ensure that the education system remains important and actively engage students (birch & irvine, ) . successful integration of ict in schools still face myriads of obstacles (hew & brush, ) . integration of ict in developing countries is still a challenge (aksal & gazi, ) . one of the first steps to ensure successful ict integration is to consider the structural (availability of resources and classroom space, availability of ict support and maintenance) and cultural (mission and vision of the school for ict integration) elements of the school where ict is being integrated (tondeur, devos, van houtte, van braak, & valcke, ). bingimlas ( ) outline some necessary steps to ensure successful ict integration; provision of ict resources (both hardware and software), training new pedagogical approaches to faculty members resistance to change, provision of training courses on how to deal with new gadgets and modern technologies, providing sufficient time for daily lessons, and provision of continual reliable technological support. sarkar ( ) lists the critical elements for to be considered during the implementation of ict in learning; leadership issues, equitable distribution of ict resources and sustainability, and financial issues. the study adopted a qualitative method using a narrative inquiry approach to explore the perceptions of students on online learning in ghana and how to successfully integrate ict in education to improve online learning for students, especially those in urban poor and rural areas in ghana. in a qualitative study, a central phenomenon is the process, key concept or idea that is studied, and a researcher learns more from participants through exploration (creswell, ) . data was collected through interviews. a list of post-covid- strategies was formulated from extant literature based on respondents' views. the researcher used a semi-structured interview guide comprising of a list of prepared questions related to the research questions to conduct the interview. the instrument was prepared based on recurring themes in extant literature and was screened for accuracy and validity by a researcher in ghana. this allowed the researchers to ask open-ended questions to ensure respondents give their broad perspective about the topic of the study. interviews allow a researcher to probe and get an in-depth meaning of the feelings, perceptions and attitudes of participants (gaffas, ) . all tertiary students from urban poor and rural areas who took part in the online learning in ghana formed the target population. fifteen ( ) of the students were randomly selected to be part of the study. five ( ) students were taken each from the most cosmopolitan regions in ghana (greater accra, ashanti region, and central region) to make up the total sample of the study. the student came from the universities, teacher and nursing training schools in the country (table ) . students from the tertiary institutions in ghana who were taking part in the online learning in ghana were recruited to find answers to the research questions. an introductory letter was sent to the randomly selected students about the purpose of the study and to seek their consent to be part of the study. after the consent of the study respondents were gained, the researcher scheduled an appointment with each of the participants to conduct the interview. all interviews were conducted in english using the "whatsapp" application. the researcher transcribed the recorded interviews verbatim and the data was analyzed into themes and sub-themes using the nvivo . software. the interviews were replayed severally to ensure the accuracy of the transcription. the researcher used pseudonyms for each of the participants to ensure confidentiality. almost all the barriers associated with e-learning in literature reviewed earlier were prevalent in the ghanaian context (see table ). the findings of the interviews conducted suggest that the online learning in ghana is not effective enough and is also fraught with a lot of challenges. the section concludes with innovative and some novel solutions found in extant literature to the problems identified in the study and a conceptual framework for transitioning to e-learning. most of the students interviewed indicated that the online learning is the best alternative approach to teaching and learning during this pandemic. however, because of its spontaneous nature, and not an approach to education carefully thought of my school leaders and the government, they felt the online learning was not effective as they hoped for. social interaction an ample amount of the students felt the lack of student-student interaction and teacher-student interaction negatively affected the effectiveness of the course. "oh ok, personally, i think this online learning is not that effective. let me take campus for example, on campus you go for lectures, you meet the lecturer, you will have this interaction, like face-to-face, so that makes you really comprehend what the lecturer is putting across, and aside that you even have the teaching assistants who are willing to help you understand or if you have any difficulty they are able address that issue." [lucy-university] student outcomes only few of the students believed students' outcomes in the online learning would be better than the traditional approach. many believed that the difficulty with internet access and network challenges will result in a negative effect on the outcomes "the student outcome of online learning as compared to the traditional approach is very sad and heartbreaking. let me take the quiz for example, you will take a quiz online, and the system gets jammed, you've really learnt, not that you didn't learn, you've really learnt, and you go, and you're able to answer the questions, let me say if it is out of , you are able to get or correct, and then you get an f, it just saddens my heart" [ellen-university] communication some of the students were of the view that sometimes communication between teacher and students is not possible because the e-learning system can go off for a while before it starts functioning. "the intercommunication between lecturers and students is very poor. communication is not good. you will be having a class, and then the network starts misbehaving, meanwhile, the teacher is talking! how do you retrieve the words he has already said? what if the words he has said is the stepping stone to understand the next sentences?" [sandra-nursing training] traditional versus online approach more than half of the participants interviewed believed that the traditional approach to teaching and learning is more suitable for them as compared to the online learning they were experiencing. "ok, what i can say is my university, for example, am reading chinese and political science, so with chinese the lecturer is supposed to write down the characters on the whiteboard for us to really eerrm know the stroke orders. also, there are instances that you need you need to even, eerrm for chinese oral you need to listen to the lecturer, like look at the lecturer's mouth, the expression that she makes for you to be able to understand whatever she is saying. so i think i prefer the marker-board because taking my course, for example, it really helps, yes." [ellen-university] cost one of the major challenge mentioned by almost all of the participants was the financial commitments they have to make to ensure they actively take part of the course. according to the students, the online method of learning was expensive than the traditional approach to learning they experienced. "online learning is quite expensive. so far the has given us a data sim which gives us . gigabytes every month. but the problem is, this bundle is just something small. it doesn't get us anywhere. i remember my first zoom class was not more than minutes, and megabytes was already gone." [ted-university] online platform persistently, the students lamented about the breakdown of the online platform. "with the accessibility to the online platform, i think with that is okay. sometimes you log in, and the site just jams, so that really hurt and when you have quiz to take, and you log in and the system jams and just log you out of the system." [paul-university] study materials the students believed that study materials were readily available to download at any time. "oh okay, every course has its learning materials on the site provided they have not given us already" [ted-university] ict tools a considerable amount of the respondents asserted that ict tools were not given to them prior learning. every student had to get an ict tool for himself/herself to engage in the online mode of delivery. "we use our own ict tools, like phones and laptops. the school does not provide us with ict tools. if you don't have these ict tools, you have to share that of a friend." [joe-university] prior knowledge most of the participants had little exposure to online mode of learning prior to their current online method of learning. "mmmm as for background knowledge i don't have much experience but per our experience of sending messages through e-mail and using other platforms to send documents that is what helped us in using the online learning platform, since we couldn't have an orientation on how to engage in e-learning." [bright-teacher training] internet access accessing the internet was one of the major challenges students mentioned. "good internet access is a huge challenge. so most of the students we adopted that midnight is when we will log into the online learning site to download and upload materials. it is effective as compared to the normal day hours. however, this has affected our sleep" [paul-university] electricity there were mixed views on the availability of electricity for the online learning. some believed lack of electric power affected their learning while others were okay with it. "hmmm electricity is another impediment. recently our transformer got spoilt, and it took almost two weeks for the local government to fix it. meanwhile, tests and studies were ongoing." [mercy-university] education many students indicated orientation of teachers and students on ict for teaching and learning is integral for successful integration of online learning in schools. "for me, i think it is not only students who have to be educated on e-learning. my brother is not ict teacher and has no special skills in ict, but he is also supposed to use online learning platforms. he likes to use social media than to use the online platform for sending documents." [ted-university] provision of ict tools some students called for the provision of ict tools for schools and students who can't afford the tools for themselves. "the government should provide laptops to students in the middle or high school so that by that the time the student comes to the tertiary level, he or she has a laptop and can have access to many things online." [joe-university] motivation the students believed the motivation of both teachers and students would improve the online learning. "personally, i think the government should motivate teachers and students to engage in the e-learning. e-learning can be effective when there is motivation. the government can give allowances to teachers and reduce our school fees". [julius-university] "we students in the rural areas have no joy in this online learning. the challenges are too much. electricity and internet access are a major problem. if the government wants ict to be effective, all these problems should be solved." [prince-teacher training] school leadership students mentioned that school leaders should liaise with the government to improve the online learning. they believed school leaders could act as a channel for their voices to be heard. "school leaders like principals and vc have to eerrm, we have open forum where students bring their grievances on board, so as the src also take eerrm an active role in presenting the pleas and plights of students the school authorities, they also have to make the students' grievances known to the government so that the government can put the necessary measures in place to provide the tools that are needed to help the teachers and the students as well." [ellen-university] . post covid- strategies to promote e-learning providing electricity solar power gadgets and human-powered electricity have emerged as a promising solution to the increasing digital divide as a result of lack of electric supply (wyche & murphy, ) . the authors states that although solar photovoltaic-powered devices can charge mobile phones and some ict gadgets for e-learning, human-powered electricity are more preferable because human power is abundant worldwide. human-powered electricity is when human activities such as cranking (by hand) and pedalling (using the legs) are captured to turn a dynamo to generate electrical charges for electronic applications. in kenya, the researchers found the two models effective for providing micro-electricity for electronic devices. jimba & ogundele ( ) opined that solar power supply, biomass, standby power generators and wind power supply are promising solutions to generating electricity for virtual classrooms in nigeria. according to the authors, this makes teaching and learning effective without any disruption in power. hamajoda ( ) is of the same view that solar power supply and standby generators can facilitate e-learning by dealing with the challenges associated with electricity in rural areas. fostering acceptance of e-learning academics are often slow to embrace e-learning but are required to adapt positively to changes resulting from technology (flavell, harris, price, logan, & peterson, ) , and one of the best ways to foster adaptive learning of technology is to improve instructor and student self-efficacy (solangi, shahrani, & pandhiani, ) . flavell et al. ( ) state that one of the ideal ways to empower academics to be adaptive with e-learning is to engage them in recreational activities such as reading on technological devices for pleasure, playing games, or using social media. this makes users comfortable with the e-learning and also increases their self-efficacy. media literacy (such as the use of social media) can foster acceptance of e-learning and increase digital literacy (nowell, ) . collaborative e-learning also promotes exchange of experiences and ideas among students, encourage students to work together, develop their academic competence, increase their self-efficacy, develop their social skills and also fosters both their social and cognitive qualities for e-learning (ngai, lee, ng, & wu, ) . a wide range of e-teaching and e-learning methodologies can be introduced to encourage both teachers and students to embrace e-learning such as podcast and vodcast (uren & uren, ) . also, to ensure rapid acceptance of e-learning, a clear pedagogical rationale for online teaching which is rooted in instructor's personal philosophy for teaching and learning should be communicated to instructors (donnelly and o'rourke, ) . user-need analysis for adaptive e-learning adaptive e-learning has to do with the personalization of e-learning in accordance with individual user's knowledge and behavior, and one way to ensure that is through user-need analysis (agustini, ) . developers of e-learning platforms need to perform a user-need analysis; they have to take into account the learning styles of individual learners when creating, selecting, and evaluating e-learning platforms (muhammad, albejaidi, & akhtar, ) . according to the authors, user needs can be solicited by employing mix techniques including direct observation, expert review, administering web-based and paper questionnaires, and interviewing teachers and students. online learning should be planned to meet the learner's expectations (hachey & lachapelle, ) . alhabeeb & rowley ( ) adds that identifying both student and instructor characteristics for e-learning is a critical success factor for e-learning, "success" for one group does not necessarily connote "success" for another group. learners on e-learning platforms should be thought of as customers by making it easy to use, making effective use of learner's time, and it has to be attractive and comfortable (morrison, ) . leaner preferences and experiences are integral for a flexible mode of e-learning delivery (arthur-nyarko and kariuki, , b). teacher's presentations and course materials for e-learning should also be prepared based on students' needs and learning styles (osubor & chiemeke, ) . digital literacy of users the training of digital users is instrumental to ensure the successful transition and integration of e-learning platforms (muhammad, albejaidi, & akhtar, ) . training has been recognized as having a positive influence on the usage of e-learning systems (solangi, shahrani, & pandhiani, ) . training is a critical success factor for e-learning and should be provided for both learners and instructors (alhabeeb & rowley, ) . professional development training programs provide teachers with "hands-on" activities, it is essential for them to develop ict competence and technological pedagogical content knowledge for twenty-first-century learning (alt, ) . course facilitators should be trained on computer literacy and application for effective e-learning (jimba & ogundele, ) . one way to ensure digital literacy for students is to embed digital literacy skills in the curriculum (johnston, ) . school leaders can ensure students develop their own skills by supporting them during orientation activities on technology, peer learning, and encouraging them to use personal technology (sharpe & benfield, ) . workshops and training on ict for e-learning are crucial for users especially teachers, for a flexibility in online delivery (forsyth, pizzica, laxton, & mahony, ) . infrastructure support infrastructure and technical support that provides an opportunity for teachers and students to adopt e-learning should be made available (solangi, shahrani, & pandhiani, ) . availability of telecenters which are equipped with computers and internet connectivity in a poor rural community can help in the integration of ict in developing countries (avgerou, ) . research findings on ict in ghana revealed that institutions engaged in online learning need technology infrastructural support from the government, such as ict devices (arthur-nyarko and kariuki, , b). the "one student one laptop" policy by the ghanaian government failed to realize its goal and was an expensive investment. heeks ( heeks ( , argues that mobile devices can now be used to surf the internet and create new content, it could be used as an alternative for poor households in accessing the internet for learning purposes to defray the cost of expensive laptops, mobile technologies can be an alternative. school leaders can lassie with the government to also establish e-learning centers in the various tertiary institutions (piña, lowell, & harris, ) . the e-learning centers may be staffed with professionals such as technology specialists, media, administrators, and faculty support specialists who provide training support and training for effective engagement with e-learning tools. funding aside fees from students and government which are made available to schools, institutions which are new to online learning can establish e-learning centers and charge some type of fee (convenience fee) or online tuition rate (piña, lowell, & harris, ) . funds from the general student population and the government are often claimed by other areas. according to the authors, students who prefer the flexibility of taking online courses are willing to pay this extra fee. the institution can decide to access an online learning fee or a higher online tuition rate, which could serve as direct source of funds to e-learning centers on campus. it is near to impossible to reassign such funds to other areas. the institution receiving such funds would have the capacity to run e-platforms effectively. motivation incentives and reward systems can motivate teachers and students to engage smoothly in e-learning (o'doherty, et al., ) . when teachers are rewarded on the time spent instructing students on e-platforms, they are motivated to spend extra time and dedicate more efforts in instructing students. in a study conducted in russia, students decision to engage in online courses was due to available incentives (markova, glazkova, & zaborova, ) . incentives for teachers can be in the form of allowances and compensation. students can be provided with free wifi or subsidized cost of internet charge. this would encourage them to spend more time surfing for information on the internet, downloading course materials and uploading assignments. the government of ghana can work with internet service providers in the country such as mtn and vodaphone to provide internet access with high bandwidth to prevent them from withdrawing from e-platforms. supervision and evaluation an uninterrupted technical support is required from elearning users (teachers, students, and administrators) in addressing hardware and software problems associated with the computer application (muhammad, albejaidi, & akhtar, ) . rigorous supervision will help address glitches associated with eplatforms to ensure its continual functional. it personnel and e-platform administrators can be assigned to monitor the progress of the online learning to identify and solve all hardware and software challenges. academics involved in e-learning need assistance on shifting from the conventional mode of teaching and learning to a virtual teaching and learning environment (donnelly and o'rourke, ) . this assistance can be provided by "e-champions" and ict skilled personnel hired by the school. the authors mentioned that feedback of users on e-platforms are also essential for evaluating the success of e-learning, and this can inform school leaders on what to include in subsequent workshops for e-learning users. also, using data derived from users of eplatforms will help the administrators and designers of the e-platform on how to structure the platform to meet students' needs and the unique culture of the institution. blended learning picciano ( ) define blended learning as a combination of both online and face-to-face interaction. response from the participants suggests that a blended learning approach could help address the differences among students. picciano also mentioned that a blended learning approach could mitigate the challenge associated with geographical distance. students who are far away from their institutions and prefer an online mode of delivery can learn from home through their e-learning platforms while those who prefer the traditional face-to-face interaction can learn at the classroom. onguko ( ) believes that a blended mode of delivery is more ideal for universities who are not yet ready for only online learning. the author indicated that some universities in kenya incorporated a face-to-face session in their virtual classes to address some difficulties connected with online learning. the model serves as a framework for universities and academic institutions for an emergency transition to e-learning. this is adapted from texas tech university health science center el paso (ttuhsc ep) in their response to rapid transition to e-learning during the novel coronavirus pandemic (mulla et al., ) . quality e-learning programs require time and unprecedented efforts to ensure successful implementation. the model suggests that for successful implementation and sustenance of e-learning programs, school leaders must first inform faculty leaders about available resources and the best method to ensure the transition; a simulation course should be created, faculty staffs need to be trained and assisted, as well as soliciting their feedback and suggestions; the course can then be submitted; an e-learning compliance committee (elcc) should be set up for peer evaluation and for acquiring copyright permissions to keep the e-learning platform functioning (fig. ) . the paper adds value to prior literature on ict and online learning by first identifying the challenges associated with online learning in the developing context like ghana during the covid- pandemic. the study concluded by highlighting on some practical strategies for the adoption and usage of online learning in institutions in developing countries new to online learning. findings from the study suggest that the mulla et al. ( ) online learning in ghana is fraught with a lot of challenges apart from high cost and infrastructure (asunka, ; bean, et al., ; cradler & bridgforth, ; turk & cherney, ) . to address the problem of cost, school leaders are encouraged to establish e-learning centers which can generate funds solely for the purpose of online learning. also, the limited amount of electric supply for e-learning activities can be mitigated by using affordable solutions like solar power gadgets, biomass, and humanpowered electricity which are readily accessible in the country. again, school leaders are to employ recreational approaches like the use of social media and games to increase the self-efficacy of students for online learning. collaborative e-learning for teachers and recreational approaches are essential for fostering acceptance of e-learning by both faculty staffs and students. in addition, to effectively develop an e-platform tailored to the needs users, a user-need analysis has to be performed to know individual preferences and need. the university administration also has to set up professional training programs for teachers to improve their digital literacy. courses needed to improve students' it skills can be mounted during the first year at school or during the few weeks of orientation. moreover, because of geographical distance and individual learning styles and behavior, a blended mode of delivery is preferable such that students can choose either a face-to-face session or an online mode of delivery. it was also identified that the motivation of teachers and students is integral for smooth online learning. school leaders should motivate teachers and students in the form of incentives, allowances, free wifi and subsidized cost of data bundle. the school administrators can laisse together with the government to employ mobile technologies to replace the high cost of laptops. furthermore, because e-learning often experience hardware and software issues, school administrators should put in place a team of experts and technical resources for routine supervision and the evaluation of the elearning program. overall, findings of the study provide novel insights for educators and policymakers for the transition and usage of e-learning in the and post covid- pandemic. despite the significant investment of most low-income countries such as ghana in ict, challenges such as access to ict, reluctance by both teachers and students to use ict, network and electricity issues still persists in ghana. in lieu of the online learning activity taking place in most institutions in ghana, the study revisits how ict is fundamental to online learning and education in general. the principal objective of the study was identify possible solutions to some perceived barriers in e-learning and ict integration in ghana. findings from the study suggests that access to ict resources in ghanaian schools is still a challenge. as a result, students perceived the online learning is not effective. according to the students, although the online learning is a good initiative, they prefer the traditional approach as opposed to the online learning, which is fraught with a lot of challenges. the lack of social interactions, poor communication, and poor students' outcomes were associated with the perceived ineffectiveness of the e-learning. the students cited a lack of ict tools, internet, electricity as some of the barriers to online learning. most of the students interviewed did not have prior exposure to online learning or using ict tools to study. the students believed that orientation of both teachers and students on ict for online learning, motivation, and school leadership practices affect the integration of ict in education. the usage of solar power gadgets, the establishment of e-learning centers, acquiring funds from e-learning centers, adoption of blended learning, and providing infrastructural support such as using mobile technologies to replace the cost of procuring laptops are some of the listed strategies for educators to consider. ict plays an integral role in education and the economy of any country, help in resolving the barriers associated with online learning, and facilitates the successful integration of ict in education to enhance online learning. dessalegn & dagmawi ( ) opined that developed countries benefited from the integration of ict in education, unlike developing countries. the fact that higher education plays a vital role in the success of students and countries but there is limited access in africa, online learning can help bridge this gap (lembani, gunter, breines, & dalu, ) . it is therefore vital for stakeholders in education to integrate ict in education in ghana, and implement realistic and rigorous ict policies to ensure effective online learning where the needs of both urban, urban poor, and rural students are taken into consideration. the author recommend that future research examine the effectiveness, challenges of e-learning and ict integration in other contexts support their findings in literature with empirical evidence using a quantitative approach with a large sample. the sample of the study is very small, which makes it difficult for generalization. the study only focused on students' perspectives of the online learning in ghana without including the voices of teachers instructing students. also, the participants of the study were only from tertiary institutions in ghana without including pre-tertiary students who were also taking the part of the e-learning. promoting e-learning in distance education programs in an african country the adaptive elearning system design: student learning style trend analysis providing information communication technology support to distance education students: a case of the university of ghana examination on ict integration into special education schools for developing countries e-learning critical success factors: comparing 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education barriers of administrators and faculty at a u.s. university in lebanon ict-enhanced teacher standards for africa (ictetsa) covid- educational disruption and response eteaching and elearning to enhance learning for a diverse cohort in engineering education the effects of ict on achievement: criticizing the exclusion of ict from world bank's education sector strategy powering the cellphone revolution: findings from mobile phone charging trials in off-grid kenya publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements the author sincerely expresses his special thanks to professor yu zeyuan (southwest university, china), robert kyei (nsawam presby basic school), and edna agyemang (university of ghana). key: cord- -tv f authors: qazi, javaria; naseer, khulla; qazi, atika; alsalman, hussain; naseem, usman; yang, shuiqing; hardaker, glenn; gumaei, abdu title: evolution to online education around the globe during a sars-cov- coronavirus (covid- ) pandemic: do develop and underdeveloped cope alike? date: - - journal: child youth serv rev doi: . /j.childyouth. . sha: doc_id: cord_uid: tv f background educational institutes around the globe in this st century is facing challenges of sars-cov- coronavirus infectious disease. they are required to conduct online learning to avoid face to face contact in emergency scenarios such as covid- pandemic and continuing academic year while keeping social distancing. students need to adapt to new roles of learning through information technology to succeed in academics amid covid- . objective however, access to the impact of access & use of online learning resources, to what extent, these students are satisfied with online learning amid covid- particularly in handling new challenges are critical to explore. therefore, in this paper, we aimed to assess and compare the access & use of online learning of bruneians and pakistanis amid enforced lockdown imposed by the governments using a five-items satisfaction scale underlying existing literature. method for this, a cross-sectional study was done in the first half of june after the pandemic situation among students’ across pakistan and brunei and strata with a pre-defined questionnaire. data were analyzed with statistical software package spss . . results the finding showed that there is a relationship between students’ satisfaction and access & use of online learning. outcomes of the survey suggest that bruneian are more satisfied ( %) with the use of online learning amid lockdown as compared to pakistanis ( . %). living in the urban area as compared to a rural area is also a major factor contributing to satisfaction with the access and use of online learning for both bruneian and pakistanis. moreover, previous experience with the use of online learning is observed prevalent among bruneians (p=. ), while among friends and family is using online learning (p=. ) were encouraging factors contributed to satisfaction with the use of online learning among pakistanis amid covid- . correlation results suggest that access and use factors of online learning amid covid- were positively associated with satisfaction among both populations amid the covid- pandemic. however, bruneian is more satisfied with internet access (r=. , p<. ) and affordability of gadgets ((r=. , p<. ) as compare to pakistanis((r=. , p<. ) and (r=. , p<. ). conclusion: the study suggested that it is crucial for the government and other policymakers worldwide to address access and use of online learning resources of their populace amid pandemic. implications and future recommendation were discussed satisfied ( %) with the use of online learning amid lockdown as compared to pakistanis ( . %). living in the urban area as compared to a rural area is also a major factor contributing to satisfaction with the access and use of online learning for both bruneian and pakistanis. moreover, previous experience with the use of online learning is observed prevalent among bruneians (p=. ), while among friends and family is using online learning (p=. ) were the novel coronavirus disease first appeared in wuhan city of china at the end of last year and the world health organization (who) has declared it as 'pandemic' on march (who, ; pelmin, ). most of the governments around the world have initiated a common goal to curb the spread of this highly contagious disease by imposing lockdown, social/physical distancing, avoiding face-to-face teaching-learning, and restrictions on immigration (gonzalez et al. ). pakistan reported the first covid- case from karachi and currently, the country is facing a covid- spike. the government of pakistan has initiated many strategies to contain the viral transmission, and nationwide educational institutions have been shut down as the preliminary prevention step. this closure has led to an unprecedented impact on students, as the students and teachers are being urged to switch from conventional teaching to online learning sources [ , ] . covid- outbreak has led to a digital revolution in education via the use of online lectures, digital books, teleconferences, and virtual classrooms [ ] [ ] [ ] . however, online learning is primarily discriminatory against poor students, who cannot afford the necessary gadgets and devices for online education. in the underdeveloped and developing nations, many students cannot afford a reliable internet connection or the necessary gadgets needed for online connectivity and therefore are marginalized. the covid- lockdown has significantly hampered the teaching-learning process by the use of online modules. it is imperative to thoroughly understand the teaching-learning process, to take the necessary steps to smoothly run the two-way process [ ] . this study, therefore, aims to identify learning status, learning modules, and issues that are being faced by the students during the pandemic. the use of technology is important because it is often found to be positively correlated with satisfaction [ ] . to the best of our knowledge, this is the very first study in accessing the student satisfaction with the use of online learning resources amid covid- . we used wellestablished literature for the development of satisfaction scale and explored the students' satisfaction amid covid- with online learning. a cross-sectional study was done in the first half of june after the pandemic situation among students' across pakistan and brunei and strata with a pre-defined questionnaire. a structural questionnaire link using 'google form' was sent to students' through whatsapp and facebook groups. the informed consent was fully provided to participants before participation in the online survey. data were analyzed with statistical software package spss . . both ( ) descriptive statistics and inferential statistics were carried out to understand the distribution of study participants and the impact of preparedness on satisfaction with online learning during the covid- pandemic. the opinion on educational decisions and problems related to study due to the lockdown was also recorded and analyzed using a sentiment analysis approach. to assess which items predicted the outcome of satisfaction, logistic regression analyses were performed for students' demographics information. for this, univariate analysis and multivariant logistic regression analyses are used. the sample characteristic and satisfaction level amid covid- was explored by univariate analysis. further, multivariate logistic regression was performed to estimate the strengths of associations demonstrated by the odds ratio (or) with a % confidence interval (ci). spearman's correlation coefficient, r, was used [ ] to evaluate the association between preparedness and satisfaction with online learning resources amid covid- . the p-value p< . was considered statistically significant. the questionnaire is consistent with the following sections. introduction, demographics moreover, the participants responded to the -item of satisfaction with the use of online learning amid covid- . the measurement of satisfaction is commonly done through either an aggregate (single-item) or attribute (multi-item) level of measurement [ ] . the satisfaction items were developed under published literature from covid- pandemic, related literature on satisfaction, and some items are taken from a well-established student satisfaction scale [ , , , ] . using the online learning makes me feel satisfied, i'm satisfied with educational progression, i'm satisfied with the course content delivered by the teacher using online mode, i think i can complete the syllabus amid covid- pandemic, i feel the policy of online learning to avoid covid- is a good move, i like the way things are going for me. respondents were asked to rate ranging from (low) to (high). the demographic section of the survey included scores yes ( ) and no ( ) responses. all participants voluntarily gave consent for participation in the survey. since participants were kept anonymous, no formal ethical approval was needed. table shows how the satisfaction level of students was affected to varying degrees amid covid- . of the students, more than % of bruneians have low or moderate low satisfaction, whereas more than % of pakistanis showed signs of low satisfaction with online learning in lock-down amid covid- pandemic. the signs of moderate-high to high were more prevalent among bruneian ( . %& . %) as compared to pakistanis ( . % & . %). this result shows that people belonging to economically unstable nations are more unsatisfied with the leaning strategy amid covid- . this is because prolonged lockdown will ultimately lead to basic life needs being inaccessible. figure presents the demographic characteristics of the respondents. it can be seen that over % of the respondents were satisfied with the use of an online learning system amid covid- . when asked about the mode of online classes at lockdown the results were insignificant for both brunei and pakistan. figure below shows the percentage rations of gender, education level, and learning mode among bruneian and pakistanis students'. the association of satisfaction with the used to attending online learning system before the outbreak of covid- was significant among bruneian(p=. ) and pakistan (p=. ). likewise my friends and family are using online learning to avoid the spread of covid- is a sign associated with satisfaction among bruneians (p=. ) and pakistanis (p=. ) respectively. the mode of learning was insignificantly related to satisfaction for bruneian and pakistanis. in bruneian were more frequent as compared to pakistanis. outcomes suggest that use and access to online learning resources during novel infectious disease a sars-cov- coronavirus (covid- ) pandemic is crucial for student satisfaction. survey-based studies carried out earlier to assess the impact of lockdown due to covid- on education [ , , ] [ , ] . the study mainly aims to assess the effect of access & use of online learning resources amid the covid- lockdown on student satisfaction. outcomes suggest that level of easy access and use are linked with student satisfaction in both pakistan and brunei. student satisfaction is also linked to residence location, previous online learning experience, use of online learning resources by a friend or family. however, it is noted that there is no effect of gender and education level on the satisfaction of the student [ , ] . outcomes of the multivariate logistic regression suggest that students living in urban localities are more satisfied with online learning as compared to students of the rural areas for both nations. this is because urban localities have better access to reliable internet connectivity resources [ , ] . the previously experienced students are more satisfied with online learning modules for both brunei and pakistan. however, a comparison shows that satisfaction was higher among bruneian at ( . %) as compared to pakistanis ( . %). this is because bruneian students are used to practicing online learning more as compared to pakistanis. these outcomes are in line with previous studies which indicates that previously experienced online learners are more satisfied with the ongoing education system amid covid- lockdown [ , ] . another interesting aspect is the use of online learning mode by friends and family. the use of online learning tools by peers provides a motivation that increases satisfaction among students in both countries. however, comparative analysis shows that pakistanis ( . %) are more satisfied as compared to bruneians ( . %) [ ] . online learning apps such as zoom/youtube live/skype/google meet/ms team/ or other were found to be linked significantly with satisfaction for bruneian students, however, for pakistani students, these were insignificantly associated with satisfaction level. these outcomes show that bruneians are more adapted to the use of online learning apps as compared to pakistanis [ , ] . outcomes are consistent with the proposed hypothesis, which states that access and use of many studies have reported that closure of educational institutes due to the covid- lockdown will have a significant impact on the education that demands online learning [ ] . moreover, the privileged students who have better access to online learning can perform better that ultimately leads to their satisfaction [ , ] . data analysis clearly shows that bruneians are more satisfied with the use of the internet (r=. , p<. ) in comparison to pakistanis. besides affordability is also a prominent factor that contributes to satisfaction among bruneians. this is because bruneians belong to established economies while pakistanis face considerable economic constraints [ ] . moreover, for access and use, online learning is correlated for both bruneian and pakistani students'. the students which have better access to online learning tools, are well adapted to their use and therefore more satisfied with online education as compared to underprivileged students who don't have access to online learning tools. limitations of the study include facts that the situation is not clear whether the study outcomes can be generalized. this is since outcomes are limited to a handful of responses from both nations. therefore, a larger study involving more participants is needed to generalize the research findings. the study has, however, looked into substantial factors concerning access and use of online learning resources which impact students of developing and developed countries amid pandemic. however, other possible factors like lack of entertainment, cultural, and social services can also be evaluated in conjunction with satisfaction. however, students' satisfaction is affected during the lockdown in both regions due to bans on gathering, events, travel, shutting down the educational institutes disturbing routine life [ ] [ ] [ ] . in general terms, countries with a strong economy can better cope with the emergency and provide robust attention to less privileged areas that are necessary during public health emergencies. the covid- lockdown has made significant disruptions in academic activities globally. in this study, we aimed to assess the satisfaction status of pakistani and bruneian students with online learning during this pandemic. although a substantial proportion of students are using digital platforms for learning, many of them face a lack of satisfaction due to several challenges of access and use in online study. the outcomes of this study suggest the following recommendation to the government, policymakers, and institutional authorities. there should be made a uniform academic plan for the universities and colleges to continue the learning process during an emergency e.g. this pandemic. the infrastructural facilities should be availed to the education institutions which can regulate the digital learning process during future health emergencies. adequate funding needs to be ensured to improve the education system and provide training to stakeholders. a targeted intervention strategy is needed to develop positive study space for students belonging to the vulnerable section of society. in this critical public health crisis, open-source digital learning strategies should be adopted by teachers for conducting online classes. it is need of the hour to develop multiprolonged strategies to build resilient education system, which can ensure skill development for the productivity of the young minds. to increase socioeconomic status for access and use, students would be helped with scholarships because socioeconomic status is an effective variable predicting life satisfaction. since, emergence of covid- in late december , educational activities around the globe have been hampered significantly. most of the educational institutes globally have shifted from conventional education to online learning. in this study we aimed to assess the satisfaction of students with online learning along with parameters that affect satisfaction level. outcomes revealed that there is a relationship between students' satisfaction and access & use of online learning. it is concluded that bruneian are more satisfied with online learning as compared to pakistanis. living in urban area is also a major factor contributing to satisfaction. moreover, previous experience with use of online learning is prevalent among bruneians, use of online resources by friends and family is another factor contributing to satisfaction with online learning among pakistani students amid covid- . correlation analysis suggest access and use of online learning amid covid- were positively associated with satisfaction among both populations. however, bruneians are more satisfied with internet access and affordability of gadgets as compared to pakistanis. this 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editorial board the time of covid- and students'perception: a review economic diversification in brunei darussalam world health organization declares global emergency: a review of the novel coronavirus (covid- ) the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak covid- control in china during mass population movements at new year. the lancet the work is supported by researchers supporting project number (rsp- / ), king saud university, riyadh, saudi arabia. none key: cord- -clyhurjl authors: jumat, muhammad raihan; wong, peiyan; foo, ke xiang; lee, irene cheng jie; goh, suzanne pei lin; ganapathy, sashikumar; tan, thean yen; loh, alwin hwai liang; yeo, yen ching; chao, yinxia; cheng, lionel tim-ee; lai, siang hui; goh, sok hong; compton, scott; hwang, nian chih title: from trial to implementation, bringing team-based learning online—duke-nus medical school’s response to the covid- pandemic date: - - journal: med sci educ doi: . /s - - - sha: doc_id: cord_uid: clyhurjl nan in response to the increasing community spread of covid- in the first quarter of , the singapore healthcare system moved to prioritize pandemic management over other nonessential services. the delivery of medical school curriculum and learning processes, which heavily involves clinical faculty from various healthcare institutions, had to be reconfigured and reengineered as healthcare staff reassignment and infection containment practices are escalated. a few years earlier, in , duke-nus had implemented an elearning week, where face-to-face activities were conducted online in order to prepare for unforeseen disruptions to the curriculum. during the covid- pandemic, we first put these practices to use when enhanced social distancing restrictions were mandated across the country in february , and university guidelines required that all classes with or more students be moved online [ ] . as the pandemic escalated, singapore imposed increased movement restrictions in april and all educational institutions were instructed to move to full home-based learning [ ] . the transition to online learning may be smoother for a traditional lecture-based course, as educators can share prerecorded lectures, or even deliver live lectures through videoconferencing platforms. learning resources can be posted on their institution's learning management system for their students to access remotely. however, a growing trend in higher education is towards the use of "flipped classrooms", where the acquisition of information is done by the student prior to class, and the faculty use class time to reinforce the knowledge that students have acquired by providing opportunities for students to apply the knowledge through application exercises [ ] . a disruption in face-to-face teaching is challenging for duke-nus, for two reasons. first, the foundational science concepts covered in the first academic year are revisited and built upon later during the clinical years. disrupting the delivery of the foundational science content would have profound effects on subsequent parts of the curriculum. second, duke-nus employs a complex learning pedagogy which emphasizes peer-to-peer learning through faculty-facilitated, studentled discussions [ ] . known as teamlead (learn, engage, apply and develop), the primary mode of teaching for the first-year medical students at duke-nus is an adaptation of team-based learning (tbl). the processes of teamlead and tbl have been described elsewhere [ ] [ ] [ ] . in brief, the three defining features of teamlead and tbl are pre-class preparation, the readiness assurance tests (rats), and the team application exercises [ ] . in the teamlead and tbl class formats, students first take the readiness assurance tests individually (individual readiness assurance test (irat)), then as a team (group readiness assurance test (grat)). it is after completion of the grat that teamlead diverges from tbl. known as the modified teamlead readiness assurance process (mtrap), teams will now submit any unresolved queries to the whole class. the facilitator then assigns other teams to work on these queries, after which these queries are addressed in a faculty-facilitated, class-wide discussion. thus, at duke-nus, tbl represents a flipped classroom process that requires face-to-face interaction and is heavily dependent on student attendance and participation. here, we detail the experiences learnt from the elearning week in and the challenges faced in moving an entire module to online learning during the covid- outbreak in . in , a week of the body and disease module was delivered in an online format to the class of during elearning week. body and disease is the final module of the first-year medical curriculum, where students learn to integrate different knowledge tracks: microbiology, immunology, pharmacology, pathology and clinical investigations [ ] . the educational leadership designed an online tbl format de novo, adhering to the core principles of tbl [ ] . during the elearning week, students received hours' worth of video-recorded lectures as preassigned material. the online class session started in a similar manner to a face-to-face session, with students attempting the irat by logging into a test-taking platform, but from their homes. for the grat, the students logged onto a virtual chat room (chatzy.com) to carry out their discussions and keyed their answers into an in-house assessment tool that provided immediate feedback. the mtrap process was carried out using a shared google document (google llc, menlo park, ca, usa). students would post their questions on the shared document and the assigned team would submit their responses in the same shared document. a faculty member, a content expert on the topic, served as a facilitator. members of the education administration team provided logistical and technical support for the class. students did not use any videoconferencing platform for their discussions in . here, we present the impact of elearning on students' perception of tbl by analysing students' feedback from the elearning week, which occurred during academic week , and for the preceding week, academic week , which was carried out face-to-face. we analysed the students' ratings on whether elearning achieved the same desired tbl outcomes of developing verbal, written, collaboration skills as a face-to-face session. as a control, we analysed the standard evaluation feedback, which was administered after every session, from both academic weeks. lastly, we compared the standard evaluation feedback from the elearning week of ay / with a corresponding academic week from ay / within the body and disease module. the students from the ay / cohort felt that elearning mode of tbl was less effective in fostering their verbal, collaboration and leadership skills, compared with the face-toface mode in academic week ( table ) . a comparison of the feedback from those two academic weeks showed no difference in the perception on how elearning versus face-toface class sessions would affect their written skills (table ) . this is perhaps unsurprising, as only a chat room utility and a shared online document were used to conduct intra-and interteam communication during the elearning week. we then compared the students' standard evaluation feedback for the elearning week and academic week within ay / cohort. we found that moving the class sessions online did not significantly affect the students' perceptions of their learning experience (supplementary table ). the different study material assigned across the elearning week and academic week , however, may play a role in how the students perceived the class session. as such, we compared the standard evaluation feedback from the ay / cohort's elearning week with the ay / cohort's corresponding academic week (supplementary table ) , where students received a similar set of study material. no significant differences were found between each cohort's perceptions of their learning experience for this particular academic week. to ensure that the lack of difference in students' perception was not due to a cohort effect, we looked at the overall perceptions that students had for the face-to-face class sessions in the body and disease module. no significant differences were found between the cohorts of ay / and ay / either (supplementary table ). taken together, these findings suggested that the study material assigned during this academic week and cohort effect did not have an impact on the students' perceptions of tbl outcomes. given how moving the class online did not affect students' perceptions of their learning experience, this suggests that the elearning mode reached most of the same objectives as the face-to-face mode. students were overall receptive of this innovation. however, students felt that the online instructional mode adopted during the elearning week did not provide the opportunities to develop verbal communication skills, which they would have had in a face-to-face teamlead session. this perception was likely due to the communication during the class being limited to text-based exchanges, rather than other factors. these findings indicated to the educational leadership that a sustainable online version of this module would need to provide avenues to develop verbal communication skills. transitioning teamlead from face-to-face to online in when the national university of singapore mandated that all classes be moved online in february , the educational leadership deployed the infrastructure for online learning that was in-place after the elearning experience. while the elearning experience was a week-long, in all classes were moved online indefinitely. to ensure successful implementation and continuity of tbl online, constant feedback was sought from students, faculty and the administrators through student feedback surveys and regular faculty debriefs. keeping in mind that students preferred to have verbal communication during online classes, in , students were instructed to log on to a video-conferencing software for the entirety of the teamlead session (zoom.us, san jose, ca, usa). this proved to be a useful medium to dispense instructions to the class and for facilitated discussions during mtrap. students chose their preferred platform for communicating with their teammates during grat. this may be an alternate video-conferencing program or instant messaging platforms on their mobile phone. although the breakout room function in zoom has proven useful for online tbl [ ] , we found manually assigning students into teams to be cumbersome. additionally, using a separate communication platform allowed teams to be connected even during classwide discussions. this helped us to recreate the "side-discussions" amongst teammates that were frequently seen in class. similar to the elearning experience in , students used a university-sanctioned, password-protected, shared online document to submit their queries during the mtrap. teams assigned to answer those questions responded on the same document. to enhance communication, the assigned teams are instructed to present their answers through the videoconferencing tool. after which, the facilitators gave the class time for an open discussion. students could take this time to interact with the faculty through video. this provision was crucial as, according to the social cognitive theory, individual consciousness can only be formed through communicative interactions [ ] . in online tbl, the role of the facilitator took on a different form from face-to-face tbl [ ] [ ] [ ] . in brief, the facilitator ensured that all the participants were muted throughout the session and that only one person speaks at any one time. students were allowed to key question into the text-chat function of the video-conferencing platform. the facilitator had to be cognizant of these different prompts and channel them accordingly. the facilitator's ability to manage the participants and all the key processes in a time-sensitive manner was key in creating a conducive online learning environment. the backbone of the online classes is the administrative team from the office of education at duke-nus that helms the logistical demands of tbl. this team of administrators was pivotal in the transition and ensuring the continuity of the curriculum during the pandemic. prior to the classes, the administrative team was responsible for maintaining the online learning resources and granting access for all participants. they were also responsible for conducting training sessions the tbl reaction outcomes for the elearning week, which occurred during academic week of the body and disease module, and for the preceding week that had face-to-face classes, during academic week were compared. students from the ay / cohort felt that the elearning mode of instruction did not facilitate their development in the following tbl outcomes: verbal communication, collaboration and leadership skills n = for the elearning week, and n = for the face-to-face week in the cohort of ay / data is presented as mean (standard deviation). all comparisons were analysed using wilcoxon rank sums tests *evaluation items are scored on the following likert scale: = strongly disagree; = disagree; = neutral; = agree; = strongly agree for students and faculty on how to use the various online platforms and helping users to resolve technological problems in real time [ ] . for example, they worked with hospitalbased faculty to overcome the poor wi-fi access in their institutions. three to administrators would attend each class session to provide technical support. this included monitoring the attendance of all participants, cueing students on when to begin each phase of the assessment and communicating the scores and item analysis of the rats to the faculty. in addition, the administrative team was also responsible for troubleshooting any technological issues. they did so by remaining contactable via multiple communication modes during the class, through email, instant messaging or phone calls. examples of contingencies that they had in place include sending soft copies of the resources through email and giving instructions or acting as a conduit for student-faculty discussions through the phone. the greatest strength of this online tbl is the ability to provide an effective alternative tbl format to ensure continuity of learning amidst a global pandemic. students were still able to engage in an interactive intellectual discourse with peers and faculty [ ] . additionally, in our online iteration of the mtrap session, we used a combination of text and video. the real-time shared online document created a dynamic mtrap session, due to the ability to edit and comment on responses during the discussion. this encouraged students to remain engaged throughout the discussion. having the mtrap hosted on a shared online document is an improvement from face-to-face sessions, as the information is now stored electronically for the entirety of the module, instead of being written on a whiteboard and erased at the end of the session. having an electronic record available for an extended period also allows faculty to insert their comments retrospectively. this feature was important as clinical faculty, faced with increasing clinical demand during the pandemic, were not always available during the virtual class time. the combined use of a shared online document and a video-conferencing platform for the facilitated class discussion during the mtrap is a unique feature of our iteration of online tbl. based on the cognitive theory of multimedia learning, the simultaneous use of text and video enhances the learning experience. this theory posits that the brain interprets data from multimedia sources in an organized and dynamic manner, resulting in the production of logical mental constructs [ ] . with this, we provided students with a dynamic and interactive learning environment [ ] . difficulty in getting access to a reliable internet network or internet-enabled devices posed a major obstacle for all participants. perhaps to ensure that students can carry out online learning, the school should consider supporting their access to devices that would allow for the various processes of online learning. for the clinical faculty, they are in locations where internet separation was practised. due to the singapore health services being breached by a series of cyber-attacks in [ ] , all workstations in hospitals were disconnected from the internet. to overcome this obstacle, faculty participating from the hospitals did so from their personal devices. technological literacy ability of participants was another challenge that had to be overcome. some participants were unfamiliar with the video-conferencing platform or unsure about how to access the online documents. we overcame this through the efforts of the administrative team who provided pre-and in-class technological support. the strong dependence on the administrative team also presents as a weakness with our iteration of online tbl. without dedicated staff to manage the learning process, the faculty would face an uphill task in teaching and running the logistics of the course. institutions interested in implementing online tbl should train an administrative team to ensure the smooth running of the course or ensure that there is a co-host available to help with the administrative demands of the class. this format of online learning may suit the teaching of theoretical knowledge well but may not be ideal for the teaching of practical skills, which is an important component of medical education. faculty have also expressed concern about the inability to assess professionalism through online learning. avenues to teach practical skills and assess professionalism online need to be developed to overcome these obstacles. the potential for online tbl is far-reaching. while initially deployed to facilitate remote learning in a pandemic, this mode of learning can connect students with faculty who are not in the same geographical locality. this will be highly useful in teaching niche subjects where few experts are available. there is also an opportunity to develop a single online platform that can house all the different features of online tbl. currently, students switch between multiple platforms for each phase of the lesson. an all-encompassing video-conferencing software which contains features that allow the administration of the irat/grat, mtrap and discussion processes will be ideal. such features should include the ability to administer tests securely and store shared files. being able to carry out online tbl will give the institution the capability to conduct remote learning tbl courses. these can be credit-bearing courses which are open for any student regardless of location. most major universities offer online courses, but these courses are predominantly lecture-based modules with limited collaborative learning capacity. having this option will increase the repertoire of courses that reaches the unique learning objectives reached by tbl and appeal to the segment of learners who prefer tbl to traditional learning. while preliminary observations (table and supplementary tables and ) suggest that learning can occur through this modified online tbl format, it is unclear whether this mode of learning is sustainable and/or achieves the same the educational objectives as face-to-face modules. taking the tests online and unsupervised presents a tangible threat to the learning process. students with integrity issues might not adhere to the university's honor code. testing higher-order thinking skills and developing secure exam-taking software may mitigate this shortcoming. a worrying trend observed with the increased use of videoconferencing is hacking. incidences of "zoom bombing" have been reported by multiple institutions globally, where hackers gained access and interrupted ongoing online classes [ ] . if this trend escalates, confidential data might be compromised. in response to these intrusions, the university had suggested several guidelines to increase the security during video-conferencing sessions [ ] . video-conferencing software providers must maintain vigilance and continuously work to enhance security in order to prevent unauthorized interruptions. the data collected from the elearning experience was instrumental in our response to the covid- pandemic in . the concerns raised by the students in guided the leadership in modifying the online format for the rollout. in , we found that we were able to reproduce the face-to-face tbl conditions online by utilizing the videoconferencing tool judiciously. furthermore, students in generally appreciated the online tbl format of learning and found it easy to communicate with their peers. given our observations, further studies comparing the impact of online and face-to-face tbl classes on student's academic performance will need to be carried out. these studies would also need to ascertain if taking an online course for a prolonged period has an effect on student's well-being and mental health. overall, the preparedness of the educational leadership and the dynamic work ethic of the administrative team allowed for the successful deployment of online tbl. coronavirus outbreak: singapore raises dorscon level to orange; schools to suspend inter-school, external activities covid- : singapore makes 'decisive move' to close most workplaces and impose full home-based learning for schools, says pm lee motivation and cognitive load in the flipped classroom: definition, rationale and a call for research. higher education research & development ten steps to complex learning: a new approach to instruction and instructional design the essential elements of team-based learning team-based learning: a practical guide: amee guide no. implementation of team-based learning on a large scale: three factors to keep in mind* perspective: guidelines for reporting team-based learning activities in the medical and health sciences education literature body and disease : an integrated course teaching pathology, pharmacology, immunology and microbiology online team-based learning sessions as interactive methodologies during the pandemic social foundations of thought and action: a social cognitive theory essential skills for a medical teacher: an introduction to teaching and learning in medicine twelve tips for facilitating team-based learning redesigning team-based learning facilitation for an online platform to deliver preclinical curriculum: a response to the covid- pandemic cooperative learning, collaborative learning, and interaction: three communicative strands in the language classroom multimedia learning: are we asking the right questions? st century learning in medicine: traditional teaching versus team-based learning singapore health system hit by 'most serious breach of personal data' in cyberattack; pm lee's data targeted janowski d advisors beware of zoom bombing clarifications on the use of zoom and best practices for securing zoom meetings | it security publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements the authors gratefully acknowledge the administrative support of ms. jean huijuan xie. the authors would also like to thank the rest of the members of the education administrative team (ms. alia binte dhahfier, ms. avery soo yee ng, mr. francis kim huat law, mr. andy guanghui toh, mr. siang wee lim, and ms. chew ting puah) for their efforts in transitioning and maintaining the medical curriculum online during the covid- pandemic. conflict of interest the authors declare that they have no competing interests.ethical approval the data collected for the analysis of the elearning experience was approved by national university of singapore institutional review board.informed consent all subjects of the panel survey gave consent for anonymized data to be used for publication purposes. key: cord- - uiaruhg authors: balmford, ben; annan, james d.; hargreaves, julia c.; altoè, marina; bateman, ian j. title: cross-country comparisons of covid- : policy, politics and the price of life date: - - journal: environ resour econ (dordr) doi: . /s - - - sha: doc_id: cord_uid: uiaruhg coronavirus has claimed the lives of over half a million people world-wide and this death toll continues to rise rapidly each day. in the absence of a vaccine, non-clinical preventative measures have been implemented as the principal means of limiting deaths. however, these measures have caused unprecedented disruption to daily lives and economic activity. given this developing crisis, the potential for a second wave of infections and the near certainty of future pandemics, lessons need to be rapidly gleaned from the available data. we address the challenges of cross-country comparisons by allowing for differences in reporting and variation in underlying socio-economic conditions between countries. our analyses show that, to date, differences in policy interventions have out-weighed socio-economic variation in explaining the range of death rates observed in the data. our epidemiological models show that across countries a further week long delay in imposing lockdown would likely have cost more than half a million lives. furthermore, those countries which acted more promptly saved substantially more lives than those that delayed. linking decisions over the timing of lockdown and consequent deaths to economic data, we reveal the costs that national governments were implicitly prepared to pay to protect their citizens as reflected in the economic activity foregone to save lives. these ‘price of life’ estimates vary enormously between countries, ranging from as low as around $ , (e.g. the uk, us and italy) to in excess of $ million (e.g. denmark, germany, new zealand and korea). the lowest estimates are further reduced once we correct for under-reporting of covid- deaths. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. sars-cov- , the virus which causes the covid- disease, is a zoonotic pathogen which emerged in wuhan in late (huang et al. ) . at the time of writing, in early july , it had already claimed the lives of over half a million people globally (beltekian et al. ). in the usa covid- deaths now exceed the number of us military deaths arising from all conflict since the second world war (statista ) while in the uk the four weeks to th april saw more londoners lose their lives to covid- than during the deadliest four week period of the blitz (morris and barnes ) . this death toll is only the extremely saddening tip of the much larger iceberg of disruption that covid- has caused and continues to cause. confirmed cases across the world now exceed eleven million (beltekian et al. ) and the true infection rate is likely far higher. each case imposes a real cost on every infected individual. while symptoms may sound innocuous, including a dry cough, fever, and tiredness (who a; verity et al. ) , longer term this morbidity is likely to impose significant costs on sufferers' health, including potentially permanent lung damage or fibrosis associated with impacts upon the heart, kidneys and brain (citroner ) , all of which are likely to have negative consequences for future well-being and productivity. moreover, alongside the vast disruption that the virus itself has caused directly, preventative measures have caused further disarray in the economy. at present, there are no known specific treatments or available vaccines to either cure or prevent covid- infections (who b). therefore governments world-wide have relied upon preventative measures which aim to reduce the number of people exposed to the virus, and lower the effective reproductive number (the average number of new cases per infection, known as r), ideally suppressing it below a value of at which point the number of active cases decreases over time (ferguson et al. ) . while some of these measures impose relatively little personal or economic cost (such as simple hand hygiene and the use of face masks), the failure of such measures to stem the rapid world-wide spread of the virus has necessitated international "stay at home" lockdown requirements, entailing significant impacts across the global economy. the international monetary fund (imf) predicts a contraction in global gdp of three percent in -a decline of . % relative to its october forecast-and a decrease which it describes as being "much worse than during the - financial crisis" (imf a). short term effects are even more extreme. for example, in the uk, gdp fell by . % in april (ons a), while those claiming unemployment benefits rose nearly % to over million (ons b), although even this is dwarfed by the % increase in us unemployment over the same period (aratani ). globally sovereign debt is also soaring: predicted to grow nearly % to $ trillion in (standard and poor ) as administrations around the world race to protect cash-strapped companies from going out of business in order to prevent further unemployment. at the human level, lives and livelihoods have been turned upside-down. hence the true economic costs are more diverse and quite possibly more severe than that captured by financial metrics alone. they include negative ramifications for people's mental health (pancani et al. ; chaix et al. ; branley-bell and talbot ) ; increased kurmann et al. ( ) note that small business employment contracted by % (over . million) between mid-february and mid-april since when over million had been rehired to the end of june . prevalence of domestic violence (mclay ); and likely reduce the educational achievement of today's children (pinto and jones ; van lancker and parolin ) . as with previous financial crises (hoynes et al. ) and pandemics (nikolopoulos et al. ) , the virus and the economic fall-out are disproportionately affecting people from disadvantaged groups and lower-income households. black, asian and minority ethnic people are more likely to be infected and die (bhala et al. ; garg ; khunti et al. ; yancy ; public health england ) ; and lower-income households are less likely to be able to work from home, so face greater negative income shocks (hanspal et al. ; hensvik et al. ) , just as poorer countries are likely to suffer more than richer nations (hevia and neumeyer ) . as is well known, different countries have had very different death tolls. the usa currently has the highest death toll in the world, already exceeding , deaths (as of th july ). in contrast, vietnam-which recorded its first case just days after the usais yet to experience a single death. understanding what drives these differences is clearly crucial, potentially enabling improved responses to the continuing covid- outbreak and future pandemics. this paper begins to answer the critical question of why different countries have suffered different death rates, and what we can learn for future policy. the remainder of the paper is set out as follows. in sect. we first compare the numbers of deaths attributed to covid- across all oecd countries. the paper briefly focusses upon the uk as an example of a broader pattern; that public reporting of numbers related to the pandemic can be somewhat misleading. next, we control for any within-country under-reporting by analysing the overall increase in all deaths above what would be seasonally expected. assessing these 'excess deaths' data suggests that in most nations for which information is available official reporting of covid- tends to explain most of this unexpected mortality. however, analysis also reveals some clear exceptions, such as in the netherlands, spain and the uk where more than % of all covid- deaths seem likely to have not been counted as such. addressing such reporting problems is an essential element of providing the informational base required for an evidence-based policy response to this and any future pandemics. in sect. we assess the impact of government decisions regarding lockdown, their effectiveness and the policy trade-off between economic activity and health risk that they reveal. accepting that they are a conservative estimate of the total impact of the pandemic, officially attributed covid- deaths are used to investigate the price of life implied by lockdown policies. first we use a simple regression analysis to show that differences in mortality rates between countries are not driven by factors which are beyond the short term control of policy makers-such as differences in income and equality which, at least within the time available to fight coronavirus are effectively fixed. this in turn allows us to examine the degree of control which policymakers do have at their disposal, such as the rapidity of lockdown imposition and the duration of such controls. we use country-specific susceptible-exposed-infected-recovered (seir) models, similar to the approach of ferguson et al. ( ) , to ask how changes in the timing of lockdown measures affect the current death toll. our analyses provide good evidence that these policy tools actually determine the majority of variation in covid- impacts between countries. finally, we link these estimates to financial data to reveal a huge variation in the implied price of life across countries. section concludes. table presents the number of tests, cases and deaths that are officially recorded as (at least in part) caused by covid- across all oecd countries as of th june (data from our world in data; beltekian et al. ) . as mentioned, and considered in greater detail subsequently, these official estimates are likely to under-estimate deaths from covid- . however, the degree of under-reporting is far from constant across countries. for example, while almost all countries only counted deaths which had been confirmed to be linked to covid- , belgium adopts a much broader approach also including deaths where covid- is merely suspected as a contributory factor (chini ) . this results in much higher death rates than in other countries. arguably adopting the belgian approach internationally might provide a more accurate picture of covid- mortality. it is worth drawing attention to the very substantial variation in tests, recorded covid- case numbers and official death tolls across countries. adjusting for population, iceland has undertaken far more testing per capita than any other oecd country, at over k/ million compared to just k/million in mexico. much media attention has been expended upon reporting cumulative covid- numbers in each country. in terms of cases the roughly million cases reported in the usa is indeed a prominent result. however, unsurprisingly it is the total numbers of deaths by country which has attracted more attention and again the us total of well over , deaths is eye-catching. however, this media and policy-maker focus upon totals disguises the true comparison of these figures in failing to make even the most basic of adjustments for variation in population size between countries. once this is done then the death rate per million shown in the final column of table reveals a substantially different story. here we need to rule belgium out of comparison because its addition of suspected covid- deaths to the confirmed deaths reported by other countries, upwardly inflates its death rate. given this, the death rate reported in the uk is the highest amongst all of the oecd, exceeding even those of spain and italy which experienced their first major outbreaks much earlier on in the pandemic. it is worth highlighting how reporting elsewhere can be somewhat misleading. we do so by focussing on the uk as this is the country we are most familiar with, but the story is highly likely to be similar elsewhere. figure graphs the development of total recorded deaths (vertical axis) for a selection of countries over roughly the first days since each country recorded its th death (horizontal axis). this graph and its selection of countries is dictated by that which the uk government chose to highlight for comparison at its daily coronavirus press briefings. setting aside for the moment the us trend, clear separation can be observed between those countries such as germany and korea, which rapidly entered into lockdown and quickly controlled the growth of the virus, and those countries such as the uk and spain, the figure is a redrawing of one which was displayed daily at the uk press briefing from th march until being left out of daily briefings from th may onwards. speeches by the prime minister on covid- had been conducted before then (for example on the th and th march) but they only became a daily occurrence with a relatively standardised format from th march onwards. slides from these briefings are available here: https ://www.gov.uk/gover nment /colle ction s/slide s-and-datas ets-to-accom pany-coron aviru s-press -confe rence s. where lockdown was delayed resulting in a higher plateau. this is the first indication of the positive effects of early lockdown action, which we consider further subsequently. the uk government's decision to only display the total number of deaths in each of the countries shown took no account of even basic differences between countries such as population size; and as table has already shown, this makes fair comparison of death rates difficult. it might seem unusual to fail to make such basic adjustments, however the choice of such a display by the government is one which shows the uk cumulative total initially below that of european neighbours such as italy and spain and consistently dwarfed by that for the us, rising to more than twice the uk level. the fact that the us population is more than five times that of the uk, and that therefore per capita rates were much higher in the uk, is not obvious in this display. during the early days of the coronavirus outbreak, this omission of per capita data and focus upon cumulative totals allowed the uk government to make cross country comparisons which indicated that the country appeared to be faring better than many international counterparts (such sentiments are clear in transcripts of the verbal explanation which accompanied the graph, presented in online appendix ). for example, on the st april, the graph was described by the uk government as showing "it has not been as severe here as in france, and we are just tucked in under the usa and obviously italy on a different trajectory". however, as the pandemic developed so the performance of the uk relative to these other countries worsened. this situation was exacerbated by an outcry against the uk government's use of statistics based only upon deaths within hospitals rather than also including those in the community, ignoring obvious discrepancies such as a clear rise in deaths within care homes into which elderly hospital patients had been moved without testing for coronavirus (discombe ; grey and macaskill ) . shifting to reporting deaths from all settings revealed that the uk was faring far worse than nearly all other cumulative deaths (vertical axis) plotted for various countries (as selected for comparison in uk government briefings) over approximately the first days since each country recorded its fiftieth death (horizontal axis). note that spain's apparent decrease in cumulative deaths around day is an artefact of their reporting problems countries and indeed in per capita terms was experiencing one of the highest death rates globally (beltekian et al. ) . the impact upon the official narrative presented at uk press briefings was swift and noticeable. while initially much emphasis had been placed upon the uk's apparently favourable performance compared to other nations, now government officials started to mention the difficulty of making cross country comparisons, as highlighted by the pink dots at the top of fig. (and data presented in online appendix ). these caveats increased in both regularity and stridency until, on th may , cross country comparisons were removed from government press conferences. we have no reason to suspect that the uk government was unique in attempting to provide a positive representation of trends. however, a failure to provide clear and objective information is a well acknowledged cause of mistrust in authority (kavanagh and rich ) and is corrosive to public life at any time, but particularly in a pandemic where trust in institutions is vital. in undertaking cross-country comparisons of the impacts of covid- a first issue to be tackled is the difference in national approaches to reporting. this can be seen even in the reporting of testing statistics, differences which some authorities have argued may be politically motivated (norgrove ) . likewise, some countries (e.g. belgium) are far more likely than others to ascribe a death as caused by covid- (chini ) . given these concerns, we complement our comparisons of official covid- statistics with analysis of patterns in excess mortality data. here we define excess mortality for a country as the deviation in mortality rate during the period january to april compared to a baseline of expected deaths from previous years. excess mortality data is therefore not biased by differential rates of covid- testing or legislation on ascribing cause of death. there are however important caveats to the excess mortality figures. such numbers do not exclusively capture the increase in mortality that is directly caused by the presence of the novel virus. in addition, people may be less likely to visit hospital and therefore less likely to get treated for what are, in normal times curable diseases, thus tragically dying at a higher rate (thornton ) . similarly, first response services may get overwhelmed and therefore be less able to respond to life threatening emergencies such as heart attacks and strokes, again causing higher than expected death rates (oke and heneghan ) . acting in the opposite direction, government responses to coronavirus such as lockdown, may reduce the number of deaths from other causes; transmission rates for other communicable diseases are likely to be suppressed while a reduction in travel reduces the mortality associated with traffic accidents (alé-chilet et al. ). it is therefore not a priori obvious whether excess mortality is positive or negative. nonetheless, comparison of excess mortality with official covid- deaths will provide a more informed picture of the overall impacts of the pandemic within and across countries. table presents excess mortality data for the subset of oecd countries for which it is available. in general, the data are from the economist ( ) but are supplemented for some countries by data from other sources. baseline mortality is typically calculated as the mean number of deaths occurring in january-april - . excess deaths are calculated as the difference between the number of deaths observed in january-april and baseline mortality. the final column is the ratio of excess death to cumulative deaths at the end of april for each country, as reported by our world in data (beltekian et al. ), calculated as: the heterogeneity that was present in the statistics of officially recorded covid- deaths is also present in the excess mortality data. some countries, such as austria, iceland and portugal see only very marginal increases in death rates as compared with background death. there are countries which appear to do even better; denmark, finland, germany, israel and norway all observing fewer deaths than expected. as discussed above, these negative excess death numbers could be the result of measures to combat covid- reducing other-cause mortality, or from previous years used to calculate the baseline number of deaths being particularly bad. indeed does seem to have been a year with relatively few deaths from influenza (center for disease control ). at the other extreme, countries which appear worst hit based upon the officially recorded per capita death data are also those experiencing the highest percentage increase in mortality: belgium, spain and the uk all record deaths that are more than % higher than expected. note that italy too may well have been in this list, but the data for italy is only available to th march, about the time the country experiences its peak daily mortality. turning to the ratio of excess deaths to officially reported deaths, again there appears considerable heterogeneity across countries, suggesting countries are indeed measuring the death toll from the pandemic by very different yard sticks. generally, countries officially reporting high deaths tolls are also those which have the highest ratio of excess deaths to officially reported deaths. indeed, austria, iceland and portugal report more covid- deaths than the excess deaths they experience. it is worth noting this is not to say that these ( ) ratio = excess deaths∕officially reported deaths the other data sources used for particular countries are: austria -http://www.stati stik.at/web_de/stati stike n/mensc hen_und_gesel lscha ft/bevoe lkeru ng/gesto rbene /index .html); belgium-https ://epist at.wivisp.be/momo/; finland -https ://pxnet .stat.fi/pxweb /pxweb /en/kokee llise t_tilas tot/kokee llise t_tilas tot__vamuu _koke/statfi n_vamuu _pxt_ ng.px/; iceland-https ://hagst ofa.is/utgaf ur/tilra unato lfrae di/danir -tt/; ireland (note these are death registrations rather than government figures)-https ://rip.ie/death notic es/all; israel-https ://www.healt h.gov.il/units offic e/hd/ph/epide miolo gy/pages /epide miolo gy_repor t.aspx?wpid=wpq &pn= ; new zealand-https ://www.newsr oom.co.nz/ / / / , , /arethere -hidde n-covid - -death s-in-nzs-stati stics ; spain (importantly accessed on th june, after there was a major addition to the figures)-https ://www.scb.se/conte ntass ets/edc b f ad d e ed / - - %e % % pre limin ar-stati stik-over-doda-inkl-eng.xlsx; usa-https ://data.cdc.gov/ nchs/exces s-death s-assoc iated -with-covid - /xkkf-xrst. even among the countries for which data is available, mortality data are only available for a few months of the year, generally at least to the end of april, hence the focus january-april deaths. data tend to be aggregated to the week level, hence the exact endpoint is rarely th april . rather, the last day used in is determined by the data availability, and chosen to be as close as possible to th april. in all cases, we compare like-for-like, such that the baseline deaths are recorded over the same time period. likewise, the cumulative death toll we use to calculate the ratio of excess to reported death is that which was officially reported on the last day of the mortality data we use for each country. for some countries data availability means this is not possible. for austria, belgium and germany it is - ; iceland and usa use - ; for spain baseline deaths are modelled by momo. countries are recording deaths as covid- when they are not; rather it is entirely plausible the interventions to prevent covid- in these countries have suppressed other deaths too. at the other extreme, some countries, notably the netherlands, spain and the uk, have ratios which imply upwards of % of covid- deaths that are occurring are not being officially recorded. there are of course outliers to the overall pattern. belgium, france and sweden, have ratios below despite having high per capita death tolls. likewise, chile and new zealand have very high ratios, but these are almost certainly an artefact of them having so few covid- deaths by the end of april, rather than because of under-reporting in each nation. to recap, there are vast differences in the number of cases and deaths caused by coronavirus in different countries. this heterogeneity does not merely disappear when we account for potentially different reporting guidelines in each country; rather it may even be exacerbated. so what could be driving these patterns? while most countries chose to implement a relatively similar policy response, they did so at different times in their respective pandemics and some have been criticised for only belatedly imposing lockdown. there is some early correlative evidence that differences in current death tolls could be explained by lockdown date (burn-murdoch and giles ) and we now move to consider this issue in greater detail. our investigations of the potential impact of different approaches to reporting show the usefulness of an internationally agreed standard for assessing the impact of the pandemic. however, in the absence of such a standard we use national official estimates of covid- mortality to understand the impact of lockdown policies. data is supplied by the our world in data programme (beltekian et al. ). an initial task was to estimate the overall impact which policy responses could plausibly have had on covid- mortality. to achieve this we undertook regression analysis examining the extent to which variation in covid- deaths across all oecd countries might be explained by socio-economic and demographic differences which no government could reasonably be expected to address during the timescale of a pandemic. a number of such exogenous determinants have already been highlighted in the literature. of these one of the most clearly established mortality risk factors is a positive association with age; all other things considered, older sufferers are more likely to die from contracting covid- than are younger people (dowd et al. ) . therefore, across countries, populations which include a greater proportion of elderly people are likely to report higher death tolls. similarly, those living in closer proximity to others may be more likely to pass on and contract the respiratory disease, hence variation in population density across nations may be a determinant of covid- deaths (rocklöv and sjödin ) . beyond simple average population density, the degree to which populations are clustered in large urban centres may influence covid- -related mortality (stier et al. ) . health outcomes might also differ because of within-country variation in wealth (marmot ) which we capture in our regression by controlling for the gini coefficient of income inequality for each country. richer nations are likely better placed to limit the spread of pandemics (e.g. hosseini et al. ), hence we use per capita gdp as a regressor to net-out cross-country differences owing to wealth. finally, previous studies (e.g. fraser et al. ) have highlighted that early detection may play a crucial role in halting virus spread, hence it seems plausible that countries which were exposed to covid- earlier in the pandemic, and that therefore had less time to prepare, faced worse consequences. to account for this, we use the regressor "warning days"-the length of time (in days) between the who declaring that the covid- outbreak was a "public health emergency of international concern" on th january and the country recording its th confirmed case (who c). the linear regression we use, details of which are presented alongside full results in online appendix , is deliberately simple and we are not claiming that the model necessarily captures causal relationships. however, even after including the list of exogenous factors which have been hypothesised to be major socio-economic and demographic drivers of cross-country variation in mortality rates, over % of the cross-country variation in covid- mortality differences remains unexplained. covid- deaths vary greatly across countries due to factors beyond socio-economics and demographics; the major remaining determinant is the policy responses implemented by national governments of which the most obvious difference is when different countries implemented lockdown. to investigate the impact of lockdown upon cross-country variation in covid- mortality we calibrate country-specific seir models. seir models have a long history of development (li and muldowney ) with applications across a variety of infectious diseases including measles (bolker ), hiv (shaikhet and korobeinikov ) and ebola (lekone and finkenstadt ) . more recently seir models have also been applied to covid- (e.g. annan ; flaxman et al. ; pei et al. ) . however, as far as we are aware, ours is the first study to use the seir modelling framework to examine the effects of lockdown timing across multiple countries in the same study, and the first to combine these results with financial forecasts to obtain cross-country implied price of life estimates. price of life estimates derived in this paper are of critical importance given that government intervention has the ability to save life, yet trades-off against other goods. for example, closing schools is expected to reduce the transmission of infectious disease, hence decreasing the number of lives lost in a pandemic by imposing a human capital cost on today's children (viner et al. ) . likewise, there is evidence that the more stringent the government intervention to reduce the spread of coronavirus, the fewer lives that have been lost (stojkoski et al. ). this too is not free: we all pay with restrictions on our basic freedoms. beyond coronavirus, governments spend money and introduce legislation which imposes significant costs on society in a variety of sectors: healthcare (nice ), road safety (dft ), and safety at work legislation (hse ). governments also often have to consider multiple policy options for issues of environmental concern, be that considering pollution (ackerman and heinzerling ) , climate change (stern ) or biodiversity loss (ellis et al. ) . here too, lives can be saved and lost as a consequences of policy decisions. hence understanding how governments should value life is of critical concern. indeed, a significant section of relevant policy documents is occupied by discussion of the value which a government should place on statistical life when evaluating policy (e.g. the green book; h.m. treasury ). in the case of coronavirus, there are already studies which aim to assess the economic value of particular policy interventions by reducing the number of lives lost. hale et al. ( ) ask: how much of one year's consumption would an individual be willing to forgo in order to reduce the mortality associated with covid- , suggesting the answer lies in the range one-quarter to one-half depending on exact mortality rates. underpinned by assumptions about the rate of transmission and how policies may affect this, greenstone and nigam ( ) show the economic benefit of social distancing measures in the usa to be very substantial-about $ trillion. similarly, thunström et al. ( ) use initial global estimates for the basic reproductive rate, and assume decreases to transmission from policy intervention from studies on spanish flu, to go further. they conduct a cost-benefit analysis for similar measures, again in the usa, showing that the net benefits exceed $ . trillion. gandjour ( ) and holden and preston ( ) conduct similar cost-benefit style analyses for germany and australia, respectively, both highlighting that lockdown comes out net positive. here we ask a different but related question. not whether lockdown makes economic sense, but rather what the timing of interventions reveal about the relative prices different governments place on their citizens' lives. we focus on countries with very different mortality rates and intervention timing-if there are discrepancies between countries for the price of life, they are most likely to be shown in this set of countries. in china, lockdowns were implemented on a province-by-province basis on very different dates. therefore, at the country-level our gdp calculations would be incomparable with other nations. to overcome this challenge, we additionally parameterise an epidemiological model for hubei, the province worst hit by the pandemic. we use the results from hubei in our price of life calculations to maintain comparability across countries. to be clear, the implied price of life should not be regarded as comparable to the value of a statistical life (vsl). specifically, vsl is a concept from normative economicshow much consumption should governments be willing to trade-off for an increase in the number of lives saved. this is a question which can be answered through stated-preference methods as has been done elsewhere (e.g. alberini ; carthy et al. ; jones-lee ) . rather, the implied price of life we calculate can be seen as an answer to the positive economics question of how governments actually do price lives saved in terms of consumption lost when making policy decisions. the key insight is that as the pandemic progressed governments continually had to decide when the moment was right to introduce a lockdown. earlier lockdowns would save more lives, but likely impose greater immediate costs upon the economy. likewise, delaying lockdown also delays the point at which a government becomes either morally or legally responsible for addressing the costs which such restrictions impose upon business. therefore, ex-ante the expectation was that earlier lockdown meant greater financial cost. expost, it seems governments may have been somewhat wrong to make that assumption as longer-term earlier lockdowns actually appear to be associated with shorter overall lockdown length, as is clear in online appendix , which in turn result in lower long-term economic costs (balmford et al. ). nonetheless, early imposition of lockdown imposed the certainty of cost, while a delay held out the possibility that the epidemic may turn out to be less severe than expected. gambler governments chose to delay rather than act. the chosen date of lockdown reveals a government's preferences regarding the trade-off between avoided deaths and gdp losses. relative to the chosen lockdown date, a later lockdown would have cost more lives, but reduced the financial impact. in its choice of lockdown date a government implicitly accepted the associated gdp loss rather than bear a greater death toll. earlier lockdowns would have had the reverse effect; saving more lives but at a greater cost to the economy. in choosing not to enter lockdown earlier, the government rejected the higher financial cost of earlier lockdown in favour of more deaths. hence, we are able to calculate both accepted and rejected prices for human lives: upper and lower bounds for the implied price of life in each country. a criticism of this method may be that decision makers at the time were unaware of the benefits of lockdown for public health. the evidence, however, points to the contrary. for example, it was reported in the print media at least as early as th march that the lockdown in wuhan was showing signs of slowing the spread of coronavirus (qin ) . within the uk there is evidence that scientific advisors notified the uk government of the benefits of lockdown two weeks prior to its imposition (barlow ) . calculations of the implied price of life for each country require two data points. first, the differential effect on human lives lost from a marginal change in lockdown date. second, the marginal effect on gdp from the same change in lockdown date. we use a compartmental epidemiological model to simulate the epidemic in each country and in particular to predict the outcomes of the counterfactual scenarios in which lockdown dates are changed. in this type of model, at any moment in time the population of a region or country is distributed between compartments according to disease status, and the function of the model is to describe (and predict) how the population flows between these that such a trade-off is inevitable and in principal morally defensible is not questioned, indeed it follows logically from the vsl. increasing economic costs impact upon human welfare. an approach which says that every life is of infinite value would impose infinite costs upon the economy, resulting in far greater losses of human wellbeing (and almost certainly life) than acting in a way which imposes an implicit and non-infinite price on life. it is the cross-country comparison of that implicit price which is examined here. our focus on gdp reflects both the ubiquity of this measure and a lack of available, robust, economic estimates of the wider welfare impacts of lockdown. to better understand some of those wider costs, we direct the interested reader to: branley-bell and talbot, ; burki, ; cash and patel, ; chaix et al., ; mclay, ; pancani et al., ; pinto and jones, ; sud et al., ; van lancker and parolin, . while driven out of necessity, we think that a focus solely on gdp is also justified. our interest is in the relative price of life across country. even accounting for the external costs, the relative pattern for price of life would remain; it could only be eroded if these external costs are disproportionately larger for countries with lower gdp-based price-of-life estimates. indeed grant shapps, a uk government minister, was questioned on th march , a full week before the uk entered lockdown, regarding why the uk was following the example of other countries in implementing a lockdown given evidence that such a response seemed to work. a summary of the interview is available on the sky website here: https ://news.sky.com/video /coron aviru s-uk-appro ach-entir elyscien ce-led-grant -shapp s- . there is also a video of the interview on the sky facebook channel here: https ://www.faceb ook.com/watch /?v= . compartments as the epidemic progresses. in the seir model which we are using, there are four compartments corresponding to susceptible (i.e., not infected, but vulnerable to the disease), exposed (a latent stage usually lasting a few days, where the victim has been infected but is not yet infectious), infectious (at which point they can pass the disease on to others), and removed (meaning they are no longer infectious and may be either recovered from the disease and immune, or else dead). in more complex models, the population may also be subdivided according to age and other factors, with each subdivision being compartmentalised according to disease status as previously described. this would allow for a more detailed representation of the structure of society and the progress of the epidemic as it spreads through the population, but such detail would greatly increase computational demands (especially for large ensembles of simulations as we are using here) and is not necessary for this work. for a full description of the model we are using, see annan and hargreaves ( ) and also house ( ) where the underlying model equations were originally presented. the flow of the population between the compartments depends on parameters which we estimate by fitting the model to observational data for each country. this model fitting process follows the standard bayesian paradigm of defining prior distributions for uncertain parameters, running the model numerous times with parameters sampled from these priors, and calculating the likelihood on the basis of how well the model outputs match the specific observational data that we are using. this process (using a markov chain monte carlo approach) is described in detail in annan and hargreaves ( ) . this approach requires around , model simulations for each experiment (i.e. country) and the results are represented by an ensemble of model simulations that samples our posterior probability distribution. one critical parameter of the model, which has been widely discussed in the literature and media, is the reproductive number or r, which is the number of new cases that each infectious case generates in a fully susceptible population. if r is greater than , the epidemic initially exhibits exponential growth until it infects a sufficiently high proportion of the population that the remaining susceptible fraction substantially shrinks. if r is less than , the epidemic decays, again exponentially. in our estimation procedure, we assume that all uncertain model parameters are fixed in time apart from r, which is treated as piecewise constant. we consider three discrete periods within which r is constant. first, there is an initial period prior to "lockdown" controls being imposed by governments. a new, lower value for r is then assumed to apply during the period of strict controls, with a third value applying after the controls are significantly relaxed. country specific lockdown dates that we use are detailed in online appendix . in reality, r and other model parameters are likely to vary somewhat during these periods but this piecewise constant approach has been widely used and captures the dominant features of the system (e.g. flaxman et al. ) . due to serious limitations in the testing and reporting of case numbers, we rely exclusively on daily reported death numbers for the calibration of our model. again, this is a common approach which is justified on the basis that the reporting of deaths is usually far more consistent and reliable than case numbers which depend strongly on testing capacity and policy. an alternative approach would be to use the number of excess death. while this may better reflect the number of deaths caused by covid than reported death statistics, daily excess death data are not available. moreover, the key results in the model are driven by changes in the rate of infection, hence even if death numbers in a particular country are underestimated due to systematic biases, this will not usually bias the estimates of model parameters. therefore to calibrate the models we use daily reported deaths from our world in data up to th june (beltekian et al. ) , and later suggest how accounting for excess mortality would alter our estimates. the prior estimate for r after the release of lockdown is taken to be n( , . ) which represents our assumption that the policies are intended to be as open as possible while keeping the epidemic controlled. in many cases, there are insufficient data to constrain this prior estimate strongly, and therefore it plays a greater role in our results than the priors used in earlier phases of the epidemic. estimates of all the r values, as well as our priors, are detailed in online appendix . lockdown clearly reduces the infection rate across the board. easing lockdown allows the infection rates to increase again. figure compares observed and modelled deaths in the uk, showing deaths on the (exponential) vertical axis over time. modelled mortality (the solid line) closely matches the actually observed deaths (circles), illustrating that the modelling framework is flexible enough and the methodology sufficiently rigorous that the epidemiological model well replicates the observed patterns in the uk. indeed, only on days do observed deaths fall outside the % confidence interval (shaded area), and all such occurrences are in the postlockdown period when the number of daily deaths is comparatively low. similarly, close relationships are displayed for the other countries in the equivalent plots (online appendix ), highlighting that the model well captures the country specific pandemic pathways. in order to calculate the effects of changing the dates of lockdown, we use the fitted parameter values, and perform simulations in which the date of imposing lockdown is changed-either delayed or advanced by days. we also explore advancing or delaying lockdown by or days, results of which are presented in online appendix . this approach is similar to that of others (e.g. flaxman et al. ) in which the effects of policies have been analysed. since we are using a single date to represent the net effect of multiple policies which were introduced across a period of several days, it would be more precise to interpret these scenarios as representing a change in the timing of all such policies by the given number of days. likewise, we identify the impact of lockdown using within-country variation in the rate of infection. therefore, to the extent that the stringency of policy interventions vary between countries, our simulations reflect the same countryspecific set of policy interventions of the same stringency being implemented either earlier or later. that said, the lockdown is widely believed to be the most important of these measures (flaxman et al. ) and so we consider our interpretation to be a reasonable approximation of the impacts of lockdown and variation therein. differences in total mortality for each country dependent on date of lockdown are calculated to th june . we also calculate the number of deaths that likely would have occurred were no lockdown implemented, again to the th june . for illustrative purposes, the graph of predicted daily deaths for the uk under such a scenario is in online appendix . in all cases, no correction is made for the possibility that hospitals got overwhelmed, causing an increase in infection-fatality ratios. to the extent that such an outcome would have occurred, yet more lives would have been lost under the delayed-and no-lockdown scenarios. the graphs are similar for all other countries, and hence not displayed here. table highlights the likely impacts of lockdown policy. it is clear that the imposition of lockdown likely saved in excess of million lives across the countries we examine. this overall analysis of lockdown is similar to that of flaxman et al. ( ) and comparison of overlapping results shows that they are in most cases strikingly similar. however, we caution against over-interpreting the result: it is likely that even without a formal lockdown, people would have socially distanced and engaged in other behaviours to limit covid- deaths. nevertheless, earlier governmental action would have saved a large numbers of lives, particularly in countries such as the uk and us who acted relatively late. prelockdown reproduction rates are substantially greater than one, hence across all countries, longer delays result in exponentially greater losses of life. the previous sub-section presented clear evidence that the choice of when to impose lockdown drastically affects the likely number of deaths. moreover, there is significant heterogeneity across countries in the number of lives that would have been saved had lockdown been implemented just days earlier or later. how does this heterogeneity translate into the implied price of life across countries? to assess the price of life we require estimates of the financial cost of lockdown on gdp. we first assume that the full cost of any extension to the length of lockdown is felt in the year . therefore, we estimates the cost to gdp by comparing the last imf forecasts of national gdp in prior to the pandemic (from october ; imf ) with their most recent forecast for (april , imf b). further assumptions are needed to understand the cost of a marginal extension to lockdown. the first is the relationship between lockdown length and cost to gdp. in line with the best available evidence, from studies in the us (walmsley et al. ) and thirty panglobal countries (with a focus on european nations, fernandes ), length of lockdown appears to be directly proportional to the percentage gdp loss. of course, not all of the gdp loss associated with an extended lockdown is the result of the policy decision alone: progression of the pandemic sufficient to warrant a lockdown (extension) would reduce gdp outlook anyway and there is good evidence that people were changing their behaviours to enact social distancing in advance of direct regulations (gupta et al. ) . moreover, it is not just the domestic pandemic which causes gdp losses-some is also driven by the state of the virus in other nations owing to trade (mandel and veetil ) . hence we must also make an assumption about how much of the loss in gdp in any given country is the result of the lockdown policy, rather than other factors associated with the ongoing pandemic. andersen et al. ( ) , chronopoulos et al. ( ) and goldsztejn et al. ( ) have all teased apart the effects of lockdown policy from the wider pandemic. all three suggest that the gdp loss caused by lockdown policy is approximately % of the total gdp loss experienced by each country. we note of course that there are reasons to believe this figure could be an over-or under-estimate of the proportion of cost attributable to the lockdown policy, and that this could also vary somewhat by country given that lockdown policy may have different impacts on different industries. nonetheless, we see the . estimate as offering a reasonable ball-park figure, and so adjust predicted gdp losses as per eq. : equation states that the gdp loss caused by changing the length of lockdown by some amount (either , or days; denoted i ), in country j , is calculated as the relative change in lockdown length, multiplied by the predicted change in gdp as forecast by the imf, and ( ) Δgdp ij = Δlockdown length i actual lockdown length j × imf forecast gdp loss j × . andersen et al use data from individual-level transaction data either side of the border between denmark, which imposed a lockdown, and sweden, which did not. denmark saw transactions reduce % in the immediate aftermath of lockdown imposition compared to sweden's % reduction. this suggests that . % of the gdp loss denmark experienced is caused by the lockdown rather than mere pandemic progression. chronopolous et al present evidence from either side of the uk lockdown, again using individualconsumer-level transaction data. this suggests a similar proportion of the overall cost is attributable to the lockdown policy: spending drops by . % in the week following lockdown (week beginning rd march ) relative to the previous period. goldsztejn et al conduct a modelling exercise linking economic data to an seir model for the uk again. this suggests that lockdown accounts for % of the overall economic downturn. as more accurate estimates of this key parameter become available, we would encourage the interested reader to replicate our calculations but with an updated estimate of the proportion of gdp loss attributable to lockdown policy to provide more accurate estimates of the price of life. the proportion of the loss attributable to the policy decision ( . ). we adopt the imf metric for measuring gdp in terms of purchasing power parity international dollars (ppp$) which is held constant such that it is equal to the us dollar. for hubei, we use the same formula as above, however the imf only publishes estimates gdp forecasts at the national level. therefore we partition the effect for hubei alone by multiplying by the proportion of china's gdp which hubei makes up ( . , ) . the necessary data, and calculated gdp outcomes, are presented in online appendix . it is worth highlighting two further implicit assumptions. first, we assume all of the gdp loss a country experiences occurs during the lockdown period. clearly, countries' economies were already contracting pre-lockdown, and likely will take a long time to return to normal functioning post-easement. however, our assumption ensures that the implied price of life we calculate is an upper bound. second, we assume that the date on which lockdown is eased is independent of the date on which lockdown was imposed. this is an open empirical question as it may be that earlier lockdowns halt the spread of the virus quicker, allowing an earlier end to lockdown. if earlier lockdowns result in earlier release this would lower the overall financial burden of lockdown. hence, again our assumption tends towards an upper bound estimate on the price of life. the additional assumption made for hubei may underestimate the price of life there: the contraction in china's gdp is likely most keenly felt in hubei, the worst hit province. our estimates of price of life would increase if we adjusted for this. aside from the caveat with respect to china, while our assumptions influence absolute estimates of the price of life, the only variables affecting the relative prices across countries are: ( ) the number of lives a change in the length of lockdown would save; ( ) the original length of lockdown in a country; and ( ) a country's gdp. these key variables are not assumed. to underscore the point, our assumptions cannot substantially influence the implied relative price of life across countries. to calculate the implied price of life from a change in the length of lockdown of a set number of days, i , for country, j , we link the predicted change in gdp to the change in number of lives lost as in eq. : our primary focus is for the most marginal change in length of lockdown we calculate: imposing lockdown either days earlier or later than its actual date. results for different changes in lockdown date, of and days, are presented in appendices and . these show that relative patterns remain unchanged. table showed that the exponential growth in infections means more lives are lost from a delay, than would be saved by shifting lockdown earlier by the same number of days. in contrast the modelled impact on gdp from moving the lockdown date by a fixed number of days is exactly the same; the only difference is in the sign (earlier lockdowns are a cost to gdp, later lockdowns a benefit). hence, the implied price of life is higher for moving lockdown earlier as opposed to later. ( ) implied price of life ij = Δgdp ij ∕Δlives lost ij moreover, as explained previously, by choosing not to impose lockdowns days earlier governments rejected saving more lives when the price was relatively high. similar logic reveals them to have accepted the implied price of life from a delay; they would rather bear the cost in terms of gdp than as further human lives lost. results from these analysis are presented in table . obviously, estimates for prices countries were willing to pay (accepted) are lower than estimates for the prices countries rejected. in almost all cases the estimates of the price of life are below thresholds typically used to estimate the vsl in cost-benefit analyses. hence, ex-post, it is highly likely lockdown enhance social welfare. as with progression of the pandemic, there is huge heterogeneity in the price of life across countries. comparing across countries those who pursued an early lockdown strategy reveal they are willing to pay a high price to save their citizen's lives, only rejecting prices above $ , , . the highest implied prices are in korea (> $ , , ) and new zealand (> $ , , ), both countries who acted swiftly to suppress the pandemic. however, those countries which imposed lockdown relatively late-on in their respective pandemics were clearly only willing to pay far less to protect lives. belgium, italy and the uk reject prices of life around $ , . clearly, delayed action in the face of exponential growth cost lives, and implied low price of life in those countries imposed lockdowns relatively late in the pandemic. two comparisons make this cross-country variation in the implied price of life particularly clear. first, the accepted price of life in china ($ , ) is about % higher than that for an american ($ , ). this is despite our methods meaning the calculated price of life for china is likely an underestimate. second, compare the acceptable price of life in germany ($ , ) with that in the uk ($ , ). the price of life for a german is nearly an order of magnitude greater than that for a british citizen. that vast difference is despite the two countries being very similar in terms of gdp per capita. these relative implied price of life comparisons are particularly pertinent. our methodology uses ex-post estimates of the number of lives saved to infer what government policy implies for the price of life. yet, these governments were clearly making the decisions ex-ante. nonetheless, these governments were making lockdown decisions at around the same time (except hubei which was far earlier), with nearly identical information sets. thus any differences in relative estimates would hold true even if the pandemic had proved to be far less deadly than it actually is. moreover, this heterogeneity in the price of life is not explained by different values for life. indeed, the implied prices are often far lower than official vsl estimates-seemingly, cash flowing through the market is worth much more than value passing through wellbeing, at least to some countries. the low rejected prices also imply that very few quality ideally we would assess all of the consequences of interventions (e.g. the mental health costs of lockdown) before making such an assertion. however, the difference between vsl values and our price of life estimates suggest that our statement is defensible (certainly for those countries where the latter measures are particularly low). moreover, vietnam would have been included in the modelling exercise, but we were unable to robustly parameterise our epidemiological models as so few cases (let alone deaths, of which there have been none) have occurred. this is true to the extent to which officially reported covid- deaths in china are accurate. if officially reported deaths are far lower than the number of deaths which have actually occurred, this figure may well be an overestimate of the price of life in china. we have not found data from china on excess mortality and so cannot speculate on the degree to which mortality data are accurate. adjusted life years (qalys) are assumed to be saved by governments in reducing covid- -related mortality; otherwise delays to lockdown seem nonsensical. for reference, in the uk the national institute for health and clinical excellence views a qaly costing between £ , and £ , as good value (nice ). as we mentioned when discussing table , those countries with high reported covid deaths, tend to be countries with high ratios of excess mortality to reported death, i.e. there is substantial under-reporting. to examine the extent to which our estimates change when we account for this under-reporting, we focus on the set of countries for which we have reliable estimates of that ratio, and where under-reporting appears prevalent. these countries are: italy, the uk and the usa. the estimates reported in table are calculated by dividing the estimates of the price of life by the ratio of excess mortality to reported deaths (from table ). the intuition behind this is that our estimates of lives saved by lockdowns (used in table ) are based upon reported death data, and hence should be scaled upwards by the degree of under-reporting of deaths. implicit in this correction is the assumption that the ratio of excess death to reported death is constant within a country throughout the pandemic. it is possible that the ratio declines during the tail of the pandemic when covid cases and deaths are less common, and tests more available. nonetheless, our correction offers what is currently the most comparable cross-country figure. table shows that for those countries which under-report covid- deaths, implied price of life is substantially reduced, highlighting once again that earlier lockdowns would have increased social welfare tremendously. for example, in the uk, the country for which we estimate a relatively high rate of under-reporting of covid- deaths, the adjusted rejected price of life is just $ , (equivalent to just over £ , ). the accepted price of life is lower still, at $ , (£ , ). this study has begun to disentangle the extent to which cross-country comparisons of responses to covid- are valid despite difficulties caused by both exogenous factors and differences in testing rates and the recording of cases and deaths. the results presented in this paper suggest that policy interventions may well explain the majority of cross-country variation in officially reported covid- deaths. for some countries, deficiencies in official approaches to the recording of covid- mortality mean that estimates based upon deviation of overall deaths away from the seasonally expected norm may provide a more accurate depiction of fatalities caused by the pandemic. such 'excess death' estimates suggest that in some, highly impacted, countries the actual number of covid- deaths may considerably higher than indicated in official statistics. for example, within the uk it seems that more than a third of covid- deaths may have gone unrecorded. where under-recording is prevalent, then the number of lives lost by delayed intervention (as well as those saved relative to even further delay) is likely to be substantially higher than estimated in this paper. any such under (over) estimation of true deaths would result in an over (under) estimation of the price of life implicit in lockdown decisions. careful consideration of cross-country differences is required if we are to glean the important natural experiment evidence afforded by countries implementing different policy approaches to the pandemic. the results presented in this paper highlight that welldesigned policy can save life. while the economic burden of lockdown is large, comparison with prior decision criteria suggest that such policies generate net benefits for society. pricing the priceless: cost-benefit analysis of environmental protection what is a life worth? robustness of vsl values from contingent valuation surveys activity and the incidence of emergencies: evidence from daily data at the onset of a pandemic pandemic, shutdown and consumer spending: lessons from scandinavian policy responses to covid- tweet posted th model calibration, nowcasting, and operational prediction of the covid- pandemic antconc (version . . ) [computer software covid- : analogues and lessons for tackling the extinction and climate crises tweet posted th coronavirus pandemic (covid- ) (online) sharpening the global focus on ethnicity and race in the time of covid- . the lancet bolker b ( ) chaos and complexity in measles models: a comparative numerical study exploring the impact of the covid- pandemic and uk lockdown on individuals with experience of eating disorders burki tk ( ) cancer care in the time of covid- uk suffers second-highest death rate from coronavirus (online) the contingent valuation of safety and the safety of contingent valuation, part : the cv/sg 'chained' approach has covid- subverted global health? psychological distress during the covid- pandemic in france: a national assessment of at-risk populations why does belgium have so many coronavirus deaths? 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d cqke authors: shetty, sandeep; shilpa, c.; dey, debayan; kavya, s. title: academic crisis during covid : online classes, a panacea for imminent doctors date: - - journal: indian j otolaryngol head neck surg doi: . /s - - -x sha: doc_id: cord_uid: d cqke introduction: covid made a serious impact on many aspects of everyday life. the world saw a paradigm shift in the education system favouring online learning during the constrains of pandemic. methodology: to assess the attitude of the students towards online learning in subject of ent, we conducted an observational study among third year mbbs undergraduate students of our institute attending online classes through the student portal of our university website. results: our survey revealed students favoured online learning to sustain their academic interest and development during this pandemic. yet, they perceived many challenges during online learning like lack of face-to-face interactions, lack of socialization, distraction by social media, technology related issues etc. students also opted for a combined approach of learning in the post pandemic period. conclusion: this article reflects the challenges faced during online learning and added the innovative methods that can be included to overcome the obstacles of online learning. during this period of covid, one must embrace the alternative to classroom learning to keep up with one’s academic development and can consider an integrated approach of learning after the pandemic. electronic supplementary material: the online version of this article ( . /s - - -x) contains supplementary material, which is available to authorized users. covid made a serious impact on many aspects of everyday life. world health organisation (who) announced covid as a global public health emergency of international concern on th january [ ] and declared it a pandemic on th march [ ] . the education system is one of the most impacted aspects of routine learning and daily life. the world saw a paradigm shift in the education system favouring online learning during the constrains of pandemic. yet, the effects and efficacy of online education and the capacity to successfully teach digitally is questionable. this sudden and rapid transformation from an environment of conventional learning to virtual learning has made a great impact on the attitude of the students towards learning [ ] . in our institute, regular undergraduate online classes are being conducted through student portal of our university website. this enables students to access the digital contents and the recorded lectures even after the class. to assess the attitude of the students towards online learning in subject of ent, we conducted a short survey among third year mbbs undergraduate students of our institute attending ent classes. this will also help us to assess the feasibility and mould our approach towards online classes. an observational, descriptive study based on designed questionnaire was conducted through google forms which was circulated among the third mbbs undergraduate students of our institute. online classes are being conducted. a total of third mbbs undergraduate students participated in the study. the designed questionnaire consisted of set of questions to know the attitude of undergraduate students regarding online vs classroom learning and to know what are the reasons for their likes and dislikes about online and class room learning. initial questions included socio demographic data and the gadget being used for online classes. part a of the questionnaire was based on the opinion of students towards classroom and online classes. part b consisted of statements for which their opinion was obtained by yes/ no/ may be responses and end questions on what kind of approach they would prefer during the pandemic either online or classroom and after this pandemic with the options of online classes, classroom classes and a combined approach were given. our study included students of which were males and were females within the age group of - years. the average attendance for online class was found to be %. % of the students opted for using mobile, % laptops and % of them used tablets as devices for online classes (fig. ) . part a of the questionnaire (table ) suggested a comparable result in terms of content covered in both online ( %) and classroom learning ( %). % of the students felt understanding concepts is better in classroom learning while % students felt retention of the topic was better through classroom learning. majority of the students ( %) felt that they had better access to online study materials. students favoured classroom learning in terms of student teacher interaction ( %), punctuality & discipline ( %), acquiring practical skills ( %). students predominantly favoured online classes for doubt clarification ( %). apprehension of exams were nearly equal in both. part b (table ) revealed students preferred online classes in terms of ease of participation, attending classes ( %) and time investment ( %). students felt that the outdoor activities, group projects and development of communication skills were better in classroom learning ( %). % of the students sensed that poor internet connections, social isolation and eye strain as the commonest problems faced during online learning. when asked a specified question regarding preference of classes during the pandemic, majority of the students preferred online classes ( %) to sustain their academic interest and development during this pandemic. (fig. ) . for the opinion of preferred approach of learning after covid pandemic, % of students opted for the option of only classroom learning, % opted for only online learning where as % of the students opted for combined approach of classes (fig. ). since the serious outbreak of this global pandemic covid- [ ] , majority of the countries practiced lockdown. currently there are in excess of million cases of covid- . social distancing and restrictive movement policies are being implemented to curb this rising curve of cases [ ] . it also has markedly deranged conventional education practices as most of the schools and colleges are being temporarily shut down. this present situation has made us implement an alternative and innovative approach in sustaining academics of medical undergraduates through online classes. due to the constrains of classroom learning in this indeterminate time course of pandemic, online learning has come to the forefront to partly resolve perplexity. online classes are being conducted through the student portal since the outbreak of pandemic. the average attendance for the online classes was found to be % over a period of months. most of our students possess a mobile phone, making it the most accessible and feasible platform to attend online classes ( %). % and % students preferred using laptops and tablets respectively as they might feel more distracted while using mobile phones. students themselves gave the feedback that accessing online classes on mobile was sometimes distracting them. they feel the urge to access social media, check messages, answer calls while using mobile phones which leads to loss of interest and attentiveness during the class. conventional learning has face to face interactions, motivates one to learn, better interactions among student and teacher and most important a feel of togetherness in learning and sharing opinions. [ ] some of these aspects lack in online learning. our survey suggested that although both methods of teaching covered almost equal content of a particular topic yet the students preferred classroom learning for understanding and retention of a topic. the students also preferred classroom learning as practical knowledge, punctuality and self-discipline is better acquired through a reciprocal interaction among teachers and student in a classroom. online learning creates a good platform for acquiring newer methods of learning with less apprehension among students in clearing their doubts, ease of participation, good coverage and understanding of the topic by usage of d % % online learning classroom learning animations, less time investment and easy availability of the resources to review the topics through the online portal. [ , ] our survey revealed a similar preference among the students. they also relished the concept of multiple choice questions incorporation during the class as it added up to their interest and attentiveness during the class. flexibility and lowering the cost of transportation and accommodation with access from any part of the world are engrossing aspects of online learning. [ ] long duration of online classes can cause eye related problems, distraction by social media. [ ] decreased outdoor activity, group projects, communication skills causes social isolation in an individual. [ ] our students also reported that % of them lost interest during online classes due to issues with the internet connection when the class went on for more than an hour. sedentary life with decreased outdoor activity and project works was a major disadvantage of online classes as pointed out by % of our students. % of the students complained eye related issues like eye strain, epiphora and headache while attending long online sessions. technology related challenge and clinical skill training are the two paramount constraining factors. [ , ] other crucial constraining factors include student interest captivation and emotional wellbeing. these could be overcome by using simulation based training apps, establishing a fast and reliable internet connection, prior training of teachers in using this technology, flexibility in time and a shorter duration of classes. incorporating virtual whiteboards, videos on clinical examination, d images, surgical videos if applicable, weekly one to one student teacher counselling sessions, regular feedback from the students may help in overcoming the obstacles and escalating favourability of online classes. in view of present scenario our students preferred online classes during pandemic which is similar to other studies. [ , , ] majority of our students preferred for a combined approach of teaching after the pandemic for their better academic development. this finding is similar to the study done by rajab et al. [ ] . one of the participants of our survey rightly said 'there is a difference to play football on ground and in mobile' but in this apprehensive socially distanced period of covid, one must embrace the alternative to classroom learning to keep up with one's academic development. though the replication of classroom learning is not completely attainable through online learning, yet it is a convenient method with ease of participation, sustaining the academics and maintaining the student teacher interaction amidst pandemic. a combined approach can be considered post pandemic for a finer learning with more innovative methods. funding no external funding has been received. conflict of interest the authors declare that they have no conflict of interest. ethical approval appropriate ethical clearance has been obtained from the institute.informed consentinformed consent was obtained from all individual participants included in this study. who: covid public health emergency of international concern who declares covid- a pandemic online teaching during covid- : perception of medical undergraduate students covid- ) advice for the public online learning amid the covid- pandemic: students' perspectives student's perception of online learning during covid pandemic online learning: a panacea in the time of covid- crisis sustaining academics during covid- pandemic: the role of online teaching-learning distance learning in the era of covid- challenges to online medical education during the covid- pandemic publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- - t pu i authors: garip, gulcan; seneviratne, sanju rusara; iacovou, susan title: learners’ perceptions and experiences of studying psychology online date: - - journal: j doi: . /s - - - sha: doc_id: cord_uid: t pu i this study aimed to explore the lived experiences of six international and mature online learners studying on an undergraduate psychology course to identify barriers and facilitators to studying online. a secondary aim was to deductively explore the applicability of the capability, opportunity, motivation, and behaviour model to participants' narratives related to self-regulated online learning. online interviews with six demographically diverse participants were conducted and analysed using interpretative phenomenological analysis. the overarching theme was 'the balancing act of online learners', which consisted of three major themes (and respective subthemes): ( ) 'identity as an online learner' ('in today's world, we're all very busy'), ( ) 'access to resources' ('importance of location' and 'comparing online to on-campus teaching and learning'), and ( ) 'changing nature of social interactions' ('tutors as a crutch' and 'peer-to-peer interactions'). a number of facilitators and barriers related to these themes were identified, which are applicable to the com-b model. the com-b model offers a novel approach in designing and delivering learning materials and activities that may instil or help maintain self-regulated learning in online psychology students. online learning has made education accessible to those previously restricted by factors such as geographic location or employment (allen and seaman ; christensen et al. ; kumar et al. ; zhu et al. ; larmuseau et al. ) . 'online learning' in the context of this paper will refer to any form of learning and teaching through a primarily electronic medium; with interaction between learners and their educational materials and activities, and engagement with peers and tutors taking place synchronously or asynchronously in a virtual environment (e.g. via blackboard, moodle, etc.; yanuschik et al. ; mayer ) . while the popularity of online learning can be attributed to the flexibility inherent to its medium, research has identified concerns related to student engagement (prior et al. ) , retention rates (mubarak et al. ; jo et al. ) , and reported perceptions of missing out on traditional classroom experiences (ragusa ; martinez et al. ) . current trends indicate that a greater proportion of students engage in online learning than in the past (li et al. ). this highlights the need for educators and researchers to examine practical and evidence-based models that support the development of online courses that foster self-regulated learning. self-regulated learning can be defined as "an activity that students do for themselves in a proactive way" (zimmerman and schunk , p. ) or as an "interaction" through which learning is constructed (rhode ). self-regulated learning requires the effective management of time and learning resources; selfregulated learners set goals, plan ahead, and regularly reflect on and monitor their learning process (zimmerman ; wong et al. ). previous research demonstrates that self-regulated learners persevere in challenging learning situations (e.g. cho and kim ; cochran et al. ; shea and bidjerano ; li et al. ) . consequently, the skills and strategies associated with self-regulated learning can support successful learning in an online context (yeh et al. ) . research in this field has focused on remedying poor student engagement and retention rates among online learners, with particular attention given to the selfregulated learning strategies recognised as being key correlates of student success (wei and chou ; kahu and nelson ; tsai et al. ) . several well-established models of self-regulated learning in educational psychology draw on social cognitive learning theory (bandura ), self-determination, and constructivist approaches to provide a framework for developing and delivering courses (panadero, ) . schraw and colleagues ( ) discuss the implications of self-regulated learning in science education, wherein self-regulated learning is conceptualised as consisting of cognition (i.e. cognitive, problem solving, and critical thinking strategies), meta-cognition (i.e. knowledge of cognition and regulation of cognition), and motivation (i.e. self-efficacy and epistemology). according to this theory of self-regulated learning, learners engage in a combination of intra-individual strategies and processes to understand and control their learning environments. while these strategies may be shaped by the learners' interactions with others and their contexts, this view of self-regulated learning does not explicitly take the learning context into consideration. this paper introduces an interdisciplinary and dynamic model that considers the learning context when examining the mechanisms of self-regulated learning in online psychology students (see crutzen and peters ) . more recent research indicates that educators are increasingly drawing on theoretical models to increase student engagement in online courses for specific subject areas (arvaja ; garrison ; hersman and schroeder ; mastel-smith et al. ) . further, the present study responds to the fifth international summit on information and communication technology in education's call to action to understand the learning landscape in a digital age, as it undergoes fundamental changes (voogt and knezek ) . therefore, it is imperative that we identify the experiences and expectations, as well as perceived barriers to, and facilitators of online learning that may differ in students across subject areas. the capability, opportunity, motivation, and behaviour (com-b) model proposed by posits that behaviour is influenced by the interaction of the following constructs: • capability: an individual's psychological and physical capacity to engage in the activity concerned, relies on the individual having the necessary knowledge and skills to perform the behaviour; • opportunity: all the factors that lie outside the individual that make the behaviour possible or prompt it; • motivation: all those brain processes that energise and direct behaviour, not just goals and conscious decision-making. it includes habitual processes, emotional responding, as well as analytical decision-making. according to this model, motivation and opportunity influence an individual's capability to generate behaviour . behaviour, in the context of this study, refers to actions associated with being a self-regulated learner. as this is a dynamic model, it also explains how self-regulated learning may in turn influence the three constructs. each psychological construct is well supported in terms of its influence on behaviour . this is the first study to explore the application of the com-b model in the context of self-regulated online learning in psychology. this model is unique in that an individuals' context is taken into account in relation to the behaviour of interest. the model states that behaviour occurs when the individual perceives they are capable of carrying out the behaviour, they have the opportunity to engage in the behaviour, and are motivated to perform the behaviour. self-regulated learners may engage in a number of behaviours that help them understand and control their online learning environments. the model has primarily been applied to developing and understanding interventions (including online interventions) to equip people with the skills to engage in health behaviours, which rely on self-regulation. there are parallels between the skills and strategies needed to learn in the context of one's health and to learn in a subject area (e.g. psychology; aunger and curtis ; wong et al. ) , which highlights the relevance of the model in this context. we build on previously established conceptualizations of online educational courses as complex online behavioural interventions (wong et al. ) to explore the utility of the com-b model ) when examining how behaviours associated with self-regulated learning are impacted in online psychology learners. shih et al. ( ) predicted that qualitative research would become a popular method for exploring student experience in an online context, due to its utility in the identification of new avenues and opportunities for research (kember and leung ; symeonides and childs ) . symeonides and childs ( ) conducted a qualitative interview study with online learners and emphasised the need "…to recognize learners as experts of their own experience" (p. ) to help educators identify and develop more effective ways to facilitate online learner engagement. interpretative phenomenological analysis (ipa; smith and osborn ) was developed to uncover and interpret how individuals (i.e. the participants) make sense of their lived experiences, making it an ideal method to understand the perceptions and experiences of learners studying psychology online. further, ipa-derived from phenomenology, hermeneutics, and idiography (smith et al. )-accepts personal perceptions and subjective accounts to contribute to existing theory or to generate new research questions. it also acknowledges the interpretative role of the researcher in bringing the participants' accounts together. purpose of the study . taking the above together, the present study answers the following research questions that were designed to build on each other: what does online learning mean to learners studying psychology online? . what are the facilitators and barriers to studying online in this group? . to what extent is the com-b model applicable to self-regulated learning in an online context? the present study explored the lived experiences of online learners studying an undergraduate psychology programme at a higher education institution based in the united kingdom, in accordance with the principles of ipa (smith and osborn ) . these experiences were then used to identify perceived facilitators of and barriers to studying online in this group. finally, the applicability of the com-b model was examined to potentially identify and explain the mechanisms of self-regulated learning in this sample. this study is notable for its detailed examination of the lived experiences of online psychology students from varied backgrounds, which builds on previous research that has identified the importance of human factors when considering self-regulated learning in online platforms (wong et al. ) . the integration of human factors and learning theories in the development of online learning environments will facilitate more adaptive support systems that optimise learning at an individual level (wong et al. ). the study is also unique in that it uses the com-b model, which has not been used in this context previously (keyworth et al. ) , to interpret self-regulated learning behaviours in online psychology students. additionally, research utilising the com-b model is widespread in health psychology, e.g. guiding data collection and analysis in qualitative studies (atkins et al. ) , and informing intervention development (barker et al. ) . it is essential, therefore, to consider the com-b model within the context of online learning as it addresses wide-ranging influences on self-regulated learning behavior, which in turn can support educators in improving and enhancing online learning environments (grant et al. ) . beyond this, understanding and preparing students to become self-regulated learners has been made all the more relevant in these times, with the landscape of learning evolving due to the th industrial revolution (hirschi ) and the shift towards remote learning as a result of the coronavirus pandemic (bishop ) . the present study was designed, conducted, and analysed according to the principles of interpretative phenomenological analysis (ipa; smith and osborn ) , which "invite[s] participants to offer a rich, detailed, first person account of their experiences" (smith et al. , p. ) . this study utilises semi-structured interviews, which are better suited to gaining insight into previously unexplored samples. there are several examples of interview studies of online student experiences but these studies favour descriptive accounts and lack interpretation (cochran et al. ) . all authors were involved in the development of an interview guide containing open-ended, non-directive questions. this was an iterative process, involving the trial and revision of the questions by the study team. this process involved a consideration of what the interview was likely to cover, as well as any potential difficulties likely to arise due to the wording of the questions (smith & osborn, ) . the interview questions were intentionally left openended to avoid restricting lines of conversation and to encourage participants to produce rich narrative accounts of their experiences studying psychology online. box presents a sample of the questions that were included in the final interview guide. can you please tell me why you chose to study psychology online? what were your expectations of studying online? what does 'studying online' mean to you? could you describe your online experience so far? have you experienced any opportunities while studying online? have you faced any challenges while studying online? could you describe your typical study habits? could you describe your interaction with your peers online? could you describe your interaction with your tutors online? could you tell about how studying online may influence other life commitments? ethical approval for the study was granted by the host university's research and ethics committee. participants were deemed eligible if they were an online student enrolled in an undergraduate psychology programme at a uk-based higher education institution, had completed at least three modules, and had been studying online for at least a year to ensure that they had sufficient experience of online learning to share. based on the eligibility criteria, it was anticipated that participants would be well positioned to share their experiences of online learning, including their perceptions of barriers to and facilitators of online learning. an invitation to potential participants was advertised on internal course webpages. participation was voluntary and no incentives were offered. a "relatively homogenous" (smith et al. , p. ) sample was sought to ensure that in-depth data was gathered relating to the research questions. six participants took part in a single online interview with the second author. smith et al. ( , p. ) state that "there is no right answer to the question of […] sample size", however, smaller sample sizes are dictated by the idiographic aspect of ipa. mastel-smith and stanley-hermanns ( ) recommended a sample size between and participants, with an addendum to adjust the sample size according to the richness of the data collected. therefore, the sample size of was considered the ideal median for our study. given that significant insight into the lived experience of a fairly homogenous sample of students had been already reached by participant , we concluded that we had reached saturation of themes and decided to maintain the sample size of to allow for a deeper examination of each individual case as per the tenets of ipa methodology. table presents the participants' demographic characteristics; including interview duration, the participants' location at the time of interview, their age, marital status, gender, nationality, employment status, and years since starting online study, as well as the number of modules completed at the time of interview. the participants were categorised as being mature students by the higher education funding council for england ( ) . informed consent was obtained from all participants taking part in the study. all names were replaced with pseudonyms to protect participants' identities during transcription by the second author. participants contacted the second author and arranged an online interview (via skype™). the participant and the second author were the only individuals present during the interview in an effort to maintain confidentiality and ensure participant interested participants contacted the second author to arrange the online interviews. regular supervision meetings were held to review the interview process and analysis stages with the first author. all interviews were audio recorded and transcribed verbatim before being analysed in accordance with ipa. there were two stages to data analysis: ( ) the iterative and inductive ipa stage to explore participants' experiences of online learning, and ( ) a deductive stage involving the mapping of the com-b constructs against participants' reported experiences of online learning. first, interview transcripts were read and re-read by the first and second author, and a paper trail of handwritten notes were maintained in conjunction with the initial stages of familiarisation and coding. the second stage involved inductively identifying themes by each author separately. these themes were then inputted into a spreadsheet to be organised into higher level themes. an example of this process is depicted in table (the raw analysis is available upon request from the corresponding author). throughout this process, the first two authors met to discuss the development of themes between those initially identified, and to organise said themes into higher level categories. the third stage involved the development of a coding manual for each of the major themes and the elucidation of the inter-relationship among these themes. at this stage, the third author checked for validity and reliability of the themes by working backwards from the coding manual against the transcripts. the four broad principles presented by lucy yardley ( )-sensitivity to context, commitment and rigour, transparency and coherence, and impact and importance-were used to assess the validity and reliability of the study. we have demonstrated sensitivity to context through an appreciation of the interactional nature of the ipa interview process employed, which was specifically required to show empathy and put the participant at ease (smith et al. ). further, all of the researchers were involved in the development of the interview schedule and in-depth analyses of each case to demonstrate rigour and commitment to the ipa methodology. throughout these stages, the researchers interpreted how participants' made sense of their experiences and perceptions of studying psychology online while acknowledging our own influence in the development of the themes presented in the paper (smith et al. ). following completion of the ipa, a deductive approach was taken by the first author to explore whether the com-b model constructs were applicable to participant transcripts, which was then confirmed by the rest of the research team. data analysis identified 'the balancing act of online learners' as being the overarching theme. this related to the participants' experiences of balancing the following: extraneous commitments with online study (e.g. family, work, etc.), expectations arising when comparing online and on-campus teaching/learning, and lastly, social interactions with peers and lecturers online. three major themes were identified: (i) identity as an online learner, (ii) access to resources, and (iii) the changing nature of social interactions. these three themes are interrelated and inherently linked to the overarching theme as demonstrated in the paragraphs below, and depicted in table . illustrative quotes from participants are provided to support themes. a majority of the participants (i.e. andrea, jade, karen, sophie, and tae) recognised their interest in psychology at a young age, which motivated them to pursue a psychology degree. in contrast, edward recognised his interest in psychology due to recent life experiences as a football coach. all the participants reported their motivations for studying psychology online in order to facilitate a career change. they viewed online learning as being a means to pursue this goal in spite of the varied obstacles that might have impeded them. for most of the participants (i.e. karen, jade, tae, edward, and sophie) studying psychology was a means to an end, whereas andrea focused on the inherent enjoyment and satisfaction gained from studying psychology online. to andrea, who reported experiencing chronic pain, online learning meant the "…freedom to be anywhere i want and be able to connect and still do study". the availability, accessibility, and flexibility afforded by online learning were common motivators for choosing online learning, as reported by the participants. karen perceived online learning as being the more appropriate, though less desirable alternative to on-campus teaching and learning, at a time when she was very busy: "...i have to say, in today's world when we are all very busy with our own lives, its, uh, its better, it's more appropriate… i cannot say it's more effective, but participants discussed the decision-making processes that were involved in the juggling of their online studies with other commitments that included work, family, social lives, and leisure activities. "…but for me my biggest hobby, well, sort of passion is football. ehm, and i have a season ticket holder for my local football team. that's one thing that i'm not giving up and i refuse to give up football for studying or anything. so, on a saturday, saturday afternoon, my brother and i go off to football and i go home and i study. …but i think you reign your social life in a wee bit, a little bit just to, you know, you can't have everything, when you think about your life before studying you know, you just didn't have time to study, so you have to make that time". (jade) for jade, online learning required a re-prioritisation of some activities and social encounters to make time for studying. her account suggests that she felt the need to defend these decisions when viewed from her friends' perspectives. similarly, sophie reported that online learning has resulted in her becoming more organised than she had been previously: "…i think doing online learning is a different way of learning. because obviously, coz it is self-directed i think it makes you, it is making me much more um organised, i am so so much more organised than i have ever been in my life or having to be, having to be. because i'm not only studying obviously, i'm working, and i have a family, you know i have to sort of have to juggle everything, and it's making me organise everything". (sophie) when reflecting on her experience as a mature online student, sophie concludes that she is more likely to be successful in her studies now than she would have been at a younger age: "was a very very scary thing for me doing a degree, because obviously i'm not a young year old… and i think now i'm not , i think its, i'm a better, i'm a better student because i'm older, and yeah, i think its been really good for me for my professional development. i'm very proud of myself actually [laugh]". edward shared that, in his experience, approaching online learning with an open mind and a curiosity about the subject allowed him to maintain the focus he needed to 'get the job done' (i.e. obtain his psychology degree). andrea echoed this sentiment to some extent, as she believed that a curious attitude towards the subject made it more rewarding to learn. her curiosity also meant she was keen to make the most of available opportunities to learn, at the risk of scattering her attention across many different elements (i.e. modules, massive open online courses, research projects). jade talked about having to disguise her true motivation for studying psychology (i.e. career change to become a psychologist) to potential employers out of concern that she may not be perceived as a committed accountant: "…i'm applying for accountancy jobs, whereas, in complete honesty, i don't want to be an accountant in five years' time. d'you know like, ehm, and it's almost like that whole acting thing, so i'm going to these interviews and i'm completely being myself until they ask that question of where do you see yourself and i'm not, i don't like lying or deceiving or that sort of thing and its. i'm very open and i tell them at the end that i am doing degree and they'll get all interested and they ask what's it in and whenever i say psychology, they kind of, it's almost like first question is "why?!" d'you know and that's. and i'm sure like, one of my, my last role actually, we ended the conversation where basically i just went, 'as a hobby' (laugh). d'you know like, 'i do it in my spare time' (laugh) but it's not a hobby, it's what i want my future career. but i can't tell people that in an interview. because they'll look at me as not committed to being an accountant. when i, whereas i am but i don't want to do it forever. so, that to me is quite tricky". (jade) jade's account detailed the tension stemming from her balancing her current role as an accountant with her identity as an online psychology student in training for a career in psychology. the authors designed the interview guide to focus solely on online learning, without encouraging participants to compare online and campus-based teaching and learning. it is therefore noteworthy that all participants, at various stages of the interview, made positive and negative comparisons between the two mediums. tae, edward, and jade highlighted the importance of the online degree leading to an accredited qualification that was similar to, or the same as, what was awarded on-campus. jade explains how the meaning of online learning has changed for her since she started studying online: "…for me, if you'd asked me before i did this degree, ehm, online learning. i was probably one of those people that viewed online learning as not as good as attending university. ehm, but since doing the degree, i'm seeing how much hard work it is and how much dedication it takes and i view online learning as.. same as usual, people are still working hard to do it, and i'm working hard to do it. so, i.. you know, when people say to me, oh, where do you study, i say derby and they say, oh is it an online course, and i was like, well, yeah, but it is still the same degree. so i find myself now pushing back on people because for me i value online learning a lot more now i'm actually doing it and part of a course". (jade) karen raised concerns relating to her level of english proficiency, and worried that it was not of the same standard as her english-speaking peers. this resulted in some hesitation at contributing to discussion board activities in the virtual learning environment: "sometimes i have to say i do feel a bit shy, because in a group we have … [other students'] english is very proficient, in the comments it's like 'wow!' so i feel a bit shy, and i won't do my activity, because i think 'oh my god if i give my thoughts or express myself it will look funny,' you know, because they sound so professional, which actually is not good, so i'm pushing myself to [do the activities]". (karen) the com-b constructs, when mapped against participants' narratives of selfregulated learning, can be taken into consideration by educators to better facilitate self-regulated learning. the participants reported varied motivations for studying psychology online and opportunities that either facilitated or hindered how they managed their online studies. with the exception of karen, all participants appeared confident and capable as self-regulated online learners. karen's concern around her english language skills clearly demonstrates her perceived lack of capability to contribute to online activities, although she recognised the detrimental impact that this was having on her online learning experience. all participants, with the exception of edward, compared the mediums of online and on-campus teaching and learning. this tendency could have shaped participants' expectations and experiences of online learning, and may be suggestive of a need for online education providers to establish expectations of online learning as being qualitatively different from campus-based learning. while, it is unlikely that the participants were comparing their online programmes to on-campus study on a regular basis, it was clear that using on-campus study as a reference point was useful to some participants when discussing the opportunities and challenges that arise when accessing resources online: "...and as long as there is an internet connection, then i can do this. it means i'm not, i'm not having to worry and look at a calendar every time i want to do something. …i'm not hauling a whole load of books with me… i mean if you are on a campus, you have set term times, you're aware that you can miss a class or two but there is always the worry about what if i miss this…" (andrea) being able to access the psychology programme from different geographical locations was the most commonly identified advantage of online learning. however, for some participants, being physically removed from academic institutions, services and resources meant that disengagement from their studies when other life events took priority was perceived as being more likely than if they had been studying on-campus. "and i guess you take more action when, if you have to go to the campus for example. whereas, if you study online i feel, it feels very relaxing and casual when you can just stay at home in front of your computer, the same place you watch netflix and chill, it feels very, the atmosphere feels very different, is what i mean to say". (tae) while most participants focused on the ease of access to online learning materials, karen, who was based in qatar at the time of the interview, highlights the difficulties in accessing resources (e.g. books and journals) in developing versus developed counties. karen expresses a fear of missing out arising from her geographic location (qatar vs london) rather than the medium of study (online vs on-campus): "…if you are in a big city, like in london, any actually economically developed countries, you can probably find the good libraries, but bit outside, it's really difficult, even me living in qatar… there is nothing when it comes to psychology, nothing. i mean there is national library, there is nothing when it comes to that particular subject…" (karen) this subtheme maps exclusively against the opportunity construct of the com-b model as it focuses on factors outside of the participants and educators' control. taking the experiences of varied living arrangements (e.g. household, employment, location, etc.) among online learners into consideration, may help educators and providers to tailor expectations for prospective learners. all participants reported feelings of isolation in relation to online learning as being a challenge. despite the participants having used a variety of online mediums to communicate with others, the absence of face-to-face interaction and instant feedback appeared to be a point of tolerable apprehension in this sample: "…sometimes i think it's nice just to get some feedback right away as if you're meeting them face to face. but studying online, i mean okay, there's a forum where you can provide some questions and get some answers out of that. but sometimes, perhaps our supervisor isn't there, isn't available or maybe they are occupied with something else, so we don't get the answers right away when we kind of need it. so, it could be a little bit inconvenient because of that". (tae) for edward, keeping 'a low online presence' was a personal choice that was necessary and allowed him to manage his other commitments. edward talked about interacting with peers as being 'a luxury, an added extra' that he couldn't afford due to his particular approach to online learning: "i find it beneficial when i can pick things up and let it go when it suits me…my main focus is to pass the course". alongside his studies, edward balanced a full-time job at a bank, and worked parttime as a football coach. for him, social interaction with peers and lecturers did not appear to have been perceived as being necessary to the completion of the programme: "…i'll use [lecturers] as a crutch, if and when i need their support". other participants had doubts about interacting with lecturers, particularly when they first started online learning. as andrea puts it, "i wondered about when you should contact a tutor". andrea's confidence in contacting her tutors when she had questions grew in conjunction with her familiarity with them. further, sophie explained how her confidence had increased over time to the point that she felt able to provide support to others; as a result she experienced increased interactions with her peers. for jade, reading other students' posts was daunting but as she got to know her peers through group work, she developed an appreciation for, and valued their contributions. when considering the com-b model, this theme includes examples related to the participants' capability (i.e. the ability and confidence to interact with others online), opportunity (i.e. asynchronous communication modality), and motivation (i.e. reasons for or against interacting with others) to interact with peers and tutors. the social dynamics involved in online learning have the potential to either foster or impede self-regulated learning. the primary aims of this study were to explore the experiences of learners studying psychology online and to identify potential barriers and facilitators to online study across the sample. the participants were mature students, three from non-uk countries, engaging in online learning in pursuit of a career change. as an increasing number of individuals opt for a career change, it is worth exploring means by which to support individuals balancing their existing careers with their studies. the present study identified the balancing act of online learners as the overarching theme, which has been overlooked in the field as research tends to focus on instructional design, learning outcomes, and student satisfaction (e.g. symeonides and childs ; mayer ; tanis ; altinpulluk et al. ) . when considering this, our findings are novel and carry implications of future value in pedagogic practice in the field of online learning. the first theme, 'the identity of an online learner', reflected balancing one's identity as an online learner with other commitments, roles, and responsibilities. this suggests that a truly student-centric approach requires that online learning practices consider the impact of learner identity (oztok et al. ) . it is, therefore, critical that students develop an online learner identity to facilitate self-regulated learning behaviours in their online learning experience. students who fail to do so may find it difficult to remain engaged in online learning when faced with other commitments or distractions and may not succeed in their studies. this is supported by research conducted by wong and colleagues ( ) that identified time management strategies and the regulation of effort as being critical to academic performance. the second theme, 'accessing resources', showed participants weighing the advantages and challenges of online learning. the emergence of this theme is in support of research that has established the importance of the e-learning environment in creating and maintaining positive learning attitudes, specifically an environment that considers student preferences and is adapted to specific learning situations (wongwatkit et al. ; zhu et al. ; larmuseau et al. ) . a conscious decision was made by the authors to avoid questions that specifically required that the participants compare online and on-campus study. interestingly, all participants but one spontaneously used on-campus study as a reference point when sharing their experiences and perceptions related to online learning. providers and educators that use campus-based learning as a reference point when presenting resources and opportunities in online learning may be contributing to unrealistic expectations of online learning and the fear of missing out on-campus-based learning (ragusa ) . the findings from the present study support previous research that revealed the opportunities and challenges of online learning compared to on-campus study. for example, the freedom and flexibility of online learning was viewed as a facilitator, whereas feelings of isolation and the lack of face-to-face interaction with peers and lecturers were generally seen as a disadvantage of studying online (bernard et al. ). the final theme, 'the dynamic nature of social interactions online', highlighted the variety of ways participants approached interactions with peers and tutors. while some participants favoured an isolated experience, others desired engagement with peers and tutors, despite reporting hesitation in doing so. those who had interacted with peers and tutors reported increased confidence in the prospect of future interaction. wong and colleagues ( ) highlighted the importance of these interactions in encouraging 'help-seeking actions'. additionally, previous research identified the 'student-lecturer interaction' to be critical in academic and social development in students, as well as academic achievement (alshahrani et al. ; warner et al. ; ouyang et al. ) . online educators have a responsibility to ensure that students who are not fluent in the language of learning (in this case, english) are not hesitant at participating in discussion forums, which is described by jenkins ( ) as the 'participation gap'. further, research suggests that it is important that educators reduce the fear of asking questions, and encourage help-seeking behaviours when necessary . while some students, such as edward, preferred to keep a low online profile due to other commitments, encouraging students to be proactive may lead to students shifting from self-doubt when engaging with peers and tutors to taking pride in working with and helping other students, as was evident with jade, sophie, and karen. the present study and previous research suggest that studentto-student mentoring may be an effective strategy for improving student retention and engagement in online learning (boyle et al. ) . therefore, the provision of tools and resources that facilitate these interactions can contribute to building confidence and capability in students, motivating them to engage with other students (prior et al. ) , and provide opportunities for collaborative regulated learning. the final goal of the present study was to explore whether the capability, opportunity, motivation, and behaviour (com-b) model constructs were applicable to the experiences of the sample. the results demonstrated the utility of the com-b model, and presents how it might be used to support online psychology students to achieve and maintain self-regulated learning. similarly, wong and colleagues ( ) suggested that self-regulated learning required the combination of learning motivation and strategies to affect academic performance. the com-b constructs could guide pedagogic approaches. for example, online educators can provide students with resources and activities that facilitate and help overcome barriers to behaviours associated with self-regulated learning (e.g. asking students to identify and reflect on their motivations for studying psychology). this supports research showing that learners perform better when they are aware of their role in the learning process . further, the constructs of the com-b model can be used as a guide to develop self-assessment tools for students to identify the extent to which they demonstrate self-regulated learning strategies. such tools and resources would benefit from being tailored to specific subject areas, and could be examined in future pedagogic research into online learning. the present study successfully demonstrates the potential of com-b model in guiding the development of strategies to facilitate mature psychology students in achieving or maintaining self-regulated online learner status. further, this study is limited in that the sample was self-selecting, with all participants tending to be progressing well and reporting mostly positive experiences of studying online. the participants were undertaking online studies specifically to facilitate a career change; different experiences and challenges might have arisen if online students undertaking studies as part of their initial career aspirations were sampled. while the size of the sample examined in this study raises questions as to the generalizability of its findings, the nature of ipa calls for an analysis into the perceptions and experiences of a specific group within a unique setting. further, smith and osborn ( ) posit that ipa research ought to be considered in terms of theoretical generalizability. the present study identified several facilitators and barriers to studying psychology online. a number of experiences reported by the participants can be mapped against the com-b constructs, suggesting that educators may be able to reinforce and highlight these experiences as contributing to developing a self-regulated learner identity. bjork et al. 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intention to undertake online courses: a self-regulated learning perspective acknowledgements this study was funded by the university of derby undergraduate research scholarship scheme and the paper was written up during a residential writing retreat supported by the university of derby. key: cord- -spqb pub authors: van dijk, s.d.m.; bouman, r.; folmer, e.h.; den held, r.c.; warringa, j.e.; marijnissen, r.m.; voshaar, r.c. oude title: (vi)-rushed into online group schema-therapy based day-treatment for older adults by the covid- outbreak in the netherlands date: - - journal: am j geriatr psychiatry doi: . /j.jagp. . . sha: doc_id: cord_uid: spqb pub background –: societal measures in context of the covid- outbreak forced us to transform our schema therapy-based day-treatment for older adults with chronic affective disorders and personality problems into an online program. the objective of this paper is to present first impressions of this transformation. methods –: using over-the-phone instructions initially, all patients were able to participate with the online therapy program. to reduce screen-time for patients, the non-verbal therapies were shortened. four patients, aged - years, started our online program. results –: therapists were positive about the online capabilities and resilience of patients to adapt to the new situation. prejudices on limited effectiveness of online psychotherapy were counteracted. sending homework by email and mail seems to facilitate therapy adherence. non-verbal therapy could be important to stimulate the online group process. conclusions –: we were positively surprised by the online capabilities of our geriatric mental health care patients and encourage further formal effectiveness studies.  therapists were positively surprised by the online capabilities and resilience of older patients to adapt to the online treatment program. prejudices on limited effectiveness of online psychotherapy in older adults were counteracted.  covid- related social distancing measures appeared to trigger feelings of rejection in patients with borderline personality traits, while it falsely validated indoor behavior of patients with avoidant personality traits.  patients felt being taken seriously, especially because during the online group sessions they all received detailed comments on their homework (sent by email and discussed online).  where the non-verbal sessions initially felt relaxing and fun, patients told us that these sessions also stimulated their mutual responsiveness (in schema therapy language 'facilitated their happy child mode'). background -societal measures in context of the covid- outbreak forced us to transform our schema therapy-based day-treatment for older adults with chronic affective disorders and personality problems into an online program. the objective of this paper is to present first impressions of this transformation. methods -using over-the-phone instructions initially, all patients were able to participate with the online therapy program. to reduce screen-time for patients, the non-verbal therapies were shortened. four patients, aged - years, started our online program. results -therapists were positive about the online capabilities and resilience of patients to adapt to the new situation. prejudices on limited effectiveness of online psychotherapy were counteracted. sending homework by email and mail seems to facilitate therapy adherence. non-verbal therapy could be important to stimulate the online group process. conclusions -we were positively surprised by the online capabilities of our geriatric mental health care patients and encourage further formal effectiveness studies. after the world health organization declared the covid- outbreak a pandemic on march th , mental health care providers in the netherlands restricted face-to-face contacts to emergency cases only. societal measures like social distancing and self-isolation are important for older persons as they face the highest covid- mortality rates. but lack of time spent with others may lead to more loneliness and an increase in affective symptoms. the need to switch to online health therapies for this patient group is therefore self-evident. as e-health services are gradually growing in mental health care, geriatric psychiatry departments are generally lagging, based on assumptions that older persons lack necessary computer skills and are not familiar with the online world. , converting our psychotherapybased day-treatment into an online program was also challenging as online psychotherapy generally focusses on individual (verbal) psychotherapy sessions. , our program is based on verbal and non-verbal group activities, given twice per week over a -week period. the program is entirely based on schema therapy and aims to treat older (≥ years) persons suffering from chronic and/or treatment resistant affective disorders and comorbid personality problems. schema therapy is an integrative treatment approach that combines cognitive, behavioral, experiential and psychoanalytic therapy techniques into one therapy model. schema therapy is an evidence-based treatment for borderline personality disorders, and has been adapted for other disorders, including late-life affective disorders . the covid- pandemic forced us to develop online schema therapy. in doing so, we were able to continue to provide online group sessions. the objective of this paper is to present first impressions on feasibility of transforming a psychotherapy day-treatment program for older persons into an online program. our day-treatment was originally developed for patients aged years and older suffering from an affective disorder (depressive, anxiety or somatic symptom), with comorbid personality problems considered to maintain affective symptoms and/or predispose for relapse. the standard intake procedure at our outpatient clinic includes psychiatric and neurocognitive diagnostics. patients referred to day-treatment are additionally assessed with the scid- -pd to assess the presence of a personality disorder according to dsm- criteria and fill out the -item self-report schema mode inventory (smi for the treatment to be effective, a patient has to have introspective abilities and the desire to change. these preconditions are assessed by a psychologist pre-treatment. during treatment, progress is evaluated every four weeks with the patient and their relatives. in this paper, we describe four patients who started the online day-treatment together. all patients went through the normal outpatient intake procedure. for two patients the whole pretreatment phase was conducted online. our psychotherapy day-treatment program is based on the schema therapy framework. in geriatric psychiatry, we focus on three (instead of five) most prominent maladaptive schemas to minimize cognitive burden. treatment is given twice weekly in an open group, with a maximum of eight patients at the same time over a -week period. to maintain a safe treatment environment, treatment adherence is considered mandatory and has been discussed prior to start. the original program was transformed to an online program using 'webex', with minimal changes. prior to commencement of the online group therapy, the therapy manual was sent by mail (including all forms, information sheets and questionnaires) as well as the material needed for art therapy. the nurse-practitioner called the patient to set-up and test webex. the psychologist ensured the patients understood and obeyed privacy rules. privacy rules included the use of a specific therapy room (no living or bedroom), no other people in that room during therapy and no recordings. the non-verbal components (art therapy, psychomotor therapy) were reduced in length, and behavioral therapy (given after a session of cognitive therapy) was replaced by an additional psychomotor therapy session (see table ). psychomotor therapy focusses on the bodily experiences in interaction, contact and emotions. since online group therapy hampers informal patient-therapist contact, we added one individual online session per week to jointly monitor the patient's process. three female and one male patient aged between and years participated. psychiatric diagnoses were ) recurrent, mild depressive disorder and borderline personality disorder, ) generalized anxiety disorder, ) recurrent depressive disorder, panic disorder and avoidant personality disorder with narcissistic features, and ) recurrent depressive disorder and a personality disorder nos with borderline, avoidant and schizotypical features. thus far, treatment adherence was %. patients felt being taken seriously (see quotes, supplemental digital material). firstly, because during the online group sessions they all received detailed comments on their homework (sent by email and discussed online). secondly, by having brief weekly individual contacts (either by phone or video call) with one of the therapists. while individual contacts with therapists are restricted as much as possible during our regular day-treatment program, such contacts are still quite normal during coffee breaks and lunches. where the non-verbal sessions initially felt relaxing and fun, patients told us that these sessions also stimulated their mutual responsiveness (in schema therapy language 'facilitated their happy child mode'). after two weeks, patients reported to lack informal contact with each other. since face to face day therapy offers many informal contact moments, we added a so called 'break out time' without the presence of a therapist. in the (diagnostic) pre-treatment phase, no alterations appeared to be necessary. mutual acquaintance, checking motivation for change and mentalization capabilities and setting up the individual treatment plan ran smoothly by videoconferencing. therapists had time to prepare the psychotherapy sessions, as they received homework per email and thus were able to challenge maladaptive thoughts and behavior more efficiently. while therapists considered the digital whiteboard as helpful, patients preferred to remove the whiteboard as its use reduced the size of the patients' webcam feeds. after patients got comfortable with working online and became more responsive to each other, the group schema therapy also ran smoothly. therapists felt that experiential interventions, like guided imagination, were well received. the psychomotor therapy turned out to be much easier than expected, active movements (gymnastics), relaxation and mindful exercises (e.g. tai chi) were well received by the patients. the shared-screen functions enabled patients to participate in imaginary experiential experiences like touching 'through the screen' or practicing with proximity/distance by moving towards/away from the screen. to our knowledge, no papers on an online multidisciplinary day-treatment program for older adults have been reported. therapists were initially skeptical regarding feasibility but were ultimately more than satisfied with the results of our online program (see quotes supplemental digital content). the first eligible patients were all prepared to take part and communicate online. however, our patients were relatively well-educated and could be classified as 'younger-old', which limit firm conclusions with respect to feasibilty. on the other hand, participation only requires basic e-mail skills and % of households in the netherlands have a broadband internet connection. schema therapy is considered most effective in groups, as patients trigger maladaptive schemas in each other. during online therapy, we experienced that a brief internet disruption, disconnecting a patient for a few minutes from the group, already triggered the feeling of being rejected. furthermore, covid- related social distancing measures appeared to trigger feelings of rejection in patients with borderline personality traits, while it falsely validated indoor behavior of patients with avoidant personality traits. sending homework for the verbal therapies as well as exercises for the non-verbal therapies the day before the session enabled us to conduct therapy more efficiently. this might increase adherence to the therapy protocol and even enhance effectiveness. the outbreak of covid- pushed us to overcome all prejudices towards online (group) psychotherapy. important lessons we learned were ) digital literacy of older persons is sufficient for online therapy, ) brief individual contact is important to monitor the patients' process and ) non-verbal therapies as well as informal break-out time facilitates the group therapy process. we hope that our positive experience will motivate others to start such initiatives when face-to-face day-treatment is not possible and will motivate researchers to further study its effectiveness. legend: -nurse-led behavioral activation including week opening (monday) and week closing (thursday) ceremony. green -traditional (verbal) psychotherapy, including schema therapy, cognitive therapy and behavioral therapy orange -nonverbal schema therapy, including art therapy and psychomotor therapy red -break-out time (time online for patients only) social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older americans (nshap): a longitudinal mediation analysis is computerized cognitive-behavioural therapy a treatment option for depression in latelife? a systematic review a naturalistic study of the acceptability and effectiveness of internet-delivered cognitive behavioural therapy for psychiatric disorders in older australians videoconferencing psychotherapy and depression: a systematic review effects of schema group therapy in older outpatients: a proof of concept study reliability and validity of the short schema mode inventory (smi) young schema-questionnaire cognitive therapy for personality disorders: a schema-focused approach group schema-focused therapy enriched with psychomotor therapy versus treatment as usual for older adults with cluster b and/or c personality disorders: a randomized trial changes in symptom severity, schemas and modes in heterogeneous psychiatric patient groups following short-term schema cognitive-behavioural group therapy: a naturalistic pre-treatment and post-treatment design in an outpatient clinic on behalf of the e-compared consortium: attitudes towards digital treatment for depression: a european stakeholder survey we would like to thank the patients for their consent to use their diagnostic information and comments for this paper. none. none. key: cord- -e xagi authors: rhim, hye chang; han, heeyoung title: teaching online: foundational concepts of online learning and practical guidelines date: - - journal: korean j med educ doi: . /kjme. . sha: doc_id: cord_uid: e xagi medical schools have been slowly adopting online learning into pedagogical methods for more than a decade. while some medical educators are reluctant to accept these changes, the ongoing coronavirus disease (covid- ) pandemic poses a threat to the delivery of traditional medical education, which has accelerated the inevitable implementation of online learning. this sudden change may be a new challenge to medical educators who are new to this territory. therefore, this review aims to provide foundational concepts of online learning and practical guidelines in the context of medical education. the authors first identify three foundational concepts, which are transactional distance, presence, and independent learners. in online learning, transactional distance, determined by dialogue and structure, becomes more important than physical distance. furthermore, effective and successful online learning requires the achievement and accommodation of cognitive, social, and teaching presences. it is also crucial to recognize learners not as passive recipients of information predefined by a teacher, but as active, capable, and independent individuals. the authors, then, discuss the practical guidelines for designing an effective online curriculum. five online pedagogical guidelines are laid out in this review: design structures and flows to embrace experiential learning, accommodate both synchronous and asynchronous learning, design/facilitate interactions, promote practice opportunities, and promote a learning community. by understanding the foundational concepts and applying these guidelines, the adoption of online learning in the medical school may supplement the traditional medical education or even provide additional benefits in the new normal after the covid- pandemic. although the covid- pandemic has disrupted medical education in unprecedented ways, ironically, the virus seemed to have worked as the catalyst for embracing virtual learning [ ] . in fact, prior to the covid- pandemic, medical schools have been slowly implementing online learning into pedagogical methods for more than a decade [ , ] ; however, they have been still reluctant to accept these changes [ ] . despite the uncertainty regarding how long this pandemic will persist and the possibility of a new pandemic in the future, the pedagogical reevaluation of online learning as the main curriculum environment is undergoing in medical education [ ] . however, this transition requires more than simply recording a lecture and uploading it in online platforms. it is not a simple copy and paste practice of existing face-to-face teaching activities in an online format. it is a re-mediation process of the current instructional practices, requiring to revisit the current assumptions on physical space and time in educational practices [ , ] . the covid- pandemic was unexpected and the changes necessary to continue medical educations were abrupt; thus, the adoption of online learning may be challenging to medical educators, in particular, who are new to this territory. therefore, the purpose of this review is to provide foundational concepts of online learning that can be historically traced back to distance education and discuss the practical guidelines for designing an effective online curriculum. online learning has a historical root in distance education; the latter was an alternative educational practice and program for nontraditional learners who could not have had education opportunities otherwise [ ] . online learning is described as access to learning experiences via the use of the internet and considered a more recent version of distance learning [ ] . although there seem to be subtle differences in the definitions of e-learning, online learning, and distance learning, these terms are used interchangeably and rooted in distance education [ ] . the physical and temporal distance was emphasized in shaping this new form of education centuries ago. the development of the postal system provided opportunities for non-traditional students who worked during the day and lived distant from a college. distance education enabled these students to overcome distance and time, and the subsequent advent of newer technologies such as tv and the internet closed the distance between teachers and students even more. while the current stage of technological innovations allows for faster and easier synchronous and asynchronous communications, transactional distance still needs to be considered in online learning. there are three foundational concepts for effective distance education programs, which become the basis of instructional design of online learning and teaching practices: transactional distance, presence, and independent learners. physical distance is a barrier to traditional education. however, distance in online learning is not defined by physical distance but "transactional distance" [ ] . according to moore [ ] , transactional distance is a social, psychological, and relational distance between teachers and learners that is fluid and manageable based on a function of dialogue and structure. when dialogues, meaningful interactions between teachers and learners for the creation of knowledge, are increased, the transactional distance between them can be reduced. even in a classroom, if a teacher does not have a dialogue with students, the latter would feel a greater transactional distance. the degrees and characteristics of dialogues depend on numerous factors but mainly on the structure of the course and, to a lesser extent, on the medium of communication. here, structure indicates the rigidity or flexibility of the educational program. it depicts the degree to which a course can respond to each learner's different demands and preferences. when the teaching is highly structured without consideration for the learners' differences and individualization in their learning processes with minimal dialogue, the transactional distance becomes high [ ] . online courses not providing ongoing dialogue between a teacher and learners and rarely accommodating individual students' needs would have high transactional distance and become undesirable. therefore, educators need to understand that the medium of communication would not automatically close the distance between teachers and students. furthermore, the transactional distance may remain intact depending on the extent of dialogue and structure. another foundational concept of online education is presence. there are three kinds of presence: cognitive presence, social presence, and teaching presence [ ] . when an individual is involved in online learning, it implies that the individual becomes a member of a "community of inquiry" as a learner or a teacher (or both). effective and successful online learning requires each member to achieve and accommodate these three types of presence [ ] . "cognitive presence" indicates the degree to which the learners can construct meaning through constant exchanges of thoughts-questioning, answering, brainstorming, discussing, and solving a problem [ , ] . in "social presence" can be achieved when learners project their personal feelings, emotions, questions, and characteristics into the community [ , ] . garrison et al. [ ] argued that socio-emotional interactions and support are crucial and essential at times in nurturing cognitive presence and, therefore, leading to meaningful educational outcomes [ ] . social presence helps members in the community reduce psychosocial tension and uncertainty as well as encourages the group to freely discuss and collaborate on a project, exceeding simple interactions and one-way instructions. collaborations draw learners to a shared experience space to construct and confirm meaning. in this respect, a successful online learning community needs to promote collaboration rather than simply exist as a place to download information. "teaching presence" indicates two general functions, design of the educational experiences and facilitation [ , ] . the former function may be the primary responsibility of the teacher who selects, organizes, presents course content, and develops learning activities and assessments, providing clear expectations and a basic guideline on learning activities. facilitation can be achieved by the teacher or the students in an online environment. the role of teaching presence is to support and enrich social as well as cognitive presence to accomplish meaningful educational outcomes. effective online teaching requires a fundamental perspective change regarding learners. learners are not passive recipients of information predefined by a teacher, but active, capable, and independent individuals with their own learning processes to explore their environments in knowledge construction [ ] . as briefly discussed in the previous section of teaching presence, teachers' roles lean toward the facilitation and the design of learning experiences that allow learner autonomy. however, it is also true that students have varying degrees of ability to develop a personal learning strategy, to find resources for study, and to assess their own progress [ ] . a higher transactional distance means that teaching requires more autonomous learners; however, students do not always have a high level of autonomy. the role of teachers in the online environment, then, includes not only providing information but also motivating and empowering students to enrich their learning experience. in sum, teaching online requires three foundational understandings about distance, presence, and learners. transactional distance, cognitive presence, social presence, teaching presence, and independent learners can become guiding parameters in the design of online learning programs. in the following section, we will discuss practical guidelines for online teaching that are based on those three foundational concepts. online teaching is a design of learning experiences and facilitation of those experiences. in this section, we will discuss the design of learning experiences by explaining five online pedagogical guidelines: design structure and flow to embrace experiential learning, accommodate both synchronous and asynchronous learning, design/ facilitate interactions, promote practice opportunities, and promote a learning community. effective online teaching can be achieved by embracing an experiential learning approach [ ] . however, it may extend to small group discussions, team-based learning, cadaver dissection lab during the preclinical years, and even their personal experiences before medical training. a teacher's instruction or lecture can be considered as a stimulus that provides the learner with an opportunity to observe what a content expert thinks and knows [ ] . students absorb what they have been told as a response and ought to have opportunities to connect their experiences with their observations to identify general principles [ , ] . students need to actively engage and interact with their surroundings to test what they learned, that is, students are allowed to experience further to absorb (response) given instruction (stimulus). therefore, online teaching is not one single event of lecturing but continuous facilitation of the experiential learning cycle. the flipped classroom is a pedagogical approach that allows an experiential learning cycle in an online learning environment. in a flipped classroom, students learn didactic materials at their own pace before the class using pre-recorded lectures available asynchronously. students would connect their prior experiences with the newly observed resources to create their own knowledge. then, students would bring their understandings during face-to-face or synchronous online interactions with the teacher, where they can actively test their understandings and engage in problem-solving while interacting with the teacher and peers [ ] . with the expert's scaffolding and guidance on the side, learners can further develop their own knowledge and skills that would feed into future experiences [ ] . there are four interactions that online teachers should consider: students' interaction with resources, interaction with the instructor, interaction with the peer, and interaction with self [ , ] . these interactions have been found crucial for meaningful learning experiences and effectiveness in online learning [ ] . online learning may be seen as an alternative instructional modality just for classroom learning without actual practices or experiences. as discussed in the earlier section, however, concrete experience is a crucial part of any learning process. this becomes more critical in medical education where clinical experience is the central part of medical competency development. despite the physical distance, there are ways that medial educators can facilitate learners to have clinical practices in an online environment. one is a mediated experience. can be mediated and what cannot be. for example, teaching students about working on a night shift and interacting with different healthcare professionals might be hard to mediate in an online environment. however, some experiences can be practiced in an online environment. for example, klamen [ ] argued that third-year medical students cannot possibly see all kinds of patients in clerkship rotations [ ] . even after seeing the patient, practicing clinical reasoning in which students identify differential diagnoses and treatment plans did not occur due to busy workflow in hospitals and clinics [ ] . moreover, it is also challenging for novice medical learners to observe attending physicians' thought processes on a busy clinic day. after recognizing this issue, klamen et al. [ ] adopting online learning means transforming teaching philosophy to embracing organic collective intelligence for a sustainable learning environment [ ] . in online learning, teachers are not the only source for building knowledge; students learn from teaching others, and by observing their peer students. the line between the teacher (knowledge provider) and the learner (knowledge receiver) is blurred in online learning. effective online learning can be sustainable and strengthened by a learning community [ ] . there must be a sense of a learning community at a medical school. teachers can simply recognize and facilitate the existing learning community as well as create a new one even beyond the existing school system. a sense of a learning community can be created by asynchronous interactions as well as synchronous interactions online or in-person. a teacher's asynchronous online presence at an online discussion forum can be beneficial because of the students' extended opportunity to interact with the teacher anytime anywhere. teachers take multiple roles in facilitating a learning community: an information provider, a facilitator for students' participation, collaboration and peer learning, a curator to connect students to other organized resources, and a lifelong learner, not just an evaluator. social presence is crucial in creating a functional online learning community [ ] . members including teachers should feel comfortable being who they are and be able to share struggles as well as although the covid- pandemic poses a threat to traditional medical education, it has also provided an opportunity to recognize online learning as an effective pedagogical method. its effectiveness, however, depends on the degree to which medical educators are aware of the foundational concepts of online learning. unlike a physical distance that was a barrier to traditional education, transactional distance should be considered in online education. the educators need to understand that the advancement in communication technology itself would not automatically close the distance between the teachers and students; instead, educators should try to promote dialogue and social presence as well as minimize structure in order to reduce the transactional distance. also, the role of a teacher is not limited to someone who provides information but also someone who motivates students to enrich their learning experience. we provided five online pedagogical guidelines for designing curriculum in the medical education context. practice opportunities can be more widely available through online platforms in certain patient cases. lastly, efforts need to be made to maintain a sense of a learning community even in an online environment. by understanding the foundational concepts and applying the online pedagogical guidelines (which are summarized in fig. ), the adoption of online learning in the medical school may supplement traditional medical education or even provide additional benefits in the new normal after the covid- pandemic. hye chang rhim: https://orcid.org/ - - - heeyoung han: https://orcid.org/ - - - innovation in response to the covid- pandemic crisis medical student education in the time of covid- flipped classroom improves student learning in health professions education: a meta-analysis the inevitable reimagining of medical education mediation and remediation in online learning liquid modernity learning at the back door: reflections on non-traditional learning in the lifespan e-learning, online learning, and distance learning environments: are they the same? internet high educ theory of transactional distance theory of transactional distance the theory and practice of online learning critical inquiry in a text-based environment: computer conferencing in higher education experiential learning: amee guide no. the reflex arc concept in psychology the flipped classroom in medical education: engaging students to build competency mind in society: the development of higher psychological processes asynchronous and synchronous e-learning a framework for analyzing, designing, and sequencing planned elearning interactions information age publishing three types of interaction building learning communities in online courses: the importance of interaction getting real: aligning the learning needs of clerkship students with the current clinical environment getting real: embracing the conditions of the third-year clerkship and reimagining the curriculum to enable deliberate practice learning in the real place: medical students' learning and socialization in clerkships at one medical school virtual bedside teaching rounds with patients with covid- guidelines for facilitating the development of learning communities in online courses the relationships between higher order thinking skills, cognitive density, and social presence in online learning acknowledgements: none. key: cord- - syf upw authors: dong, chuanmei; cao, simin; li, hui title: young children’s online learning during covid- pandemic: chinese parents’ beliefs and attitudes date: - - journal: child youth serv rev doi: . /j.childyouth. . sha: doc_id: cord_uid: syf upw online learning has been widely promoted to replace traditional face-to-face learning during the covid- pandemic to maintain young children’s learning and play at home. this study surveyed chinese parents’ beliefs and attitudes around young children’s online learning during the lockdown of the covid- pandemic. most parents ( . %) in the study reported that their children had online learning experiences during the pandemic, and many ( . %) spent less than a half-hour each time. the parents generally had negative beliefs about the values and benefits of online learning and preferred traditional learning in early childhood settings. they tended to resist and even reject online learning for three key reasons: the shortcomings of online learning, young children’s inadequate self-regulation, and their lack of time and professional knowledge in supporting children’s online learning. also, the hardship caused by the covid- pandemic has made them suffering, thus more resistant to online learning at home. the results suggested that the implementation of online learning during the pandemic has been problematic and challenging for families. the chinese parents were neither trained nor ready to embrace online learning. the paper concluded with implications for policymakers and teacher education. learning, opportunities, and learning experiences children receive at home (erdogan, johnson, dong, & qiu, ) . to fill this research gap, this study endeavors to understand how chinese parents perceive their young children's online learning during the covid- lockdown through a large-scale online survey. online learning refers to "the learning experienced through the internet" either in the synchronous or asynchronous environment where students engage with instructors and other students at their convenient time and place (singh & thurman, , p. ) . online learning has seen a fast growth during the past decade because it has greater flexibility in terms of time, place and pace of the study, easier and more effective access to a wider variety and greater quantity of information, and lower financial cost (chen, ; khurana, ) . in a globalized digital age, government agencies, educational institutions, corporations worldwide are increasingly promoting online learning, resulting in a shift from traditional face-to-face classes to distance and online learning (aldhafeeri & khan, ) . with the advancement of new communication technologies, online learning can provide a rich, authentic learning ecology that can facilitate collaboration and interdependence between learners (aldhafeeri & khan, ) . however, researchers (chen, ; o'doherty, dromey, lougheed, hannigan, last, & mcgrath, ) have expressed their concerns about the quality of online learning and highlighted the main difficulties in creating an online learning community with a high degree of social presence and engagement. in addition, some scholars are also concerned about the major problems of online learning, such as social isolation, lack of interactivity and participation, delayed or insubstantial amount of feedback (khurana, ) . similarly, young children's digital learning has also been debated and criticized. some scholars (jiang & monk, ; radesky, eisenberg, kistin, gross, block, zuckerman, & silverstein, ) highlighted their concerns about online risks and dangers, addiction to videos, social isolation, and physical health issues. others suggested that parents play the mediating role to prevent harm and regulate children's online activities, such as setting up technology use rules for and monitoring their children's media use (nouwen & zaman, ) . all these concerns, however, could not prevent online learning from rapidly expanding in the past decade and extensively reaching millions of young learners at an unprecedented speed (franklin, burdette, east, & mellard, ; silverman, ; zalaznick, ) . more and more online programs have been developed and delivered to support young children with disabilities and/or living in remote or disadvantaged situations to provide learning flexibility (smith, burdette, cheatham, & harvey, ; zalaznick, ) . in addition, online technologies have become the social, cultural, and personal artifacts that inhabit the contemporary child's 'multimodal lifeworld' (arnott & yelland, ) . it thus should be promoted to build a multimodal learning ecology for contemporary children, parents, and teachers. while online learning appears to be more prevalent in the future (franklin et al., ) , a lack of research has addressed online learning in the early years, specifically. this study will fill this gap by surveying chinese parents who have engaged in their young children's online learning during the covid- pandemic. parents' beliefs and attitudes around early digital and online learning have been found polarized in the past decade. on the one hand, parents have started to appreciate the value of digital devices and tended to feel comfortable with young children's use at home (livingstone, mascheroni, & dreier, ; mikelic preradovic, lesin, & sagud, ; sharkins, newton, albaiz, & ernest, ) . they also supported the appropriate use of digital devices in early years settings (isikoglu erdogan, johnson, dong, & qiu, ; kumpulainen & gillen, ) . in particular, parents even held positive attitudes towards young children's computer use and believed that children should gain valuable technical skills and should be educated on how to use computers to enhance their academic development and future opportunities, such as employment (hatzigianni & margetts, , perradvoci et al. ). in the increasingly diverse digital landscape, parents believed that a range of digital and online technologies could offer young children new knowledge and learning. and those parents with a higher education level tended to believe that digital and online learning can develop children's learning competencies, language, self-expression, and social competencies (lepicnik-vodopivec & samec, ) . on the other hand, parents were concerned about the dangerous content on the internet and the risks of unrestricted digital use. they were worried about the impact of digital use on children's social and health development (plowman et al., ; lepinic & samec, ; jiang & monk, ) . more recently, due to the rapid growth of screen technologies (e.g., ipads, smartphones), parents have expressed their uncertainty about whether mobile devices could be beneficial or harmful to their children and how to adopt these mobile screen technologies (radesky et al., , livingstone et al. , erogan et al., . the eu kids online project (livingstone, ) , for instance, revealed that parents with higher income and education had employed a wide range of practices and strategies to manage restrictions for digital device use and had spent efforts to promote offline activities for children while limiting digital activities at home. some parents set rules and limits on the frequency and duration of using digital devices but did not recognize the importance of their role and involvement in supporting young children's technological engagements (plowman , hatzigianni & margartts, . the studies, as mentioned above, have explored parents' perspectives and practices on children's digital use in general, leaving their beliefs and attitudes about online learning unstudied. in particular, during the covid- pandemic, the sudden shift to online learning has presented new opportunities and unexpected challenges to the affected young children and their parents. under such unique circumstances, there is a need to examine parental beliefs and attitudes concerning online learning and readiness and acceptance to make this drastic shift. furthermore, most of the existing studies are western-centric and may not represent views from the eastern countries, where the culture and educational philosophies might differ. indeed, parental beliefs about digital technologies and media are not formed in a vacuum; instead, they are shaped by cultural norms (mansour, ) . thus, it is of great theoretical importance to understand chinese parental beliefs and attitudes around young children's online learning during the lockdown as a unique study in terms of time and place. the outbreak of covid- in wuhan started spreading in china in december , and then was declared as the public health emergency of international concern by the world health organization (who) on january . the national authorities worldwide have responded to this crisis by implementing travel bans, lockdowns, workplace hazard controls, and facility closures. preschools, schools, and universities have been closed either on a nationwide or local basis in countries, affecting approximately . % of the world's student population (unesco, ) . china is no exception. as an urgent response to the covid- pandemic, in early february , the ministry of education of china ( a) mandated that all schools and universities stop face-to-face teaching and use internet platforms to deliver online learning. school children were required to attend online classes to continue their education. although preschools were not required to deliver online learning and had no mandatory online educational programs, ece stakeholders including educators from public sectors and private curriculum developers were proactively engaged in designing digital curriculum resources and introducing educational apps and platforms to guide parents to support their children's learning and play at home (ministry of education, b). under such circumstances, many chinese parents followed the suggestions from teachers and educational authorities to provide online learning to their children during the lockdown. such influences on parents in adopting online learning are not difficult to understand in chinese sociocultural contexts. chinese early childhood education is shaped by its social culture and educational tradition. confucian culture has strongly influenced the relationships between teachers and children in chinese society (llasera, ) , which has laid great emphasis on adoring authority and respecting teachers (hargreaves, ) . tobin et al., ( , p. ) found that the role played by chinese preschools and teachers in the relationship with families is "explicitly political and ideological." preschools are viewed as social representatives, so they have the "right and responsibility" to correct the deficiencies of indulgent parents. preschool teachers, "as government employees with a governmental mandate," carry authority into their interactions with parents and see their roles as supporting and correcting parents (tobin et al., ) . accordingly, the controversial digital and online learning for young children has been conducted under this unique and special circumstance in china. without training and preparation for online teaching, chinese parents and teachers have been engaged in this brand new experiment of digital and online learning for young children. naturally and expectedly, these parents and teachers might have encountered many difficulties, problems, obstacles in this unexpected experiment. thus, this unique scenario has provided an ideal arena for us to understand chinese parents' beliefs and attitudes around young children's online learning at home. accordingly, this study aims to address the following research questions through an online survey: . what were chinese parents' attitudes towards online learning for their young children? this survey study was conducted in an inland city of henan province, which is located in the central area of china. altogether parents whose children were enrolled in local early childhood education programs voluntarily completed the online survey. the majority of them were aged between - years ( . %), and between - years ( . %), few were aged between - years ( . %), very few were years or above ( . %), and none was under years. their educational levels were very diversified: junior secondary school, high school, associate degree, bachelor, and postgraduate degree. and their occupation also varied greatly: government/public organizations, state-owned enterprise, private enterprise, personal owned business, freelancer, and unemployed. most of the parents have one or two children; very few of them have three or four plus. half parents ( . %) reported their children were - years old, and some ( . %) were - years old. the background information of the sample is presented in table below. the questionnaire consists of three parts and includes closed questions and two open- part iii: parents' beliefs and attitudes around online learning. this section adopted a five-point likert scale (ranging from "strongly disagree" to "strongly agree") to ask for parents' perspectives about online learning. the questions could be classified into three subscales. the questions could be classified into three subscales. subscale one is about the pros and cons of online learning ( items): parents were asked to compare online learning with the traditional face to face approach. to generate an initial pool of question items for measuring parents' beliefs and attitudes, previous studies on online learning (aldhafeeri & khan, , o'doherty, dromey, lougheed, hannigan, last, & mcgrath, , singh & thurman, were identified and reviewed. in particular, the two doctoral theses on the role and the effects of online learning were used to guide the design of the questionnaire items (chen, , khurana, . in their doctoral work, they compared both traditional and online education and examined the pros (e.g. convenience) and cons of online learning (e.g. lack of social presence) for learners. the main advantages and shortcomings identified in their study were 're-examined' in this study. specifically, the questions were centered on the efficiency, content, cost, effect, learning atmosphere, outcomes of online learning for young children and families. subscale two is focused on the value of online learning for young children ( items): parents were asked to evaluate the value of online learning based on the five learning and developmental areas ( wellbeing, language, society, science, and arts) outlined by the educational authorities (ministry of education, ). as indicated earlier in the literature, specific research studying online learning in the early years is limited, this study aimed to fill this research gap by studying parents' beliefs about and attitudes towards the value of online learning for young children. as a result, the frequent topics and heated debates (e.g. brady & hill, ; elkind, ; house, , plowman, mcpake, & stephen, parents were asked to evaluate the impact of online learning on parenting and family education suggested by the educational authorities (ministry of education, ). since this study was conducted during the pandemic, online learning was provided as an alternative approach to supporting children's learning and family education at home. the questions were also used to examine the impact of online learning on parenting and family education (see the questionnaire in an appendix). the internal consistency of part iii was measured, and the reliability for its three subscales was . , . , and . , respectively, indicating satisfactory reliability. the survey was administrated in middle march after parents and children had been quarantined at home for two months since china imposed national lockdown in late january. all the parents and young children had gained substantial experiences with online learning. the participants were invited by their children's preschools to complete this online survey conducted on wenjuanxing (www.wjx.cn), the leading online survey platform in china that provides functions equivalent to amazon mechanical turk. the participants were clearly informed throughout the study that participation in this research was completely voluntary, and they could withdraw their participation at any time without any reason. both quantitative and qualitative approaches were adopted in analyzing the data in this study. first, the quantitative data were analyzed using ibm spss . software. first, data cleaning was conducted, and the very few missing values (< . %) were replaced with the mean of the concerned variable. second, descriptive statistical analysis was performed to calculate the frequency, mean, and sd of parents' characteristics and children's online learning activities during the outbreak of covid- . finally, for analysis, the responses were given a score for each item from one to five: =strongly disagree; =disagree; =neutral; =agree; =strongly agree. items that were phrased negatively were subsequently re-coded to make the scales read in the 'positive' direction, lower scores, therefore, reflecting negative or less positive beliefs. the mean scores were calculated for each scale, which provides an overall picture of the parental responses. second, the qualitative data collected from the two open-ended questions were analyzed using nvivo software. the two questions are: ( ) what areas would you allow your child/ren to continue to learn online after the pandemic? ) what are your comments or opinions on young children's online learning? the research team collaboratively conducted data coding and analysis. the process of coding the data was cyclical and iterative, involving numerous conversations among the two coders to eliminate inconsistencies in interpreting the data due to who was coding. throughout the coding process, coders worked from the same codebook, as exemplified in table , which allows each coder in the research team to consistently and reliably analyze the data. the qualitative data were parents' brief comments to the open-ended questions, and they were mainly - short sentences. generally, the qualitative data collected were straightforward for generating categories. the two coders also met to discuss any disagreements of coding and used strategies (e.g. redefining the codes) to reach agreement on coding. thematic analysis (braun & clarke, ) was employed to identify, analyze, and report patterns generated from the data. the qualitative data analysis followed their step-by-step guide in six phases. ( ) familiarising ourselves with the data; ( ) generating initial codes, such as opposing online learning; ( ) searching for themes; ( ) refining and reviewing themes; ( ) defining and naming themes; and ( ) writing qualitative results. for instance, parents' comments were first coded into two broad categories: supporting online learning and opposing online learning. the initial categories were then reorganized and sorted into themes around reasons for and against online learning. among all the reasons identified, the three themes emerged: shortcomings of online learning, young children's inadequate selfregulation, and parental lack of time and professional knowledge. overall, most parents ( . %) reported that their children had online learning experiences during the pandemic, and many ( . %) spent less than a half-hour each time. specifically, these parents indicated that their children learned online once ( . %) or multiple times ( . %) per day, whereas some had only once or twice or three times per week. in addition, about one-third of the children had less than minutes of online activities per time, and some had an average between - minutes. the majority of the parents used free online learning resources with no or meager cost. and the children's online learning was mainly delivered and guided by preschool teachers or other staff; some were guided by online apps, webs, and others, as shown in table . table presents the analysis results about the young children's online learning activities during covid- . first, many young children watched the recorded lessons online once, or multiple times per day, some children watched only once or twice or three times per week, only a small percentage of them never did so. the children's online learning content was varied, including literacy, brain exercises, and science, as well as arts. a small number of parents commented in the open question that their children were learning physical exercise and language online. second, many young children attended the live class online once, or multiple times per day, some children attended only once or twice or three times per week, about of them never did so. third, many young children used wechat once, or multiple times per day, some children used it only once or twice or three times per week, and many of them never did so. fourth, many young children used the learning apps once, or multiple times per day, some children did it only once or twice or three times per week, but half of them ( . %) never did so. fifth, majority of the children attended online with parent presence once ( . %) or multiple times ( . %) per day, some children did it only once ( . %) or twice or three times ( . %) per week, very few of them ( . %) never did so. sixth, many children interacted with the instructor online once or multiple times per day, some children did this only once or twice or three times per week, many of them ( . %) never did so. last, many parents interacted with the instructor online once ( . %), or multiple times per day, half of them interacted only once or twice or three times ( . %) per week, whereas many of them ( . %) never did so. the quantitative data showed that the parents had relatively less positive beliefs about the value of online learning. the subscale one measured parental beliefs about the pros and cons of online education compared to traditional learning in educational settings. the mean for this scale was . , with a medium standard deviation of . . only a small percentage of participants believed that online learning has better learning content ( . %), better learning outcomes ( . %), and is more efficient ( . %) than the traditional approach. about half parents neither agreed nor disagreed on the statements about the pros and cons of online learning, indicating a neutral position on the value of online education. there were very few parents ( . %) among those who provided the comments, indicating that under the special pandemic situation, online education can be used to support children's learning. furthermore, the qualitative data indicated that the parents believed that traditional learning in educational settings was better than online learning in creating a learning atmosphere with better learning outcomes. some parents even commented that "online learning at home does not have a learning atmosphere" (parent ), "the efficiency of online learning is not high " (parent ), and "online learning atmosphere is not good " (parent ). these parents also explained their negative beliefs on online learning: lacking social interactions with peers, children did not treat online learning as a formal class; therefore were unable to focus on the learning. in addition, parents found it difficult to manage children's online learning at home as they did not have teachers' authority, as shown in the following quotes from their responses to the two open questions. the quantitative analysis indicated that the parents were less positive about the benefits of online learning. the subscale two had a mean of . and a medium standard deviation of . . a small percentage of parents believed that online learning could enhance young children's language development ( . %), literacy ( . %), social skills ( . %), independent skills ( . %), arts ( . %) and physical health ( . %). in general, more parents perceived that online learning could help children gain more science knowledge ( . %). approximately half of the participants had a neutral attitude towards the role of online learning for supporting children's development in language, literacy, independence, social skills, science knowledge, and arts. the qualitative analysis found that some parents commented that "during the special [pandemic] situation, children can learn online" (parent ). in contrast, others argued that "although children can learn via online approaches, the learning quality is not good" (parent ), and "the learning effect of online learning is bad" (parent ). some parents further explained that young children had weak self-regulation and a short attention span thus could not engage in online learning. for instance, they commented " children are too young, and their mind can't concentrate" (parent ) and "online learning efficiency is low, and children's self-regulation is poor, " (parent ) and "their initiative is not high, although they were learning the content as they were in school." in addition, the parents indicated their strong resistance and opposition towards online education caused by their concerns about the negative effects on children's development. as shown in the following quotes from their responses to the two open questions, the parents believed that online learning had more harm to young children than its benefits. among all the concerns, the most critical one is about the negative effect on young children's eye vision. some parents emphasized the potential harm to young children's social development and physical health, especially eye vision. there was a dilemma for parents to adopt online learning for their children, as revealed by a parent: children can learn some knowledge via online approaches, but they would develop an interest in watching smartphones and tv, which is not good for their eyes. in general, many parents stated harm and challenges caused by online learning without mentioning any benefits, as shown in the following quotes. the quantitative data from subscale three measured parents' beliefs and attitudes about the impact of online learning on parenting and family education, with a mean of . and a standard deviation of . . approximately half parents believed that online learning kept their children from doing nothing at home during the outbreak of covid- ( . %) and improved parent-child relationship ( . %) and inspired their educational ideas ( . %), and allowed them to see that children can participate in many forms of activities ( . %). overall, the parents had slightly more positive perceptions of the impact of online learning on their family education. in contrast, the qualitative data found that some parents perceived children's online learning as inconvenient, challenging, and time-consuming. about . % of the parents expressed that "[online learning] wastes too much adults' working time (parent ) and adds burden to parents (parent ) and affects parents' work significantly (parent ). this is because children do not have adequate self-control abilities (parent ), and children's online learning needs parents to stop their job to accompany them at home (parent ) and cost time and efforts (parent ). in addition, these parents mentioned various barriers for them to implement home online learning, including time constraints and professional knowledge in teaching children. notably, the parents who had more than one child identified more barriers to their younger children's online learning and juggled between their carer and worker responsibilities. in total, about . % of the parents commented that they would not recommend online learning in the early years, and they hoped online learning to be ceased as soon as possible after the pandemic. for instance, one parent wrote "disapprove online learning after the kindergarten reopens," while another commented, "hope to start kindergarten soon to implement traditional education." among these parents, some questioned the 'appropriateness' of online learning and similarly stated, "children are too young with weak self-regulation, and online learning is not appropriate," and ' online learning is not suitable for young children" (parent ). such finding is also supported by the quantitative findings that only a few parents ( . %) were willing to pay for online learning after the pandemic, and more than half of parents indicated that they would not allow their children to learn online once the covid- lockdown is over. as the first exploration of chinese parents' beliefs and attitudes around online learning during the covid- pandemic, this study has found that many young children had online learning experiences that were delivered by their kindergarten teachers or online learning apps at no or low cost. their parents, however, had different views about this online learning experience. this section will discuss these findings and their implications for future studies and practical improvements. firstly, this study found that the parents held a belief that online learning is less effective than traditional learning in early childhood educational environments. they believed that online education lacked a learning atmosphere and social interactions to engage young children, resulting in poor learning outcomes. these generally negative beliefs about online learning could be related to the two major causes. the first one is that the lockdown of covid- has caused a sudden shift to online learning. thus, it has challenged the traditional parental understanding of childhoods and expectations about early childhood educational practices, which should include free play and outdoor activities (stephen & edwards, ) . as noted by arnott and yelland ( , p. ) , "challenges remain in our understanding of childhoods in the st century and in integrating new technologies into children's learning cultures." the dominant ideas and popular discussion about childhoods in a digital age are either passive/at-risk or empowered (craft, ; dong, ; mertala, b; stephen & edwards, ) . such polarised debates have led parents and educators to believe that young children's use of digital technology is inappropriate and often caused dilemma and confusion for those seeking to incorporate digital technologies into young children's learning (dong & mertala, ; house, ; isikoglu erdogan et al., ) . to support educators, parents, and children to use new technologies better, researchers advocated a reconceptualization of 'childhoods' and 'play' in the digital age so digital artifacts can be embraced as unique and distinct resources to provide them with new opportunities for learning and play (arnott & yelland, ; edwards, ) . therefore, these chinese parents need to update their knowledge and develop a new understanding of 'childhoods,' 'learning,' and 'play' through parental education or family-school partnership programs. the second cause might be the major shortcomings of online learning, as noted by the critics (khurana, ; chen, ; doherty et al., ) : social isolation and lack of interactivity, which have repeatedly been reported by the parents during this unexpected experiment. vlachopoulos and hatzigianni ( ) have emphasized the need to address critical issues around students' online learning experiences and course outcomes. this study, however, found that all these critical issues had not been solved, even though many advancements had been made in digital and online technologies. therefore, chinese parents tended to have negative perceptions of digital and online learning. secondly, this study found that most chinese parents had a major concern about vision problems caused by online and digital learning. such concern has been shared by many parents and early childhood educators internationally (hatzigianni & kalaitzidis, ; mertala, a; sharkins et al., ; wartella & jennings, ) . in china, the prevalence of myopia appears to have rapidly increased in recent years, and more and more young children are reported to be short-sighted (ku, steptoe, lai, hu, chu, yen, & chen, ) . this problem has been attributed to the increased screen-time by the public (guarino, ) . therefore, the ministry of education and the seven other national authorities jointly issued (ministry of education, ) to regulate children's technology use by limiting the screen time. therefore, this concern reported by the chinese parents in this study is sensible and should be carefully addressed by the developers and designers of digital and online learning programs. thirdly, this study found that the parents were also worried about the lacking of physical activity as well as the addiction to screens such as tv and smartphones caused by digital and online learning. this concern is also reasonable and understandable, given that all the young children were quarantined at home during the covid- pandemic, and digital and online learning became their only channel to interact with teachers and peers. this finding is consistent with the existing ones that have suggested that parents and educators were concerned about the negative effect of screen time on young children's health development (edwards et al., ; livingstone et al., ; radesky et al., ; rhodes, ) . the chinese parents in this study reported using different strategies to restrict digital device use and making many efforts to promote offline activities for children while limiting digital activities at home. and some chinese parents have even planned to stop children's access to online learning once the pandemic is over. all these findings jointly indicated that chinese parents tended to view digital and online learning negatively. though this study was conducted in a different context (china) at a unique time , the findings of chinese parents' negative beliefs and attitudes around online learning are consistent with some western studies conducted in eu countries (livingstone, et al.,) and australia(australian government, ), which found that parents have been concerned about online risks and too much online time. specifically, the recent national survey of parents of children aged - that parents believed that their children spent too much time playing games, using social media, and streaming tv shows. however, the chinese parents tended to be more worried about children's eye vision deterioration caused by watching screens, which may be due to their younger age of their children in this study. first, this study found that chinese parents tended to reject online learning because their children had no or low self-regulation. this finding provides empirical evidence to support the claim that self-regulation is a prerequisite for successful online engagement and learning (vlachopoulos & chatzigianni, ) . furthermore, the chinese parents highly valued the linkage of self-regulation to the confucianism heritage that children should be self-restraint and self-regulate to follow the social rules and norms. this is more than the definition of self-regulation: "self-generated thoughts, feelings, and behaviors oriented to attaining goals" (zimmerman, , p. ) . however, this finding indicates that chinese parents might expect their children to learn and show self-control and self-regulation at a young age (luo, tamis-lemonda, & song, ) . second, this study found that chinese parents tended to reject online learning because their children were uninterested, inactive, and unfocused during online learning. this finding suggests that the young chinese children could not be regarded as self-regulated learners, who should be "metacognitively, motivational and behaviourally actively participants in their learning" (zimmerman, , p. ) . this finding, however, contradicts with the existing ones that young children were strongly interested in media and technology (sharkins et al., ) and that chinese children were curious and excited about digital programs (dong, ; dong & mertala, ; jiang & monk, ) . this discrepancy might be caused by the difference in the quality of digital and online learning, as one parent said that "the content of online learning is not very attractive to children" (parent ). therefore, it might be the poor quality and boring content of online learning that has caused the resistance and even rejection of chinese children and parents. the media of digital and online learning itself might not be the cause. this is why vlachopoulos and hatzigianni ( ) suggested that the design of online learning played an important role in shaping learners' perceptions of online learning. third, this study found that many parents, especially those with more than one child, tended to reject online learning because they had no time to support children's online learning at home. this finding is consistent with that study by (li, shi, wu, & li, ) , who found chinese parents of only-child tended to have more opportunities and educational resources than those of non-only children. the parents of only-child would invest more time and energy to help their child to excel in academic performance. besides, the chinese parents in this study generally perceived online learning as time-consuming and burdensome. similarly, smith et al. ( ) found that online learning required parents' significant time commitment. but the american parents in their study still wanted to be engaged in their children's online learning, even though they were shocked by the time required to support their child's online learning. the chinese parents in this study, however, did not realize the importance of their involvement and tended to reject to support their children's online learning. last but not least, this study found that the parents were negative about online learning because the covid- lockdown had made them suffering from the hardships and the unexpected demand from online learning. they felt unable to educate young children as their conventional role was not the teacher of a child, and they were not trained to do so. chinese parents and grandparents were often blamed by teachers for spoiling their children (tobin, hsueh, & karasawa, ) and allowing too much screen time (dong & mertala, . therefore, they tended to feel unconfident to teach their children at home and believed that their "children listen more to their teachers and have a better learning atmosphere at school" (parent ). accordingly, they were so eager to send their children back to preschools. digital and online learning is gaining popularity due to its advantages, such as greater flexibility, wider access, and low cost (khurana, ; chen, ) . however, this study found that the implementation of online learning during the covid- pandemic has been problematic and challenging for chinese families. chinese parents generally had negative beliefs and attitudes about the values and benefits of online learning and preferred traditional learning in early childhood educational environments. this is because they were neither trained nor ready to embrace online learning. the hardship caused by the covid- pandemic has made them suffer, thus more resistant to online learning at home. and these chinese parents were more concerned about the shortcomings of online learning, their children's inadequate self-regulation, and their lack of time and professional knowledge in supporting online learning. this study, however, has certain limitations. first, a large-scale quantitative study can provide representative and diversified evidence about the target topic. still, it has no way to gain an in-depth understanding of individualized situations and problems. interview or mixed-methods studies should be conducted to thoroughly explore chinese parents' authentic views, concerns, and difficulties. second, this online study simply collected self-report data, which might have a socially desirable bias. further studies with triangulation of methods (i.e., teacher-, self-, and peer-report) are needed to cross-check the results. nevertheless, for the first time, this study has investigated chinese parents' beliefs and attitudes concerning digital and online learning during the outbreak of covid- . the national lockdown has unavoidably affected many children's physical attendance at educational settings and made online learning an emergent alternative to maintain the continuity of learning and play at home (early childhood australia, ; silverman, ). even though online learning has been widely promoted in china to replace traditional education during the pandemic, the findings of this study indicate that the chinese parents were neither trained nor ready for doing so. this implies that the educational authorities need to do more to get chinese parents ready for online learning and to consider more about young children's age and learning interests. the findings from this study have implications for policymakers and educators globally who are promoting online learning as an alternative to young children and their families during the pandemic. the promotion and implementation of online learning to replace traditional early childhood education during emergent situations like covid- need to be carefully considered and well planned to support families, rather than adding extra burdens to them. this means that the promoters should consider the complexity and diversity of families (e.g. more than one child learning online and parents' working full time at home) when suggesting an online class to young children, and provide parents with flexibility and convenience. in addition, the provider of online learning should improve the design of online programs (e.g. easy login) to make parents effortless in using the program. elkind, d. 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(equity). district administration self-regulated learning and academic achievement: an overview becoming a self-regulated learner: an overview. theory into practice: becoming a self-regulated learner ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☒the authors declare the following financial interests/personal relationships which may be considered as potential competing interests:there is no research fund fo the project and the research has followed ethical procedure throughout the study. there is no conflict of interest. key: cord- -lj x qdd authors: niner, holly j.; johri, shaili; meyer, judith; wassermann, sophia n. title: the pandemic push: can covid- reinvent conferences to models rooted in sustainability, equitability and inclusion? date: - - journal: socio ecol pract res doi: . /s - - -y sha: doc_id: cord_uid: lj x qdd the covid- pandemic necessitates a change in conference formats for . this shift offers a unique opportunity to address long-standing inequities in access and issues of sustainability associated with traditional conference formats, through testing online platforms. however, moving online is not a panacea for all of these concerns, particularly those arising from uneven distribution of access to the internet and other technology. with conferences and events being forced to move online, this is a critical juncture to examine how online formats can be used to best effect and to reduce the inequities of in-person meetings. in this article, we highlight that a thoughtful and equitable move to online formats could vastly strengthen the global socio-ecological research community and foster cohesive and effective collaborations, with ecology and society being the ultimate beneficiaries. international conferences are valued as important for the development of both researchers and knowledge (fraser et al. , p. ; timperley et al. , pp. - ). yet, the traditional conference model that brings delegates together in a single 'destination' demands costly international travel and often high registration fees. given the associated carbon emissions and inequities in access, there is a particularly strong moral onus for those engaged in the field of socio-ecology to develop conference models or practices that do not contribute to the very problems that the discipline seeks to address. the forcing hand of covid- has opened an opportunity to trial online formats and to reinvent conferences as a core institution of research and practice. a global rise in community goodwill and flexibility in response to the challenges of 'lockdown' (morgan ) provides an opportunity to address some of the long-term ethical quandaries that relate to both sustainability and accessibility (ford et al. ; arend and bruijns ; timperley et al. ) posed by traditional conference formats. equal participation at conferences is restricted by access to financial support for travel and registration fees. the costs of visas, flights, registration and accommodation are an insurmountable obstacle for many involved in socioecological practice (xiang ) and research. funding for attendance is frequently limited for those in practitioner positions outside of the academy and those based in lowincome nations (fullick ; waruru ) . in our experience organising several non-profit international socio-ecological conferences, raising finance to support attendance in constrained funding landscapes remains challenging, despite the ethical and moral imperatives to diversify participation. beyond access, societies have moved to address issues of inequality faced by participants. these efforts include codes of conducts to manage in-conference interaction (favaro et al. ) , mentoring (timperley et al. , p. ) , childcare provision, employing mediators to manage disputes and incentivising leadership roles and participation of historically and structurally marginalised groups including women, people of colour, those with physical and mental health disabilities, and lgbtq + (e.g. imcc ). additionally, travelling internationally to a conference is not sustainable. some conferences offset their participants' travel emissions (holden et al. (holden et al. , p. . however, the compensation of carbon emissions is controversial and, according to the carbon management hierarchy, should only be used as a last resort after exhausting all other options for mitigation (hyams and fawcett , p. ). online conference formats remove the need for travel and reduce the costs of attendance, but they do not preclude inequality in access and participation. new challenges are posed by a move online, such as replicating the much valued spontaneous and informal opportunities of traditional in-person conferences, where non-verbal cues are more easily detected (fish et al. , p. ; erickson , p. ) . furthermore, the different norms of interaction in an online setting may exacerbate inequalities in participation. for instance, online communication is often associated with a degradation in politeness (hardaker , p. ) . cultural insensitivity and impoliteness are known causes of lower levels of minority faculty representation in the academy (louque and thompson , p. and p. ) . accordingly, online communication may make it harder for inexperienced or minority community members to establish themselves in a global network of colleagues. this may have long-term impacts on the diversity and innovation potential of the socio-ecological research community. another immediate issue is access to technology and infrastructure for online participation. minority participants likely experience the digital divide disproportionately. for example, only % of urban households in india have internet access, dropping to . % for rural households (government of india p. ). further, primary users of the internet in india are male ( %) with only % of women having access to mobile internet, the primary mode of digital connectivity (gsma , p. ). this underlying disparity in digital access is partially neutralised by reliable internet access for those engaged at a subset of governmental, private and higher education institutes. however, with the current shelter-in-place restrictions, institutional access is restricted, forcing users to rely on in-home or mobile internet, which is frequently unavailable, with only . % of urban households having access to a computer (government of india , p. ). access is likely even worse for conservation practitioners based in rural settings globally and for students 'sent home' from universities. in africa in march , only . % of the total population could access the internet, compared to the rest of the world at . %, with smartphone access at % in south africa, % in kenya and extremely low at % in tanzania (ngware ) . increasing global access to the internet is central to achieving the un sustainable development goals, and a shift to online conferences supports this aim. however, increasing access will increase the carbon emissions associated with the internet, which are estimated to exceed those of the aviation industry (boston consulting group , pp. - ; malmodin and lundén , pp. - ) . evidently, 'going online' does not completely neutralise the carbon emissions of a conference (taylor ). as such, accounting for the carbon footprint of conferences remains relevant for online formats, but could legitimately meet the demands of the carbon management hierarchy. the covid- pandemic offers an opportunity to understand and demonstrate how online platforms can address issues of equity in access and sustainability. the elimination of travel costs clearly reduces the barriers to participation as long as conference registration fees associated with inperson events are similarly reduced. however, engagement online must be fostered to allow online formats to confer the same value as traditional formats. additionally, the associated technological requirements could risk widening the inequities for participants who are already the most disadvantaged in the socio-ecological community (martin ; un news ) . a key 'entry cost' to participation remains in the issue of technology access and internet infrastructure. while many conference participants may have adequate access to internet and technology, to address issues of diversity, equity and inclusion, online platform selection should consider associated requirements for high bandwidth, high-performing devices and training in these technologies. in the absence of uniform digital access, conferences can make use of a variety of more widely available technologies, such as dissemination of conference content in recorded, live and audio-only formats accessible via telephone, radio (ngware ) , podcasts and other popular smartphone applications such as whatsapp (bouhnik and deshen , pp. - ; taru ) . meeting format can address inequalities in participation, but success will depend on community goodwill to actively engage in the programme. formats can be adapted to support the cultivation of 'social presence' through careful consideration of scheduling around time zones, and a combination of live and recorded presentations and interactive events, such as live question and answer sessions or break out groups (tu and mcisaac ) . mentorship and clear communication of expectations of engagement as set out by a code of conduct could also assist in supporting aims of equitable inclusion and in providing space for all voices to be heard. the optimal model for online conferences may differ more drastically from the in-person format. rather than large, immersive conferences held over a set time period, it could include perennial platforms (e.g. professional societies or established communication hubs) integrating a range of technologies that host 'special issues' or informal networking events. these 'smaller' yet more frequent events may ensure active and sustained participation across geographic and disciplinary sectors, ensuring a true diverse and inclusive conference model. the potential to address long-standing inequities in the socio-ecological community through online conferences is a bright spot in the post-covid- landscape. for now, online formats tend to follow the traditions of in-person conferences, being focussed over a defined period and based around thematically grouped presentations or posters. the current pandemic has led to a shift in forms of communication (taru ; wen ) , and as people adapt to forging and maintaining relationships online rather than in person, innovation of the conference model to avoid the risks of continuing or exacerbating issues of inclusion and access online will be key. the reinvention of conferences required by covid- shows us that there are viable options for professional and knowledge development that do not sit at odds with ambitions for an equitable and sustainable future. however, this reinvention must carefully consider the requirements for equitable access and will depend on ongoing and enthusiastic engagement of audiences. as the covid- response challenges the need for and moral standing of the traditional conference, we have been given an opportunity to experiment and begin to explore what works best for all sectors of society. funding open access funding provided by projekt deal. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/ . /. 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-those -who-fear-the-phone xiang w-n ( ) ecopracticology: the study of socio-ecological practice. socio-ecological practice research dr. holly niner is a research and knowledge exchange fellow working on the one ocean hub at the university of plymouth. through her work, she seeks to support the sustainable, equitable and just use of marine and coastal resources and space. she is a co-chair of imcc .dr. shaili johri (ph.d. genetics) is pursuing postdoctoral work at stanford university with a research focus on conservation genomics of marine wildlife. in her capacity as the diversity officer of the society for conservation biology marine section, shaili engages in addressing issues of diversity, equity and inclusion affecting conservation research/practice. after a -year postdoc position at geomar helmholtz centre for ocean research kiel, she transitioned into science management in and is now employed as scientific project manager at the center for ocean and society in kiel, germany.sophia wassermann is in the last few months of her ph.d. in marine science at the national university of ireland, galway. her research focuses on applying theoretical concepts and quantitative methods to practical issues in fisheries and ecosystem sustainability. she is a co-chair of imcc . key: cord- -gjdza bh authors: hawdon, james; parti, katalin; dearden, thomas e. title: cybercrime in america amid covid- : the initial results from a natural experiment date: - - journal: am j crim justice doi: . /s - - - sha: doc_id: cord_uid: gjdza bh the covid- pandemic has radically altered life, killing hundreds of thousands of people and leading many countries to issue “stay-at-home” orders to contain the virus’s spread. based on insights from routine activity theory (cohen & felson ), it is likely that covid- will influence victimization rates as people alter their routines and spend more time at home and less time in public. yet, the pandemic may affect victimization differently depending on the type of crime as street crimes appear to be decreasing while domestic crimes may be increasing. we consider a third type of crime: cybercrime. treating the pandemic as a natural experiment, we investigate how the pandemic has affected rates of cybervictimization. we compare pre-pandemic rates of victimization with post-pandemic rates of victimization using datasets designed to track cybercrime. after considering how the pandemic may alter routines and affect cybervictimization, we find that the pandemic has not radically altered cyberroutines nor changed cybervictimization rates. however, a model using routine activity theory to predict cybervictimization offers clear support for the theory’s efficacy both before and after the pandemic. we conclude by considering plausible explanations for our findings. presence of a suitable target, and ( ) the absence of a capable guardian. routine activity theory proposes that victimization stems from the "recurrent and prevalent activities" that individuals are involved in, which in turn influence the likelihood that the three necessary factors are present (cohen & felson, ) . therefore, routines influence an individual's risk of being victimized. while rat cannot be directly applied to the online world (see yar, ; yar, ; tillyer & eck, ) , the cyberlifestyle-routine activities perspective (see reyns, henson, & fisher, ; eck & clarke, ) overcomes the primary issue limiting the theory's applicability. most notably, while offline victimization requires a convergence in time and space of offenders and victims, cybervictims and offenders can come into virtual contact through their networked devices, and this contact can happen asynchronously (leukfeldt & yar, ; reyns et al., ; vakhitova, reynald, & townsley, ) . with this modification in mind, online routine activities can increase the likelihood of victimization by bringing potential targets into virtual contact with offenders in environments lacking guardians (see eck & clarke, ; reyns et al., ) . researchers have now applied rat to a variety of types of cybervictimization, ranging from fraud and identity theft to harassment and other forms of cyberviolence (e.g., bossler & holt, ; bossler, holt, & may, ; costello, hawdon, ratliff, & grantham, ; hawdon, bernatzky, & costello, ; hawdon, oksanen, & räsänen, ; hawdon, oksanen, & räsänen, ; holt & bossler, ; holt & bossler, ; marcum, higgins, & ricketts, ; navarro & jasinski, ; navarro & jasinski, ; pratt, holtfreter, & reisig, ; reyns, ; reyns & henson, ; van wilsem, ) . studies using rat to predict cybervictimization generally find that engaging in risky online behaviors such as downloading games and music from unknown websites, using file-sharing programs, instant messaging, opening unknown email attachments, and clicking on pop-up messages increases cyberharassment (hinduja & patchin, ; marcum, ; marcum et al., ; navarro & jasinski, ) . similarly, general computer use, anonymously confiding in others online, playing video games, spending time in chatrooms, online shopping, and the use of social networking sites, and adding strangers as friends to the social networking accounts have been reported to increase the likelihood of being a victim of cyberviolence (e.g. bossler & holt, ; bossler et al., ; costello et al., ; hawdon, oksanen, & räsänen, ; holt & bossler, ; leukfeldt & yar, ; navarro & jasinski, ; reyns et al., ; reyns, henson, & fisher, ; van wilsem, ) . the use of target-hardening devices such as antivirus programs, firewalls, and filtering and blocking software can potentially reduce cybervictimization, although the effect may only apply to economic victimization (e.g., leukfeldt, ; marcum, ; marcum et al., ) . as mentioned above, the stay-at-home orders enacted to combat the spread of covid- have radically altered the daily routines or millions of americans. with decreased mobility due to shelter-in-place orders, people are increasingly teleworking. according to one study, % of organizations have encouraged or required their employees to work from home because of the pandemic (gartner, ) . in addition to more people relying on technology to telework, the use of social media sites such as tiktok, twitter, facebook, and instagram are also spiking (yitzhak, ) . as we spend more time online, our cyber-routines change, and we would anticipate these changes would alter cybervictimization rates. but how specifically would the covid- pandemic likely alter our proximity to motivated offenders, suitability as a potential target, and online guardianship? let us speculate on each of these. covid- and virtual proximity to motivated offenders first, the unemployment rate has surged above % and is expected to reach levels not seen since the great depression, millions have lost their jobs, had their hours reduced, or have been furloughed, and the nation's small business owners are struggling to remain in business (bartash, ; lambert, ; wolfer, ) . as a revised version of rat argues (see bryant & miller, ) areas with large secondary labor markets have high crime rates in part because workers in the secondary sector frequently experience unemployment, which may compel them to find alternative means of support. thus, the radical shift in the employment structure of the nation to which these dire economic numbers attest has likely led to heightened economic need and increased motivations to steal. combined with the increase in the number of people going online, we would anticipate an increase in the virtual presence of motivated offenders in cyberspace. the increased presence of motivated offenders in cyberspace during the pandemic, assuming it is indeed the case, should increase overall rates of cybervictimization. while this proposition is likely to be true, motivated offenders are a necessary but not sufficient condition for victimization. indeed, cohen and felson ( ) assumed such offenders were omnipresent, and this truism is probably even more enhanced in cyberspace because its asynchronous nature allows offenders to be "virtually present" even when they are not personally online. thus, while more motivated offenders being online is likely to elevate rates of cybervictimization, the overall patterns are likely more affected by changes in target suitability and guardianship that result from the pandemic. covid- and target suitability independent of the number of offenders prowling virtual space, the online routines of potential victims also shapes their likelihood of being victimized by determining a target's suitability. suitable targets include any person or object that can fulfill the needs or wants of a motivated offender (cohen & felson, ) , and target suitability is a function of viva: the target's value, inertia, visibility, and access (felson & clarke, ) . value is the worth a person or object has in the eyes of a potential offender, inertia is the target's ability to avoid the offender, access is the opportunity for an offender to commit the illegal act, and visibility is the extent to which offenders can see a possible victim. these factors are interrelated and also related to the extent of contact targets have with motivated offenders. it is likely that the pandemic would influence target suitability in several ways. as noted above, the pandemic has resulted in people spending more time online. all things being equal, spending more time online would increase the potential victim's visibility to likely offenders. indeed, research indicates that the proportion of users who access the internet only from home is positively related to cybertheft victimization (song, lynch, & cochran, ) . however, simply spending more time online may not necessarily result in a greatly enhanced probability of being victimized because overall time spent online is likely less important than the specific online activities in which one engages. for example, spending hours online teleworking is probably not likely to bring one into a virtual space where motivated offenders lurk. in contrast, spending even hour surfing the dark web very well might increase one's exposure to motivated offenders. thus, online activities that lead one to visit "dangerous virtual spaces" will increase a potential target's visibility and the offender's access more so than those activities that occur in more secure online spaces (see costello, barret-fox, bernatzky, hawdon, & mendes, ; räsänen et al., ) . how the covid- pandemic and resulting stay-at-home orders will likely affect target suitability is undoubtedly complex. for example, as previously mentioned, the limited available evidence suggests that some activities known to be related to victimization because they may lead users into dangerous virtual spaces have undoubtedly increased (yitzhak, ) . these "dangerous" online routines would include surfing the dark web, playing online video games, online shopping, and visiting social media sites as all of these activities have been reported to increase cybervictimization (bossler & holt, ; bossler et al., ; costello et al., ; hawdon et al., ; leukfeldt & yar, ; navarro & jasinski, ; reyns et al., ; van wilsem, ) . all of these activities would increase the target's visibility and the offender's access, and we would anticipate that increases in these behaviors would result in higher rates of cybervictimization. however, time spent performing other online routines, such as working online or reading the news, may have also increased due to the pandemic, but these activities are unlikely to affect cybervictimization since they would not bring one into "dangerous" virtual spaces. another factor that can influence target suitability by decreasing an offender's access and possibly increase the target's ability to avoid an attack (i.e. decrease the target's inertia) is the use of target-hardening devices. some evidence suggests that the use of antivirus programs, firewalls, and filtering and blocking software can reduce the likelihood of becoming a victim of an economic cybervictimization; however, there is little evidence such devices can protect one from violent cybercrimes (see holt & bossler, ; leukfeldt, ; marcum et al., ) . how the pandemic would influence the use of target-hardening devices is difficult to predict. while one would hope people would be more vigilant in terms of updating their anti-virus software and making sure their firewalls are set, the pandemic has probably not influenced the overall use of computer technology for those with high levels of computer skills since these people were probably frequent users prior to the pandemic. instead, the pandemic has probably led to more inexperienced and unsophisticated computer users spending more time online. if this is the case, we would predict that overall rates of economic cybervictimization should increase. we note here that we would not expect violent cybercrimes to increase since these are reportedly unaffected by target-hardening devices. finally, another factor that patterns victimization is guardianship. guardianship is "the presence of a human element which acts-whether intentionally or not-to deter the would-be offender from committing a crime against an available target" (hollis, felson, & welsh, : ) . the findings with respect to guardianship and cybercrime are inconsistent (e.g., bossler & holt, ; leukfeldt & yar, ; reyns, ) , in part due to conceptual uncertainty across both study design and types of victimization (vakhitova & reynald, ). yet, as argued by costello, hawdon, and ratliff ( ) , the virtual world is a truly socially disorganized community. in cyberspace, actors are truly transient as they come and go regularly, and they do so anonymously. moreover, many online spaces have no way for anyone even trying to monitor the activity to intervene, and most offenders likely know this. even sites that closely monitor activity and have policies to censor or delete material struggle to keep pace with the amount of activity that must be monitored. moreover, online norms that would stimulate intervention on one's behalf tend to be weak and underdeveloped (see costello et al., ) . thus, overall guardianship is always low online and the pandemic is unlikely to have changed that. as such, we would not anticipate rates of cybervictimization to have changed due to any influence the pandemic would have had on cyber guardianship. taking all of these factors together, we would anticipate an increase in cybervictimization amid the covid- pandemic due to more motivated offenders, a change in some "dangerous" online routines, and perhaps less target-hardening. however, given that many online routines that have likely increased would not necessarily result in increased victimization and the fact that guardianship is likely unchanged by the pandemic (because it is always lacking online), any observed increase is expected to be modest. the above discussion gives rise to the following hypotheses that will be tested using samples collected pre (november ) and post (april ) pandemic. first, as stated above, given the anticipated changes in online routines, we hypothesize (h ) rates of cybervictimization will be modestly higher among post-covid- respondents than they are among pre-covid- respondents. next, as explained above, we anticipate the increase in victimization because people were forced to shift their daily activities online and radically enlarge their digital footprint. thus, we hypothesize that (h ) the extent to which respondents engage in online activities will be higher in the post-covid- sample than in the pre-covid- sample. we now turn to our analysis. data were collected using online panels from dynata. dynata uses random digit dialing, banner ads, and other permission-based techniques to recruit respondents. from this database dynata randomly invites panel members to participate in the survey. the sample was balanced based on us census data to represent sex, ethnicity, and race. online proportional sampling has been found to yield similar results as random probability-based samples due to several strategies (weinberg, freese, & mcelhattan, ; simmons & bobo, ; contrast macinnis, krosnick, ho, & cho, ) . first, both repeat participants and individuals who speed through the survey are eliminated to increase sample validity (wansink, ; evans & mathur, ) . in addition, the rewards offered by the panel company have been shown to increase validity of the overall data (see wansink, ). the first survey was fielded between november and november , (pre-covid- sample), and the second was fielded between april and april , (post-covid- sample). overall, respondents began the pre-covid- survey, but respondents completed the survey in less than min and were considered "speeders." they were removed from the sample. in addition, participants did not complete the survey and were eliminated from the analysis. in total, respondents had usable data and were included in our analysis. in the post-covid- sample, respondents began the survey, with "speeders" who were dropped from the analysis. dropping these respondents resulted in a sample of participants in the post-covid- sample. a comparison between the pre-covid- and post-covid- sample in terms of demographics can be found in table . of note was an expected increase in unemployment in the post-covid- sample. in addition, the samples differed in average age and education, but did not differ in terms of racial/ethnic composition or gender. to examine the first hypothesis, we investigate rates of cybervictimization in the two samples. to measure cybervictimization, respondents were asked if they had been a victim of seven different types of cybercrime (see table for the types of crimes and survey items used to measure them). we created a summated variable of all victimization behaviors. this count variable reflected the number of different victimization experiences the participants had experienced in the past months. even upon visual inspection we noticed that, if anything, victimization was slightly higher in the pre-covid- sample. we examined victimization in relation to the samples using a negative binomial regression because our data are over-dispersed count data. we examined the differences between the samples by regressing victimization on a covid- indicator variable ( = pre-covid- ; = post-covid- ). the covid- indicator variable failed to reach standard levels of statistical significance, and the overall model had extremely low predictive power, with a pseudo r of <. . as such, our first hypothesis is not supported, at least when we consider overall cybervictimization. given that certain types of cybercrimes may have increased while others decreased, we also examined specific victimization and self-protection behaviors between the pre and post-covid- sample to help understand why we were not seeing a difference between the samples. we utilized χ tests to consider differences between the samples. types of victimizations tested included scams, identity theft, unknown transactions, notification from organizations about data theft, online bullying, online sexual harassment, and malware/viruses. only one significant difference was found. the post-covid- sample reported fewer notifications by companies that their data had been stolen (χ = . ( ), p = . ). in the pre-covid- sample % of respondents indicated they had been notified by a company about data loss whereas in the post-covid- sample only % indicated they had been notified by a company about data loss. we also examined differences in self-protection measure use in the pre/post-covid- samples using similar χ tests. only one significant difference was found. while % of the post-covid- sample indicated that they used virus software or firewalls, only % of the pre-covid- reported that they did (χ = . ( ), p = . ). we advise caution in interpreting this result as the p value was close to . and we ran a total of χ tests, increasing the likelihood of a false positive. all victimization and self-protection difference tests can be found in table . to test our second hypothesis regarding differences in computer behaviors between the samples, we compared pre-covid- and post-covid- computer-related activities. these activities include playing online games, reading news or other articles online, browsing social media, using a computer while working, and shopping online. as seen in table , only one activity, reading news or other online articles was significantly higher in the post-covid- sample (t = − . ( ), p < . ). therefore, our second hypotheses is also not supported. given the failure of either of our hypotheses to be supported, we investigate if the rat model still applies to cybervictimization in the post-covid- world. given the reported fourfold increase in cybercrimes during the pandemic (cimpanu, ; england, ) yet our data not reflecting such an increase, we need to consider if to do this, we turn to a test of rat using our two samples. to examine if rat is an adequate predictor of cybervictimization, we included several variables in a negative binomial regression. the model included an index variable of pre/post-covid- sample, time spent in the various online activities mentioned above, computer self-protection behaviors, and demographic variables. table reports the results of the analysis. overall the model was significant (p < . ). factors related to increased risk of victimization included dark web use per week (irr = . ; p < . ), time reading online news/articles (irr = . ; p < . ), time browsing social media (irr = . ; p < . ) and age (irr = . ; p < . ). age was the only demographic factor to achieve statistical significance in the model. factors significantly related to lower risk of victimization included time working on a computer (irr = . ; p < . ) and all protective behaviors including covering a webcam (irr = . ; p < . ), having identity theft protection (irr = . ; while the covid- indicator was again not significant, almost all of the ratspecified variables were significant predictors in the model, and all of the relationships between these variables and cybervictimization were in the direction rat would predict. it is also worth noting that age was the only demographic variable that was significantly related to cybervictimization. this finding is also supportive of rat's argument that one's routines determine victimization. finally, we tested to see if any interaction between the covid- indicator variable and the rat variables were significant to be certain that rat applied equally well in the pre and post covid- world. results (not shown here) indicated that no interactions were significant, suggesting that indeed rat still performs well as an explanation of cybervictimization even during the pandemic. to our knowledge, our study is the first empirical evidence concerning how the covid- pandemic influenced cyber-routines and cybervictimization. we assumed that the pandemic and the results of stay-at-home orders would result in increased online presence, an increased level of routine activities online, and, as such, enhanced levels of target suitability and target proximity to motivated offenders. consequently, we expected that rates of cybervictimization would be higher in the post-pandemic sample than what was observed in the pre-pandemic sample. the results show that we were clearly wrong. based on our results, the stay-at-home orders did not radically alter our cyber-routines, and cybervictimization did not increase either. instead, global levels of cybervictimization were nearly identical pre and post-pandemic, and only one type of victimization (being informed that your identity or private information had been stolen) changed. moreover, this victimization decreased in the post-covid- sample. among the indicators of cyber-routine activities, including playing online games, a scale is nonlinear as hours were represented in increasing increments, , < , - , - , - , - , - , or more *p < . , **p < . , ***p < . reading news or other articles online, browsing social media, using a computer while working, and shopping online, only reading news or other online articles increased. one online activity, online shopping, even decreased in the post-covid- sample. we also wanted to see if specific types of victimization and protection behaviors changed after the pandemic. among all the specific victimization variables, only one showed a significant difference: there was less notification from companies concerning data theft in the post-covid- sample. in terms of target-hardening behaviors, participants reported using more self-protection (i.e. virus software and a firewall) in the post-covid- sample. thus, while there were minor differences between the samples, contrary to our expectations and fbi reports (cimpanu, ; england, ) , our data show that the pandemic has not radically altered our cyber-routines or levels of cybervictimization. fearing rat may not apply in the post-pandemic virtual world, we tested it with a negative binominal regression. our model showed dark web use, time spent online reading newspapers and other articles, and time using social media significantly increased the likelihood of being a cyber victim. time spent working on a computer, protective behaviors such as covering the webcam, having identify theft protection, freezing credit, and having virus protection were all inversely related to the likelihood of victimization. these results clearly support rat, and the insignificance of the covid index variable or any interactions between it and the various cyber-routines indicate that the theory applies equally well in the pre and post covid- world. although cybervictimization has not changed substantially, our binominal regression model indicates that rat can account for patterns of cybervictimization in both pre and post-pandemic samples. so why were our expectations so wrong? first, proximity to motivated offenders may have increased as people went online to work, study, and network, but target suitability did not increase as, according to our results, people likely used online platforms similarly to how they had before the pandemic. most of their online behaviors did not put them at more than average risk of victimization. there was no evidence that dangerous online behaviors such as dark web use, online shopping, or visiting social media platforms changed significantly after the pandemic. indeed, our data suggest users abandoned online activities such as online shopping that would pose risk to their bank accounts. instead, it seems that people kept their cyber-routines concentrating on less dangerous routine activities, such as working online and reading news articles. the online routine activity that significantly increased was reading online news, but that activity would not heighten victimization as most traditional online news sites are reputable and do not increase their readers' target suitability. we also expected that the overall rates of cybervictimization, and especially economic cybervictimization, would increase because of the nation's swift shift to the virtual world likely did not leave time for users to upgrade their computer security measures (e.g. firewalls, anti-virus software, etc.). while more computer savvy users likely have security measures already installed, those with fewer computer skills could be more vulnerable now that they are spending more time online. however, our data indicated that more people engaged in target-hardening measures and cybervictimization was unrelated to computer familiarity. a plausible explanation for this is that workers' relatively unfamiliar with computers were moved online by their companies who provided sufficient it support. we cannot say this happened, but it is likely that corporations were keenly aware that some of their less-thantech-savvy employees who were now teleworking needed support and failing to do so could put their company at heightened risk. indeed, there is reason to suspect there was heightened concern about cybercrime and possibly greater vigilance practiced to protect oneself from it. for example, the fbi noted how cybercriminals would likely target both companies and individuals working from home via teleworking software, education technology, and business email platforms. on april , the us departments of state, homeland security, and treasury, and the fbi issued an advisory to raise awareness of the cyber threat posed by north korea's malicious cyber activities, a significant threat to the integrity and stability of the international financial system (us cert, ). on april , the fbi charlotte warned (fbi charlotte, ) social media users to pay attention to trending social media topics (e.g. high school support photo trend, posting a picture of your first car, answering questions about your best friend, providing the name of your first pet, identifying your first concert, etc.), which might collect users' personal information, including passwords to reset accounts and gain access to protected data. thus, it is possible that these warnings worked. while we lack the data to adequately test if companies' policies attempted to protect their users or the government warnings worked, this possibility should be further explored by future research. our data allows us to say that the relative unchanged nature of our respondents' "dangerous" cyber-routines combined with their use of stronger security measures such as antivirus software and firewalls likely kept cybervictimization low, even if there was elevated motivation among offenders due to souring rates of unemployment and economic struggles. we can also say that our findings contradict recent reports about heightened levels of cybercrime being reported to the fbi (cimpanu, ; england, ; ic , ) . like us, the fbi anticipated that virtual environments will be increasingly affected adversely by cybercriminals, and as of march , (ic , ), their data gives credence to their fears. the fbi internet crime complaint center (ic ) reports receiving more than complaints related to covid- scams, including phishing campaigns against first responders, ddos attacks against government agencies, ransomware against medical facilities, and fake covid- websites downloading malware to users' computers. in total, the fbi reports cybercrimes have quadrupled during the covid- pandemic (cimpanu, ; england, ) . how do our results showing decreased cybervictimization make sense when cybercrime has an upward trend in the news and in fbi reports? it might just show the usual discrepancies between official crime statistics relying on reporting and victimization surveys. it is well documented how official statistics seriously underestimate crime rates. what we might be seeing is that while rates of crime are actually unchanged, rates of reporting crimes is increasing. the repeated warnings of federal and state law enforcement and international policing agencies about the expected increase in cyber-offending may alert people and lead them to the dangers of cybercrime. this heightened awareness would then lead them to notice and report these crimes more than they did prior to the pandemic. another possibility is that the increased rates of reporting to the fbi are more due to attacks on companies than on individual users. our data focused on individual, not corporate, victimization. thus, because our survey only included individual level cybervictimization while ignoring attacks on companies and critical infrastructures, we may not be detecting the increase in cybercrimes through our victimization surveys. this possibility should also be investigated by future researchers. our lives have been radically altered by a pandemic that is considered to be among the most widespread in history. the change in our daily routines appears to have resulted in an abrupt drop in street crimes. however, the shift to the digital world undoubtedly creates new opportunities and platforms for motivated offenders to engage in various illegal activities. this shift should increase the number of suitable targets, as millions of people are confined to their homes and forced to work, study, and socialize online. the current shift was swift, but, at least according to our data, this shift apparently did not result in people being more affected by cybercrime. they may be reporting more of it, but it is also possible that the pandemic has led to a decrease in most street crimes, an increase in domestic crimes, and no change in cybercrimes. the reasons of the crime drop experienced all over the world in the s (pope & pope, ) is still debated (rosenfeld & messner, ) and is indeed a complex issue. it is likely the current crime trends will be studied and debated for some time too. our aim here was simply to provide one piece of evidence that will hopefully significantly contribute to that future analysis and debate. we live in unprecedented times. we did not, nor can we, measure every possible underlying reason why cybervictimization occurs. we cannot predict if cybervictimization will remain low as social distancing continues. however, we can say that routine activities theory appears to still apply. we live in unprecedented times, but we still have theories to help us make sense of them. thomas dearden : is assistant professor of sociology at virginia tech. dr. dearden specializes in research technology and crime, and corporate crime. he has conducted research for organizations across the globe, including the polynesian cultural center in hawaii, food for life vrindavan in uttar pradesh, india, and pay tel in north carolina. he has published his research in peer-reviewed journals including the journal of financial crime and the journal of investigative psychology and offender profiling and has presented at a dozen different conferences. unemployment rate could approach great depression-era levels on-line activities, guardianship, and malware infection: an examination of routine activities theory predicting online harassment: victimization among a juvenile population routine activity and labor market segmentation. an empirical test of a revised approach fbi says cybercrime reports quadrupled during covid- pandemic social change and crime rate trends: a routine activity approach predictors of viewing online extremism among america's youth confronting online extremism: the effect of self-help, 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macro-social exploratory analysis of the rate of interstate cyber-victimization routine activities north-korean cyber threat cyberguardians: an empirical study of guardianship against cyber abuse toward the adaptation of routine activity and lifestyle exposure theories to account for cyber abuse victimization worlds tied together? online and non-domestic routine activities and their impact on digital and traditional threat victimization editorial: the power of panels comparing data characteristics and results of an online factorial survey between a population-based and a crowdsource-recruited sample the unemployment rate is probably around percent. the new york times accessed the novelty of 'cybercrime': an assessment in light of routine activity theory cybercrime and society social media interest is spiking worldwide-except for linkedin. the next web the great american crime decline publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations james hawdon : is a professor of sociology and director of the center for peace studies and violence prevention at virginia tech. he researches how communities influence the causes and consequences of violence. most recently, he has focused on how online communities influence political polarization, online hate, extremism, and cybercrime. he has been funded by the national science foundation, the national institute of justice, the national consortium on violence prevention, and several other agencies she evaluated cyberbullying programs of the massachusetts aggression reduction center as a fulbright fellow, and was awarded the european safety and prevention award for channeling academic research results to schools. she has published in peer-reviewed journals such as the pediatrics, the acknowledgements this research was funded by the center for peace studies and violence prevention at virginia tech (grant number - ), the institute for culture, society, and environment at virginia tech, and the integrated security destination area at virginia tech. key: cord- -mrace ux authors: saphores, jean-daniel; xu, lu title: e-shopping changes and the state of e-grocery shopping in the u.s. evidence from national travel and time use surveys date: - - journal: nan doi: . /j.retrec. . sha: doc_id: cord_uid: mrace ux abstract in spite of the popularity of e-shopping, only % of us adults have ordered groceries online, and out of of those who currently buy groceries online do so at most twice a month. understanding the determinants of e-grocery shopping is important for grocers, supply chain managers, and urban planners. in this context, we first explore how deliveries from online shopping have been changing over time. from our analysis of the and national household travel surveys, we found that online shopping has been embraced by increasingly diverse households, although income, education, and some racial/ethnic differences persist. our analysis of the american time use survey shows that americans are times more likely to shop for groceries in stores than online. moreover, in-store grocery shoppers are more likely to be female and unemployed, but less likely to belong to younger generations, to have less than a college degree, or to be african american. the gender imbalance in grocery shopping is larger online than in stores, but e-grocery shoppers do not otherwise differ from the general population. future travel and e-shopping surveys (especially for e-grocery) should combine time use and travel questions with retrospective questions about online purchases. by expanding the range of products available to consumers, stimulating competition, and enhancing shopping convenience, e-commerce is changing the way people shop. its popularity is growing. according to the pew research center (smith and anderson, ) , four out of five americans have purchased items online at least once (up from % in ) . globally, ecommerce is taking an increasing share of total retail sales, rising from . % in to . % in (emarketer, n.d.) . these changes have widespread implications for freight and supply chains management (perboli and rosano, ) , travel (calderwood and freathy, ; suel and polak, ) , the environment (cherrett et al., ; dost and maier, ) , in-store shopping (farag et al., ; lee et al., ) , and land use planning (pettersson et al., ) . the growth of online shopping (e-shopping) is far from homogeneous from a geographic point of view, however. for example, in online retail sales were approximately . % of total consumer retail sales in china (insideretail hong kong, n.d.) , versus less than % in the united states (us census bureau news, ). moreover, e-shopping in a given sector can differ widely even between countries that are culturally and economically similar. indeed, despite an average annual growth of . % between and (us census bureau, a), e-commerce sales of food, beer, and wine in the united states represent currently only . % of total food and beverage purchases (us census bureau, b). by comparison, online sales made up . % of total food retail sales in the uk (office of national statistics, ), which outlines the need to study e-grocery in the united states, even though this topic has already received much attention elsewhere, especially in europe. in this context, this empirical study has two purposes. our first purpose is to understand changes between and -two years selected because of data availability -in residential deliveries from online shopping in the united states. we focus on residential deliveries because national data on grocery deliveries from online purchases in the united states are not, as far as we know, publicly available. understanding residential deliveries from e-shopping is clearly important to logistics managers (so they can supply warehouses serving residences), to transportation engineers (so they can maintain residential roads and adequately update their design), and to transportation planners (so they can mitigate the externalities of changing freight flows and accommodate new delivery options). better quantifying the traffic and environmental impacts of residential deliveries from online shopping is particularly of concern because soaring uncoordinated deliveries will increase residential traffic congestion, noise, and air pollution, and exacerbate parking shortages in dense urban areas. our second purpose is to characterize us households who are shopping online for groceries, which is salient because of the importance and the challenges of grocery retailing. since we are not aware of any public national dataset on household deliveries of groceries in the us, an indirect way of analyzing e-grocery deliveries is to couple characterizations of e-grocers with an understanding of deliveries from online purchases, as analyzed in the first part of this paper. although a number of papers have analyzed online shoppers (e.g., see brashear et al., ; ganesh et al., ; crocco et al., ; bressolles et al., ; or harris et al., , and references herein), much of the recent literature has focused on europe, and there is a dearth of academic research on e-grocery in the united states. profiles of online shoppers generated by consultants for grocers can also be found online, but they typically rely on univariate analyses and none of the profiles we found analyzed datasets representative of the us population. to the best of our knowledge, our paper is the first to analyze recent changes in residential deliveries from online shopping in the united states and to examine online grocery (e-grocery) shopping using publicly available survey data. our point of departure is the latest ( ) national household travel survey (nhts), which we contrast with its previous edition, the nhts. we analyze these two national surveys because they asked participating households how many deliveries from online shopping they received in the days preceding their assigned survey day. to explain the number of these deliveries and understand how they changed between the and the nhts, we estimate similar zero-inflated mixture models on (n= , ) and (n= , ) nhts data, and test differences in model coefficients for these two years. since the nhts does not ask about e-grocery shopping, we also analyze data from the american time use survey (atus) to contrast socio-economic characteristics of people who engage in online grocery shopping with conventional grocery shoppers. to do so, we first estimate logit models on a subset (n= , ) of the atus to consider only households likely to have had access to e-grocery shopping in . since the number of people who shopped for groceries online in the atus is small, we compare the distributions of selected socio-economic characteristics of e-grocery shoppers with those of conventional grocery shoppers using kruskal-wallis tests. finally, we contrast the distributions of shopping start times (i.e., when a customer starts browsing to buy groceries) between these two groups, since proponents of e-grocery shopping highlight the convenience of shopping at any time. in the next section, we review how e-grocery shopping first emerged, assess what obstacles led to early failures, and explain how they were (at least partly) overcome. we then briefly discuss characteristics of e-shoppers in the united states, and review some potential in this paper, (n=number) refers to the size of the sample on which specific models were estimated. impacts of e-shopping and e-grocery. in sections and , we respectively present our data and introduce our modeling approach. in section we discuss our results. in section we summarize our findings, discuss potential impacts on local deliveries, outline some limitations of our study, and propose some avenues for future work. alternative channels to traditional retail (e.g., mail order) predate by decades the arrival of online shopping but their market share has always been small, especially for groceries (white, ) . the emergence of the internet was a game changer because it considerably expanded consumer choice, sped up deliveries, and provided new ways to learn about products (seaman, ) . the first big push to develop online grocery shopping took place in the late s when consumers started buying products over the internet. grocery was an early target because it is the single largest retail sector, most consumers shop for groceries frequently, and many do not particularly enjoy it (saunders, ) . proponents argued that e-grocery would give consumers the freedom to shop at the time and from the place of their choosing, expand consumer choice, and stimulate competition by facilitating price comparisons. convenience and time saving were seen as major advantages at a time when women's participation in the labor force was rising (morganosky and cude, ) . e-grocery pioneers were technology companies eager to leverage their knowledge of information technologies to take over what they saw as an underachieving sector (saunders, ) . companies like webvan (founded in ) and homegrocer.com (started in ) rode the dot.com bubble. they attracted large investments to buy warehouses, delivery vans, and marketing campaigns, and built from scratch purely online businesses. however, when consumer demand failed to meet expectations, investments dried up with the burst of the dot.com bubble and they went bankrupt (webvan purchased homegrocer.com in september , and it filed for bankruptcy in july ) (grunert and ramus, ; saunders, ) . partly as a result of these failures, online grocery shopping has been called "the bermuda triangle of ecommerce" -a place where investments vanish without leaving a trace (mcdonald et al., ) . what went wrong? us e-grocery pioneers overlooked several key characteristics of the grocery sector, and underestimated the magnitude of the change they wanted to introduce. first, e-shopping implies that a number of tasks previously undertaken by customers, including picking, packing, and delivering goods, are taken over by the retailer. this adds to the costs of retailers and squeezes their already thin profits. second, since groceries are quite diverse and some are perishable, they require more complex logistics (murphy, ) . moreover, delivering to a customer's residence raises new issues. indeed, if no one is present to receive an order, coming back at a different time is costly. conversely, if an order is left on a buyer's doorstep, delivered goods could spoil or be stolen. the problem is especially acute for prepared foods, whose temperature, texture, taste, and appearance can quickly change over time. third, early e-grocers did not appreciate the difference between buying groceries online and shopping for groceries in a conventional store (robinson et al., ) . in particular, sensory information (e.g. smell and touch) and interpersonal interactions are lacking online (hansen, ) . this is not an issue for search goods (whose characteristics are easily evaluated before purchase), but it matters for experience goods (which can only be evaluated after a purchase) (nelson, ) . in brick-and-mortar stores, fresh produce can be touched and smelled so they are search goods, but for online shoppers they become experience goods (weathers et al., ) . in spite of its failure, the first wave of e-groceries caught the attention of traditional grocers as online shopping revolutionized shopping in other sectors, such as books or electronics. as the first wave of internet-only grocers were closing, traditional grocers started experimenting with on-line shopping. moreover, new start-ups began emerging with innovative solutions to address some of the shortcomings of earlier e-grocery shopping models. in addition to attractive and easily navigable websites (freeman and freeman, ) , one key to success in e-grocery shopping is low operational costs in order to offer competitive prices and effective delivery services (kamarainen et al., ; anckar et al., ) . this lesson was learned by both traditional grocers and mega retailers such as walmart or target, and amazon, which acquired whole foods in to boost its physical presence. to keep costs down, some grocers partnered with start-ups that provide a platform to customers who order from the grocers' websites and have their employees pick, pack, and deliver orders in exchange for payments from both grocers and shoppers (they also make money from customer information). the largest of these start-ups is instacart, created in (lien, ) . by the end of , instacart had partnerships with over retailers operating over , grocery stores. a number of other start-ups have been offering similar services, including deliv, doordash, postmates, or shipt (acquired by target at the end of ). to avoid unsecured deliveries, e-grocers have experimented with different alternatives: ) click and pick, where consumers order online but pick up at a store or a warehouse; ) bring to a local storage area and deliver when customers are home; ) allow the delivery person to leave purchases inside a customer's home. this service is offered by smart lock maker august with delivery partner deliv and several retailers (macy's, best buy, bloomingdale's and petsmart). it is also offered by amazon for its prime customers who live in selected cities, and subscribe to amazon key. amazon key requires buying an amazon cloud cam and installing a compatible smart lock at home (wollerton, ) ; and ) deliver an order to the customer's car trunk, if he/she is an amazon prime subscriber, has an active connected car service plan, drives a gm or a volvo vehicle from or newer, and lives in one of us cities (hawkins, ) . leading e-grocery retailers in include wal-mart, costco, sears (which filed for bankruptcy in ), amazon, kmart, but also kroger (the largest overall grocer in the us), and safeway (an albertsons brand). however, this sector has been changing quickly with amazon's purchase of whole foods and target's acquisition of shipt (both in ), for example. while in just over % of grocery stores in the us offered home delivery/store pickup of online orders, this percentage had jumped to over % by (conway, ) . to inform our choices of explanatory variables, we also reviewed paper characterizing people who engage in e-grocery shopping. early studies reported that online grocery shoppers are typically younger, better educated, and tend to have higher incomes than the general population cude, , ) . they are also more likely to be female because women are typically more involved in grocery shopping cude, , ) . other studies reported that some seniors and some disabled individuals also shop online for groceries (white, ; anckar et al., ) . as expected, convenience is a driving force behind e-groceries, but situational factors (such as a recent baby or a deteriorating health) also matter (hand et al., ) . people comfortable navigating the internet are not necessarily online shoppers, however, and when they shop online, they do not usually discontinue offline shopping (hand et al., ) . furthermore, kang et al. ( ) showed that the impact of convenience depends on experience with eshopping and with the type of product considered. moreover, although the time requirement to access offline grocery markets has no effect on the adoption of online grocery shopping, it may affect the amount of groceries purchased online. a number of papers have inquired about the determinants of consumers' channel choice (e.g., see melis et al., ; . melis et al. ( ) found that when consumers start buying groceries online, they tend to select the online store from their preferred offline stores; moreover, the offline environment is important when customers are new to online shopping, although it matters increasingly less as they gain more experience with on-line shopping. the device used for e-grocery shopping also seems to matter: according to , m-shopping (i.e., shopping via smartphones or tablets) increases the rate of orders, especially for low-spending customers. in spite of high growth rates and enthusiasm for online grocery shopping, a recent gallup survey (redman, ) showed that % of us adults have never ordered groceries online, and that out of of those who buy groceries online do so twice a month or less. as e-shopping and e-grocery become more common in the us, they may have multiple impacts. here, we briefly consider impacts on land use, retailers, and supply chain planning. as they become increasingly affordable and ubiquitous, information and communication technologies (ict) are decoupling activities such as work or shopping from specific times and spaces (kwan, ) . by decreasing the cost of exchanging information, ict may weaken agglomeration forces and promote the emergence of decentralized, smaller urban centers (ioannides et al., ) . however, concrete evidence that internet use (and in particular eshopping) has impacted urban structure is still lacking (ioannides et al., ) , possibly because it takes years to substantially change the structure of an urban area, but also because of the complexity of the changes induced by ict, and more particularly by e-shopping (nahiduzzaman et al., ) . while we can expect to see a shift in demand from retail space to warehousing or other types of storage space, the magnitude of that shift is still uncertain. it may be amplified, however, with the widespread adoption of self-driving technologies, which are expected to substantially cut the cost of freight transportation (wadud, ; andersson and ivehammar, ) . this shift may be less important for e-grocery than for e-shopping in general. it will also depend on the dominant form of grocery (e.g., click-and-pick vs. home deliveries) and on the extent to which grocers adopt omni-channel strategies, where the business processes of multiple retail channels are increasingly integrated (marchet et al., ) . although online shopping is often invoked to explain high-profile bankruptcies among us retailers (e.g., sears, sport authority, payless) and store closures by major retailers such as j.c. penney and macy's that took place over the last decade, other factors may have contributed just as much to retail store closures in the us, including an excessive number of malls and shifts in consumers' spending habits (thompson, ) . grocery stores have also been affected as they are facing increasing competition from walmart, aldi, and amazon (meyerson, ) , but casualties so far have only been small and regional firms that were out of sync with the markets, or could not afford costly investment to expand online (meyerson, ) . in addition to the obstacles associated with e-shopping in general, such as risks associated with the safety of internet connections and the payment system, or the lack of complete information about online orders (wat et al., ) , e-grocers need to adopt efficient home delivery solutions that can accommodate the requirements of groceries (punakivi and saranen, ). this entails ensuring delivery during tight time windows while observing adequate temperature requirements, the ability to promptly respond to demand, and having enough information to avoid failed home deliveries due to a customer's absence (punakivi and saranen, ) , all of which are issues that delivery service companies or the postal service typically do not face. a number of options have been proposed to manage the demand for grocery deliveries based either on time slot allocations or time slots pricing, either in static (i.e., forecast-based) or dynamic (i.e., real-time) settings (agatz et al., ; klein et al. ( ) . more generally, brick-and-mortar retailers aiming to be competitive online need to redefine their logistics networks (wollenburg et al., ) . this involved adapting inventory management, distribution settings (i.e., the number and type of logistics facilities handling online orders), fulfilment strategy, deliveries, and return management policies (marchet et al., ) . as explained in the introduction, this study relied on data from several publicly available datasets. first, to understand how deliveries from online shopping have been changing over the last few years, we analyzed data from both the and the national household travel surveys (nhts) (fhwa, (fhwa, , . these surveys provide comprehensive national data on households, their members, their vehicles, and daily travel for all purposes and by all modes of transportation. second, since (to the best of our knowledge) there is no publicly available national dataset on e-grocery in the us, we analyzed data from the american time use survey (atus) to characterize us consumers who shop online for groceries. these datasets and our variable choices are presented in turn. compared to the nhts, data for the nhts were collected using a new sampling strategy and a new methodology (e.g., data were retrieved using of a self-completed web-based survey instead of via an interviewer assisted phone survey) to lower the burden on respondents and improve coverage. in , the sample frame was obtained using random digit dialing of landline phone numbers, but this approach is no longer appropriate because since over half both the and the nhts inquired about the number of times each respondent purchased something online and had it delivered in the days preceding their survey day. we note, however, that the nhts question specifies deliveries to home, while that nhts question we analyze does not. we aggregated individual answers to this question by household to create the dependent variable for our models that explain deliveries from online shopping. we focused on households here because it is not uncommon for one household member to order goods for other household members, especially if they are children. both surveys also asked how frequently respondents use the internet. we used this information to exclude households who stated they never use the internet but receive deliveries from online purchases. to explain deliveries from online purchases, we relied on a wide range of directly observable household characteristics and on land use variables available in both the and the nhts. first, our models include variables describing household composition (see table ), and a count of the number of household women over , as women are often in charge of shopping. since the age of household members likely matters, we kept track of the number of children (household members under ), and of the number of household members or older from each generation, as defined by the pew research center ( ). <insert table approximately here> because income categories differ between the and the nhts, we created approximate quintiles ( % strata). we also added the number of household adults who work part-time and full-time since working decreases the time available for activities such as shopping. to capture the highest educational achievement in the household, we relied on the five common categories shown in table . in addition, we included in our models race variables, a hispanic/latino indicator, and we counted the number of household members born abroad. the purpose of these variables is to help capture cultural differences or uneven access to online shopping. people with a medical condition that impairs their mobility would likely benefit from online shopping, so we created an indicator variable for them. home ownership (a wealth indicator) may also play a role here, and so could the number of vehicles per adult. finally, we created two population density indicator variables (< people per square mile and ≥ , people per square mile) and an indicator variable for heavy rail. the lowdensity variable could reflect that people in rural areas have fewer shopping options and may therefore benefit more from online shopping. conversely, the high-density indicator (and the heavy rail variable) could capture impacts from enhanced online shopping and delivery options. after removing households with missing data and with over deliveries per day because the latter are unusual and influential observations ( and table . to get a profile of us consumers who shop for groceries online, we analyzed data from the atus. the main goal of this survey is to understand how noninstitutionalized us residents who are civilians or older allocate their time. atus samples individuals who participated in the current population survey. it is conducted annually by the us census bureau by phone, using computer assisted interview software. although grocery shopping is a household activity, our basic unit of analysis here is the individual because only one person per household participates in atus. for each person in our sample, we gathered a broad range of socio-economic variables. individual characteristics include marital status, gender, generation (based on pew research center definitions), work status, education level, race, hispanic/latino status, and presence of a mobility impairment. household characteristics include the number of children and annual income. we considered two dependent variables obtained by combining activity (grocery shopping) and location data. the first dependent variable indicates whether or not a respondent shopped for groceries in a store during their atus survey day. the second dependent variable indicates whether or not a respondent shopped for groceries online (i.e., when the respondent shopped for groceries, he/she was neither in a grocery store nor in another store/mall). out of , persons in our sample, , ( . %) shopped for groceries in a store, but only ( . %) shopped for groceries online. this low percentage is not surprising since by august , of the % of us adults who had ever ordered groceries online, out of did so twice a month or less (redman, ) . interestingly, nobody in the atus dataset shopped for groceries both in a store and online on their survey day. since e-grocery shopping was not available everywhere in the united states in , we pared down our sample by keeping only respondents who reside in core-based statistical areas where at least one atus respondent shopped for groceries online. this reduced our atus sample to , respondents. this sample includes only people who are african american, asian, or white, and it does not include people with a mobility impairment. as a result, other ethnic variables and the variable indicating the presence of a mobility impairment could not be included in the logit models estimated on that sample. summary statistics for our two atus samples are presented in table . <insert table approximately here> in this section, we first describe the mixture models we relied on to explain changes between and in residential deliveries from online shopping in the united states. we then explain our strategy to characterize americans who shop at brick-and-mortar grocery stores versus americans who engage in e-grocery. combining results from both analyses could allow identifying areas with a high potential for the delivery of groceries from online shopping. we first explained the number of deliveries from online shopping by household in the last days preceding their assigned survey day, and how it changed between and . in , . % of households had no deliveries from internet shopping during the days preceding their survey day; in , this percentage fell to . %. to account for this relatively high percentage of zeros, we estimated mixture models (greene, ) , which assume that our samples are composed of two distinct groups of households. households in the first group never purchase goods online, and therefore get no deliveries from online shopping. households in the second group make online purchases from time to time, so the number of their deliveries is modeled via a count model. to model the probability of belonging to either group, we relied on a logit model. the resulting mixture model can be written (greene, ) : where: • n i designates the random variable that generated n i , which is the number of packages from online shopping received by household i in the days up to their survey day; • ϕ is the probability that household i belongs to the group that never makes online purchases (the first group); • | is the probability that household i received n i ≥ packages from online purchases over the days up to their survey day; • γ γ γ γ and β β β β are vectors of unknown coefficients that need to be estimated; and • z i and x i are vectors of explanatory variables, respectively for the logit model that identifies households who never buy goods online (the first group) and for the count model. if we model counts with a poisson process, we obtain a zero-inflated poisson (zip) mixture model; using a negative binomial regression model instead gives a zero-inflated negative binomial (zinb) mixture model (long, ) . to avoid multicollinearity, we checked that the variance inflation factors for all our explanatory variables are below (they are). to assess if the estimate of the coefficient for an explanatory variable ( to obtain a baseline profile of americans who shop at brick-and-mortar grocery stores, we first estimated a logit model (greene, ) on our full atus sample (n= , ). we then estimated two more logit models on the sub-sample (n= , ) of atus respondents who live in core-based statistical areas where at least one person shopped for groceries online. as mentioned above, we constructed this sub-sample because e-grocery shopping was not available everywhere in the united states in . the first logit model estimated on our atus sub-sample again characterizes atus respondents who shopped at a physical grocery store. it allows us to check that grocery shoppers in this sub-sample do not differ substantially from those in the full atus dataset. the second logit model characterizes atus respondents who shopped for groceries online. since only people shopped for groceries online in the atus, it is difficult to fully capture the determinants of online grocery shopping. we therefore also compared the distributions of selected socio-economic characteristics of people who shopped for groceries online with those who shopped in stores using kruskal-wallis (kw) tests (conover, ) . a kw test assesses whether different samples originate from the same distribution. finally, we analyzed the distribution of shopping start times (the self-reported time when atus respondents started browsing for groceries online) since one argument for e-grocery is the convenience afforded by the ability to shop at any time. as discussed above, we estimated zinb (a mixture consisting of a negative binomial regression model with a logit) and logit models. for a negative binomial regression model, the coefficient of an explanatory variable represents the difference of the logs of expected counts when that explanatory variable is increased by one unit, holding constant all other explanatory variables (long, ) . in a logit model, the coefficient of an explanatory variable represents the change in the logit (the log of the probability of divided by the probability of ) of the probability associated with a unit change in that explanatory variable holding all other predictors constant. our results were obtained with stata . . they are presented in tables and , and illustrated on figures to . in table , shaded numbers indicate when the value of a coefficient differs from its value. to better link our explanations with results presented in tables and , we occasionally report estimated coefficients and their statistical significance (see notes below these tables). before discussing results from our count models, it is instructive to contrast monthly household package deliveries from online shopping for and ( figure ). results are weighted to be representative of the us population. as expected, figure shows a sharp reduction in the percentage of households who do not get any deliveries (it drops from . % to . %) together with an increase in the percentage of households who received packages. this increase is especially marked for the - deliveries category (from . % to . %) and for more than deliveries (from . % to . %). <insert figure approximately here> for robustness, we estimated poisson, negative binomial, zip, and zinb models for our and nhts samples using maximum likelihood. the zinb models presented in table have the best (lowest) aic and bic values. <insert table approximately here> from table , we first see that the impact of household composition on deliveries from internet shopping has been changing over time. overall, the likelihood to never order online has decreased for most household types, and especially for households with or more retired adults (- . **). these households are now less unlikely than baseline households to shop online, possibly because older adults with a spouse are more likely to use modern information technologies (vroman et al., ) . however, differences in deliveries have sharpened the importance of the generational structure of households has also been changing, suggesting a broader adoption of online shopping. in , an increase in the number of household members from younger generations (gen x and gen y, and to a lesser extent baby boomers) sharply reduced the likelihood of never shopping online. furthermore, increasing the number of household adults raised the number of deliveries. by contrast, in , the magnitude of model coefficients for gen x and gen y decreased. as baby boomers aged, however, they became more likely to never order goods online ( . ***), although not as much as members of the silent generation ( . ***). as parment ( ) boomers often prefer to start a purchase with a retailer they trust, before eventually committing to a purchase, either online or in a store. the impact of household income is monotonic. as their income rises, households are less likely to never order goods online and they tend to get more deliveries (as in wang and zhou, ) . similarly, as their level of education increases, households are less likely to never order goods online, and their deliveries increase. except for households with less than a high school education in , this relationship is monotonic. this result echoes the reported correlation between education and computer proficiency (burroughs and sabherwal, ) . as reported by ren and kwan ( ) people with a medical condition that hinders their mobility appear to take better advantage of the convenience of online shopping. whereas in they were more likely to never order goods online ( . ***), this effect disappeared in and those who shopped online received more deliveries in ( . ***) than in ( . ***). home ownership decreases the likelihood of never ordering goods online but it does not impact deliveries from online purchases. likewise, households who have more vehicles per adult are less likely to never order goods online and they tend to receive more packages from online shopping. this result agrees with zhou and wang ( ) , who reported that online shopping stimulates shopping trips and found that the number of household vehicles is positively correlated with the level of online shopping. as expected, population density also plays a role here, although its impact is relatively small. in lower density areas (< people per square mile), households are more likely to never order goods online, but those who do received slightly more deliveries in ( . ***). this result illustrates that e-shopping has the potential to increase the range of products available to households currently under-served by brick-and-mortar stores. conversely, in denser areas (> , people per square mile), households are slightly less likely to never order goods online and they receive more deliveries (in , not the presence of heavy rail is binary) are more difficult to interpret. results from our analysis of the characteristics of us grocery shoppers are shown in table . in this table, a positive coefficient for a variable indicates that the probability to shop for groceries (or e-groceries for the last column of table ) increases with that variable. <insert table approximately here> starting with the logit model that characterizes people who shopped at brick-and-mortar grocery stores on their asus survey day (column in table ), we see that women are more likely to shop for groceries than men ( . ***), which is well-known (e.g., see morganosky and cude, ; or li et al., ) . apart for members of the z generation who are less likely to shop for groceries, there are no generational effects. likewise, the number of household children does not matter, and neither does household income, except for members of the highest income group ( . *). as expected, grocery shoppers are more likely to be "unemployed" ( . ***), likely because they take care of the household while other household adults are at work and homemakers (still usually women) are consider unemployed. interestingly, people with less education are less likely to shop for groceries. race matters but only for african americans, who appear to shop for groceries less frequently than other groups, which agrees with previous findings that african americans have less access to supermarkets (morland et al., ; beaulac et al., ) . to compensate, poor people in predominantly black neighborhoods or in poor rural areas tend to shop at dollar stores (whalen, ) , and rely more on fast food outlets (james et al., ) . lastly, respondents with a medical condition that impairs their mobility are less likely to shop for groceries (- . ***). when we focus on core-based statistical areas where at least one respondent in our sample shopped for groceries online (column in table ), we observe two main differences. first, members of the y generation are less likely to shop for groceries. second, all income groups become equally likely to shop for groceries. by contrast, the only socio-economic characteristics that is statistically significant for people who shopped online for groceries is gender: women are more likely to shop online for groceries ( . **) than men, and this gender gap appears wider than for in-store shopping. this result echoes the findings of morganosky and cude ( ) in their study of us markets based on three datasets collected between and . however, when interpreting these results, it is important to keep in mind that the underlying dataset (n= , ) only includes people who shopped for groceries online (we lost respondents from our initial sample because their location is unknown). to take full advantage of our relatively small sample of only grocery shoppers, we also explored differences in the distribution of selected socio-economic characteristics of people who shop for groceries in stores and online using kruskal-wallis (kw) tests. figure shows the empirical distributions of selected characteristics of the , people in the atus dataset who shopped for groceries in stores and the who shopped online (so times more people shopped for grocery in stores than online on a given day in ). only the kw test for gender (not shown) was significant and it indicated that the gender difference for grocery shopping online is more marked than for grocery shopping in stores. crosstabulation analyses using χ tests gave similar results. <insert figures and approximately here> figure contrasts the distributions of the time when people start grocery shopping online and in stores. it shows that online shopping activity picks up early afternoon (especially between noon and pm) at a time when conventional grocery shopping tends to subside, and between pm and midnight, when in-store grocery shopping tappers off. these differences highlight the added flexibility and convenience of online grocery shopping. in this paper, we first analyzed data from the and the national household travel surveys to understand changes in deliveries from online shopping in the us. results from our zero-inflated negative binomial models show that online shopping in the us has been embraced by a much larger percentage of the us population, and that e-shoppers are more varied in compared to , although differences in the number of deliveries resulting from online shopping are sharper than in . in particular, households with more adult female members receive significantly more deliveries, and so do households with higher incomes and higher educational achievements. even after controlling for other socio-economic characteristics, we found that minority households are less likely to buy goods online, a disappointing finding that requires further investigations (one possible reason may be more limited access to credit cards). finally, households with mobility impaired members rely more in than in on online shopping to satisfy their needs. understanding the determinants of e-shopping is important for supply chain managers so they can adapt the facilities handling online orders, adjust deliveries, and plan product returns. it is also of interest for planners and policymakers concerned with the externalities generated by deliveries of online orders (congestion, traffic accidents, air pollution, and noise) so they can consider appropriate incentives (e.g., subsidies for electric delivery vehicles in denser areas) and regulations (e.g., on the power train technology of delivery vehicles, hours of deliveries, or maximum noise levels). since us national household travel surveys do not track what e-shoppers purchase, we also analyzed grocery shopping data from the atus using logit models and nonparametric tests. consistent with the literature, our results show that in-store grocery shoppers are more likely to be female and unemployed (because homemakers, who are still often female, are considered unemployed), but less likely to belong to younger generations, to have less than a college education, or to be african american, because poor people in predominantly black neighborhoods or in poor rural areas in the us tend to shop at dollar stores and rely more on fast food outlets. by contrast, the only significant socio-economic variable for online grocery shoppers is gender: again, women are more likely to shop for groceries, and the gender gap is larger than for in-store grocery shopping. while this result may be partly due to the small number (only ) of online grocery shoppers in our sample (n= , ), the small number of people for groceries online reflects that e-grocery is not common currently in the us: on any given day, people are times more likely to shop for groceries in stores compared to online. combining the profile of people who order groceries online with information about households who receive many online orders and data on local stores offering e-grocery could help understand where e-grocery is likely to succeed in the us. policymakers concerned with access to fresh foods in underserved neighborhoods may then consider subsidizing delivery costs and the creation of grocery packing and delivery jobs. emergency programs may also be put in place to deliver groceries to groups who cannot go grocery shopping, such as the elderly with impaired mobility or persons at-risk during contagious epidemic diseases (such as covid- ). as online shopping becomes ever more popular, the need for residential freight deliveries will keep on increasing. however, the magnitude of that increase and its impacts on traffic and the environment depend crucially on how last mile deliveries are organized. if packages are delivered to people's doorsteps with little coordination, soaring residential freight deliveries will increase congestion, noise, and air pollution, not to mention exacerbate parking shortages in denser urban areas. if, however, last mile deliveries are coordinated, performed as part of existing daily deliveries (e.g., via the us postal service), done by bicycle or electric vehicles, and/or go to lockers or neighborhood convenience stores (as is commonly done in taiwan , for example), their external costs could be much reduced (e.g., see moore, online in the atus, even though this survey gathered data from a representative sample of over , americans (unfortunately only over a single day each), which reflects the current lack of popularity of online grocery shopping in the united states. a second limitation is that our e-grocery dependent variable may have missed some click-and-pick orders. in future work, it would therefore be of interest to survey us households to gather detailed data about time use and travel, with retrospective questions about online purchases, in order to better capture the links between in-store and online purchases. until e-grocery becomes more popular in the us, researchers could analyze stated preferences of us consumers for egrocery to understand their preferences for various delivery and price options, and potential obstacles to e-grocery. to better understand the impact of last mile deliveries, it would also be of interest to monitor local freight deliveries in a wide range of neighborhoods. lastly, we suggest analyzing international experiences to learn from creative solutions implemented elsewhere to reduce the external costs of e-grocery (and more generally e-shopping). ) the dependent variable is the number of deliveries to the household from online shopping in the past month. it was truncated at . ) * p< . , ** p< . , *** p< . . to assess statistical significance, we used robust standard errors to mitigate the potential impacts of heteroskedasticity. ) a shaded cell indicates that the coefficient value for an explanatory variable differs from its value (p-value ≤ . ). ) count sub-models explain the number of deliveries to each household from online shopping. logit sub-models explains the characteristics of households who never order goods online. ) lower density census tracts have less than people per square mile. higher density census tracts have over , people per square mile. ) msa: metropolitan statistical area. ) α is the inverse of the scale parameter of the gamma noise variable in the negative binomial count component of a zero-inflated negative binomial model. stata estimates and reports ln(α), as well as its statistical significance. - . *** - . *** - . *** notes: ) * p< . , ** p< . , *** p< . . ) for in-store grocery shopping, the dependent variable equals if the atus respondent shopped in a brick-andmortar grocery store on the survey day and zero otherwise. for e-grocery shopping, the dependent variable equals if the atus respondent shopped online for groceries on the survey day 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editor-in-chief, professor edoardo marcucci, and anonymous referees for helpful comments that helped improve this paper substantially. as usual, we are responsible for any remaining errors. ) the smaller sample (n= , ) was obtained by keeping only atus respondents from core-based statistical areas (cbsa) where at least one other atus respondent shopped for groceries online. we removed respondents whose ethnicity is "other" (neither african american, asian, nor white) and who had a "mobility impairment" because none of them shopped for groceries online so the impact of these characteristics on e-grocery shopping could not be estimated. key: cord- -clzt kyg authors: clavijo, raul; ramasamy, ranjith; halpern, joshua; melnick, alexis; stewart, joshua; rosenwaks, zev; brannigan, robert title: “online” and “at-home” versus traditional models of health care: enhancing access or impeding optimal therapeutics? date: - - journal: fertil steril doi: . /j.fertnstert. . . sha: doc_id: cord_uid: clzt kyg nan pro: ''online'' and ''at home'' health care enhances access to optimal therapeutics pro . raul clavijo, m.d. before the advent of telehealth, prescription medication was available to patients only through a physical encounter in a hospital or clinic with a physician. currently, in the united states, policies exist allowing the prescription of a wide range of medications after a telehealth visit ( ) . our first instinct is to be skeptical of virtual efforts to treat reproductive and sexual health conditions because of our ingrained notion that a physical examination is essential in formally evaluating all medical conditions, and therefore assessing risk-benefit profiles for medications. however, this skepticism is best imparted individually in our field, based on the diagnosis and potential therapeutic options, separating sexual health from infertility diagnoses. first, it is important to understand that con: ''online'' and ''at home'' health care impedes access to optimal therapeutics con . alexis melnick, m.d. in recent years, we have seen an upswing in the number of direct-to-consumer telehealth companies offering prescription medications. this trend has now reached the reproductive and sexual health spheres, with companies such as roman and hims garnering the most attention for treating men with ed. more recently, we have seen the emergence of athome in vitro fertilization kits, which provide patients with a protocol of oral ovulation induction drugs and a nasal gnrh antagonist after an initial telehealth visit. the patient is first seen in person at the time of their retrieval, after monitoring for ovulation at home with urine luteinizing hormone test strips. although these approaches seemingly allow for increased convenience and privacy, they pose sig-stigma is more likely stigma associated with a patient seeking advice for sexual concerns compared with infertility ( ) . one study showed that < % of patients with sexual dysfunction sought care with a physician in comparison with another study revealing that % of couples with infertility sought professional care ( , ) . thus, owing to the lack of physical exposure to clinical settings, it is likely that our patients with sexual dysfunction, with or without infertility, who stand to benefit the most from our taking a potential risk of prescribing medications after virtual care. this being taken into account, medications approved by the u.s. food and drug administration for sexual dysfunction are more likely to be considered in a virtual care setting than is the off-label use of medications ( ) . diagnosing and treating erectile dysfunction (ed) with phosphodiesterase type inhibitors such as sildenafil is a prime example of how sexual health prescription medications can be prescribed online safely. the safety profile in a patient can be mostly derived from history taking and careful chart review, focusing on medications such as nitrates that can lead to potentially fatal conditions. it is rare that a physical examination finding alone would deter a physician from prescribing phosphodiesterase type inhibitors. however, if there is a need to move on to second-line options such as penile injections or vacuum erection devices, a physical examination is useful to assess for conditions such as buried penis that would limit the efficacy of those options. at least, by this point, patients have a baseline physician relationship established, likely facilitating their choice to present at a physical clinic. similar to the reliance on history to diagnose ed, certain sexual dysfunction diagnoses such as hypoactive sexual desire disorder in premenopausal women do not strictly require a physical examination ( ) . however, prescribing medications such as flibanserin, despite being approved by the food and drug administration, becomes problematic in the minds of many, mostly owing to a lack of overwhelming safety data and side effect profiles, such as that available for phosphodiesterase type inhibitors. in fact, this difference is obvious in a comparison of the menu of treatment options available through widely advertised digital health companies. men are offered treatment for conditions such as ed and premature ejaculation, whereas the menu for women has no mention of conditions such as hypoactive sexual desire disorder or dyspareunia. the makers of flibanserin, nevertheless, do offer telemedicine options advertising the ability to avoid physical clinical encounters. along these lines, reproductive medications such as clomiphene citrate are relatively more appropriate for online procurement in men. for example, in men with oligospermia and low testosterone, both of which can technically be determined with at-home testing, it is conceivable that clomiphene can be prescribed empirically without a formal physical examination because contraindications such as thrombotic coagulopathies can be derived from a history. the risk in this situation would be missing a testicular tumor because no physical examination is available. for women, empiric treatment with clomiphene after an isolated virtual encounter becomes problematic because most practitioners nificant risks to patient health while likely providing suboptimal care. the greatest limitation of these modalities is the inability to conduct a complete physical examination at the time of the telehealth encounter. this is particularly concerning for ed patients. ed has been shown across several studies to be a proxy of overall health and a sentinel marker for cardiovascular disease, diabetes mellitus, and metabolic syndrome, particularly in men under years old-the demographic most likely to use direct-to-consumer services ( ) . for this reason, the american urological association guidelines recommend a complete physical examination and selective laboratory testing in all men presenting with ed, which cannot be achieved with even the most comprehensive screening questionnaire and telehealth visit ( ) . consequently, for many men using direct-to-consumer platforms, life-threatening comorbidities will not be identified. the lack of an in-person encounter also restricts the ability to screen for contraindications before prescribing medications. self-administered checklists may be effective for most patients but not all. a study of women screening for contraindications to the use of oral contraceptive pills revealed underreporting of hypertension ( ) . therefore, simply relying on a patient's report of a recent blood pressure measurement, as hims and roman do, is insufficient. the remote screening for women using at-home in vitro fertilization kits will similarly fail to adequately identify contraindicated conditions for ovulation induction and/or pregnancy, such as hypertension, thyroid disease, and ovarian cysts. furthermore, not all risk factors for ovarian hyperstimulation syndrome can be assessed remotely. although the incidence of ovarian hyperstimulation syndrome from clomiphene and letrozole is low, it is not zero. given the potential for severe disease in women with ovarian hyperstimulation syndrome, it is prudent to identify upfront those patients at risk. last, and perhaps most importantly, the direct-to-consumer approach to sexual and reproductive health allows patients to circumvent their general medical care. a report from accenture found that only % of generation z patients have a primary care physician, in contrast to % for prior generations ( ) . whereas online health platforms clearly state that they are not a substitute for a primary care physician, by allowing for a ''quick fix'' they discourage a visit to the doctor in which a discussion of chief complaint will be followed by a thorough health history, a comprehensive physical examination, and a conversation about preventive care. it is often a problem-focused visit that leads to the establishment of a long-term doctor-patient relationship. the direct-to-consumer approach may therefore cause more harm than good, both within the domains it is aiming to treat and to the overall health of its consumers. pro: ''online'' and ''at home'' health care enhances access to optimal therapeutics (continued) con: ''online'' and ''at home'' health care impedes access to optimal therapeutics (continued) advocate for a baseline pelvic ultrasound and hysterosalpingogram before a clomid cycle is attempted, both of which require physical interaction with a clinic. overall, the availability of prescription medications with well-defined risk profiles to patients through virtual sources is only likely to enhance the access to care for sexual and reproductive health conditions by easing the pain of embarrassment some patients may experience. furthermore, the ability to provide prescription medications virtually will increase the relevance of virtual health visits because ''something was done to treat my condition'' in the minds of patients. given the current circumstances of the covid- pandemic, where both patient-centered care and social distancing are important issues, home-based testing for fertility is becoming increasingly important. semen analysis (sa) evaluation with manual microscopic analysis and computer-assisted sa are labor intensive, time limited, and expensive ( ). furthermore, many men are reluctant to seek conventional clinical testing because of embarrassment, long wait times, inconvenience, and social stigma. men may be more willing to use homebased sa kits that can provide point-of-care fertility diagnostic analysis ( ) . a valid critique of the existing home sa kits includes that they lack adequate quality control, they are vulnerable to false-negative results by the provision of rudimentary quantitative or qualitative results, and they are prone to sample handling errors ( ) ( ) ( ) . however, new approaches to home sa testing are overcoming the challenges of current technology by including paper-based diagnosis ( ), smartphone-based computer-assisted sa system ( ), digital holography ( ) , and microfluidic channels ( ) . with the development of the y smartphone-based computer-assisted sa system, which uses the smartphone's camera and light source to measure motile sperm concentration, there's great potential to support home testing and evaluate fecundity in a young generation familiar with information technology without formal training ( ) . both the y device in addition to the increased availability of direct-to-consumer prescription medications, we have also witnessed a dramatic shift in the number of patients using at-home fertility testing. what was once only available through the physician's office is now easily accessible through the internet or in grocery store aisles. after home collection of a finger prick blood sample, patients can send away for anti-m€ ullerian hormone, folliclestimulating hormone, and thyroid hormone levels. additionally, at-home testing is also available for sa and genetic carrier screening. ancestry and andme, just two of the many commercial companies branded as ''health and ancestry services,'' offer direct-to-consumer home dna kits. at-home testing within the reproductive health space presents unique implications for both patients and healthcare providers, particularly as it relates to counseling, reliability, and privacy. commercial companies are not mandated to provide pretest and posttest counseling for the testing they offer, and when it is provided, it often requires the patient to take the initiative. in many situations, the individuals undergoing testing are not aware of the possible implications of the results on themselves, their families, and society as a whole. for example, at-home ovarian reserve testing is often marketed to individuals with amenorrhea or suspected polycystic ovary syndrome. after receiving the results, the consumer is left to interpret them on her own, which may result in false reassurance or the opposite-unnecessary anxiety. real harm may be encountered if in-pro: ''online'' and ''at home'' health care enhances access to optimal therapeutics (continued) con: ''online'' and ''at home'' health care impedes access to optimal therapeutics (continued) and paper-based devices claim to show . % and % agreement with the results of computer-assisted sa, respectively ( , ) . currently, less than a quarter of cancer patients bank sperm, and the most common reason for not doing so is lack of access to facilities ( ) . timely cryopreservation is critical for cancer patients because in some cases, > visit will be required to cryopreserve a sufficient amount of sperm, or there's an urgent need to start anticancer therapy ( ) . hence, home-based cryopreservation kits will be a valuable alternative. home sperm-testing kits can be used to evaluate azoospermia after vasectomy. however, goldstein et al. ( ) observed that home sa kits failed to significantly improve compliance and suggested that there be partner involvement. home-based ovulation predictor kits have the potential to increase autonomy and empowerment to women who face barriers to enacting decisions in relation to their sexuality and reproduction. ovulation predictor kits aid women in fertility awareness with regard to when ovulation should occur during their menstrual cycle and identify anovulatory cycles, which may prompt them to seek medical assistance earlier. during artificial reproduction treatment, patients need to be monitored by serial endovaginal ultrasound, which entails economic, logistic, emotional, and potential environmental cost and also reduces practitioners' time for more complex tasks. self-operated endovaginal telemonitoring was specifically designed for this use and proved noninferior to traditional two-dimensional transvaginal sonographic monitoring ( ) . despite physical separation and asynchronous communication, couples stated a better doctor-patient relationship when home-based diagnostic tests were used ( ) . in light of the current situation of the covid pandemic along with the boom of telemedicine, physicians should consider incorporating home-based kits for both male and female fertility testing with the caveats that even though we may not get accurate data all the time, data from these kits can be used to guide care. the coronavirus pandemic has quickly catapulted telemedicine to the forefront of healthcare delivery ( ) . the value of telemedicine during the pandemic is clear-the ability to treat patients without the risk of exposure to and spread of the highly infectious covid- virus is paramount. but dividuals substitute at-home testing for a thorough medical evaluation and counseling regarding the overall health and fertility implications of certain conditions. furthermore, diagnosis of genetic carrier status and risk of associated health conditions, such as with brca testing, requires thoughtful interpretation regarding the implications for individuals and families. this testing and concurrent counseling should be conducted in conjunction with an experienced genetic counselor and physician. the reliability of test results is another major issue with athome testing, even with one of the most widely used tests, urinary ovulation predictor kits. while luteinizing hormonebased ovulation tests have demonstrated accurate and superior ovulation detection when compared with basal body temperature charting, calendar calculation, or observation of cervical discharge changes, errors can still occur ( ) . furthermore, these kits have not been consistently associated with increased pregnancy rates when used alone. in one prospective cohort study in a population that conceived via donor insemination using either home monitoring with urinary luteinizing hormone kits compared with laboratory serum luteinizing hormone testing, pregnancy rates were significantly reduced in those performing home testing: . % per cycle versus . % over the same time period (p< . , % ci . - . ) ( ) . with all forms of athome testing, there is significant variability in the sensitivity and reproducibility of various tests, as well as user error, which may account for these differences in outcome. last, issues of data privacy and confidentiality must be considered with at-home fertility testing. commercial testing allows significant data mining, often without consumers' consent or knowledge. testing results may become part of large databases that incorporate demographic and genetic information, which may have unintended negative consequences for consumers. at the time of this publication, the covid- pandemic has fundamentally changed the way we deliver care to our pa-pro: ''online'' and ''at home'' health care enhances access to optimal therapeutics (continued) con: ''online'' and ''at home'' health care impedes access to optimal therapeutics (continued) telemedicine offers advantages that will persist beyond the pandemic, such as increased access, cost savings, and patient and physician satisfaction. access to care is among the greatest barriers to delivering quality healthcare in reproductive medicine. the american society for reproductive medicine recognizes the responsibility of providers and policy makers to address disparities in access to reproductive medicine, including the need to reach underserved populations and geographic areas ( ). nangia et al. ( , ) found substantial geographic disparities in access to both artificial reproduction treatment and male reproductive specialists, and harris et al. ( ) estimated that approximately . million women of reproductive age lived in an area without an artificial reproduction treatment clinic. women and men seeking fertility care who are geographically distant or cannot present for in-person visits can establish care through telemedicine. although physical examination and in-office diagnostics are paramount for the evaluation of both female and male fertility, an initial telehealth visit can uncover pertinent history, identify risk factors, and establish the physician-patient relationship. a telemedicine visit not only provides the couple with initial counseling and a sense of progress but also can initiate a diagnostic cascade, most of which can be performed locally such as serum hormone and sperm analyses, and possibly formulate treatment approaches. hernandez et al. ( ) found that implementation of an electronic telehealth intervention for women presenting for fertility evaluation resulted in shorter time to diagnostic testing and artificial reproduction treatment. telemedicine is also useful for couples seeking a second opinion because telehealth democratizes access to national experts, enabling couples to seek consultation beyond their typical geographic boundaries. last, zwingerman et al. ( ) demonstrated that telemedicine can improve access to fertility preservation services among women presenting with cancer at geographically remote satellite centers, offering an expedient solution for a time-sensitive problem. implementation of telehealth can be seamless with rapid integration in just a few days ( ) . and whereas the initial investments in training and infrastructure for telemedicine may be costly, there is a long-term savings potential. telehealth decreases the use of on-site resources, reducing the need for and optimizing the use of clinical space. zholudev et al. ( ) found that urologic telemedicine visits were $ cheaper and more efficient than face-to-face encounters. the wide availability of telemedicine through free interfaces such as doximity or even a simple phone call has democratized access for both physicians and patients alike. there are already robust data to suggest that patients prefer telemedicine. reed et al. ( ) found % patient satisfaction with telemedicine across specialties within a large healthcare system, and others have shown high patient satisfaction within urology specifically ( ) ( ) ( ) . although data regarding physicians' perspectives are limited, the potential tients. one significant change has been an increased use of telehealth services. certainly, even before the current health crisis, patients were increasingly using social media and fertility tracking applications on their electronic devices to obtain and engage with reproductive health information ( ) . although these technological advances may offer some benefits, it is critical to ensure the safe delivery of the highest quality care and the dissemination of accurate information. the greatest limitation to telehealth is the lack of an inperson physical examination. unlike other areas of medicine that may be amenable to video consultation, many topics and diagnoses within sexual and reproductive health cannot be easily diagnosed and discussed. subjective aspects of the physician-patient interaction, such as body language, are often lost during telehealth encounters, making patients feel less at ease, especially when discussing sensitive topics. without the face-to-face interaction, the physician's ability to make an accurate diagnosis can be limited, with the potential for greater patient loss to follow-up. technical issues such as slow internet speed and poor audio or video quality can further complicate these encounters. many telehealth applications require patients to set up and log into third-party portals, which often are not patient friendly and can be overly burdensome. this has been shown to lead to lower use of telehealth services by men and women of lower socioeconomic status, further accentuating health disparities in the delivery of care ( ) . to effectively deliver reproductive health care through telehealth, we need to first improve user-centered design to optimize patient engagement. additional concerns with telehealth involve privacy, physician liability, and reimbursement ( ) . currently, standardized guidelines are not available to support appropriate safeguards and regulatory oversight, such as ensuring that these telehealth applications are compliant with the health insurance portability and accountability act. furthermore, delivery of reproductive medicine services via telehealth may present unique quality and safety risks for patients and may increase physician liability. for instance, given that as telehealth allows the delivery of care across state lines, physicians and practices are confronted with the complex issue of conflicting state licensure requirements. last, current reimbursement structures present a major barrier to the adaptability of this technology. the current procedural terminology codes have been insufficiently updated to facilitate reimbursement in both fee-for-service and value-based models of care delivery, and additional research is required to determine the effect of alternative payment models that use bundled telehealth services. all in all, physicians and patients should recognize that these emerging technologies require further refinement and may not always adequately substitute for previously accepted, traditional approaches to medical care. pro: ''online'' and ''at home'' health care enhances access to optimal therapeutics (continued) con: ''online'' and ''at home'' health care impedes access to optimal therapeutics (continued) for increased flexibility in hours and practice location has great upside for physicians and could even have a significant impact in reduction of burnout, which also confers clear long-term cost savings. detractors may point to potential hurdles to the implementation of telemedicine for reproductive health, but they are easily overcome. data have already shown equivalent outcomes for obstetric and fertility care provided via telemedicine ( , ) . the lack of physical examinations could result in missing critical diagnoses such as testicular masses, but telemedicine is intended not to supplant but to augment inperson examination ( ) . others have raised concerns regarding the regulatory burden, reimbursement, and medical-legal liability of practicing telemedicine, particularly across state lines. however, fogel and kvedar ( ) found no cases of medical malpractice pertaining to telemedicine. if physicians and institutions familiarize themselves with federal, state, and payer requirements, telemedicine can be practiced safely and with optimal physician reimbursement. as providers, payers, regulators, and professional societies scramble to determine a roadmap for the implementation of telemedicine, one thing is clear: telemedicine is here to stay. the american society for reproductive medicine has task forces and guidelines in place to usher our specialties into the era of telemedicine. while we look forward to future studies examining efficacy across a variety of metrics we should continue to proceed with telemedicine integration, albeit with caution, given the many potential benefits of this novel platform. pro: ''online'' and ''at home'' health care enhances access to optimal therapeutics (continued) con: ''online'' and ''at home'' health care impedes access to optimal therapeutics (continued) home sperm testing device versus laboratory sperm quality analyzer: comparison of motile sperm concentration standard operating procedures for taking a sexual history group. a population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the united states of america international estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care fda approval of flibanserin-treating hypoactive sexual desire disorder hypoactive sexual desire disorder: international society for the study of women's sexual health (isswsh) expert consensus panel 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millennial and gen z consumers paving the way for nontraditional care models, accenture study finds urinary-based ovulation and pregnancy: point-ofcare testing ovary and ovulation: home ovulation testing in a donor insemination service infertility influencers: an analysis of information and influence in the fertility webspace barriers and facilitators that influence telemedicine-based, real-time, online consultation at patients' homes: systematic literature review key: cord- -twiye jv authors: lourenco, stella f.; tasimi, arber title: no participant left behind: conducting science during covid- date: - - journal: trends cogn sci doi: . /j.tics. . . sha: doc_id: cord_uid: twiye jv abstract cognitive scientists have ramped up online testing in response to the coronavirus pandemic. although research conducted online solves the problem of data collection, a lack of internet access among low-income and minority communities may reduce the diversity of study samples and, thus, impact the generalizability of scientific findings. when her children's school district closed its doors to curb the spread of the coronavirus, tamara solis had to make a difficult decision [ ] . she could pay for internet access so that her kids could complete their virtual coursework, but doing so would limit her ability to afford food and rent. the covid- pandemic has upended life in more ways than one. people like tamara solis, for example, are being confronted with the harsh reality of how to pay for food and housing in a time when millions and millions of people have lost their jobs [ ] . students graduating from college will not experience the ceremonial milestone they cherish. and cognitive scientists who study human populations have been forced to close their labs in order to uphold social distancing measures. among the challenges facing scientists today is how to collect the data needed for publications, grant submissions, dissertations, promotion materials, and so on. online testing offers a potential solution to this problem, even for fields like developmental psychology where in-person testing is paramount. indeed, many child development laboratories are going online for the first time, a shift that is being facilitated by resources such as the parent and researcher collaborative (https://childrenhelpingscience.com), a single, crowd-sourced platform where researchers from different labs can post their studies for families to participate in. and as more and more cognitive scientists are conducting their research online, we find ourselves wondering who is (and isn't) participating in this research. online testing offers numerous benefits--it is fast, efficient, and inexpensive [ ] . one might even argue that platforms such as amazon mechanical turk (mturk) and turkprime have revolutionized behavioral data collection. as excited as we are about the promises of online testing (e.g., in fields like developmental psychology where data collection is typically slow and expensive), we are also concerned about how the demographics of online participants may shift during covid- . in particular, we worry that online testing may reduce the diversity of participants--especially those from low-income and minority households-whose participation in scientific research has been essential in understanding all sorts of phenomena, from language proficiency [ ] and spatial reasoning [ ] to academic achievement [ ] and brain development [ ] . at first glance, such a concern may seem unwarranted. after all, studies conducted online seem to be more diverse than studies conducted in laboratories [ , [ ] [ ] . in fact, with respect to household income, some estimates suggest a greater number of lower-income workers on mturk than expected given the general population of workers [ ] . following this point, the monetary compensation associated with these studies could very well increase the diversity of participants, especially given that turkers participate in numerous online experiments to supplement their income [ , ] . so why are we worried about less diverse online samples during an economic downturn? j o u r n a l p r e -p r o o f participation in online studies requires internet access, a staple among many, though not all, households. in the u.s., there is a well-known 'digital divide', in which americans in rural and poor communities are less likely to have internet in their homes than urban and more affluent communities [ ] . the federal communications commission estimates that more than million americans do not have broadband connection with download speeds of at least megabits per second, and nearly half of all households making less than $ , per year have no connection whatsoever. moreover, black and hispanic americans lag behind their white counterparts in internet adoption even when controlling for income. nevertheless, in normal times, individuals without home internet access might be able to get online in public places such as schools, libraries, coffee shops, fast food restaurants, and even parking lots. but these are not normal times. amenities such as the internet may become a luxury as more and more people continue to lose their jobs and struggle to pay their bills. what is more, people who would normally gain internet access in public places may now be unable to do so because of stay-at-home orders and/or fear of contracting the coronavirus. accordingly, it is possible that participants in online studies may now consist of those who can afford to weather the economic storm and/or have the time to participate in research studies given new demands on family care while working from home. thus, the push to online testing at this time may exclude a large segment of the population, thereby limiting the generalizability of findings and posing challenges to reproducibility. to be clear, we are not claiming that online testing should stop. if anything, we commend our colleagues for the dedication and generosity they have shown in promoting resources for online testing (especially within our own field of developmental psychology where such resources were not widely available). at the same time, we think the time is now ripe for a discussion about how science can progress in a way that is mindful of access and inequality, a problem that strikes us as particularly acute these days. there are several steps we can take to ensure and promote the diversity of study samples. below we sketch out some recommendations aimed at advancing demographic diversity during and after the covid- pandemic. we recognize that this list is not exhaustive, and we also recognize that some of these recommendations will be difficult and costly to implement. nevertheless, we hope that what follows serves as a launching pad for further consideration. first, we recommend that studies conducted online collect and report detailed demographic information of study participants. one potentially efficient way to mandate demographic data collection is to set it as a default for all studies that are posted online. in this vein, we also encourage journals to require authors to report the characteristics of their study samples. for example, the society for research in child development (srcd) enacted a sociocultural policy across all of its journals earlier this year, in january . we recommend that other journals follow suit. although the simple reporting of demographics j o u r n a l p r e -p r o o f will not itself increase diversity within samples, it nevertheless ensures transparency and promotes future reproducibility. second, we urge scientists to make efforts to provide temporary internet connection to low-income participants. there are mobile hotspots available for purchase, which could be mailed to participants or dropped off at their homes to allow for participation in online studies. we recognize that the financial burden here is likely to be disproportionate across researchers, some of whom will have funding to support such a move and some who may not. relatedly, as a longer-term goal that transcends the issue of online testing, scientists and grant-funding agencies might consider lobbying government for subsidies related to internet costs, and perhaps even advocate for universal availability of internet access, which is essential for living and operating in contemporary times. some internet companies have already reduced prices for qualifying customers and have provided free access to online educational resources [ ] . this is a promising start, but much more will be needed to ensure availability to those who need but cannot afford internet access. finally, we recommend that scientists who have the resources to implement off-site testing consider using such an approach to reach participants in low-income and minority communities. some universities (e.g., university of illinois at chicago, university of iowa, and indiana university) have developed mobile laboratories with portable technology. these laboratories may be especially useful in the years to come, particularly if the necessary precautions are taken to ensure the safety of experimenters and participants, including the use of personal protective equipment (ppe) and regular disinfection of study materials. even if we succeed in flattening the curve, resurgences in infection are likely until (or if) a vaccine for the coronavirus can be developed. thus, we may be on the precipice of a new normal, in which threats of disease may require long-term social distancing practices and may differentially impact those in low-income and minority communities. at a time when access to a large segment of the population may be hampered, we must not forget the value and necessity of diverse populations in uncovering the human experience in terms of its universality and its variability [ ] [ ] . after all, this is what cognitive science is all about. getting free internet is hard for poor students despite provider promises, survey finds. the los angeles times nowhere to hide' as unemployment permeates the economy. the new york times an evaluation of amazon's mechanical turk, its rapid rise, and its effective use language learning, socioeconomic status, and child-directed speech socioeconomic status modifies the sex difference in spatial skill socioeconomic status and child development the neuroscience of socioeconomic status: correlates, causes, and consequences separate but equal? a comparison of participants and data gathered via amazon's mturk, social media, and face-to-face behavioral testing lookit (part ): a new online platform for developmental research research in the crowdsourcing age, a case study social heuristics shape intuitive cooperation the digital divide to fight coronavirus, millions more americans need internet access. the new york times the weirdest people in the world? the persistent sampling bias in developmental psychology: a call to action key: cord- -y tws p authors: yusoff, muhamad saiful bahri; hadie, siti nurma hanim; mohamad, irfan; draman, nani; muhd al-aarifin, ismail; wan abdul rahman, wan faiziah; mat pa, mohamad najib; yaacob, nor azwany title: sustainable medical teaching and learning during the covid- pandemic: surviving the new normal date: - - journal: malays j med sci doi: . /mjms . . . sha: doc_id: cord_uid: y tws p during the first phase of the movement control order, many medical lecturers had difficulty adapting to the online teaching and learning methods that were made compulsory by the institutional directives. some of these lecturers are clinicians who need to juggle between clinical work and teaching, and consider a two-week adaptation during this period to be not enough. furthermore, converting traditional face-to-face learning to online formats for undergraduate and postgraduate clinical programmes would reduce the learning outcomes, especially those related to clinical applications and the acquisition of new skills. this editorial discusses the impact that movement restrictions have had on medical teaching and learning, the alternatives and challenges and the way forward. the clicking time bomb the coronavirus disease (covid- ) outbreak was designated as a public health emergency on january ( ) . subsequently, the world health organization (who) declared covid- to be a pandemic after , cases had been detected with , deaths across countries ( ) . the rapid spread of covid- has had an enormous impact on many aspects of human life including social development and education and has caused many countries to activate emergency risk management ( ) . malaysia reported its first covid- case on january ; the patient contracted the disease from chinese tourists who had crossed the border from singapore two days earlier. after that, the number of cases continued to escalate, few clusters of the spread could be identified and the first death was reported on march ( ). malaysia took preventive action with the announcement of the movement control order (mco) on march ( ), through the prevention and control of infectious diseases act and the police act (figure ). the first phase came into effect on march , with extensions to be announced as per ministry of health inputs and the implementation managed by the malaysian national security council. chronological events during covid- pandemic leading to the mco and usm online teaching and learning initiatives the dawn of the mco the main objective of the mco is to isolate the sources of covid- cases and break the chain of infection. the methods of preventing the disease and isolating the sources of the cases include prohibition of movement and mass assemblies nationwide, including all religious, social, sports, cultural and education activities ( ) . however, the mco that resulted from the covid- pandemic has created significant challenges for the higher education community in ensuring continuous provision of education to the students. in terms of undergraduate and postgraduate medical curricula, the continuity of medical programmes is important so that medical students can become familiar with practice settings and the teams to which they are assigned. at the same time, it is important for teachers of medicine to assess their students' abilities with regard to patient care and safety, as well as the development of their professional behaviours. continuity in the relationships between teachers and students in medicine also allows the teachers to evaluate their students' learning needs, not only those related to cognitive competency but also their requirements in addressing other issues relating to mastering skills and acquiring learning values ( ) . it should be noted that if the duration for the mco following the covid- outbreak were to exceed two months, which is now the case, it was essential for medical schools to activate emergency risk management for the implementation of online teaching and learning during the outbreak. online teaching and learning have rapidly become a delivery method for higher education in many countries including malaysia. the new technologies appear to offer many advantages over conventional formats, such as being more cost effective, giving greater levels of access to students, providing more flexible teaching and learning approaches and, therefore, enhancing educational opportunities ( ) . since their introduction, online teaching and learning have often been regarded as a supplementary teaching approach rather than replacing face-to face classes ( ) . online sessions were initially adopted to overcome problems with traditional face-toface teaching, such as to improve opportunities for students to access formal education, to increase students' autonomy and expedite the completion of their degree programmes ( ) and, hence, to enable the rapid growth of blended learning ( ) . however, online teaching continues to be an adjunct teaching method for medical curricula, as face-to face teaching is still required for the development of certain learning outcomes such as the acquisition of clinical skills and development of values (i.e. professionalism) ( ) . in spite of the increasing use of technologyenhanced learning in medical curricula ( , ) , it was never viewed as a method that would totally replace face-to-face teaching until the covid- outbreak. being able to conduct fullblown online teaching and learning in medical schools during this pandemic is critical to ensure the continuity of educational delivery to medical students after the prohibition of movement and mass assemblies had been undertaken to break the chain of infection. nevertheless, the adoption of online learning is not without obstacles. studies have shown that the attitudes of teachers and learners are strong determinants of the successful implementation of online learning and of its effectiveness ( ) ( ) ( ) . the interest and curiosity of teachers have been the main impetus for trying the online learning mode. the greatest resistance to it is found in relation to logistical and organisational problems, mainly resulting from lack of access to the internet or not having adequate skills in using it, and in cultural difficulties, such as strong preferences for face-to-face interaction. there have also been misconceptions about distance and online teaching methods that have resulted in lecturers being opposed to conducting online learning. among these are lecturers and students' perceptions that they have total freedom with regard to participation in time and in space ( ) . however, collaborative learning processes in fact require mutual commitment, whether they are conducted in real-time or not ( ) . there is also frequent disagreement regarding the potential of online written and asynchronous communication, with reference to their abilities to foster deep learning ( ) . some other misconceptions and anxieties that lecturers have about online teaching are that it lacks digital literacy or that using computers could not allow for the achievement of learning outcomes in their programmes. some lecturers insist that students love face-to-face teaching, even though there is no empirical or proven evidence for this ( , ) . a number of lecturers have echoed their concerns about converting face-to-face learning to online formats for undergraduate and postgraduate clinical programmes, which they believe might limit their chances of achieving their learning outcomes, especially those related to clinical application and the acquisition of skills. a number of suggestions have been made to overcome the teacher's resistance and misconceptions regarding online teaching and learning ( , ) . successful online teaching is multifactorial, as it is the result of complex interplay among personal, pedagogical, contextual and organisational factors within higher education institutions. these factors include providing lecturers with continuous professional development training pertaining to the online teaching and learning, providing good internet support and web-based platforms for the lecturers so that they can develop their own autonomies and creating positive cultural environments such as rewards and recognition with regard to online education ( ). these efforts would be able to stimulate the internal motivation and willingness of the lecturers to conduct online teaching as one of their routine teaching approaches. clearly, the unprecedented outbreak of the covid- pandemic has led to changes in the way online teaching and learning are perceived. with the complete lockdowns, called the mco in malaysia, that were enforced in many countries, educators worldwide have been left with no options except to conduct online teaching and learning to ensure continuous provision of education to students. this has also been the unique real-time experience of many medical lecturers in malaysian medical schools, as they must conduct online teaching and learning within their own capabilities and in spite of their limitations. at the time of writing this, universiti sains malaysia has just released an appreciation note on the amazing number of , online teaching and learning sessions conducted in the second week ( april- april ) of its implementation directive (figure ) ( ) . a study is needed to provide an initial evaluation of the implementation of online teaching, learning and assessment during the mco, by exploring the enablers and the challenges faced by the lecturers. world health organization declares global emergency: a review of the novel coronavirus (covid- ) covid- pandemic: perspectives on an unfolding crisis risk management of covid- by universities in china malaysia confirms first covid- death, victim is pastor from sarawak. channel news asia a critical appraisal of covid- in malaysia and beyond managing crisis with "unprecedented situation deals with unprecedented measures": the case movement control order on coronavirus disease (covid- ) in malaysia why continuity matters exploring strategies for online teaching and learning why use the online environment with face-to-face students?: insights from early adopters factors influencing faculty satisfaction with online teaching and learning in higher education from face-to-face teaching to online teaching: pedagogical transitions the impact of e-learning in medical education the ederm online curriculum: a randomized study of effective skin cancer teaching to medical students medical students' and residents' use of online social networking tools: implications for teaching professionalism in medical education online learning: attitudes, expectations and prejudices of adult novices. proceedings of the iasted web based education conference what drives a successful e-learning? an empirical investigation of the critical factors influencing learner satisfaction a descriptive study of community college teachers' attitudes toward online learning online learning and teaching in hospitality, leisure, sport and tourism: myths, opportunities and challenges computer selfefficacy, anxiety, and learning in online versus face to face medium a professional development framework for online teaching factors contributing to teachers' successful implementation of it usm online learning getting positive, encouraging response key: cord- -wymqvwjt authors: price, alex title: online gambling in the midst of covid- : a nexus of mental health concerns, substance use and financial stress date: - - journal: int j ment health addict doi: . /s - - - sha: doc_id: cord_uid: wymqvwjt this study examined the emerging impact of covid- on gambling during the first weeks of emergency measures in ontario, canada. a cross-sectional online survey of gamblers, including a sub-sample of online gamblers (age years and older), was administered to assess risky gambling behaviours and motivations, financial impacts from covid- , the influence of covid- on online gambling, mental health concerns and substance use. a series of odds ratio comparisons and measures of association were carried out. results show significant likelihood of online gambling among those classified as high-risk gamblers (according to the problem gambling severity index) and those with past experience of online gambling, though migration from land-based gambling was apparent. among high-risk online gamblers, the most predictive risk factors included moderate and severe anxiety and depression, reduced work hours, being influenced to gamble due to covid- , gambling under the influence of cannabis or alcohol and risky gambling motives tied to mental health concerns, including gambling because it helps with nervousness and depression, chasing gambling losses and seeking to earn income. this study has confirmed many of the risk associations presented in emerging covid- -related studies and past research on global economic crisis relating to gambling risk, mental health concerns and substance use. however, unlike many past studies, the present paper takes note of all of these elements holistically and provides incremental clarity on online gambling risk factors during the pandemic, specifically. during covid- , online gambling, in particular, has become a lens through which to observe serious public health effects. broadly speaking, the pandemic has negatively impacted many social and economic determinants of health in jurisdictions around the world. in canada, the national statistics agency reported a . % fall in employment between february and march (statistics canada ). as a result, over . million applications to the federal government's covid- financial assistance program, the canada emergency response benefit, have been submitted as of may . this wide-scale financial disruption has raised questions about the potential impacts on public health outcomes and risk factors. thus far, gambling behaviour during the pandemic has been characterized by stable or decreased participation, although some at-risk groups featuring vulnerability to high-risk gambling and alcohol misuse have increased their gambling activity (håkansson ). more investigation is necessary, however, as evidence has been limited by self-report research designs. at the time of writing, few studies have presented analyses of online behavioural data but do report modest online gambling activity compared with pre-pandemic levels, overall (auer et al. ) . decreasing rates of gambling participation in some jurisdictions have been tied to a variety of factors, including the limited access to land-based venues, disruptions to professional sporting competitions, financial instability and others (auer et al. ; gambling commission ) . although evidence is still limited, emerging discourse on secondary impacts of covid- has included substance use and gambling. many papers take note of the effects of isolation, mental health concerns, pre-existing substance use disorders and ongoing access to online gambling and some substances (douglas et al. ; marsden et al. ) . for instance, in many jurisdictions under lockdown, alcohol has remained an official essential commodity and even featured relaxed licensing for distribution, resulting in sale surges (ahmed et al. ; dubey et al. ) . emerging evidence from china also note a . % increase in internet use and dependence (including a % increase in severe internet addiction) as well as an increase in alcohol consumption and alcohol relapse among ex-drinkers (sun et al. ) . international research on the financial crisis has also noted similar patterns of comorbidity, including the strong relationship between financial stress and illicit drug use, alcohol use and gambling (dom et al. ; economou et al. ; yang et al. ) . for instance, in the european union (eu), overall substance use fell during this crisis, although key sub-populations experienced increased levels of harmful consumption (dom et al. ) . in this and other studies, clear associations were established between alcohol-related harms and severe economic losses, characterized by unemployment (colell et al. ; gili et al. ; harhay et al. ) . young adults ( - years) were identified as a population vulnerable to risky substance use and pronounced negative socio-economic impacts during a global financial crisis. research evidence from greece, iceland and the united states (us) has also highlighted marked increases in risky gambling behaviour that was strongly associated with severe financial hardship during (economou et al. ; olason et al. ) . in recent months, a number of papers published on the impact of covid- have focused specifically on mental health. many of these studies have consistently shown increased anxiety, depression and other mental health conditions (brooks et al. ; gritsenko et al. ). one clinical case study from ireland involving patients suffering from addiction noted heightened expressions of stress and anxiety as well as addictive behaviour (i.e. problem gambling) and substance misuse (columb et al. ) . these issues were compounded by increasing social isolation and the difficulty of patients in accessing physical clinics due to social distancing measures. one chinese study (n = ) examining effects on anxiety, depression and sleep quality noted significantly higher prevalence of anxiety among younger adults (< years) and higher levels of depression among older adults (≥ years) (huang and zhao ) . although a full understanding of key factors affecting mental health concerns relating to the covid- pandemic is still emerging, some studies have identified the novel mediating effects of fear and uncertainty on depression, stress and anxiety and positive outlook (ahorsu et al. ; bakioğlu et al. ) . other mediating factors relating to the severity of anxiety during the pandemic among college students in china have included living in urban areas, family income stability and living with parents (or close social relations) (cao et al. ) . studies of online gambling, in particular, have noted comorbid relationships between mental health outcomes, substance use and problem gambling (awaworyi churchill and farrell ; gainsbury ; hing et al. ; laplante et al. ; lloyd et al. a; scholes-balog and hemphill ; wardle et al. ) . for example, early studies of the relationship between mental health and online gambling report much lower levels of mental health than those who never gambled online (petry ) . subsequent research involving university students (n = ) using the general health questionnaire confirms this association and further notes that poor outcomes can be significant in both frequent and infrequent online gamblers (petry and weinstock ) . other studies of undergraduate students (n = ) in the us have found a significant statistical correlation (p < . ) between pathological levels of gambling, problematic alcohol consumption and depression (martin et al. ). further research shows depression severity was predicted by gamblers involved in multiple online games and, to a lesser degree, but still significant, online sports betting and casino play (lloyd et al. b) . early research on the relationship between substance use and online gambling has also noted strong connections between multiple online game activities, the use of nicotine and illicit drugs and problem gambling (lloyd et al. b; mcbride and derevensky ) . some large prevalence studies have strengthened this field of research, which has been typically cross-sectional to date. for instance, analysis of the british gambling prevalence survey data confirms that binge alcohol consumption is significantly associated with problem gambling and that the risk of gambling problems is statistically higher among those who gambled online . notably, this representative data has also suggested that a large proportion of online gamblers also gamble in-person, and therefore relates gambling risk with profiles of mixed and multiple game players described previously . with regard to cannabis use and online gambling, specifically, the literature is more limited, but some evidence highlights an emergent connection between problem gambling and depression (potenza et al. ) . examinations of online poker players have also found anxiety and depression to be predictive of gambling problems (barrault et al. ; hopley et al. ; mitrovic and brown ) . despite the research evidence, our holistic understanding of the intersection of risky gambling behaviours, financial crisis and stress, negative mental health outcomes and substance use has yet to consider the specific effects of online gambling during a time of increased social isolation and significant economic instability. this paper presents findings from an online survey of gamblers (n = ) in the canadian province of ontario and a sub-sample of online gamblers (n = ). the survey was administered approximately weeks after the province declared a state of emergency for covid- (march , ) . the declaration resulted in the closure of all recreational centres, public parks and playgrounds, schools, public libraries, bars, restaurants, movie theatres, concert venues and places of worship, land-based gambling venues, and extended further restrictions on non-essential work and public gatherings of or more people (office of the premier ). the purpose of this study was to understand the emerging impact of covid- in the first weeks since provincial emergency measures were declared. the focus of inquiry was on gambling behaviours, mental health concerns, substance use and online behavioural risk factors. findings from the study were intended to rapidly advance knowledge in these areas, support follow-up research and inform the adaptation and improvement of community outreach and prevention programming. data was collected from ontarian gamblers, years or older between april and , . of the total sample, respondents confirmed their online gambling participation based off of the question: over the past weeks, have you gambled online? respondents were recruited by delvinia, an online survey vendor located in toronto, ontario, canada. the vendor utilized the askingcanadians panel population of over million canadians who are registered to receive survey recruitment notifications, if they meet basic inclusion criteria. as an incentive, delvinia compensated participants through consumer point programs, such as hudson bay company (hbc) rewards, aeroplan, via preference, petro points as well as their internal program points that can be redeemed for amazon e-gift cards and various prizes. using background information on panel members, respondents were sampled based on their age ( years and older), if they were permanent residents of ontario, and if they had gambled at least once in the past months. respondents were then presented with an informed consent statement outlining the question topics and their right to opt out of any or all questions at any time. the first few questions of the survey screened for the inclusion criteria again before advancing to other questionnaire items. a quota-based sampling strategy was employed to match age and gender distribution with official census data and produce a balanced sample reflective of the population (statistics canada ). during data collection, the survey vendor monitored the completion rate by quota-based sampling categories to ensure the final sample was balanced. based on a % confidence level, the survey is estimated to have a ± . % margin of error. the survey consisted of demographic questions related to age, gender and the highest level of education completed. age was recorded as a specific discrete number (e.g. years) and later coded into a categorical variable (e.g. - years). gender included response options for male, female, transgender, other and prefer not to answer. educational attainment included the options no high school or general educational development (ged), high school or ged, trade or technical certification, bachelor's degree, master's degree, professional degree (e.g. law, medicine, dentistry) and doctoral degree. respondents were also asked if their employment status and household income had been affected by covid- on a -point likert scale of strongly agree to strongly disagree, neither agree nor disagree and do not know. mental health concerns were captured using the patient health questionnaire (phq- ) for depression screening and the general anxiety disorder (gad- ) questionnaire (homans ; lowe et al. ; spitzer et al. ) . both instruments are prompted by the same question: over the last weeks, how often have you been bothered by any of the following problems? the phq- is the depression sub-scale of the phq, which is itself a self-administered version of the primary care evaluation of mental disorders (prime-md) diagnostic instrument for common mental disorders (homans ; kroenke et al. ). this sub-scale includes items from the diagnostic and statistical manual of mental disorders, th edition (dsm-iv) criteria for depression (e.g. little interest or pleasure in doing things, feeling tired or having little energy, feeling down, depressed or hopeless) that are scored from to and totally to . the total scores are interpreted based on depression severity including non-minimal ( - ), mild ( - ), moderate ( - ), moderately severe ( - ) and severe ( - ). this tool has been thoroughly validated, demonstrating high sensitivity ( %) and specificity ( %) for major depressive symptoms and high internal consistency (cronbach's alpha = . - . ) (american psychiatric association ). the gad- assesses symptoms of anxiety using items from the dsm-iv for generalized anxiety disorder (e.g. feeling nervous, anxious or on edge, not being able to stop or control worrying, trouble relaxing) (homans ; spitzer et al. ). the scale is scored in a range from to and interpreted by the categories non-minimal ( - ), mild ( - ), moderate ( - ) and severe ( - ). at the threshold score of , the gad- has a sensitivity of % and a specificity of % (kroenke et al. ). in addition, respondents were asked if they had experienced a mental health concern any time prior to covid- , be it self-diagnosed or diagnosed by a professional clinician. this question included several response options reflecting mental health disorders commonly associated with problem gambling, including depression, stress and anxiety, impulse control issues and addiction-another option was also included that could be filled with further details (coman et al. ; hounslow et al. ; lightsey and hulsey ) . additional response options allowed respondents to answer with "i'm not sure" and "no, i have not". substance use was assessed through three questions, including one on the consumption of alcohol and cannabis during the period of emergency measures (i.e. in the past weeks, have you used any of the following substances?). two other questions asked if substance use had increased as compared with the period before emergency measures (i.e. please respond to the following statement: in the past weeks, i have consumed more substances than i did before this time period.) and, lastly, if individuals had gambled online under the influence of a substance (i.e. in the past weeks, have you ever gambled under the influence of the following substances?). various questions were also posed on the topic of gambling behaviours, including typical participation, recent online participation and if covid- had any influence in decisions to gamble online (e.g. please respond to the following statement: emergency measures implemented due to covid- influenced my decision to gamble online over the past weeks). key items were pulled from the gambling motives questionnaire, including ( ) because it helps when feeling nervous or depressed and ( ) to win back money lost gambling (lambe et al. ; stewart and zack ) . a third motive, to earn income, was also assessed based on its strong monetary focus and distinct association with risky gambling (lee et al. ; nower and blaszczynski ) and risky online gambling in particular (mulkeen et al. ). these items were selected to reflect additional emphasis and characteristics of gambling under the influence of mental health concerns (i.e. depression and anxiety), as noted previously, as well as escape from and desired relief of financial stress (wood and griffiths ) . finally, various questions were posed to capture gambling risk, including the validated nineitem problem gambling severity index (pgsi) (currie et al. ; ferris and wynne a, b; lopez-gonzalez et al. ) . this tool scores total responses in a range of to and interprets them according to four categories, including non-problem gambling ( ), low-risk gambling ( - ), moderate-risk gambling ( - ) and high-risk gambling ( - ). the pgsi has shown satisfactory reliability (cronbach's alpha = . ) (ferris and wynne a, b) , though its non-problem gambling and high-risk gambling categories have the most predictive values (currie et al. ). a general descriptive analysis was conducted and included frequencies, proportions and other summary statistics for key variables. a series of cross-tabulated chi-square tests, odds ratios and % confidence intervals were also carried out to compare relevant discrete, dichotomous variables. the level of statistical significance was set at p < . . key comparisons included those who engaged in online gambling during the weeks since emergency measures were instituted, and those who did not gamble online. additional analysis was carried out on the sub-sample of online gamblers (n = ) comparing high-risk gamblers to non-high-risk gamblers as well as an examination of high-risk gambling motives. males and females in the sample were equally distributed at approximately % each with . % reporting as "other". the average age was ( . -year standard deviation) and ranged from to years. educational achievement consisted of no high school or ged diploma ( . %), high school or ged diploma ( . %), trade or technical certification ( . %), bachelor's degree ( . %), master's degree ( . %), professional degree (e.g. law, medicine, dentistry, pharmacy) ( . %) and doctoral degree ( . %). among the entire sample of gamblers, approximately % had gambled online during the period of emergency measures. in contrast, typical gambling behaviour reported for the past months was predominantly land-based only ( . %), followed by a mix of land-based and online ( . %) and online only ( . %). within the full sample, the majority of respondents were classified as non-problem gamblers ( . %) and low-risk gamblers ( . %), according to the pgsi scale. moderaterisk gamblers ( . %) and high-risk gamblers ( . %) made up the remainder of respondents. tests of reliability for the nine items of the pgsi scale revealed high internal consistency (cronbach's alpha = . ). nearly half of the sample ( %) reported some form of employment disruption attributed to covid- . among this cohort, % reported lost employment, . % reported reduced work hours, . % reported a shift to working full-time from home and . % reported a shift to working part-time from home. approximately one-quarter reported no changes in their fulltime ( . %) or part-time ( . %) employment or work. one-fifth ( . %) indicated they were not employed or looking for employment-over % of these individuals were retirement aged ( years or older). exactly half of the total sample reported their household income had been negatively affected by covid- . approximately one-third of gamblers noted they had experienced a mental health concern any time prior to covid- - . % self-diagnosed and % diagnosed by a professional clinician. anxiety and depression were the most reported conditions among self-diagnosed ( . %, . %) and clinically diagnosed ( . %, . %) respondents, respectively. the gad- questionnaire revealed . % of the sample did not have notable symptoms of anxiety. the remaining respondents were classified as having mild anxiety ( . %), moderate anxiety ( . %) and severe anxiety ( . %). among the total sample of gamblers (n = ) , this scale instrument demonstrated excellent internal consistency (cronbach's alpha = . ). the phq- questionnaire found that . % had no serious symptoms of depression. the balance of the sample was characterized by mild depression ( . %), moderate depression ( . %), moderately severe depression ( . %) and severe depression ( . %). scale reliability for this instrument demonstrated high internal consistency (cronbach's alpha = . ). the majority of gamblers reported consuming alcohol ( . %) during the first weeks after provincial emergency measures. among these respondents, . % confirmed that their alcohol consumption had increased during this period of time, as compared with the time preceding emergency measures. cannabis use ( . %) was less prevalent among gamblers, relative to alcohol consumption. however, of those reporting cannabis use, . % reported increased consumption compared with the time preceding emergency measures. online gambling compared with non-online gambling several significant differences emerged between those who gambled online during emergency measures and those who did not (as shown in table ). males were more likely to gamble online (n = , . %; or = . , p < . ) than females (n = , . %; or = . , p < . ). younger adults were much more likely to have gambled online, including - -year-olds (n = , . %; or = . , p = . ) and - -year-olds (n = , . %; or = . , p = . ), whereas seniors ( + years) had much lower odds of online gambling (n = , . %; or = . , p = . ). gamblers who typically played only at land-based venues were less likely to gamble online during the period of emergency measures (n = , . %; or = . , p < . ), though they made up the majority of online gamblers. typical online only gamblers (n = , %; or = . , p < . ) and those reporting a mix of land-based and online plays in the past months (n = , . %; or = . , p < . ) had similarly high likelihood of online gambling during the weeks of emergency measures. non-problem gamblers were half as likely to gamble online than other risk categories (n = , . %; or = . , p < . ). moderate-risk gamblers had about twice the odds of the n/% values are all in reference to totals for online gambling and no online gambling or odds ratio (for online gambling status), ci confidence interval, pgsi problem gambling severity index, gad- general anxiety disorder questionnaire, phq- patient health questionnaire *p < . ; **p < . ; ***p < . a three individuals self-identified as transgender, four opted not to report gender and three reported "other" (two non-binary and one as none). males and females represented . % of the total sample (n = ). non-m/f gender responses were excluded from analysis gambling online during the period of emergency measures (n = , . %; or = . , p = . ), and high-risk gamblers had nearly times the odds (n = , . %; or = . , p < . ). those with no symptoms of anxiety (gad- : n = , . %; or = . , p = . ) and no symptoms of depression (phq- : n = , . %; or = . , p < . ) had decreased odds of gambling online. in contrast, those with moderate anxiety (gad- : n = , . %; or = . , p < . ) had slightly greater odds of online gambling. those with symptoms of moderately severe depression (phq- : n = , . %; or = . , p = . ) and severe depression (phq- : n = , . %; or = . , p < . ) were even more likely to have gambled online during emergency measures. comparative analysis of those who gambled online and those who did not failed to reveal extensive differences in covid- financial impacts or substance use. among the limited significant findings, negative impact on household income attributed to covid- featured a positive association with online gambling (n = , . %; or = . , p = . ). respondents who reported increased alcohol use during the first weeks of emergency measures also had slightly increased likelihood of online gambling (n = , . %; or = . , p = . ). however, young adults ( - years) did experience greater and more significant financial impacts from covid- , overall and among those who gambled online, relative to older cohorts. overall, . % of young adults reported lost employment (n = ; or = , % ci = . - . , p < . ) and . % experienced negative impact on household income (or = . , % ci = . - . ). among young adults who gambled online, . % reported lost employment (n = ; or = . , % ci = . - . , p < . ) and . % experienced negative impact on household income (or = . , % ci = . - . , p < . ). within the sub-sample of respondents who gambled online during emergency measures (n = ), several significant associations with high-risk gambling status emerged (as shown in table ). males had a higher likelihood of being high-risk gamblers (n = , . %; or = . , p = . ) while females had a lower likelihood (n = , . %; or = . , p = . ). respondents aged - had the greatest odds of high-risk gambling status (n = , . %; or = . , p < . ), whereas those aged - years (n = , . %; or = . , p < . ) and + years (n = , . %; or = . , p < . ) had much lower odds of high-risk gambling. assessments of both anxiety and depression shared a positive linear relationship with gambling risk. respondents who were screened as having no symptoms of anxiety (gad- : n = , . %; or = . , p < . ) or depression (phq- : n = , . %; or = . , p < . ) had the lowest likelihood of high-risk gambling status. those presenting moderate anxiety (gad- : n = , . %; or = . , p < . ) and severe anxiety (gad- : n = , . %; or = . , p < . ) had over times the odds of being classified as high-risk gamblers. similarly, those screened with moderately severe depression (phq- : n = , . %; or = . , p < . ) and severe depression (phq- : n = , . %; or = . , p < . ) had nearly times the odds of being high-risk gamblers. negative financial impacts attributed to covid- were significant features of high-risk gamblers in the online cohort. those who reported losing their employment (n = , . %; or = . , p = . ) or having work hours reduced (n = , . %; or = . , p = . ) had greater odds of high-risk gambling status than other respondents whose employment was not so affected. respondents who reported that emergency measures influenced their decision to gamble online also had a higher likelihood of high-risk gambling (n = , . %; or = . , p < . ). the n/% values are all in reference to the totals for high-risk gambler and non-high-risk gambler or odds ratio (for high-risk gambler), ci confidence interval, pgsi problem gambling severity index, gad- general anxiety disorder questionnaire, phq- patient health questionnaire *p < . ; **p < . ; ***p < . a three individuals self-identified as transgender, four opted not to report gender and three reported "other" (two non-binary and one as none). males and females represented . % of the total sample (n = ). non-m/f gender responses were excluded from analysis b sample total differ for those who gamble online under the influence of substances (n = ) as they must first confirm online gambling and general substance use as pre-conditions cannabis use was associated with high-risk gambling among online players (n = , . %; or = . , p < . ). those reporting gambling online while under the influence of cannabis had over times the odds of being high-risk gamblers (n = , . %; or = . , p < . ). alcohol use among online gamblers was not significantly associated with high-risk gambling, though increased alcohol consumption during the first weeks following the declaration of emergency measures was (n = , . %; or = . , p = . ). most notable, those gambling online under the influence of alcohol had nearly times the odds of being classified as high-risk gamblers (n = , . %; or = . , p < . ). three self-reported gambling motives stood out as being most predictive of high-risk gambling status among online gamblers. gambling to earn income (n = , . %; or = . , p < . ), to win back money lost gambling (n = , . %; or = . , p < . ) and because it helps when feeling nervous or depressed (n = , . %; or = . , p < . ) all had the highest odds for high-risk gambling status. further analysis of these gambling motives revealed significant associations with elevated forms of anxiety and depression, negative financial impacts due to covid- and problematic gambling under the influence of substances (as shown in table ). tests of scale reliability for these three gambling motives demonstrated good internal consistency (cronbach's alpha = . ). covid- has had a turbulent effect on the lives of canadians, including gamblers in ontario and especially those who play online. this research has contributed new insights into the table association of elevated anxiety and depression, covid- financial impacts and problematic substance use and high-risk gambling motives among online gamblers (n = ) high-risk gambling motives because it helps when feeling nervous or depressed (n = ) to win back money lost gambling (n = ) to earn income (n = ) statistics are cases (n), odds ratio and % confidence intervals gad- general anxiety disorder questionnaire, phq- patient health questionnaire *p < . ; ***p < . effects of public health emergency measures, including increased isolation and the closure of multiple services and businesses. it has also reinforced many of the emerging findings on the secondary effects of covid- . discourse on the secondary impacts of covid- has focused on the effects of isolation, substance use, online gambling and other online behaviours (douglas et al. ; marsden et al. ) . only very recently has evidence begun to reflect these concerns, primarily as they relate to increased alcohol consumption and internet use and dependence (sun et al. ) . similarly, martin et al. ( ) point to a pronounced relationship between problematic alcohol consumption and disordered gambling in their study of college students (n = ) in the us. the evidence presented herein adds additional weight to this discourse by reporting increased alcohol as well as cannabis consumption during the period of study and establishing a significant comorbid relationship between co-occurring substance use, online gambling and high-risk gambling status. specifically, gambling under the influence of alcohol or cannabis increased the odds of high-risk gambling status by approximately times (p < . ). this appears to be a novel finding as the extant literature has to date featured limited examination of online gambling under the influence of alcohol and other substances. though, the effects of pathological gambling and substance use have been compared and show similarities with respect to impulsivity and compulsivity in decision-making tasks (leeman and potenza ; settles et al. ) . the impact of covid- on mental health has also been a topic of considerable interest and current research activity. recent evidence has largely highlighted the associations that anxiety and depression appear to have with fear, uncertainty, pre-existing history of addiction and substance use (ahorsu et al. ; bakioğlu et al. ; gritsenko et al. ). in the present study, those screened for moderate and severe forms of anxiety ( . %) and depression ( . %) were more likely to gamble online during the first weeks of emergency measures and be classified as high-risk gamblers. this finding is a confirmation of past studies that have established the relationship between anxiety and depression and problematic gambling (barrault et al. ; el-guebaly et al. ). among ontarians who had gambled online, high-risk gambling was even more strongly tied to severe forms of anxiety and depression, financial disruption, co-occurring substance use and risky gambling motives. conversely, the absence of symptoms of anxiety and depression appeared to have a protective effect on highrisk gambling among those who had gambled online. recent evidence from china have presented potential mediators of severity relating to mental health concerns, such as anxiety, including urban living, income stability and cohabitation (cao et al. ) . financial stress, in particular, has been found to be a catalyst for mental health concerns and problematic gambling in previous representative population studies from the us (ronzitti et al. ). in the present study, those who gambled online appeared more deeply affected by covid- 's financial impact. research on the financial effects impacting gamblers during covid- , specifically, is still emerging. although, the findings of this study support past research on the global economic crisis that have noted a strong relationship between risky gambling and financial hardship (olason et al. ). in the current study, approximately half of all respondents reported disruptions to employment and negative impact on household income attributed to covid- . in both cases, online gamblers felt this impact more substantially, although only greater negative effect on household income was significant (p = . ). however, young adults ( - years) who gambled online were to times as likely to have experienced negative impact on household income and lost employment than older cohorts, respectively. past studies also point out that young adults experiencing financial hardship are more susceptible to problematic gambling and substance use (colell et al. ; gili et al. ; harhay et al. ; olason et al. ) . negative impact on household income was also correlated with online gambling (p < . ) as well as being influenced to gamble online due to covid- (p < . ). those who were influenced by covid- to gamble online also had up to times the odds of being either moderate-or high-risk gamblers. economou et al.'s ( ) study of the effects of economic crisis in greece also reflects the association between financial hardship and problem gambling. the authors also note that the odds of experiencing problem gambling can be increased for those who started gambling during the economic crisis. while the present study did not measure this phenomenon exactly, findings show that a substantial proportion of online gamblers ( . %) had typically only played in-person over the past months, indicating a partial migration of land-based players to a new, unfamiliar online environment. however, these players had much lower odds of being high-risk gamblers (n = , %; or = . , % ci = . - . , p < . ), indicating that experience with land-based play may have a protective effect, even if online gambling is a less familiar platform, or perhaps participation was characterized by less risky games, such as lottery. broadly speaking, this research has reaffirmed relationships articulated in past research on risky online gambling and comorbidities, including mental health concerns and substance use (awaworyi churchill and farrell ; gainsbury ; hing et al. ; laplante et al. ; lloyd et al. a; scholes-balog and hemphill ; wardle et al. ) . notably, this research adds to the limited evidence showing significant associations between cannabis use, online gambling and mental health concerns-particularly depression (potenza et al. ) . for instance, evidence presented herein separately show that high-risk gambling was predicted by moderately severe and severe depression as well as cannabis use and gambling under the influence of cannabis. in addition, previous prevalence study analysis showing a typical mix of land-based and online plays among individuals indicating online gambling behaviours was evident in the current study . in this case, over % of the sample had technically migrated from self-reported land-based-only play in the past months to gambling online during the period of emergency measures. further study is required to understand if respondents understood typical land-based-only gambling as being strictly exclusive or simply a general distinction as well as the number of games played and its relationship with gambling risk. finally, those indicating they gambled online because it helps when feeling nervous or depressed, to win back money lost gambling and to earn income had increased odds of highrisk gambling status between -and -times that of gamblers who did not endorse these motives (p < . ). these findings compliment past research highlighting the risk of problem gambling among those endorsing these motives (lambe et al. ; nower and blaszczynski ) . as mentioned previously, these motives were intended to reflect key mental health factors (i.e. anxiety and depression) as well as escape from and relief of financial stress (wood and griffiths ) . for example, the economic crisis in iceland saw increased likelihood of gambling if individuals had experienced financial difficulties (olason et al. ) . the present study has linked these motives to comorbid mental health concerns, substance use while gambling and financial vulnerabilities due to covid- . for instance, all three of these motives featured strong predictive relationships with moderate and severe symptoms of anxiety and depression. variously, these motives were also associated with covid- related financial impacts, including reduced work hours, lost employment and negative impact on household income. these motives also significantly increased the odds of gambling under the influence of alcohol and cannabis, an association that has typically been highlighted in adolescent gambling and not online gambling among a general population (hammond et al. ; welte et al. ). as a cross-sectional online panel survey, the data is not able to provide causal assessment of the key associations identified. self-reported behaviours are also prone to a degree of response bias which is a typical limitation of survey methods and designs. although questions assessing anxiety and depression as well as gambling risk have been validated and shown to be reliable, other questions relating to covid- 's impact on financial well-being and substance use have not been previously vetted. in addition, the inclusion of selected questions from the gambling motives questionnaire, instead of the entire validated instrument, limits the broader understanding of gambling motives and may give the impression negative gambling bias. the intention in this case was to reflect the influence of mental health concerns and financial stress that are a focus on this study. as such, the inclusion of the motive to earn income, added a monetary distinction not represented in the full gambling motives questionnaire and is particularly relevant to risky online gambling (mulkeen et al. ) . despite these limitations, this survey has rapidly delivered key insights during a critical moment in human history on social dynamics and public health determinants that clearly merit further study. as such, this study will soon be followed up by another linking the same respondents at a future time. follow-up research will carefully examine potential changes in behaviours and comorbidities as the pandemic evolves and as gambling changes with the resumption of professional sports and the widespread re-opening of land-based venues. this study has confirmed many of the risk associations presented in past research on global economic crisis, gambling risk, mental health concerns and substance use. however, unlike many past studies, the present paper takes note of all of these elements together and provides a clear emphasis on online gambling. together, the strength of high-risk gambling motives in predicting problematic gambling status, mental health concerns, financial difficulties and risky substance use among online gamblers was a novel insight worth further exploration. overall, covid- 's unique effect of creating significant population health impacts, financial disruptions and changes in social interaction and recreation adds importance to this study's findings and raises key questions. for instance, future studies may benefit from observing changes in online gambling behaviours and associated risk factors during the pandemic or how the eventual re-opening of land-based venues may affect gambling sentiments and behaviours. further examination of government and industry response to covid- and gambling harm prevention will also be critical to understanding these complex phenomena. knowledge from this and other studies of the impact of covid- on online gambling and various comorbidities should also serve to inform decision-makers on harm prevention and mitigation efforts, as already indicated by some experts in the field (király et al. ) . mitigating the wider health effects of covid- pandemic response covid- and addiction problem gambling in greece: prevalence and risk factors during the financial crisis epidemiological associations between gambling behavior, substance use & 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versus non-problem gamblers ontario prohibits gatherings of more than five people with strict exceptions gambling in the mist of economic crisis: results from three national prevalence studies from iceland internet gambling: an emerging concern in family practice medicine? family practice internet gambling is common in college students and associated with poor mental health correlates of at-risk/problem internet gambling in adolescents stress moderates the relationships between problem-gambling severity and specific psychopathologies relationships between online gambling, mental health, and substance use: a review negative urgency: a personality predictor of externalizing behavior characterized by neuroticism, low conscientiousness, and disagreeableness a brief measure for assessing generalized anxiety disorder: the gad- census profile, census: ontario and canada weekly update -friday development and psychometric evaluation of a three-dimensional gambling motives questionnaire increased addictive internet and substance use behavior during the covid- pandemic in china defining the online gambler and patterns of behaviour integration: evidence from the british gambling prevalence survey simultaneous drinking and gambling: a risk factor for pathological gambling a qualitative investigation of problem gambling as an escape-based coping strategy binge alcohol and substance use across birth cohorts and the global financial crisis in the united states publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -py lbg authors: stephany, fabian; dunn, michael; sawyer, steven; lehdonvirta, vili title: distancing bonus or downscaling loss? the changing livelihood of us online workers in times of covid‐ date: - - journal: tijdschr econ soc geogr doi: . /tesg. sha: doc_id: cord_uid: py lbg we draw on data from the online labour index and interviews with freelancers in the united states securing work on online platforms, to illuminate effects of the covid‐ pandemic. the pandemic's global economic upheaval is shuttering shops and offices. those able to do so are now working remotely from their homes. they join workers who have always been working remotely: freelancers who earn some or all of their income from projects secured via online labour platforms. data allow us to sketch a first picture of how the initial months of the covid‐ pandemic have affected the livelihoods of online freelancers. the data shows online labour demand falling rapidly in early march , but with an equally rapid recovery. we also find significant differences between countries and occupations. data from interviews make clear jobs are increasingly scarce even as more people are creating profiles and seeking freelance work online. we combine data from the online labour index (oli) and an interview-based panel study of freelance workers in the united states to provide insight into the changes in online labour markets relative to the ongoing pandemic arising from the global spread of the novel coronavirus, covid- . we do so to contribute evidence and insight to the ways in which a global pandemic appears in the localised context of one of the economies most impacted. the freelance workers that are the focus of this analysis are those taking on projects and contracts for knowledge work: technology support, software development, bookkeeping, accounting, web content, writing and editing, and other types of cognitive work. the growth in online labour markets, and the project-or task-based structure of freelance labour, provides a unique window into effects of a pandemic on work. the oli provides a global perspective; the panel study provides for a more localised set of insights. we pursue this work recognising that as the scope and breadth of the global covid- pandemic continues to grow, the implications to workers and labour markets grow more profound. even conservative estimates of a contained global outbreak are showing significant global macroeconomic impacts (mckibbin & fernando ) . similarly, models at the country level are showing serious economic impacts (atkeson ) . early research is also showing distinct demographic and industry differences in the impact of the pandemic (wenham et al. ; stephany et al. ) . building on the emerging covid- related research, we examine a specific subset of labour markets -the online labour market and its workers -to understand the near-term impacts of the pandemic. online freelancers are in precarious work arrangements generally, and the pandemic presents a particularly challenging scenario to them for at least three reasons. first, the online nature of their work makes them susceptible to greater competition (dunn ) . second, freelance work is project-based: there is little to no commitment between employer and worker beyond the specifics of the project's contract (wood et al. ) . finally, in many countries their status as independent contractors leaves online freelancers in vulnerable positions especially during economic downturns. for example, in the united states, benefits such as health care are tied to formal, full-time employment and are not provided to freelancers. indeed, in comparison with many industrialised countries, there are relatively fewer labour and employment regulations governing non-standard work arrangements in the united states (ilo ; mckay et al. ). on the one hand, online labour markets could be experiencing a boost in demand as companies move operations online. on the other hand, the sharp economic downturn could be causing companies to reduce the use of online labour platforms alongside other types of non-standard work. we address this issue by examining recent changes in the global demand for online labour. and while viruses may be blind to nation-states, policies and interventions are nation-state specific. cross-national comparisons can therefore provide insight on the economic implications of specific policies and interventions. research has already begun to understand the economic implications of country specific interventions (e.g. thunstrom et al. ) . in this initial rapid analysis, we therefore use quantitative data to examine changes in the demand for online labour in three important regional economies with different countermeasures towards the pandemic: united states, germany, and south korea. the data show distinctly different geographic patterns between countries, with us data showing a particularly acute drop in demand for workers, with a simultaneously sharp increase in supply of available workers. the data also make clear that not all occupations in the united states are experiencing the shocks similarly. tech and software development occupations show a significant increase in both online labour demand and number of registered profiles. because of the significant market shock evident in the united states and its notable occupational differences, we complement the quantitative view with interviews with us-based online freelance workers, helping us to understand the significance, implications and lived experiences of the market shock to online freelance workers. online labour platforms are websites that mediate between buyers and sellers of remotely deliverable cognitive work (horton ) . the clients range from individuals and early-stage startups to fortune companies (corporaal & lehdonvirta ). the sellers are either self-employed independent contractors, or people in regular employment who earn additional income by moonlighting as freelancers via the internet. the platforms match clients and workers using a variety of mechanisms, such as allowing clients to post projects for bidding, and allowing freelancers to post resumes for clients to evaluate. besides matching, the platforms also handle contracting, time tracking, monitoring, billing, and dispute resolution, allowing the entire relationship to be carried out remotely. online labour platforms can be further subdivided into freelancing platforms (e.g. upwork, toptal, fiverr) where payment is on an hourly or milestone basis, and microtask platforms (e.g. amazon mechanical turk) where payment is on a piece rate basis (lehdonvirta ) . of these, freelancing platforms appear to be much larger in terms of user numbers (kässi & lehdonvirta ) . online labour platforms are also sometimes called online gig platforms, but they are conceptually distinct from local gig economy platforms such as uber or deliveroo, which involve physical on-site service delivery (wood et al. ) . the global market for online labour has grown approximately per cent over the past three years (kässi & lehdonvirta ) . but as the covid- pandemic is hitting the world's economies, causing a massive rise in unemployment in the united states, it is pertinent to ask how the pandemic is affecting the market for online labour. pandemic's potential effects on online labour demand -there are several potential mechanisms through which the pandemic could be causing a positive demand shock for online labour. the pandemic appears to be forcing companies in affected countries to shift from collocated office work towards home-based remote working arrangements, known in previous literature as telework (huws et al. ) or telecommuting (mokhtarian, ) , and now colloquially referred to as 'work from home'. the pandemic is also likely pushing companies to increase the use of virtual collaboration as a substitute to travel and face-to-face meetings. telework and virtual collaboration have been slowly and unevenly gaining in popularity already since their introduction in the early s. now, there appears to be an unprecedented surge of interest towards them. for instance, interest in remote working and related search terms in google search approximately tripled from its pre-pandemic baseline to march (clement ) . the stock market value of teleconferencing software company zoom video communications approximately doubled in the same time period. given this surge of interest in remote work and virtual collabouration, it is conceivable that remote-by-design online labour markets could be seeing a significant demand boost. companies looking to engage new contractors might now favour remote online contractors hired through web-based platforms over on-site contractors hired through conventional staffing agencies. already before the pandemic, many skilled workers located in rural areas of the united states appear to have successfully used online labour markets to remotely access opportunities in urban areas . it is also possible that some companies might be moving existing contractor relationships to online labour platforms, in what is known as the 'bring your own freelancer' model (corporaal & lehdonvirta ) . platforms provide features for monitoring and managing contractors remotely, which can partly substitute for the missing in-person controls ). shortterm contractors are typically subject to more performance-and outcome-based controls than regular employees, whose loyalty may be sought with cultural and incentive-based controls (ouchi ) . furthermore, the pandemic and the switch to remote work and virtual collaboration might also be creating additional demand for certain types of labour, some of which is supplied through online labour platforms. in particular, it is conceivable that there is a significant positive demand shock for information technology contractors who can help companies set up and maintain remote work and virtual collaboration infrastructure, and provide training on their use. systems integration work and database management work might also increase as organisational reliance on systems over in-person interactions increases. large firms often have existing it services outsourcing providers, but small-and medium-sized companies may be turning to online labour platforms for these needs (bunyaratavej et al. ) . however, it is also conceivable that the pandemic could be causing a significant reduction in demand for online labour, through a few possible mechanisms. online labour is part of the broader category of non-standard work, which includes other independent contractors and temporary workers. many companies in the united states use non-standard workers as a flexible buffer that can be rapidly reduced in economic downturns to protect core workers (kalleberg ) . online labour can also be seen as a form of outsourcing , which is likewise something that companies can adjust to respond to changing demand. given that the pandemic and its public policy responses have in many countries already resulted in a general economic downturn of historic proportions, it is conceivable that companies could be cutting their use of online labour platforms to engage contractors. already before the pandemic it was apparent that demand in the online labour market was very responsive to events such as public holidays (kässi & lehdonvirta ) , and workers felt that demand for their services could fluctuate a lot (lehdonvirta ) . two opposing effects of the covid- pandemic on demand for online freelance labour are thus conceivable. on the one hand, to the extent that online labour is a substitute to onsite labour, we can expect to see an increase in demand. the technical and organisational effort involved in switching to remote operations might also cause an increase in the demand for specific types of online labour, especially it services. we will refer to all these demand-increasing mechanisms collectively as the distancing bonus. on the other hand, to the extent that online labour is a complement to general economic activity, we can expect to see a decrease in demand, as companies facing declining revenues reduce non-essential spending, including external online contractors. we refer to this as the downscaling loss. pandemic's potential effects on online labour supply -the pandemic can also be expected to have a significant impact on the supply of labour on online labour markets. the supply generally speaking consists of two margins: the number of workers offering their services through online platforms, and the number of hours that they are willing to supply (horton ) . the number of workers offering services online might conceivably increase, because the pandemic and its countermeasures have led to record-high unemployment in many countries, freeing up skilled workers (del rio-chanona et al. ) . workers who were already offering a small number of hours online on top of their regular work (i.e. moonlighting; pesole et al. ) might increase the hours offered as a result of being laid off. on the other hand, workers who are not laid off from their regular jobs might decrease the number of hours they supply through online labour markets, to signal loyalty to their employers. both moonlighters as well as existing full-time online freelancers might also decrease the hours supplied online as a result of falling ill or having increased care and housework duties, as schools and daycare centres close or family members fall ill. geographic and temporal variation in the effects -the pandemic's possible positive and negative effects on online labour supply and demand are likely to vary across space and time, for a variety of reasons. some reasons have to do with the dynamics of the pandemic itself. the pandemic unfolds in phases, from initial discovery to growing spread and eventual public and private countermeasures, followed by an easing up of the countermeasures and possible additional waves of infection (bedford et al. ). owing to differences in initial entry time, infection rates, and response speed, different countries are at different phases, with different impacts on economic activity. country differences in public and private countermeasures, severity of the epidemic, and underlying economic conditions are also likely to generate geographic variation in effects seen in online labour markets (ilo ). moreover, dynamics of the online labour market itself provide plenty of reasons to expect geographic differences (beerepoot & lambregts ) . generally speaking, a clear global north--global south trade pattern is evident in online labour markets, where the majority of employers are located in high-income countries (kässi & lehdonvirta ) while most workers are located in low-and middle-income countries ). different employer countries have different demand profiles in terms of the occupations they are buying from online labour platforms, although these differences are surprisingly small (kässi & lehdonvirta ) . changes in supply and demand in different countries are ultimately reflected in the global aggregate online labour supply and demand. although there is evidence of preference and discrimination in online labour markets (galperin & greppi ) , overall the market functions globally, with workers with similar skills and experience considered reasonably good substitutes for each other regardless of location the resulting overall effects on the market have substantive policy implications. if and when online labour demand experiences a distancing bonus effect while supply remains relatively constant, then the growing online labour market could offer an avenue for laid-off workers to recover some of their earnings. but if the downscaling loss effect dominates and/ or the market is flooded with additional labour supply, then people thus far earning their main income through online labour platforms are likely to join the ranks of self-employed people urgently in need of financial assistance. in the following section we present a rapid initial quantitative assessment of which effects dominate, across time and selected countries. we draw on the oli for a first quantitative assessment of how online labour markets are affected by the covid- pandemic. the oli is an index that measures the utilisation of online labour platforms over time and across countries and occupations (kässi & lehdonvirta ) . it serves a similar function as conventional labour market statistics on new vacancies. the index is constructed by continuously collecting data on tasks and projects posted on major online labour platforms in near real-time. the results of the oli are published as an open data set and an interactive online visualisation, updated daily (http://ilabo ur.oii. ox.ac.uk/onlin e-labou r-index /). in this rapid initial assessment, we examine the effects of the pandemic on the aggregate global market, followed by three important regional economies. finally, we present additional analyses pertaining to the united states. as discussed in the literature review, online labour markets have a distinct geography. our data allows us to provide a detailed picture of how the demand for online labour is geographically distributed on the platforms monitored by the oli. as shown in figure , the largest share of online labour demand originates from employers based in the united states, who posted per cent of all projects recorded in . the second largest buyer country for online freelance work is the united kingdom ( %), followed by india ( %). europe excluding the united kingdom generates per cent of online labour demand, with germany as the biggest demander in this group. only three per cent of the demand for online workers comes from the entirety of africa. given these very uneven geographies of online labour demand, it is fair to assume that global developments on online labour markets are often driven by buyers from the united states. changes in online labour demand -over the past several years, the oli has shown a clear seasonal pattern: demand drops during the year-end holiday season, and then rises again to reach a plateau in february, which normally persists until may. however, as figure shows, this is not the case in . by mid-march, when the world health organisation declared that covid- had become a pandemic, the oli was in deep decline, in comparison to and . this finding indicates that the downscaling loss effect may be dominating over the distancing bonus effect. however, in early april the oli began to rise again, surpassing by far the usual level of previous years by the end of april. this observation, on the other hand, indicates that at this stage of the pandemic, the distancing bonus may have started to dominate over the downscaling loss. to further examine this fast-changing dynamic, we are interested in examining the biggest demander country, the united states. however, the united states was not the first economy to be impacted by the pandemic and its countermeasures. it is useful to contrast it with other important regional economies with different covid- trajectories and responses. in this study, we limit ourselves to examining three important regional economies: germany, south korea, and the united states as the three economies confronted the pandemic at different points in time and opted for different countermeasures. figure shows a cross-country comparison of online labour demand from germany, south korea and the united states. each country shows a distinct pattern. south korea was one of the first economies that had to face the consequences of covid- early in . demand from south korea fell from mid-february to mid-march, but bounced back rapidly in late march. demand from germany similarly fell from february to march, and experienced a more modest rebound in april. demand from the united states started falling roughly two weeks later than the demand from south korea and germany and fell furthest, but by early may was close to reaching pre-crisis levels again. (normile ) . germany established early and localised testing, which allowed the government to impose only relatively moderate restrictions and to permit local business to open again in the beginning of april. demand from the united states can also be seen bouncing back from mid-april onwards, even though restrictions remained largely in place. this could reflect businesses adjusting to the new normal of remote work, rather than a return to pre-pandemic operations. given the particularly clear drop in demand for online labour from the united states, we are interested in how this drop may vary across different types of work. the oli categorises online labour into six different occupations: clerical and data entry, professional services, software development and technology, creative and multimedia, sales and marketing support, and writing and translation. for a more detailed description of these categories, see kässi and lehdonvirta ( ) . as figure shows, not all occupations have experienced a drop in demand. demand in creative and multimedia or sales and marketing support has shrunk significantly as the pandemic has unfolded. but requests for projects in the software development and technology category remain largely unaffected. this finding is consistent with an interpretation that companies are cutting non-essential freelance contracts, such as marketing and sales campaigns, while maintaining freelance outsourcing that is essential for continued business operations, such as tech support and database management. the figures are also consistent with the idea that the rapid push towards videoconferencing and other remote operations across companies has created additional demand for freelance it specialists who are able to help with this. changes in online labour supply -the oli does not provide us with a direct measure of labour supply, but we are able to observe the number of registered worker profiles on a smaller set of online labour platforms. this can be used as an imperfect proxy for the number of workers offering services through online labour platforms. we are not able to observe changes in the number of hours the workers are supplying. an increase in the number of registered freelancer profiles in the united states is evident since the beginning of april. in particular, as shown in figure , a very significant number of new freelancers have registered in the software development and technology category. other occupations do not show a similar increase in registered workers. this is consistent with an interpretation that recently laid-off workers across the economy are not registering en masse on online labour platforms to attempt to make up for lost income. some workers are probably doing so, but to some extent the increased supply in the software development and technology category might also be attributable to the pull of increased opportunities due to growing demand. in sum, while we observe a downscaling loss for most online labour occupations in the united states, software and tech jobs appear to profit from a distancing bonus effect. however, even in this category labour supply growth in the united states appears to have outpaced labour demand growth, suggesting that the workers are likely to be experiencing a tight market. to better understand the workers' experiences, we draw on data from an ongoing panel study in the united states that relies on structured interviews to provide insights on how these trends are being manifested through the lived experiences of workers. our interview data come from an ongoing panel study of freelance workers who are located in the united states and seeking work online via the online labour platform upwork (see http://upwork.com). upwork is one of many online labour platforms and routinely seen as a dominant player. the focus on upworkers serves as a window into the career plans and work strategies of freelance workers seeing work online. the study is designed around a carefully constructed sample of people who pursue freelance work as a primary or secondary source of income, and reflect a range of work types, skill levels, experience online, gender, ethnicity and success with this work. participants are hired and paid as they would for other jobs found on upwork. once hired, participants complete a ' survey that provides us an overview of their working plans, outcomes and experiences and a ' interview. the interview builds on the survey data and follows a carefully designed protocol of semi-structured questions. interviews are done by one of the six members of the digital work research group, a joint effort of syracuse university and skidmore college, both in new york state. the research team members were trained on the protocol and meet frequently and routinely to review the protocol, the data, and pursue interim analyses (as is customary in field studies). beginning in mid-march , we asked freelancers how they were faring in the face of the covid- pandemic. since then, we have done interviews. for this paper, we completed an interim analysis of these freelancers, reviewing the transcripts of the interview, drawing on the field notes, and looking to secondary sources for additional insight. specific to comparing with the oli, the panel study design and this initial analysis, relies on the job classifications provided by upwork, grouped into three broader categories (see table for summary statistics): . administrative work to include: accounting, customer service, translation, editing. in the oli, this category roughly responds to the occupations 'writing and translation', 'professional services', and 'clerical and data entry'. . technology work to include: web, mobile and standard programming, engineering and architecture, data and analytics, it and networking. in the oli, this category roughly responds to the occupation 'software development and tech'. . creative work to include: design, graphics, sales and marketing, writing, and some oneoffs like crisis response public-relations. in the oli, this category roughly responds to the occupations 'creative and multimedia', 'writing and translation', and 'sales and marketing support'. data from the panel study provide substantial evidence in support of downscaling loss effects. the freelancers with whom we spoke report that there are fewer jobs being posted. freelancers who have long-standing clients tell us these clients are pausing current projects and not adding new projects. furthermore, freelancers indicate that there are many more people bidding for the jobs: sometimes six times more than even a month ago (e.g. + bids now, versus five bids). this seems to align very well with the data presented in figure . freelancers are also reporting that in response to the increased number of people seeking work online, they are having to bid on more jobs to keep securing work, and often are bidding for work below their target salary rates, and even below minimum wage rates. while each freelancer's situation is unique, work-seeking strategies in our initial analysis, seem to be externally focused. that is, while many have relied on existing relationships, their predictability of these relationships producing work are now more tenuous. in turn, freelancers indicated that they are diversifying and applying to different type of work, increasing the number of jobs they simultaneously are bidding for, bidding for lower paying contracts and lowering their hourly rates. from this initial analysis we see little evidence of distancing bonus effects in the united states across the platforms broadly, although we see initial evidence of distancing bonus effects at the occupation level. at first these changes were not affecting one broad category of work more than another. by april , those respondents in creative spaces (marketing, design, web content) noted work was slowing dramatically, while work supporting digital infrastructure (web services, backend web work) was steady or even increasing, corroborating with the data in figure . this suggests that clients are starting to look into the concerning future and prioritising basic operations over customer-facing efforts. beyond these insights on distancing bonus and downscaling loss effects, two additional observations from our interviews warrant mention. first, these us-based freelancers are reporting changes in their life worlds that are reshaping their labour strategies and working arrangements. nearly all of the respondents report spouses and partners being laid off or having to work from home, and that their children are now at home for schooling. these changes are requiring the freelancers to alter their own working arrangements and work availabilitywith most having less time to pursue work. the scope of these changes is increasing each week, and the changes are becoming more impactful as the economy continues to slow down. the current arrangements are no longer new, not yet normal, and uncertainty clouds things. these changes dampen the ability of workers to take on typical work loads, providing some opportunity for new entrants. finally, every one of the participants in the panel study is casting an increasingly worried eye on the longer term as the economic slowdown in the united states continues to press on most but the wealthy. panel data make clear that fewer than per cent of our respondents have health care: a profoundly disturbing finding given that many of their spouses and partners are losing jobs. panel data also make clear that fewer than per cent of our respondents had more than a few weeks of savings: seven weeks into massive social distancing and million people losing their jobs, these workers are exhausting these reserves, well before the economic crisis is over. taken together, the low number of freelancers with healthcare, and savings, showcases the precarity of the workspace and amplifies the implications of the changes to the online labour markets as demonstrated above. findings suggest the downscaling loss effect may be dominating over the distancing bonus effect. at the same time, the number of workers seeking income through online labour platforms is increasing. this, in turn, suggests freelancers earning their income through online labour platforms are more likely to see a tighter market and larger variations in their income in the face of a more uncertain online labour market. for the us-based freelancers with whom we spoke, their situation is further complicated by the structural and legal landscape they face. to wit, their employment classification (as independent contractors) restricts access to social policies that could serve as a social safety net (e.g. access to healthcare and unemployment benefits). the broad and chaotic response by the united states' federal government in the face of the economic crisis is more poignant for freelance workers as their status relative to what counts as work often means they are not able to access unemployment benefits and may not be eligible for the stimulus checks associated with the cares act. given the social and labour policies, significant market shocks, like the pandemic, make visible the risks associated with non-standard work arrangements in the united states. these risks may be one of the reasons why the oli figures for the united states vary so much more than do those of south korea and germany. while this analysis has focused on the united states, to fully understand the nuances and differences in the online labour market, future analysis exploring other countries is essential. furthermore, the data also only provide a freelancer perspective, so understanding changes and behaviors of clients (employers) and their impact (and how they're impacted) would provide an important perspective in the market dynamics discussed here. we see value in the further interrogation of the downscaling loss and distancing bonus effects from other analytic perspectives to include temporality, geography, and demography. the magnitude of downscaling and distancing are likely to change over time, as the pandemic and its consequences unfold. moreover the effects are likely to vary across geography, due to national differences in economic structures, the phase and severity of the pandemic, and countermeasures adopted. we also see distinct differences in demands for different occupations. considering the gendered and racial differences in occupations (e.g. women, for example, are overrepresented in the sales and creative occupations and minorities are overrepresented in service occupations, see https://conte xts.org/blog/inequ ality -durin g-the-coron aviru s-pande mic/#rea), we then may see certain groups disproportionately affected. as can be seen, one possible roadmap for near-term research related to the pandemic can be: (i) the examination in the differences driven by occupation; (ii) analysis of the differences in country-level trajectories; and (iii) further investigation of gender and racial disparities found in freelance work. these implications illustrate the questions that emerge from this early view into changes in the online labour markets for freelance work arising from the global pandemic. at a broader level, the covid- pandemic produces a unique window of opportunity to gauge the interdependencies between the online labour market and the regular economy. initially, the sharp decline in the online labour market closely mirrored the broader labour market. as the pandemic has continued, our analysis shows a rebound in the online labour market. this not only suggests that online labour markets can transcend its traditionally complementary role in the broader markets, but may play a key role in bridging gaps in the broader economy caused by sudden economic shocks. we speculate this is being manifested in at least three ways. first, firms are using more project-based work, which is more conducive to the use of freelancers. second, firms are increasingly becoming more accustomed to distributed and remote working arrangements, which is also more conducive to freelancers. while both of these are independent of the current pandemic, they are macro-level changes in employment relations that we see as catalysts to the increases in the demand for online freelancers. third, online platforms allow people to more easily seek freelance work, which blurs the boundaries between online and traditional labour markets. as a more efficient matching system for work, online labour markets help to alleviate the friction associated with job searches and allow workers to seek work beyond their local geography. all of these things allow online labour markets to normalise more quickly during periods of economic shock. as the evidence in our analysis suggests, the online labour market demand has recovered, and in some occupational areas has surpassed, relative to pre-pandemic levels. the raw data (used in figure ) are collected by periodically sampling workers from four major online labour platforms: fiverr, freelancer, guru, and peopleperhour what will be the economic impact of covid- in the us? rough estimates of disease senarios covid- : towards controlling of a pandemic competition in online job marketplaces: towards a global labour market for outsourcing services? global networks icts and the urban-rural divide: can online labour platforms bridge the gap? information, communication, & society, - conceptual issues in services offshoring research: a multidisciplinary review interest in remote working related search terms during covid- outbreak platform sourcing: how fortune firms are adopting online freelancing platforms supply and demand shocks in the covid- pandemic: an industry and occupation perspective digital work: new opportunities or lost wages? geographical discrimination in digital labour platforms. in: m digital economies at global margins online labour markets telework: towards the elusive office flexible firms and labour market segmentation: effects of workplace restructuring on jobs and workers online labour index: measuring the online gig economy for policy and research flexibility in the gig economy: managing time on three online piecework pplatforms. new technology, work and employment the global platform economy: a new offshoring institution enabling emerging-economy microproviders available at <https://assets.aspen insti tute. org/conte nt/uploa ds/ / /autom ation -and-a-chang ing-econo my_the-case-for-action the global macroeconomic impacts of covid- : seven scenarios defining telecommuting. transportation research record coronavirus cases have dropped sharply in south korea. what's the secret to its success a conceptual framework for the design of organisational control mechanisms platform workers in europe the corisk-index: a data-mining approach to identify industry-specific risk assessments related to covid- in real-time the benefits and costs of using social distancing to flatten the curve for covid- covid- : the gendered impacts of the outbreak networked but commodified: the (dis)embeddedness of digital labour in the gig economy we thank raghav raheja (syracuse university) and gabrielle vaccaro (skidmore college) for their central role in the qualitative data collection efforts. likewise, we would like to acknowledge dr. otto kässi for engineering most of the oli data collection infrastructure. about of do: acceptances and declinations are tracked. research guidelines require paying those who agree to this job even if they do not finish: this work is voluntary and they can cease working at any time. about in begin, but do not finish. all who begin are rated five stars (as performance ratings matter greatly for online workers). many of those who have completed the work leave a positive review of the work. there are no negative reviews. . for example, there are active sub-threads for experiences with platform work, generally, and upwork, specifically, to be found in the online platform reddit, as well as facebook groups devoted to both. . upwork changes its categorisation of workers from time to time, making classification a challenge. . cares act, see: https://www.congr ess.gov/ bill/ th-congr ess/senate-bill/ /text?q=produ ct+update. key: cord- - qz authors: jindal, rupinder p.; gauri, dinesh k.; li, wanyu; ma, yu title: omnichannel battle between amazon and walmart: is the focus on delivery the best strategy? date: - - journal: j bus res doi: . /j.jbusres. . . sha: doc_id: cord_uid: qz a large body of academic research has recently focused on omnichannel retailing especially on brick-and-mortar (offline) retailers adding and integrating online capabilities. relatedly, trade press has highlighted how offline retailers have been investing heavily in the use of their existing physical retail network for quicker delivery and pick-up of online orders. looking at the competition between amazon and walmart, however, we demonstrate that focusing on quicker delivery is not the best strategy for offline retailers when opening online channels to compete with online retailers. we estimate a multivariate probit model using data from a customer survey and find that offline retailers should instead focus on delivering the fundamentals of retailing to their online customers too – larger assortment, competitive prices, and purchase convenience. further, we employ cluster analysis to show which demographics are good targets for retailers as they develop omnichannel capabilities, as well as which demographics retailers need to keep loyal to their original channels. in the past decade, trade press and academic research in marketing has highlighted the rise of omnichannel retailing. this type of retailing involves employing multiple channels and integrating activities within and across these channels to correspond with how customers shop (ailawadi & farris, ) . the marketing science institute (msi) has recognized omnichannel retailing as one of the five marketing research priorities for - (marketing science institute, . the growth of internet raised a number of challenges for brick-and-mortar retailers (denoted as offline hereon) starting with the advent of digital-first retailers (denoted as online hereon). manufacturers started using both kinds of retailers to market their products, which resulted in offline retailers facing cross-channel competition from online retailers. because online retailers had a lower cost structure, they were able to offer lower prices to customers. this resulted in showrooming where customers would use physical stores to inspect the merchandise but then purchase the merchandise through online stores (ratchford, ) . to compete, offline retailers started opening online channels too. on the other hand, online retailers started realizing the importance of physical stores in retailing specific product categories (such as grocery and apparel) and started opening physical stores. such omnichannel retailing provides customers a seamless experience across offline and online channels of the same retailer (bhatnagar & ghose, a) . research has shown that this makes shoppers spend more at a retailer and increases customer loyalty (neslin et al., ) . in this context, a lot of attention has been focused on the rivalry between amazon and walmart -the respective leaders in online and offline retailing -both in general merchandise and, more recently, in grocery. according to the national retail federation, retail (at . trillion dollars in sales) is about one-sixth of the entire gdp of the united states. of this, the "food and consumer products" category is the largest with nearly trillion dollars in sales. according to nielsen, online grocery sales accounted for just percent of the total sales (nassauer, c) . this share was expected to double by the year though covid- pandemic has caused a spurt in online purchases by consumers (nassauer, b) . what proportion of this pandemic-induced online purchasing persists is debatable but the bulk of sales will still be conducted offline for the foreseeable future. offline grocery stores in the u.s. are of various kinds. these include supermarkets such as kroger, supercenters such as walmart, natural food stores such as whole foods, limited-variety stores such as trader joe's, and warehouse stores such as costco. online food shopping has been considered one of the last major holdouts in online retailing because items are often perishable, fragile, or heavy; and, customers prefer to see, touch, smell, and sometimes taste the products (in the form of samples) to validate their freshness and quality before purchase. most customers shop for groceries at offline stores located close to them; in this context, delivery fees for online orders are usually high in proportion to the total bill which acts as a disincentive against their online purchase (griffith, ) . for online retailers, relatively low margins, small average order size, and the perishable nature of products, along with high consumer price sensitivity and strict delivery preferences, raise economic and logistical challenges (kumar & mittal, ) . for example, customer purchases show cyclical patterns, with increased purchasing over the weekends. this implies that trucks customized for grocery delivery are likely to be under-utilized on weekdays. also, customer density in a given locality needs to be above a certain threshold to justify the economics of sending a delivery truck (mcdonald, christensen, yang, & hollingsworth, ) . because offline retailing is expected to continue accounting for the bulk of grocery sales, there is immense interest in the activities of wellestablished offline grocery retailers as they try to protect their market shares by initiating and integrating their own online channels. trade press has reported extensively on the activities of such retailers as walmart, target, and kroger. although research in retailing has identified a multitude of attributes that influence customer's store choice behavior, these retailers seem to be focused inordinately on leveraging their physical infrastructure to provide quicker delivery of online orders as they attempt to compete with amazon for a larger share of online shoppers. in this article, we explore whether or not this focus on quick delivery is the best strategy for offline retailers to compete with online retailers when attracting online shoppers. we conducted an online survey to collect primary data from customers of both amazon and walmart to understand reasons for their patronage behavior. using a multivariate probit choice model, we show that the key reason customers choose amazon home delivery lies in the fundamentals of retailing -large assortment, competitive prices, and purchase convenience. offline retailers such as walmart should thus focus on providing these attributes in their online stores to wean away customers from online retailers such as amazon instead of investing inordinately in their physical infrastructure to provide quicker delivery of orders. first, they need to generate an online order by being attractive, competitive, and convenient before they can demonstrate their speed of delivery. to the best of our knowledge, this is the first study to look at the relative importance of the determinants of channel or format choice in an omnichannel context that includes more than one retailer. furthermore, we employ cluster analysis to show which demographics are good targets for retailers as they develop omnichannel capabilities and which demographics they need to keep loyal to their original channels. our results provide meaningful and actionable insights, especially for offline retailers looking to optimize their investments in omnichannel retailing. this article is organized as follows. in the next section, we look at recent omnichannel activities by both amazon and walmart. then we consider extant research in determinants of customer patronage behavior of channels or retail stores. next, we explain our data, measures, and model estimation technique. we follow this with the discussion of results. we conclude with managerial implications of our findings, limitations of the study, and avenues for future research. walmart started with, and continues dominating, offline retailing which still accounts for almost percent of retail sales in the u.s. by contrast, amazon started with, and continues dominating, online retailing. although both have been aware of the challenges posed by each other, both also "stayed in their lanes" for a long time. with the increasing demand for omnichannel retailing, however, each company has been attracted to the other's predominant channel. towards this end, amazon has taken steps to increase its presence in offline retailing whereas walmart has taken steps to increase its presence in online retailing. both retailers are integrating their new channels with existing ones. amazon is using offline locations as pick-up and return points for online orders, whereas walmart is using online channel to generate orders that can then be fulfilled by its vast network of stores. starting in as an online book retailer, amazon has diversified into multiple product and service categories and is now the most dominant brand in online retailing. its reach among u.s. online shoppers is at least ten times that of any offline retailer (redman, ) . it offers the largest assortment of products available at competitive prices. when trying to compete with offline retailers, one of amazon's disadvantages however has been the delivery time, especially for certain product categories, such as groceries. in a recent survey, percent of the respondents who were prime members indicated that their primary motivation for shopping at amazon was fast, free shipping (kestenbaum, ) . amazon has been investing heavily to make next-day delivery standard for prime members. these investments include linking together its fulfillment/distribution centers by adding smaller jets to its rented air-cargo fleet of aircrafts, opening local sortation/collection centers close to large metropolitan areas, operating its own delivery vans, and even asking its own employees to deliver packages (cameron, ) . it now operates more than fulfillment centers, some of which are larger than a million square feet, and sortation centers (which group goods by destination) across the u.s. (mims, ) . amazon has a fulfillment node within miles of half of the us population, which is up from the mere percent of the us population within that radius in (collis, wu, koning, & sun, ) . to increase the speed of its supply chain further, amazon is planning to open a central air hub near cincinnati in and regional air hubs in major population centers such as southern california and central florida (troy, ) . to cut costs and complications in the last-mile delivery, amazon has acquired zoox, an autonomous vehicle company, for $ . billion. it is expected to utilize zoox's self-driving technology to automate its distribution network (acosta, ) . in addition to these initiatives for faster delivery, amazon is also increasing its brick-and-mortar presence, betting that shoppers still want to buy groceries and other consumer products at physical stores. amazon acquired whole foods stores in for about $ . billion. the company has now started offering grocery pick-up and one-hour delivery from some whole foods stores and plans to expand these services to nearly all stores. amazon is planning to build whole foods stores in more suburbs and other areas to put more customers within range of a two-hour delivery service (haddon & stevens, b) . amazon's brick-and-mortar initiatives also include amazon go convenience stores, which are just square feet in area but sell a range of drinks, prepared foods and groceries (haddon & stevens, a) . with improvements in camera technology, amazon extended its go concept in early to an urban grocery store larger than ten thousand square feet (herrera & tilley, ) . it is also exploring purchase of smaller regional grocery chains to broaden its reach. another kind of stores launched in are named " -star" stores which carry such items as amazon devices, electronics, toys, books, and home goods rated at least four stars by customers on amazon.com. prime members get preferential prices at these stores (accardi, ) . amazon also has thousands of self-service kiosks/lockers in almost a thousand cities in the u.s. it has installed lockers at whole foods markets, various convenience stores, and at thousands of apartment complexes and college dormitories throughout the country for residential package pick-up. it is also leveraging existing offline retailers' infrastructure to expand last-mile delivery options to its online customers. for example, shoppers will be able to pick up their online purchases at specialized counters in more than rite aid locations by the end of the year (herrera, a). walmart dominates offline retailing in the u.s. with domestic annual revenue of about $ billion in (excluding its international revenue and sam's club revenue). the company has a store within miles of percent of americans. walmart entered grocery sector in with the opening of its first supercenter. since then, food and other staples have come to account for more than half of walmart's total revenue in the u.s., and it has become the country's largest grocer with a percent share of the market (hsu, ) . in fact, walmart's revenue from grocery is more than double of kroger's and five times that of amazon's in the sector (nassauer, a) . walmart is taking several initiatives to continue its hold on grocery retailing as online purchasing has gradually increased. walmart has been aggressively pursuing click-and-collect model where customers buy an item online and pick it up at the store, usually curbside or in the parking lot. compared with home delivery, click-and-collect is an attractive model for retailers because they can achieve higher profit margins by avoiding shipping fees (meyersohn, ) . it offers customers the best of both conventional offline shopping and home delivery of online orders -they can make their purchases in the comfort of their home and get it faster than waiting for delivery or without waiting in a checkout line at the store. walmart has added grocery pick-up to more than , of its approximately , stores in the past four years, and pick-up of general items to stores in the past two years. it has cut the number of new store openings in favor of offering pick-up and sameday delivery options at more stores (haddon & fung, ) . trade press has highlighted related moves such as partnerships with start-ups employing automated carts to fulfill grocery pick-up orders at stores (griffith, ) , as well as restructuring store employee roles to adapt to shifting shopping habits. in the past, walmart resisted the more expensive model of home delivery in favor of click-and-collect but is now investing heavily in quick home delivery too (chin & nassauer, ) . in , walmart began opening dedicated online fulfillment centers and increased product quantities in these centers to deliver online orders more quickly. these centers are supplemented by a large number of smaller centers, as well as store shipments. this allows walmart to put percent of the u.s. population within two days of ground shipping (mims, ) . it is also offering delivery from stores, with another planned this year, mostly by joining hands with firms such as doordash and instacart that crowdsource drivers. it is testing employing its own store workers to make deliveries in a few locations too (nassauer, b) . walmart offers free next-day delivery of about , products on orders costing $ or more in of the top u.s. metro areas. through this strategy, it aims to match amazon prime, which is considered a key driver of amazon's growth and has set standards for fast shipping of online orders. walmart is also testing out delivery services with an eye on the future including delivering groceries directly to customers' refrigerators. this move is in response to amazon's prime now service which drops orders (including fresh groceries from whole foods) on doorsteps within hours, and its in-home delivery service "key by amazon" which leaves fresh groceries just inside a door, garage or the trunk of a car (nassauer, c) . although we have primarily looked at walmart's activities in expediting delivery, it is not the only offline retailer trying to compete with amazon in getting products into customer's hands more quickly. other retailers are devising their own strategies too. target, for example, is utilizing its local stores as distribution hubs, rather than developing dedicated distribution centers for online orders. using shipt, a delivery company it acquired in , target is able to deliver over percent of its online orders within days (mims, ) . this has allowed it to keep its delivery costs low. on the other hand, kroger, the largest supermarket chain, is building a network of automated warehouses for online grocery services (haddon & fung, ) and has announced a partnership with ocado, an online grocery company, to use its robots to pack online orders (griffith, ) . it now offers delivery or pick-up of online orders at more than percent of its stores (haddon, a) . existing research has identified several factors that influence customer choice of a channel or retail store. these can be categorized into product-related factors (e.g., product quality), store-related factors (such as product assortment, price, convenience, purchase experience, order-fulfillment time, store atmosphere, service quality, friendliness of salespeople, and store image), and customer-related demographic factors (primarily age, income, and gender) (blut, teller, & floh, ; gensler, verhoef, & böhm, ; melis, campo, breugelmans, & lamey, ; neslin et al., ; pan & zinkhan, ) . research in store patronage behavior has extensively employed the theory of reasoned action (tra) which asserts that perceptions of important attributes determine customer attitudes which in turn determine their behavior (fishbein & ajzen, ) . thus, customer perceptions of these key attributes of each channel are assumed to translate into the attractiveness of each channel's value proposition, which in turn affects customer channel choice (verhoef, neslin, & vroomen, ) . we too employ this theoretical lens in our study to identify which attributes have the strongest influence on each of the customers' choices across both offline and online channels of both retailers. product assortment has been identified as one of the most important determinants of customers' channel choice (briesch, chintagunta, & fox, ; verhoef et al., ) . it is usually measured by the extent of breadth (number of product categories), depth (number of skus within a category), and brand choice (number of brands) available. research has shown that customers' attitudes toward a retail store or website are strongly related to the assortment offered (srinivasan, anderson, & ponnavolu, ) . they are also likely to evaluate selected items more positively when the assortment is more comprehensive (morales, kahn, mcalister, & broniarczyk, ) . as long as it does not confuse the customers, a larger assortment is preferred because it offers more choice flexibility, reduces search costs, and enhances feelings of autonomy for the customer (iyengar & lepper, ; oppewal & koelemeijer, ; sloot, fok, & verhoef, ) . pan and zinkhan ( ) found that product assortment had the highest average correlation with store choice, followed by other factors such as service quality, product quality, store atmosphere, price, purchase experience, fast checkout, and friendliness of salespeople. price dimension has also been shown as a strong determinant of store patronage and customer satisfaction with a channel (gensler et al., ) . besides the price of the product and any discounts, the price dimension also includes acquisition cost, i.e., the cost a customer incurs in either traveling to the store or the cost she pays for home delivery. customers consider price differences when choosing a store and are more likely to purchase at the channel that offers them most attractive price (bell, ho, & tang, ; vroegrijk, gijsbrechts, & campo, ) . time dimension of order fulfillment varies depending on the mode of purchase and delivery. for offline purchase, it consists of travel time and transaction time, i.e., the time required to locate the product and checkout. for home delivery of an online order, it consists of the time required to place the order and to wait for its arrival, i.e., time taken for the product to be delivered. for pick-up of an online order, it consists of the time required to place the order, travel time, and pick-up time, i.e., time required to pick up the order from dedicated pick-up area inside or outside the store. customers are more likely to choose the channel that minimizes overall time taken (baker, parasuraman, grewal, & voss, ) . purchase experience is an amalgam of perceived savings in time and effort during the purchase process, including the stages of search, evaluation, and acquisition (gupta & kim, ) . thus, purchase experience subsumes such attributes as store atmosphere, service quality, friendliness of salespeople, and ease of returning the product. customer evaluations of purchase experience and service also determine customer satisfaction with both offline and online shopping experiences (benoit, evanschitzky, & teller, ; berry, seiders, & grewal, ; wolfinbarger & gilly, ) . in addition to product-and store-related factors, consumer-related demographic factors are also dominant predictors of customers' channel patronage and shopping frequency (pan & zinkhan, ) . given their greater comfort with using internet for shopping, younger shoppers and those with higher levels of education may be more likely to adopt newer channels such as buy-online-pick-up-in-store (bopis). income level may play a role in using home delivery formats because of the need to pay delivery fees or to purchase above a certain amount to qualify for free delivery. household characteristics, such as the number of members who work, may influence preference for pick-up formats. relatedly, multi-channel customer segmentation has gained attention too (konus, verhoef, & neslin, ) , which can help retailers more effectively target potential patrons. most of these store-, product-, and customer-related attributes have been conventionally studied in offline and online retailing separately. some attributes of choice behavior (such as service quality) are ideally comparable within-channel competition only (i.e., comparing service quality at offline channel of one retailer with service quality at offline channel of another retailer). however, other attributes (such as assortment and price) are agnostic of within-channel (within offline or within online channels) or cross-channel competition (between offline and online channels) in that they are comparable across disparate channels of different retailers (brynjolfsson & smith, ; degeratu, rangaswamy, & wu, ) . for most of the attributes, amazon and walmart had conventionally taken opposite approaches as they offered different value propositions (either offline or online) to customers (kumar & mittal, ) . when choosing one channel over the other, customers made trade-offs according to their individual preferences. sometimes these preferences could be mapped along demographic dimensions. in this cross-channel competitive scenario, it was easy to understand customers' choice of amazon or walmart because these two retailers (with their dominant channels) clearly differed in their relative strengths on various attributes (verhoef et al., ) . but their efforts in omnichannel retailing to become attractive to customers of each other have turned this cross-channel competition into a mix of simultaneous within-channel and cross-channel competition. although the direction of patronage determinants' association with each channel is conceivable, their relative strengths for each channel of each retailer are an empirical issue. in the past few years, exploration of attributes leading to channel patronage in the context of omnichannel retailing has gathered pace. for example, emrich, paul, and rudolph ( ) showed that limitedline retailers who have a high assortment depth (compared with broadline retailers who have a high assortment breadth) are better off having the same product assortment at their offline and online stores. broadline retailers, on the other hand, are better off providing a larger assortment at their online channels. in grocery retailing, melis et al. ( ) showed that shoppers adopted the online channel of their preferred offline grocer at first but with time chose an online grocer on the basis of online product assortment. a large proportion of research in this stream has focused on the effects of opening an offline (online) channel for an online (offline) retailer and has documented positive effects on overall sales (avery, steenburgh, deighton, & caravella, ; gallino & moreno, ; pauwels & neslin, ) . research on the effects of integrating multiple channels to provide customers an omnichannel experience has also documented overall positive results (cao & li, ) . specifically examining the issue of delivery, fisher, gallino, and xu ( ) used quasi-experimental data to show that faster delivery of online orders increased sales in both online and offline channels of an apparel retailer. they showed that each business-day reduction in delivery period increased online sales of the apparel retailer by about . percent and offline sales by about . percent. the average reduction in delivery time across various states however was just about half a day from the baseline delivery period of business days. in this study, we consider competition between amazon and walmart both of which have much shorter delivery periods for most online orders. consumer behavior too likely differs in purchase of apparel and grocery due to factors such as concern for freshness and quality of groceries, and feasibility of returning grocery purchases. furthermore, we explore the relative importance of various attributes in customers' choice behavior across online and offline channels of both retailers. we also show which demographics are good targets for them as they develop omnichannel capabilities and which demographics they need to keep loyal to their original channels. in table , we provide a summary of relevant empirical research in omnichannel retailing. opening an offline store increased catalog and internet sales for the retailer in the long run. gallino and moreno ( ) store-level purchase data & differencein-difference model buy-online-pick-up-in-store (bopis) mode decreased online sales of the retailer but increased offline sales resulting in a net increase. cao and li ( ) archival data & panel estimation integration of multiple channels improved overall sales for the retailer. emrich et al. ( ) experimental data limited-line retailers who have a high assortment depth (compared with broad-line retailers who have a high assortment breadth) are better off having the same product assortment at their offline and online stores. melis et al. ( ) household panel data & multinomial logit model grocery shoppers adopted the online channel of their preferred offline grocer at first but with time chose an online grocer on the basis of online product assortment. pauwels and neslin ( ) time-series purchase data & varx models opening an offline store cannibalized catalog sales of the retailer but did not significantly reduce its internet sales. overall, it led to higher revenue. gallino, moreno, and stamatopoulos ( ) customer-level purchase data & pareto curve regression ship-to-store mode increased the sales of less popular items at offline channels of the retailer. wang and goldfarb ( ) customer-level purchase data & poisson regression opening an offline store increased online sales of the retailer in areas with no prior brand presence but decreased online sales in areas with existing brand presence. fisher et al. ( ) quasi-experimental design faster delivery of online orders increased sales in both online and offline channels of an apparel retailer. this study survey data & multivariate probit model when opening online stores, offline retailers should provide larger assortment, competitive prices, and purchase convenience instead of relying unduly on quicker delivery to compete against online retailers. we designed a survey and asked participants to report their shopping behavior at amazon and walmart, as well as their perceptions of the various factors discussed in the previous section. the survey was administered in early by a market research company which recruited a random population of respondents from its sample panel of consumers in the u.s. the company recruits individuals from across the u.s. using a variety of methods to obtain sample diversity, and regularly cleans the database so that it reflects a representative sample. respondents completed all survey questions. we report the summary statistics in table . among these respondents, percent shop frequently (defined as more than once per month) on amazon.com and have products delivered to home, while only percent frequently use the pick-up option when shopping on amazon.com. regarding walmart, percent of participants shop frequently at walmart stores; percent shop frequently on walmart.com and choose to ship to home; and percent shop frequently on walmart.com and use the pick-up option. fig. depicts an upset plot of the proportion of respondents who frequently use a shopping mode exclusively or various combinations of the five shopping modes. percent of respondents are male, and the average age is around years. percent respondents are married, and almost two-third of the respondents have children. the largest proportion of respondents ( percent) have college degrees and the largest proportion of respondents ( percent) earn between thousand and thousand dollars per annum. almost one-third of the respondents each report that either one or two members in the household work. the various attributes conventionally considered influential in store choice and outlined in the previous section may be correlated. to reduce the dimensions of the ratings, we performed a principal component analysis to extract orthogonal components. we report the rotated factor loadings in table . for the attributes we identified three components (with eigenvalue of . , . , and . respectively) that account for percent of total variance. the first component -comprised of such attributes as offering pleasant shopping experience, speedy checkout, good customer service, helpful employees, and free day shipping for online purchases -broadly reflects purchase experience, customer service, and product delivery. hence, we named this component experience, service, and delivery (esd). the second component -comprised of such attributes as offering competitive prices, a wide range of product choices, preferred brands, easy returns, and an easy-to-use website -broadly reflects product assortment, competitive price, and purchase convenience. hence, we named this component assortment, price, and convenience (apc). the third componentcomprised of such attributes as offering fresh produce, quality privatelabel products, quality meat and poultry, and availability of organic items -broadly reflects freshness and quality of products, as well as the ability to validate these qualities. hence, we named this component freshness and quality validation (fqv). we propose a multivariate probit model (mvp) to explain a survey participant's decision to shop frequently at one or more of the five options -amazon home delivery, amazon pick-up, walmart in-store shopping, walmart home delivery, and walmart pick-up. a multivariate probit model is a flexible approach to explain the contemporaneous incidence outcomes in this situation where participants may choose more than one option (see seetharaman et al., for a review). we assume the utility of buying from option i(i = ,…, ) for household h can be written as: where h stands for participants, i stands for the five shopping options, esd, apc, and fqv are the three principal components, and x h is a vector that includes demographic variables for household h. the observed shopping decisions (more than once per month vs. less frequent) for option i can be written as: we assume that the error terms of different options for a survey participant, ɛ h = {ɛ h , ɛ h , …, ɛ h }, follow a multivariate normal distribution. that is, where ∑ is a × covariance matrix. the covariance matrix allows very flexible substitution patterns and captures the co-incidences in the outcomes (manchanda, ansari, & gupta, ) . for identification purposes, all diagonal elements of the covariance matrix are set to , and the covariance matrix is essentially estimated as a correlation matrix. we estimated the model using simulated maximum likelihood implemented by stata cmp module (roodman, ) . we report the estimation results in table and present them for each choice available to the customers. we have standardized the coefficients (covariates only) to infer the strength of each attribute in forming a customer's preference for each choice. home delivery of online orders placed at amazon.com seems to be preferred the most by customers who place high importance on apc, i.e., product assortment, price competitiveness, and purchase convenience (β std = . ; p < . ). amazon home delivery is preferred second most by customers who place high importance on esd, i.e., purchase experience, customer service, and product delivery (β std = . ; p < . ). it is interesting to note that the choice of home delivery mode is driven more by apc than by esd. fqv, i.e., product freshness and quality validation understandably drives customers to amazon home delivery to a much smaller extent (β std = . ; p < . ). this is driven partly by the fact that it is difficult to validate quality for a product that is going to be delivered. comparing the three attributes, apc is almost twice as effective as esd and almost two and a half times as effective as fqv. in terms of customer demographics, this mode is preferred by males (β std = . ; p < . ), younger customers (β std = − . ; p < . ), customers with a master's degree or higher (β std = . ; p < . ), customers earning between , and , dollars per year (β std = . ; p < . ), and customers earning between , and , dollars per year (β std = . ; p < . ). picking up one's amazon orders at one of the stores or pick-up points provided by amazon seems to be preferred primarily by customers who place high importance on fqv (β std = . ; p < . ). it is also preferred by customers who place importance on esd, though not to the same extent (β std = . ; p < . ). choice of this mode does not seem to be associated with the level of importance customers place on apc (β std = − . ; n.s.). understandably, those customers who consider purchase convenience important are less likely to choose picking up their own purchase. this could also be partly driven by prime members who qualify for free delivery and may not want to expend time and money involved in pick-up, which effectively increases the price for them. comparing the attributes, fqv is more than twice as effective as esd, whereas apc is not effective at all. in terms of customer demographics, this mode is preferred by male customers (β std = . ; p < . ), younger customers (β std = − . ; p < . ), customers with adult children (β std = . ; p < . ), and customers earning more than , dollars (β std = . ; p < . ). preference for this mode among households with adult children may be driven partly by the availability of additional adults to pick up online orders. offline purchasing in-store at walmart seems to be preferred the jindal, et al. journal of business research ( ) - most by those customers who place high importance on fqv (β std = . ; p < . ). this finding is self-explanatory -purchasing products at a store in person provides the best opportunity to validate freshness and quality. however, it is not associated with importance customers place on esd (β std = . ; n.s.) nor on apc (β std = . ; n.s.). other than giving shoppers an opportunity to validate freshness and quality of products, walmart does not seem able to attract customers on any other attribute. in terms of customer demographics, this mode is preferred by married customers (β std = . ; p < . ) but less preferred by customers with college degrees (β std = − . ; p < . ). surprisingly, shopping at walmart stores is not significantly associated with any other demographic variable, which implies that no customer demographic segment has offline shopping at walmart as its favorite mode. home delivery of online orders placed at walmart.com seems to be preferred by customers who place high importance on esd (β std = . ; p < . ). it is also preferred, though to a slightly lower extent, by customers who value apc (β std = . ; p < . ). choice of this mode does not seem to be associated with the level of importance customers place on fqv (β std = . ; n.s.). in terms of customer demographics, this mode is preferred by males (β std = . ; p < . ), younger customers (β std = − . ; p < . ), and customers who have children between ages and (β std = . ; p < . ). picking up online walmart orders at one of the stores seems to be preferred by customers who place high importance on esd (β std = . ; p < . ). it is preferred second most by customers who place importance on apc (β std = . ; p < . ). valuing fqv also drives customers to walmart pick-up, though not to the same extent (β std = . ; p < . ). comparing the three attributes, esd is more than twice as effective as apc and more than two and a half times as effective as fqv. in terms of customer demographics, this mode is preferred by males (β std = . ; p < . ), younger customers (β std = − . ; p < . ), and customers earning more than , dollars (β std = . ; p < . ). home delivery of online amazon orders and in-store shopping at walmart are the original formats of these two retailers and are in a way a study in contrasts. results broadly suggest that shoppers prefer amazon home delivery primarily because they think they get better product assortment, competitive prices, and purchase convenience; other factors influence amazon shoppers too, though not to the same extent. in-store walmart shoppers mainly shop there because they think they can validate product freshness and quality; they do not seem to be motivated by any other factor. to cut into each other's market share in these formats they need to counter their rival's main attraction for the customers, i.e., amazon needs to provide an opportunity for product freshness and quality validation while walmart needs to provide a stronger motivation for customers who value assortment, price, and convenience. by expanding into pick-up of online orders from various kinds of pick-up points including whole foods stores, amazon seems to have successfully achieved its objective. the influence of freshness and quality validation is the main driving factor for customers choosing amazon pick-up and is almost fifty percent more than the influence on customers choosing walmart in-store shopping. hence, between its two formats amazon seems to provide incentives for most customers. by expanding home delivery of online orders and pick-up of online orders from its stores, walmart seems to have addressed the insufficiencies of purchase experience, customer service, and product delivery associated with the retailer's in-store shopping. customers who place higher importance on experience, service, and delivery are more likely to choose walmart's newer formats, though pick-up more so than home delivery. trade press validates walmart's vast investments to provide experience, service, and faster delivery especially through pickup of online orders for the past few years. however, these new formats do not seem to have fully addressed the key reason amazon home delivery shoppers use amazon -product assortment, competitive prices, and purchase convenience; such customers are still more likely to choose amazon home delivery. the effect of these attributes on customers choosing walmart delivery is more than forty percent less than its effect on customers choosing amazon delivery. the attributes' effect on customers choosing walmart pick-up is less than half of the effect on customers choosing amazon delivery. this is especially ironic given walmart's everyday low prices (edlp) strategy and its slogan of "always low prices" since inception. hence, the key challenge for notes: all tests are two-tailed. coefficients are standardized. income category "less than $ k" is the base category for income, and education level "high school or less" is the base category for education. * : p < . . ** : p < . . *** : p < . . walmart is to deliver a larger assortment at competitive prices while making shopping convenient for customers. this challenge is distinct from that of delivering purchase experience and quick delivery, which has been a focus for walmart over the past few years. a piece of validating empirical evidence: walmart's online assortment of stock keeping units (skus) is only ten percent of amazon.com's assortment, which is more than half a billion. walmart needs to actively enlarge its online assortment in order to effectively cut into amazon's market share. although it professes "always low prices," empirical evidence has also shown that walmart's prices are not always the lowest (profitero, ) . in terms of attracting specific demographic segments, amazon home delivery appears popular among males, younger customers, customers with higher education, and customers with a middle-to-high income. by expanding into pick-up, amazon not only seems to have retained males and younger customers but has also attracted households with the highest levels of income and households with adult children at home, perhaps because the number of members in the household who can pick up online orders is higher. on the other hand, there is no particular demographic group that appears to be strongly attracted to walmart instore shopping. by providing home delivery and pick-up of online orders, walmart seems to have attracted more males and younger customers, who form the core customer base for amazon home delivery. thus, it seems that at least to some extent walmart has succeeded in attracting amazon customers with its newer channels. walmart home delivery also seems to have attracted households with school-going children, which could perhaps be because they appreciate their purchases home-delivered due to paucity of time. walmart pick-up seems to have attracted households with highest levels of income. however, this segment seems to prefer pick-up option at amazon too. thus, compared with amazon, walmart still needs to do more to attract customers with higher levels of education and income to its newer formats. overall, amazon seems to have had greater success at adopting omnichannel retailing than walmart. walmart should focus more on offering larger online product assortment, competitive prices, and purchase convenience in addition to making investments in customer experience and faster delivery. additionally, it should increase its efforts in attempting to gain the more educated and higher income shoppers that amazon currently attracts. ailawadi and farris ( , p. ) suggest that "segmenting consumers not just based on their preferences for different channels but based on the attributes or reasons for those preferences is important. segmentation schemes that show whether and how the importance of convenience-and price-based attributes correlate in different segments can give suppliers insight into how they need to control the availability, presentation, and pricing of their brands online. and they can give retailers insights into how they can differentiate to appeal to important segments while controlling costs on aspects that are less important to the segments." multichannel customer segmentation has frequently been identified as a key consumer behavior issue for designing effective multichannel strategies (bhatnagar & ghose, a , b ganesh, reynolds, luckett, & pomirleanu, ; konus et al., ; namin & dehdashti, ) . to further understand the differences in customer needs, we conducted a segmentation analysis on the extracted principal components using k-means clustering. a three-cluster solution provides clear distinction between respondents' shopping choices, and we report the results in tables and . approximately percent of respondents seem loyal solely to amazon home delivery, driven primarily by better product assortment, competitive prices, and purchase convenience available at amazon, as well as by better purchase experience, customer service, and product delivery provided by the retailer. this cluster also has very low perception of walmart on all the three key factors. unmarried customers, customers with children years and older, those with college degrees, and customers earning between thousand and thousand dollars seem to be relatively better represented in this cluster. approximately percent of the respondents seem to have embraced omnichannel retailing unmindful of which retailer it is. they may choose one retailer or channel over another to meet their specific needs at the time of purchase (kumar & mittal, ) . as expected, they seem to rate both amazon and walmart high on purchase experience, customer service, and product delivery, as well as on product freshness and quality validation. younger customers, as well as customers with legally minor children, with higher education, with higher levels of income, and double-income households are relatively better represented in this cluster. approximately percent of the respondents seem hesitant to utilize new formats introduced by their preferred retailers. a larger proportion of these respondents shop in-store at walmart and seem to be doing so for the ability to validate freshness and quality of product. a smaller proportion use amazon home delivery for reasons of purchase experience, customer service, and product delivery, as well as product assortment, competitive price, and purchase convenience. female customers, as well as customers with relatively lower levels of education and income seem to be better represented in this cluster. overall, as these retailers invest in newer formats, the ideal potential customers for those formats are highly educated married young people (with or without young children) with high incomes, especially with both members of the household working. this desirable profile is widely validated in popular press too. at the same time, amazon needs to hold on to college-educated singles with a middle-to-high level of income, a demographic that seems to form their loyal customer segment. finally, female customers with lower levels of education or income appear averse to trying out new formats from both retailers. hence, both retailers will do well to hold onto this core set of their customers. offline retailers may be making a mistake in the way they are trying to compete with amazon. most of their recent investments and activities are focused on quicker delivery of online orders. this focus is understandable given their ready network of delivery and pick-up points in the form of thousands of physical stores. but what they need to examine is why a customer will shop at their online store in the first place if the best they can do is match amazon on delivery. offline retailers are focused on gaining parity in distribution of online orders-but what about the assortment and price of products they are making available online and the convenience with which customers can shop for those products? most offline retailers' online assortment is a fraction of what is available at amazon. for example, compared to million skus available on amazon.com in , walmart.com had only million skus (collis et al., ) . some offline retailers, including walmart, have tried to charge higher prices online than they do in their stores. is that an attractive proposition to compete with online retailers? teixeira ( ) argues that the misplaced focus may be based on offline retailers' assumption that their industry is being disrupted by technology and innovation of online retailers. he contends that although technological in nature the roots of this disruption lie in better customer value. the recession in enhanced the importance of price and value for the customer, but traditional grocers kept increasing prices at historical levels to maintain their gross margins. this harmed their value perception. customers started seeing higher value in online retailers, given their larger assortments and lower prices. amazon calls it the "flywheel" effect: more product selection and growth leads to lower costs and prices, which gives customers reasons to keep shopping at amazon (haddon & stevens, b) . offline retailers need to recognize this phenomenon, otherwise their investments in technology to ensure quicker delivery of online orders will only further raise their costs. if these costs are then passed onto customers in the form of higher prices, these investments will ultimately worsen their value perception (gomes, ) . in a survey conducted by forrester, the price of an item was the biggest reason shoppers favored a particular retailer; expedited shipping drove purchase decisions for less than percent of the respondents (smith, ) . offline retailers need to understand and leverage their comparative advantages (gomes, ) . they should invest in tracking their supply chain in real time to get a better sense of what, and how much of it, is where and when. evidence suggests that faster delivery may not be as important for customers as "certain" delivery, i.e., meeting the promised delivery date (kumar & mittal, ) . in an analysis of its online business, rei inc. found that "if we can provide four-day or less service for our customers consistently, we're retaining them and getting wallet share" (smith, ) . when amazon missed its two-day delivery promise to several of its prime customers on prime day in it led to such reactions as "if you can't fulfill it, don't promise it." amazon explained the high traffic of customers through price: "people are not focused on speed, they are focused on deals." this validates the primary importance of pricing in customers' patronage behavior. (herrera, b) . tracking their inventory in real-time would allow offline retailers to fulfill their promised delivery dates. most grocers lack the ability of real-time tracking - percent of consumer products listed on u.s. online ordering services are out of stock when it comes to fulfilling them (haddon, b) . these items are not in the nearest stores fulfilling a delivery order, which forces employees to make necessary substitutions in the order, but these substitutions are not always optimal. at instacart, the largest thirdparty grocery-delivery service, incomplete orders are the second most frequent source of customer dissatisfaction, after high price. mishandling substitutions often lead to returns and refunds which decrease an online order's profitability (haddon, b) . in conclusion, walmart perhaps has the best physical distribution and retail network in the world. instead of imitating amazon, which offers a different value proposition to its customers, walmart should invest in this competitive advantage. it has moved away from focusing on its brand identity as a retailer providing everyday low prices. it should invest in and leverage its core competencies both offline and online and make it convenient for shoppers to make purchases (yohn, ) . although based on competition between amazon and walmart, the key results of this study have managerial implications for all retailers pursuing omnichannel strategies. online retailers' key limitation is that shoppers cannot validate freshness and quality at the time of purchase. they can overcome this limitation by offering pick-up of online orders in customers' vicinity. pick-up option seems to especially attract high very income customers too. offline retailers need to ensure that their online assortment and prices are competitive with major online retailers and the purchase experience is convenient for the shoppers. these are the key attributes that attract shoppers, especially younger shoppers, to online channels. it may be overrated for them to invest inordinately in quicker delivery, as evidence suggests that delivering on a "promised" date is as effective as, if not better than, quicker delivery. in general, omnichannel retailers would be advised to target younger double-income households with higher levels of education and income, as they seem the most receptive to addition of newer channels by retailers. however, when targeting these segments of customers by adding newer channels, retailers need to continue providing benefits for their existing customers to maintain their loyalty. these customers likely have lower levels of education and income, which again highlights the critical need to offer greater assortments at competitive prices while making the purchase process convenient to attract all different although this study contributes to our understanding of strategies omnichannel retailers can utilize to compete more effectively, there are some limitations. first is the issue of generalizability. our analysis is based on customers' patronage of two retailers only -amazon and walmart. as such results may be biased by certain unobservable dimensions of competition between these two specific retailers. future research should consider other major offline and online retailers too. second, the retailing sector is undergoing changes and developments at a fast pace especially after the economy was hit by covid- pandemic at the beginning of year . as such, results based on data collected more than a year ago may not fully hold now or in the future. third, we have not considered the relative cost or capacity issues involved in terms of providing various attributes to the customers. future research should consider these issues as well in omnichannel retailing. fourth, we collected information only about the frequency with which customers shop at each of the channels -more frequently than once a month or not. we did not collect how they divided their budget between these different channels, which could have provided a more insightful outcome variable to validate the relative effects of various attributes. fifth, our results suggest that by expanding into various kinds of pick-up points, amazon seems to have addressed the freshness and quality validation issue. picking up an order however is not a direct validation of product freshness; after all, one cannot validate the freshness or quality unless one unpacks the order. thus, there could be a number of reasons why customers perceive picked up orders to be high on freshness or quality. for example, picking up an order may cut down the transit time from the time of packing to the time one acquires the product, or picking up one's order at whole foods store may psychologically bestow "freshness" on the order. future research should explore the reasons for this customer perception. finally, we utilized cross-sectional data of consumer perceptions, but arguably longitudinal data could better capture the 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on grocery industry: rivals stock up on startups. the new york times value-driven internet shopping: the mental accounting theory perspective: value-driven internet shopping kroger shares fall as online investments dent profit. the wall street amazon to whole foods online delivery customers: we're out of celery, how's kale? the wall street journal grocers brace for another blow from amazon. the wall street amazon tests its cashierless technology for bigger stores. the wall street amazon plans to add whole foods stores. the wall street journal amazon adds rite aid locations to package delivery network. the wall street journal amazon's two-day shipping standard slips for some on prime day. the wall street journal amazon opens cashierless supermarket in latest push to sell food walmart is finding success in the grocery aisle. the new york times when choice is demotivating: can one desire too much of a good thing amazon could be vulnerable to competition, and this is how multichannel shopper segments and their covariates amazon and walmart on collision course the "shopping basket": a model for multicategory purchase incidence decisions amazonfresh: rekindling the online grocery market the impact of the multichannel retail mix on online store choice: does online experience matter retail's amazon antidote: buy online, pickup in store the prime effect: how amazon's two-day shipping is disrupting retail. the wall street journal perceptions of assortment variety: the effects of congruency between consumers' internal and retailers' external organization research priorities - a "hidden" side of consumer grocery shopping choice walmart posts strong holiday sales gains in u.s. the wall street walmart's food-delivery challenges: patchwork of drivers, tolls, crowded aisles. the wall street journal walmart wants to put groceries into your fridge challenges and opportunities in multichannel customer management more choice is better: effects of assortment size and composition on assortment evaluation determinants of retail patronage: a meta-analytical perspective building with bricks and mortar: the revenue impact of opening physical stores in a multichannel environment price wars -grocery the impact of digital innovations on marketing and consumers brick-and-mortar retailers narrow gap with amazon fitting fully observed recursive mixed-process models with cmp models of multi-category choice behavior the short-and long-term impact of an assortment reduction on category sales retailers are warned to step slowly into one-day shipping. the wall street journal customer loyalty in e-commerce: an exploration of its antecedents and consequences unlocking the customer value chain an amazon advantage other retailers can't replicate multichannel customer management: understanding the research-shopper phenomenon close encounter with the hard discounter: a multiple-store shopping perspective on the entry of local hard-discounter entry can offline stores drive online sales? etailq: dimensionalizing, measuring and predicting etail quality walmart won't stay on top if its strategy is "copy amazon the last author was supported by the social sciences and humanities research council of canada (sshrc- - - ). supplementary data to this article can be found online at https:// doi.org/ . /j.jbusres. . . . key: cord- -c awh y authors: elzainy, ahmed; el sadik, abir; al abdulmonem, waleed title: experience of e-learning and online assessment during the covid- pandemic at the college of medicine, qassim university date: - - journal: j taibah univ med sci doi: . /j.jtumed. . . sha: doc_id: cord_uid: c awh y objectives: during the covid- pandemic, academic institutions are promptly shifting all educational activities to the e-learning format. the present work describes concurrent procedures for online teaching and assessment performed at the college of medicine, qassim university, ksa. we also explored the impact of e-learning and assessment on the performance of students and faculty, and the challenges to their sustainability. methods: in this descriptive cross-sectional study, we recorded the number and duration of different online educational activities during the covid- pandemic. training sessions for various procedures of virtual classrooms and online assessments were organised for teachers and students. a newly established e-assessment committee arranged different online assessments. a comparison between the mean problem-based learning (pbl) grades of the same students was conducted either face-to-face or online. a student satisfaction survey and online staff focus group about the online learning experiences were conducted, and weekly staff perception reports were prepared. the results obtained were then analysed. results: a total of virtual classrooms were successfully implemented over h including theoretical lectures, pbl sessions, seminars, and tutorials. a significant increase in the mean pbl grades was observed for female students during the online sessions. out of the basic year students and staff, . % reflected their high satisfaction towards virtual classrooms, online assessment, and online workshops. conclusion: the present study elaborates on the benefits of e-learning and assessment. we observed higher student achievements and promising staff perceptions with obvious improvement in their technological skills. these findings support the shift towards future implementation of more online medical courses. ‫ﺖ‬ ‫ﻟ‬ ‫ﺠ‬ ‫ﻨ‬ ‫ﺔ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﻘ‬ ‫ﻴ‬ ‫ﻴ‬ ‫ﻢ‬ ‫ﺍ‬ ‫ﻹ‬ ‫ﻟ‬ ‫ﻴ‬ ‫ﻜ‬ ‫ﺘ‬ ‫ﺮ‬ ‫ﻭ‬ ‫ﻧ‬ ‫ﻲ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻤ‬ ‫ﻨ‬ ‫ﺸ‬ ‫ﺄ‬ ‫ﺓ‬ ‫ﺣ‬ ‫ﺪ‬ ‫ﻳ‬ ‫ﺜ‬ ‫ﺎ‬ ‫ﻣ‬ ‫ﺨ‬ ‫ﺘ‬ ‫ﻠ‬ ‫ﻒ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﻘ‬ ‫ﻴ‬ ‫ﻴ‬ ‫ﻤ‬ ‫ﺎ‬ ‫ﺕ‬ ‫ﺍ‬ ‫ﻹ‬ ‫ﻟ‬ ‫ﻴ‬ ‫ﻜ‬ ‫ﺘ‬ ‫ﺮ‬ ‫ﻭ‬ ‫ﻧ‬ ‫ﻴ‬ ‫ﺔ‬ . ‫ﺗ‬ ‫ﻢ‬ ‫ﻣ‬ ‫ﻘ‬ ‫ﺎ‬ ‫ﺭ‬ ‫ﻧ‬ ‫ﺔ‬ ‫ﻣ‬ ‫ﺘ‬ ‫ﻮ‬ ‫ﺳ‬ ‫ﻂ‬ ‫ﺩ‬ ‫ﺭ‬ ‫ﺟ‬ ‫ﺎ‬ ‫ﺕ‬ ‫ﻧ‬ ‫ﻔ‬ ‫ﺲ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻄ‬ ‫ﻠ‬ ‫ﺒ‬ ‫ﺔ‬ ‫ﺃ‬ ‫ﺛ‬ ‫ﻨ‬ ‫ﺎ‬ ‫ﺀ‬ ‫ﺟ‬ ‫ﻠ‬ ‫ﺴ‬ ‫ﺎ‬ ‫ﺕ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﻌ‬ ‫ﻠ‬ ‫ﻢ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻘ‬ ‫ﺎ‬ ‫ﺋ‬ ‫ﻢ‬ ‫ﻋ‬ ‫ﻠ‬ ‫ﻰ‬ ‫ﺣ‬ ‫ﻞ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻤ‬ ‫ﻌ‬ ‫ﻀ‬ ‫ﻼ‬ ‫ﺕ‬ ‫ﺳ‬ ‫ﻮ‬ ‫ﺍ‬ ‫ﺀ‬ ‫ﻋ‬ ‫ﻘ‬ ‫ﺪ‬ ‫ﺕ‬ ‫ﻭ‬ ‫ﺟ‬ ‫ﻬ‬ ‫ﺎ‬ ‫ﻟ‬ ‫ﻮ‬ ‫ﺟ‬ ‫ﻪ‬ ‫ﺃ‬ ‫ﻭ‬ ‫ﺗ‬ ‫ﻢ‬ ‫ﻋ‬ ‫ﻘ‬ ‫ﺪ‬ ‫ﻫ‬ ‫ﺎ‬ ‫ﺇ‬ ‫ﻟ‬ ‫ﻜ‬ ‫ﺘ‬ ‫ﺮ‬ ‫ﻭ‬ ‫ﻧ‬ ‫ﻴ‬ ‫ﺎ‬ . ‫ﻛ‬ ‫ﻤ‬ ‫ﺎ‬ ‫ﺗ‬ ‫ﻢ‬ ‫ﻋ‬ ‫ﻤ‬ ‫ﻞ‬ ‫ﻭ‬ ‫ﺗ‬ ‫ﺤ‬ ‫ﻠ‬ ‫ﻴ‬ ‫ﻞ‬ ‫ﺍ‬ ‫ﺳ‬ ‫ﺘ‬ ‫ﺒ‬ ‫ﺎ‬ ‫ﻧ‬ ‫ﺔ‬ ‫ﺭ‬ ‫ﺿ‬ ‫ﺎ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻄ‬ ‫ﻼ‬ ‫ﺏ‬ ، ‫ﻭ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﻘ‬ ‫ﺎ‬ ‫ﺭ‬ ‫ﻳ‬ ‫ﺮ‬ ‫ﺍ‬ ‫ﻷ‬ ‫ﺳ‬ ‫ﺒ‬ ‫ﻮ‬ ‫ﻋ‬ ‫ﻴ‬ ‫ﺔ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﺼ‬ ‫ﻮ‬ ‫ﺭ‬ ‫ﺃ‬ ‫ﻋ‬ ‫ﻀ‬ ‫ﺎ‬ ‫ﺀ‬ ‫ﻫ‬ ‫ﻴ‬ ‫ﺌ‬ ‫ﺔ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﺪ‬ ‫ﺭ‬ ‫ﻳ‬ ‫ﺲ‬ ‫ﺑ‬ ‫ﺎ‬ ‫ﻹ‬ ‫ﺿ‬ ‫ﺎ‬ ‫ﻓ‬ ‫ﺔ‬ ‫ﺇ‬ ‫ﻟ‬ ‫ﻰ‬ ‫ﺧ‬ ‫ﺒ‬ ‫ﺮ‬ ‫ﺍ‬ ‫ﺕ‬ ‫ﺟ‬ ‫ﻠ‬ ‫ﺴ‬ ‫ﺔ‬ ‫ﻣ‬ ‫ﺠ‬ ‫ﻤ‬ ‫ﻮ‬ ‫ﻋ‬ ‫ﺔ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﺮ‬ ‫ﻛ‬ ‫ﻴ‬ ‫ﺰ‬ ‫ﻋ‬ ‫ﻦ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﻌ‬ ‫ﻠ‬ ‫ﻢ‬ ‫ﺍ‬ ‫ﻹ‬ ‫ﻟ‬ ‫ﻴ‬ ‫ﻜ‬ ‫ﺘ‬ ‫ﺮ‬ ‫ﻭ‬ ‫ﻧ‬ ‫ﻲ‬ . ‫ﺍ‬ ‫ﻟ‬ ‫ﻨ‬ ‫ﺘ‬ ‫ﺎ‬ ‫ﺋ‬ ‫ﺞ‬ : ‫ﺗ‬ ‫ﻢ‬ ‫ﺗ‬ ‫ﻨ‬ ‫ﻔ‬ ‫ﻴ‬ ‫ﺬ‬ ٦٢٠ ‫ﻓ‬ ‫ﺼ‬ ‫ﻼ‬ ‫ﺍ‬ ‫ﻓ‬ ‫ﺘ‬ ‫ﺮ‬ ‫ﺍ‬ ‫ﺿ‬ ‫ﻴ‬ ‫ﺔ‬ ‫ﺑ‬ ‫ﻨ‬ ‫ﺠ‬ ‫ﺎ‬ ‫ﺡ‬ ‫ﻋ‬ ‫ﻠ‬ ‫ﻰ‬ ‫ﻣ‬ ‫ﺪ‬ ‫ﻯ‬ ٩٩٤ ‫ﺳ‬ ‫ﺎ‬ ‫ﻋ‬ ‫ﺔ‬ ‫ﺷ‬ ‫ﻤ‬ ‫ﻠ‬ ‫ﺖ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻤ‬ ‫ﺤ‬ ‫ﺎ‬ ‫ﺿ‬ ‫ﺮ‬ ‫ﺍ‬ ‫ﺕ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻨ‬ ‫ﻈ‬ ‫ﺮ‬ ‫ﻳ‬ ‫ﺔ‬ ، ‫ﻭ‬ ‫ﺟ‬ ‫ﻠ‬ ‫ﺴ‬ ‫ﺎ‬ ‫ﺕ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﻌ‬ ‫ﻠ‬ ‫ﻢ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻘ‬ ‫ﺎ‬ ‫ﺋ‬ ‫ﻢ‬ ‫ﻋ‬ ‫ﻠ‬ ‫ﻰ‬ ‫ﺣ‬ ‫ﻞ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻤ‬ ‫ﻌ‬ ‫ﻀ‬ ‫ﻼ‬ ‫ﺕ‬ ، ‫ﻭ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻨ‬ ‫ﺪ‬ ‫ﻭ‬ ‫ﺍ‬ ‫ﺕ‬ ‫ﻭ‬ ‫ﺣ‬ ‫ﻠ‬ ‫ﻘ‬ ‫ﺎ‬ ‫ﺕ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻨ‬ ‫ﻘ‬ ‫ﺎ‬ ‫ﺵ‬ . ‫ﻻ‬ ‫ﺣ‬ ‫ﻈ‬ ‫ﻨ‬ ‫ﺎ‬ ‫ﺯ‬ ‫ﻳ‬ ‫ﺎ‬ ‫ﺩ‬ ‫ﺓ‬ ‫ﺫ‬ ‫ﺍ‬ ‫ﺕ‬ ‫ﺩ‬ ‫ﻻ‬ ‫ﻟ‬ ‫ﺔ‬ ‫ﺇ‬ ‫ﺣ‬ ‫ﺼ‬ ‫ﺎ‬ ‫ﺋ‬ ‫ﻴ‬ ‫ﺔ‬ ‫ﻓ‬ ‫ﻲ‬ ‫ﻣ‬ ‫ﺘ‬ ‫ﻮ‬ ‫ﺳ‬ ‫ﻄ‬ ‫ﺪ‬ ‫ﺭ‬ ‫ﺟ‬ ‫ﺎ‬ ‫ﺕ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻄ‬ ‫ﺎ‬ ‫ﻟ‬ ‫ﺒ‬ ‫ﺎ‬ ‫ﺕ‬ ‫ﺃ‬ ‫ﺛ‬ ‫ﻨ‬ ‫ﺎ‬ ‫ﺀ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺠ‬ ‫ﻠ‬ ‫ﺴ‬ ‫ﺎ‬ ‫ﺕ‬ ‫ﺍ‬ ‫ﻹ‬ ‫ﻟ‬ ‫ﻜ‬ ‫ﺘ‬ ‫ﺮ‬ ‫ﻭ‬ ‫ﻧ‬ ‫ﻴ‬ ‫ﺔ‬ ‫ﻟ‬ ‫ﻠ‬ ‫ﺘ‬ ‫ﻌ‬ ‫ﻠ‬ ‫ﻢ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻘ‬ ‫ﺎ‬ ‫ﺋ‬ ‫ﻢ‬ ‫ﻋ‬ ‫ﻠ‬ ‫ﻰ‬ ‫ﺣ‬ ‫ﻞ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻤ‬ ‫ﻌ‬ ‫ﻀ‬ ‫ﻼ‬ ‫ﺕ‬ . ‫ﻋ‬ ‫ﻜ‬ ‫ﺲ‬ ‫ﺃ‬ ‫ﻛ‬ ‫ﺜ‬ ‫ﺮ‬ ‫ﻋ‬ ‫ﺪ‬ ‫ﺩ‬ ‫ﻣ‬ ‫ﻤ‬ ‫ﻜ‬ ‫ﻦ‬ ٥٢.٨٢ ٪ ‫ﻣ‬ ‫ﻦ‬ ‫ﻃ‬ ‫ﻼ‬ ‫ﺏ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺴ‬ ‫ﻨ‬ ‫ﻮ‬ ‫ﺍ‬ ‫ﺕ‬ ‫ﺍ‬ ‫ﻷ‬ ‫ﺳ‬ ‫ﺎ‬ ‫ﺳ‬ ‫ﻴ‬ ‫ﺔ‬ ‫ﺑ‬ ‫ﺎ‬ ‫ﻹ‬ ‫ﺿ‬ ‫ﺎ‬ ‫ﻓ‬ ‫ﺔ‬ ‫ﺇ‬ ‫ﻟ‬ ‫ﻰ‬ ‫ﺃ‬ ‫ﻋ‬ ‫ﻀ‬ ‫ﺎ‬ ‫ﺀ‬ ‫ﻫ‬ ‫ﻴ‬ ‫ﺌ‬ ‫ﺔ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﺪ‬ ‫ﺭ‬ ‫ﻳ‬ ‫ﺲ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺮ‬ ‫ﺿ‬ ‫ﻰ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻌ‬ ‫ﺎ‬ ‫ﻟ‬ ‫ﻲ‬ ‫ﺗ‬ ‫ﺠ‬ ‫ﺎ‬ ‫ﻩ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻔ‬ ‫ﺼ‬ ‫ﻮ‬ ‫ﻝ‬ ‫ﺍ‬ ‫ﻻ‬ ‫ﻓ‬ ‫ﺘ‬ ‫ﺮ‬ ‫ﺍ‬ ‫ﺿ‬ ‫ﻴ‬ ‫ﺔ‬ ، ‫ﻭ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﻘ‬ ‫ﻴ‬ ‫ﻴ‬ ‫ﻢ‬ ‫ﺍ‬ ‫ﻹ‬ ‫ﻟ‬ ‫ﻴ‬ ‫ﻜ‬ ‫ﺘ‬ ‫ﺮ‬ ‫ﻭ‬ ‫ﻧ‬ ‫ﻲ‬ ‫ﻭ‬ ‫ﻭ‬ ‫ﺭ‬ ‫ﺵ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻌ‬ ‫ﻤ‬ ‫ﻞ‬ ‫ﺍ‬ ‫ﻹ‬ ‫ﻟ‬ ‫ﻜ‬ ‫ﺘ‬ ‫ﺮ‬ ‫ﻭ‬ ‫ﻧ‬ ‫ﻴ‬ ‫ﺔ‬ . ‫ﺍ‬ ‫ﻻ‬ ‫ﺳ‬ ‫ﺘ‬ ‫ﻨ‬ ‫ﺘ‬ ‫ﺎ‬ ‫ﺟ‬ ‫ﺎ‬ ‫ﺕ‬ : ‫ﺃ‬ ‫ﻭ‬ ‫ﺿ‬ ‫ﺤ‬ ‫ﺖ‬ ‫ﻫ‬ ‫ﺬ‬ ‫ﻩ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺪ‬ ‫ﺭ‬ ‫ﺍ‬ ‫ﺳ‬ ‫ﺔ‬ ‫ﻓ‬ ‫ﻮ‬ ‫ﺍ‬ ‫ﺋ‬ ‫ﺪ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﻌ‬ ‫ﻠ‬ ‫ﻢ‬ ‫ﺍ‬ ‫ﻹ‬ ‫ﻟ‬ ‫ﻜ‬ ‫ﺘ‬ ‫ﺮ‬ ‫ﻭ‬ ‫ﻧ‬ ‫ﻲ‬ ‫ﻭ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﻘ‬ ‫ﻴ‬ ‫ﻴ‬ ‫ﻢ‬ . ‫ﻻ‬ ‫ﺣ‬ ‫ﻈ‬ ‫ﻨ‬ ‫ﺎ‬ ‫ﺍ‬ ‫ﺭ‬ ‫ﺗ‬ ‫ﻔ‬ ‫ﺎ‬ ‫ﻋ‬ ‫ﺎ‬ ‫ﻓ‬ ‫ﻲ‬ ‫ﺇ‬ ‫ﻧ‬ ‫ﺠ‬ ‫ﺎ‬ ‫ﺯ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻄ‬ ‫ﻼ‬ ‫ﺏ‬ ‫ﻭ‬ ‫ﺗ‬ ‫ﺼ‬ ‫ﻮ‬ ‫ﺭ‬ ‫ﺍ‬ ‫ﻭ‬ objectives: during the covid- pandemic, academic institutions are promptly shifting all educational activities to the e-learning format. the present work describes concurrent procedures for online teaching and assessment performed at the college of medicine, qassim university, ksa. we also explored the impact of e-learning and assessment on the performance of students and faculty, and the challenges to their sustainability. methods: in this descriptive cross-sectional study, we recorded the number and duration of different online educational activities during the covid- pandemic. training sessions for various procedures of virtual classrooms and online assessments were organised q for teachers and students. a newly established e-assessment committee arranged different online assessments. a comparison between the mean problem-based learning (pbl) grades of the same students was conducted either face-to-face or online q . a student satisfaction survey and q online staff focus group about the online learning experiences were conducted, and weekly staff perception reports were prepared. the results obtained were then analysed q . results: a total of virtual classrooms were successfully implemented over h including theoretical lectures, pbl sessions, seminars, and tutorials. a significant increase in the mean pbl grades was observed for female students during the online sessions. out of the basic year students and staff, . q % reflected their high satisfaction towards virtual classrooms, online assessment, and online workshops. the present study elaborates on the benefits of e-learning and assessment. we observed higher student achievements and promising staff perceptions with obvious improvement in their technological skills. these findings support the shift towards future implementation of more online medical courses. the covid- pandemic has led to the global disruption of medical education which necessitated working online. urgent response to the current situation required an increase in medical educators' awareness towards online teaching. several researches determined the effectiveness of digital technologies for life-long e-learning and continuous professional development. e-learning has been established worldwide in response to the shortage of health educators and the need to switch into teal q . , e-learning has several advantages q , such as encouraging students for self-directed learning and updating the curricula. the college of medicine at qassim university, established in , adopted the pbl system as an interactive educational strategy. the college shifted into digitalised pbl materials for one year, which was a good preparation for complete online pbl sessions. recent technologies allowed the progressive innovation of e-learning. , several studies have investigated the benefits of these technologies in medical education, especially the pbl system. , official online platforms, mainly through the blackboard learning management system (lms) version . (blackboard, washington, dc), are used in qassim university to conduct educational sessions including lectures, tutorials, pbl sessions, seminar presentations, and open discussion forums. online formative assessments, through the blackboard, were also performed. these assessments reflect the nature of online learning and give the students more responsibility for their q learning. online assessment allows the learners to demonstrate their capabilities in critical thinking and solving problems, which are the key benefits of shifting from traditional teaching to e-learning where the teacher is mainly a facilitator. the present study described the procedures performed to facilitate the urgent transition to e-learning and online assessment during the covid- pandemic and to highlight its expected benefits and impact on student and staff satisfaction and performance. it also aimed to compare the scores of male and female students during both face-to-face and online pbl sessions, and to explore the expected challenges of this experience to sustain its future implementation after the covid- pandemic. this was a descriptive observational study conducted q over days. during this period, four weeks of pbl sessions were accomplished for the basic year students. the study collected data from all the undergraduate students, involved in this e-learning experience, of preclinical phase (n ¼ ) (male students ¼ ; female students ¼ ) and clinical phase (n ¼ ) (male students ¼ ; female students ¼ ), and instructors ( basic and clinical). data of students were not included as they dropped out from both the basic and clinical phases q . the aim and procedure of the study were clarified to the participating students and staff, and their consents were obtained. students' identity will not be disclosed for ethical reasons. the confidentiality of the information obtained was maintained. all theoretical activities, including lectures, pbl, tutorials, and seminar sessions, in college of medicine at qassim university were adapted to the e-learning modality through the blackboard, version . (blackboard, washington, dc) and zoom cloud meetings . the authors contributed to the rescheduling of timetables for all these activities. all practical or clinical sessions were postponed. webinars about virtual classrooms and online assessments were presented for staff and students. an e-assessment committee was established for the first time consisting of thirteen membersdnine basic scientists and four clinical staff. this committee formulated, revised, and uploaded the online assessments with their logistics and evaluated the results using item analysis. the educational strategies for the live streaming sessions, during the covid- pandemic, at the college of medicine at qassim university included lectures, pbl sessions, tutorials, and seminar presentations to achieve the course objectives. comparisons of the mean pbl marks during control (face-to-face) and online (virtual) sessions were done for male and female students of the first and third years. secondyear students were excluded as they started a new block with the shift to e-learning. the students completed an online satisfaction survey on their perceptions of the e-learning experience, with a -point likert scale. weekly reports concerning staff perceptions on the effectiveness of live streaming activities were collected with a -point likert scale. the cronbach's alpha test was used for testing the internal consistency and reliability of the students' and staff's perceptions q . kendall's tau b, a nonparametric measure of association that exists between two variables, was used to test the correlation of the items of the students' survey. an online focus group for the staff, using the focus-groupit software (https://www.focusgroupit.com/), was performed. the questions were presented in the form of a swot analysis (figure ). the group was composed of one moderator, one observer, and seven participants (the supervisors of basic sciences departments and one radiology staff). the two-hour-long online synchronous focus group discussion was recorded. the analysed data were reviewed and interpreted by an independent investigator. the data were analysed using the statistical package for the social sciences (spss) software, version (ibm corp., armonk, ny). descriptive statistics (percentages, mean, q and standard errors of the mean) were used to describe the quantitative variables with their analysis through pairedsamples (to compare the male and female mean pbl marks) and independent t-tests (to compare the mean marks of the face-to-face and online pbl sessions). a p-value of < . was considered significant. weekly reports though the official learning management systemdblackboarddregarding the number, duration, and modality of different educational activities including the live streaming sessions and students' attendance rate were collected from the course organisers in coordination with the e-learning unit, phase coordination, and e-assessment committees. evaluation of students during their e-learning experience was done based on their assessment during the online pbl sessions. tables and present the details regarding the virtual classrooms, conducted mostly through blackboard, of the preclinical and clinical phases q . they represent the numbers of e-learning activities successfully implemented. significant increase in the mean pbl marks of the female students of both first and third years was observed during the online sessions than in the face-to-face sessions of the relevant year. additionally, there was a significant increase in the mean pbl marks of the female students of the first and third years than that of the male students of the relevant year in both face-to-face and online sessions (tables and ) . two hundred and fifty q students of the preclinical phase ( . %) completed the perception survey. students' satisfaction towards the new modality of e-learning and online assessment was reported (table ). the items covered in the students' survey included the following: the success of elearning in compensating for the urgent suspension of faceto-face teaching during the covid- pandemic, efficiency of instructions announced before the online teaching, staff's resistance and experience in e-learning requirements, and effectiveness of online assessment in testing their knowledge and skills levels. the cronbach's alpha test performed for all items of this survey resulted in an overall score of q . . kendall's tau b was used to test the correlation of these items. the correlation coefficient ranged from . to . . open-ended comments were received from out of students ( %), which were classified into two categoriesdone for teaching activities and the other for online assessment. eighty-seven per cent q (n ¼ ) of the students reflected their enthusiasm towards the e-learning modality: for example, 'very amazing; online teaching experience is the future of learning' and 'online lectures are super-satisfying' q . they expressed their satisfaction in having the same staff delivering the lectures for both male and female students. e-learning provided a chance for the shy studentsdas they could participate freely through online chattingd and motivated them for verbal discussions: 'initially, i was shy and shared my opinions during the open discussions only through chat; by the time i was encouraged to share orally q '. they expressed satisfaction with the rescheduling of educational activities and their allocated time and duration; for example, 'modification of the timetable allows more time for educational and recreational activities, thus allowing to live like a normal human'. the students expressed that some of the staff lacked adequate experience in conducting open discussions during online teaching. seventy per cent (n ¼ ) of the students reported that frequent online quizzes motivated them to study; for example, 'online quizzes are very helpful to improve my grades'. they appreciated the conduction of the mock quiz; for example, 'mock exam was very helpful for training before the online exams'. electronic assessment ensured fewer errors carried out by the students while filling out bubbles in q their answer sheets. lastly, they recommended that some courses could be implemented online in the future. staff satisfaction in virtual classrooms was also observed (tables and ) , which reflected that the live streaming sessions were very effective. the online focus group discussion was categorised into four themes based on the swot analysis. concerning the strengths, most of the staff agreed that the new arrangement of educational activities efficiently compensated for the suspension of face-to-face teaching q . they were satisfied with the university's efforts to improve staff awareness regarding virtual classrooms and online assessment through webinars q . the majority of them appreciated the tremendous shift to implement online summative assessments; for example, 'online assessment assured the staff about students' achievement of learning outcomes' and 'conduction of live oral exams based upon clear standardised checklist was highly effective'. the concerns expressed by the participants included some staff's limited online teaching experience and q the insufficient number of it technicians which interferes with proper digitalisation. regarding the opportunities that could be gained, the staff acknowledged the constitution of the e-assessment committee in the focus group; 'such committee was an urgent requirement to tackle the full first second third total bb: blackboard. a. elzainy et al. responsibility for online assessments'. they reflected the improvement of their expertise towards the novel pedagogical e-learning techniques and their enthusiasm to construct online courses; for example, 'adoption of electronic courses allows better arrangement of educational activities and gives more chances for students' self-directing learning'. two staff members reported the inconvenience of some students in taking the online quizzes, especially during the initial period, while the others specifically talked about q those who live in distant rural areas with insufficient internet coverage. four staff members emphasised the limited capabilities of the official version of blackboard, particularly in conducting the morning sessions. advanced technologies emerged during the covid- pandemic to sustain world productivity. the horizon teaching and learning report highlighted the role of advanced technology in medical education. the present study represents the major change in the educational culture. e-learning was highly beneficial for competent educators as it decreased the needs for in-class attendance. in agreement with mccoy et al., students and staff reflected that live streaming lectures efficiently compensated the suspension of face-toface teaching and provided more chances for open discussions. nomination of the same staff to virtually present each topic for both male and female students encouraged more peer sharing and competition among the students q . the rescheduled educational activities were more convenient to the students, as reflected in their attendance. recent technologies resolved the lack of physical attendance and increased learning effectiveness. , the horizon report highlighted the effectiveness of online teaching in overcoming the restrictions such as shortage of venues for large group lectures. however, one of the main challenges of e-learning, as reflected in the current work, is in teaching the psychomotor, practical, and clinical skills efficiently. murphy recently reported that most medical schools suspended q the clinical settings during the covid- pandemic. this could be overcome by using virtual-reality simulators. , unfortunately, most of the students were unsatisfied with how some staff members practiced e-learning. a previous study performed in a similar culturedunited arab emiratesdobserved that the teachers felt worried about the shift into a new educational strategy. psychological assurance was recommended to encourage them to deal with the unknown consequences. multiple webinars about proper virtual classrooms and peer sharing of experiences between the staff members solved this problem. goh et al. claimed that live streaming applications will improve the technological skills of the educators. pivot meded appreciated the free elearning webinars for health professional educators worldwide and the national coordination between medical schools in sharing such training courses. successful collaborative online learning demanded the support of it technicians, as previously reported. , the cronbach's alpha test implied that the survey tool had a good level of internal consistency and reliability for both the students' survey and staff's overall satisfaction in the live streaming experience. the correlation coefficient indicated that the items in the students' survey were well correlated. however, the application of kendall's tau b test on the staff perception was non-feasible since it measures the association between two variables, unlike the current study which focused on the staff perception on the effectiveness of virtual classrooms. the higher achievement level detected in the mean marks of online pbl compared with face-to-face sessions could be attributed to the easier access to the explanation of the phenomena. the students' assessment during the pbl sessions in this work was based upon their commitment, team spirit, interaction with peers and tutors, presentation skills, and ability for brain storming and analysing the phenomena. the students' assessment during the pbl sessions was based upon their performance during the session rather than their achievements through other summative assessment methods such as multiple choice questions which are associated with higher chances of cheating q . these findings are in agreement with the previous study which observed that online pbl enhanced critical thinking and fulfilled the intended learning objectives. therefore, online pbl could enhance the metacognitive skills, ability to solve problems, and team working. collaborative interaction in the online environment helped enhance peer sharing. after the sars epidemic, one medical school in china adopted online pbl as an educational strategy for the subsequent years. the higher pbl scores in female students could be attributed to the difference in the style of thinking, learning, and capabilities of problem-solving. makonye detected that female students have more ability for knowledge perception and reflection of their own ideas, and a higher competitive attitude. additionally, this gender variation in pbl scores could be due to a higher commitment of female students in attending different educational activities. however, ajai and imoko observed equal performance of male and female students in pbl sessions, and q recommended further studies to examine the underlining causes. validity and reliability of assessment should be established to ensure students' achievement of the learning objectives. the ability to solve any technical obstacle met during the online mock exam helped the e-assessment committee to manage the subsequent exams appropriately. results of the online assessments and their item analysis represented evidence-based high-quality evaluation. this perception was supported by jawaid et al. and bandele et al. who reported that students expressed a more positive attitude towards online exams. similar findings were also observed by martin et al. who emphasised that ideal assessment was based upon optimal evaluation strategies. the online tests were revised by the e-assessment committee, in coordination with the supervisors of the relevant departments, to estimate sufficient time for each exam. redistribution of students' grades towards more objective assessment strategies such as pbl, seminar presentations, and oral assessments was kept in consideration. this minimised the subjectivity of grading, as expressed in the feedback gained from the focus group, and discrepancy in students' grades, in agreement with ozden et al. . the procedures implemented during the online exams to minimise the chance of cheating and unauthorised collaboration with peers included scheduling of brief exams of not more than min with a timer set for the whole exam and also for each individual q question. formulation of a considerable number of scenario-based questions was implemented focusing on higher-order critical thinking, following the bloom's taxonomy. questions and answer choices were randomised; each question was presented on a separate page with forced completion of these questionsdstudents were not allowed to return to the previously-submitted questionsdin agreement with fontanillas et al. . a backup version of the questions with the same difficulty index was prepared for those students who experienced technical difficulties during submission. the answers were not displayed to the students until the examiner's permission was obtained and all participants had completed answering q . the potential use of teal in medical educationdthe future learning eradis expected after the resolution of the covid- pandemic. analysis of the benefits of e-learning in the present study could help the decision-makers of educational policies and committees of curriculum reform to implement them in the future. goh and sandars pointed out that the medical educators worldwide, being deeply involved in the current tremendous shift towards e-learning, have to adapt to the current major educational challenges. appropriate e-learning resources should be available to guarantee the implementation of these enormous changes. more use of technological tools will enable the medical schools to establish the active process of e-learning. the horizon report focused on 'learning engineering' such as the virtual reality simulators to facilitate the rapid development of teaching and learning. online courses form one of the key success factors to achieve the program learning outcomes of medical graduates. the current work explored the benefits of the shift towards e-learning and online assessment, which is a promising strategy with great educational potentials, after the who's declaration of the covid- pandemic. this successful digital learning environment was observed in terms of student and staff satisfaction, achievement, and improvement of technological educational skills. the present study recommends a sustained monitoring and updating of the e-learning resources, particularly the official lms, and availability of sufficient number of information technology personnel. multiple webinars and workshops suggested increasing the student and staff awareness of online teaching and assessment via q improving the current faculty development program. furthermore, the adoption of teaching through complete and partially online courses, and a total shift from physical attendance for pbl sessions to online ones are encouraged in the future. all data are available from the corresponding author upon reasonable request. researchers would like to thank the deanship of scientific research, qassim university for funding the publication of this project. the authors have no conflict of interest to declare. ethical approval was taken from the ethical committee of qassim university. written informed consents were obtained from all the participants. waa conceived and designed the study, conducted research, provided research materials, and collected and organised the data. ae and aes analysed and interpreted the data. all authors wrote the initial and final drafts of the article, and provided logistic support. all authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript. jtumed _proof ■ october ■ / covid- and medical education online learning 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student-led pbl tutorials the enactment of problem based approaches in pre-service mathematics and the levels of performance of teacher students in problem projects of teacher students in problem projects female students get more marks as compared to male students: a statistical study gender differences in mathematics achievement and retention scores: a case of problem-based learning method computer based assessment (cba): perception of residents at dow university of health sciences opinions of undergraduates on the use of electronic examination in a nigerian university award-winning faculty online teaching practices: course design, assessment and evaluation, and facilitation students' perceptions of online assessment: a case study taxonomy of educational objectives e-assessment process: giving a voice to online learners exploring the implementation of an electronic record into a maternity unit: a qualitative study using normalisation process theory the authors would like to acknowledge the college of medicine, qassim university for the generous facilitation of the required learning resources. key: cord- -de lbc authors: rosenberg, hananel; ophir, yaakov; billig, miriam title: omg, r u ok? [image: see text]: using social media to form therapeutic relationships with youth at risk date: - - journal: child youth serv rev doi: . /j.childyouth. . sha: doc_id: cord_uid: de lbc the rising of social media has opened new opportunities for forming therapeutic relationships with youth at risk who have little faith in institutionalized interventions. the goal of this study is to examine whether and how youth care workers utilize social media communications for reaching out to detached adolescents and providing them emotional support. qualitative in-depth interviews (n= ) were conducted with counselors, social workers, and clinical psychologists who work with youth at risk. a thematic analysis of the interviews revealed three principal psychosocial usages of social media: ( ) reaching out and maintaining reciprocal and meaningful therapeutic relationships with youth at risk over time; ( ) identifying risks and emotional distress; and ( ) “stepping in” and providing psychosocial assistance, when needed. these beneficial practices are made possible through the high accessibility and the sense of secured mediation that characterize social media communication and that complement the psychosocial needs of youth at risk. alongside these advantages, the analysis yielded several significant challenges in social media therapeutic relationships, including privacy dilemmas and blurring of authority and boundaries. given that social media communication is a relatively new phenomenon, the applied psychosocial practices are shaped through a process of trial and error, intuitive decisions, and peer learning. although the main conclusion from this study supports the notion that the advantages of social media therapeutic relationships with youth at risk outweigh their problematic aspects, future research is recommended to establish clear guidelines for youth caregivers who wish to integrate the new media in their daily psychosocial work. youth who are, or may be, at risk of physical, mental, or emotional harm suffer from a wide range of difficulties that endanger them and threaten their ability to function, currently or in the future. unfortunately, adult caregivers are not always aware of their children, patients, or students' emotional struggles and the at-risk youth often drift away from conventional supporting environments, such schools and youth movements. instead, they wander around unsupervised, seeking adventures and belongingness in alternative, and in some cases dangerous, settings (resnick & burt, ) . one of the principal challenges in supporting these detached youth is the very formation and maintenance of solid and trustful relationships. when confronting hardships, many adolescents at risk prefer not to turn to their parents or teachers for psychosocial support (grinstein-weiss, fishman & eisikovits, ) . however, in some cases they are willing to accept help from informal counselors and social workers (kaim & romi, ) . this informal help is crucial for their mental health because one of the key factors that can help at-risk youth successfully navigate their complex challenges is a rich and supportive environment and a strong relationship with a caring adult figure (gilat, ezer, & sagi, ) . remarkably, new opportunities for reaching out and supporting youth at risk have aroused with the outbreak of online social media. youth all over the world spend large amount of time online every day and perceive the various social networks technologies (e.g., instagram, whatsapp) as a most convenient channel of communication. in many cases they would even prefer text-based communication online over other forms of communication, including face-to-face (joshi, stubbe, li, & hilty, ) . recognizing these trends, some educators and school counselors have started to establish online connections with teenagers under their care in an attempt to offer them guidance and emotional support (asterhan & rosenberg, ) . however, in spite of these spontaneous initiatives, little is known about the extent and the ways in which caregivers utilize online communication for establishing positive and trustful relationships with youth at risk. the goal of the current study is to examine whether and how social media can be utilized for reaching out and providing emotional support to at-risk youth (adolescents and emerging adults). we hypothesized that youth caregivers would leverage the new media to overcome one of the main obstacles that characterize youth at risk. in many cases, these distressed adolescents disengage from institutionalized support systems, such as family, school, and youth movements and wonder around, searching for novel and distant spaces, away from their community. this allows them to achieve a sense of freedom and control but also places an obstacle in front of the adults who wish to contact and support them (kaim & romi, ) . in this study, we focus on youth caregivers who work with a unique population of youth at risk from small isolated settlements in the east border of israel, yet, the conclusions are relevant for similar rural areas around the world. like other youth at risk, they too, are at risk of substance use, problematic sexual behaviors, and school dropouts. however, they are also at risk for a unique identity crisis. in many cases, these youth rebel against their parents' religion and values. the ideological tension between the conservative small communities and the excitements and temptations that are evident in the 'big city' or in the mass media contributes to this rebellion and distance them from their families and community (shemesh, ) . these youth are also dispersed in a relatively large geographical space, with limited transportation options. youth workers in this geographical location may therefore tend to rely on non-formal communication methods, even more than in other urban communities. the current research aims to learn from the accumulating experience of these workers (psychologist, social workers, and counsellors) and provide a window to the benefits and limitations of social media therapeutic relationships between caregivers and youth at risk. the enormous popularity of social media among children and adolescents led many educators to start utilizing the various social networks for online communication with their students. this emerging trend raised multiple ethical and educational challenges, including concerns that the adult educational authority will keep deteriorating and that the privacy of both educators and students will be compromised. however, despite these concerns, some policymakers and educators have integrated the online communication in their daily educational practices (greenhow, robelia, & hughes, ; hershkovitz, abu elhija, & zedan, ; asterhan & rosenberg, ; . teachers use online communication for improving group and individual studying, extending learning time beyond school settings, and managing the logistics of their class activities. some teachers even extend their educational role to include the new media environment and took upon themselves to supervise and monitor online forums, identify signs of personal distress, and assist students in need. finally, some educators leverage the informality that characterizes the various social networks, to get acquainted with the social and cultural aspects of their students life and deepen their relationships with them (forkosh-baruch, hershkovitz, & ang, ; hershkovitz & forkosh-baruch, ; . online communication has been also leveraged by educators for delivering emotional support to their students. during the israel-gaza war for example, the majority of the teachers in the israeli cities that were exposed to war-related events provided support and empowered their students using non-formal communication methods, such as facebook and whatsapp. notably, most students valued their teachers outreach effort and reported that it contributed to their general sense of resilience (ophir, rosenberg, asterhan, & schwarz, ) . aside from benefiting from the concrete psychological aid online, it seems that the very existence of a continuous relationship online with a caring adult, had a significant contribution to the adolescent' sense of control and belonging (rosenberg, ophir, & asterhan, ) . these 'semi-therapeutic' communications join teachers efforts to detect signs of distress from their students' online activities and to provide them emotional support at normal times (i.e., not at wartime) (hershkovitz & forkosh-baruch, ; forkosh-baruch, hershkovitz, & ang, ; asterhan & rosenberg, ) . the therapeutic value of the very existence of online relationships has been examined in other, non-educational settings. for example, users suffering from depression who joined facebook support groups showed a significant improvement, especially when one of the "facebook friends" in the group was a psychiatrist (mota pereira, ). given that only very few patients in this particular study actually contacted the psychiatrist via facebook, it seems that simply knowing they had access to professional medical assistance contributed to their subjective well-being. this positive psychological experience can be explained by the authentic discourse that characterizes the instant and synchronous-textual communication in the new media (lapidot-lefler & barak, ) . the informal sharing of personal content and the removal of barriers such as embarrassment, especially among adolescents (bardi & brady, ) provide users with the opportunity to achieve emotional relief, which in some cases may even surpass the emotional benefit that is "allowed" in the traditional face-to-face communication (dolev-cohen & barak, ) . in fact, a dominant theme that emerged from a recent narrative analysis of anonymous online stories on suicide and self-harm behaviors, was 'overcoming silence and isolation'. according to the authors, the anonymous communication online enables young people who feel invisible and experience emotional distress to resist oppressive social norms and turn their emotional struggles into testimonies and stories worth telling (yeo, ) . correspondingly, qualitative interviews with young recipients (< year-old) of online outreach services reported that social medica and whatsapp communication enables them to speak freely about their emotional problems, even more than face-to-face interactions (chan & ngai, ). the unique advantage of online communication in creating a comfortable platform for emotional disclosure is well documented in the research on psychological counseling online (via email or video-chats). in fact, online counselling has gained much experience since the late s (mallen, vogel, rochlen, & day, ) and today many people use online platforms to overcome emotional distress and to improve their overall well-being (andersson et al., ; mota-pereira, ; richards & richardson, ) . indeed the specific research on social media counselling is scarce and one cannot assume that this new medium would share the same characteristics of the somewhat more formal communication through email or video-chat. however, as described above, social media communication may especially relevant to youth. in the following section we expand on the potential benefits and limitations of social media in the context of therapeutic relationships. on the one hand, using social media to improve the well-being of youth at risk seems most relevant. in contrast to adults, adolescents may be less cooperative with conventional therapeutic efforts and prefer tactics of avoidance and escape (kaim & romi, ) . in fact, a primary difficulty in working with at-risk youth is to bring them to the health service gate and therapists struggle in maintaining ongoing therapeutic relationships. adolescents are not always aware of the available mental health services and even when they are, they fear the negative stigma associated with seeking help, which will damage their "tough" image in the eyes of their peers (ben hur & giorno, ) . in the digital realm, however, adolescents can receive discreet psychological support (barak & dolev-cohen, ; dolev-cohen, & barak, ; valkenburg & peter, ), without fearing from real or imagined social sanctions (friedman & billig, ) . the online communication is usually voluntary (i.e., it is not being mandated by the adult) and the adolescent is prone to feel more comfortable and less shameful (ben hur & giorno, ) . on the other hand, despite the above-mentioned benefits, therapeutic interventions via social media have limitations and challenges, precisely due to the characteristics of online communication. first, the informality and the blurred boundaries that characterizes social media communication may undermine the caregiver authority and create a false presentation as if the relationships between the adolescent and the caregiver are symmetrical (asterhan & rosenberg, ) . therefore, computer-mediated relationship requires clear behavioral procedures to avoid deviation from an appropriate therapist-patient relationship (barak, klein, & proudfoot, ). second, the physical distance between the parties makes it difficult to establish a long-term commitment to treatment, or to provide immediate assistance in situations requiring physical access to the patient, such as cases of potential suicide (amichai-hamburger et al., ) . finally, the very notion that youth at risk will be open and responsive to social media based outreach efforts is yet to be studied. freshmen students for example, who published facebook posts that included explicit references to emotional distress, reported that they prefer being approached directly, in a face-to-face manner (whitehill et al., ) . indeed, the majority of these students were willing to accept help from their professors or teachers' assistants, but they also expressed their concerns that strangers would monitor their facebook activity, even if this is done with good intention (whitehill et al., ) . the complex picture that arises from the literature emphasizes the need for effective and safe training programs for mental health workers (barak, klein, & proudfoot, ). however, despite this growing need and despite the rising number of studies on teachers-students online communication, only little is known about the potential benefits and limitations of online treatments for at-risk youth. the goal of the current study is therefore to examine the characteristics of online therapeutic relationships between adolescents at risk and their caregivers (i.e., counselors and social workers). specifically, the study addresses three research questions: (a) how do youth workers utilize social media communication for creating and maintaining therapeutic relationships with at-risk adolescents (b) what are the potential therapeutic benefits of such communication and what distinguish it from traditional face-to-face relationships with at-risk youth? (c) what are the problems and challenges that arise from these online practices? altogether, by providing pioneering answers to these questions, we hope to promote the emerging interdisciplinary research filed of online counseling and contribute to the mental health of adolescents at risk around the world. a qualitative research design was applied due to the exploratory nature of this research (creswell, ). the study included in-depth interviews ( women and men) with youth caregivers who work in a range of facilities and programs for youth (table ) , including welfare departments and boarding schools in isolated settlements in the eastern border of israel. participants were recruited in several ways: by contacting welfare departments in the research area, using the snowball method with the help of personal acquaintances, and posting messages on social media to identify potential participants. after collecting the contact information of potential participants, a personal inquiry was sent to them, which included a description of the research topic and its objectives. from among those who agreed to participate, we made an effort to create a research group with as wide a range of faculty positions as possible. the interviewees were: youth counselors and coordinators (n = ), social workers (n = ), a clinical psychologist (n = ), a director of social welfare services (n = ), and a senior coordinator responsible for the training of faculty (n = ). for details of the interviewees, see the table in appendix . the age of the participants ranged from focusing on the perspective of the therapeutic professionals provides a broad perspective of the phenomenon, including therapeutic, institutional, and organizational aspects. data collection consisted of semi-structured in-depth interviews conducted with the purpose of exploring the personal perspectives and experience of the interviewees, through the presentation of their authentic voices regarding the phenomenon under investigation (moustakas, ; see also marwick & boyd, , on the use of interviews to reveal insights regarding new media functions in daily life). the interviews were conducted over the course of three months during , with each interview lasting between one and one-and-a-half hours. the interviews were mainly done in-person, with the exception of five interviews that were done over the phone. interviewees were asked a variety of questions about the content and characteristics of their online communication with at-risk youth, what considerations motivated them to choose social media as an aspect of treatment, and how they perceived the advantages and disadvantages of online communication in this context (for the full questionnaire, see appendix no. ). the interviews were recorded and transcribed. the data were analyzed with individual profiling and thematic analysis: first, we crafted profiles of each interviewee, which "allows us to present the participant in context, to clarify his or her intentions, and to convey a sense of process and time, all central components of qualitative analysis" (seidman, : ) ; second, we examined categories, patterns, and connections, trying to find a balance between within-case and cross-case analysis (king and horrocks, ) . the thematic analysis mostly involved an inductive approach (themes emerged from and were grounded in the data), although self-presentation was defined as a priori theme. third, the coded categories were conceptualized into broader themes. while innovative researchers are increasingly using electronic methods for coding data (mainly for the second and third stages mentioned above), due to the small size of the sample we preferred to stick to the traditional method of manual coding (see: basit, ) . following king and horrocks ( ) and neves et. al, ( ) , we preformed three steps procedures: first, the main and second authors read the transcripts independently to identify categories and themes. second, both authors coded together, using a label-coding scheme and tested for convergence. third, the coded categories were conceptualized into broader themes. finally, the third author sampled per cent of the transcripts to determine reliability of the category coding: the inter-rater reliability for category coding was per cent. the inter-rater reliability was calculated by counting discrepancies in category assignment between the coded transcripts of the two authors and the third author and by dividing them by the total category assignments throughout the research, we attempted to remember the gap between our experience as researchers in understanding the phenomenon being researched and we also aware that the qualitative researcher's feelings and emotions serve as an analytical tool, as well as constituting an integral part of our scientific work (allen, orbe, & olivas, ) . in order to improve the trustworthiness of the results we used strategy suggested by lincoln ( ), we invited three of the informant to read a review first draft of the findings analysis and conclusions, and some of their remarks are even integrated into this paper. this, in order to create a dialog wherein "the subjects of the theoretical statements become active partners in the developing process of verification of knowledge" (bauman, , p. ), in the course of conducting the research and writing the results and analysis, special attention was given to ethical considerations. all interviewees received a written explanation of the research aims, methods and ethics (considering anonymity and confidentiality). in order to ensure the privacy and anonymity of the interviewees as well as that of individuals mentioned in work-related stories that were told during the interviews, the names of the interviewees appearing in this article have been changed, while maintaining their gender and professional role. in some cases, technical and biographical details have been changed from the interview transcript (allmark et al., ). the research was approved by the ariel university irb. the primary impression that emerges from the analysis of the interviews is that therapeutic staff members view social media as an important and necessary tool in the treatment of at-risk youth. the social media platforms that used the staff was mainly facebook, instagram, and whatsapp. all of the participants reported that they see great advantages in integrating these platforms into their daily social work and therapeutic practices. some even defined this type of work as a "necessary skill." however, with the exception of several interviewees who work in a dedicated online setting (detailed below), the majority noted that because the use of this media channel for therapeutic purposes is new, their workplace does not have clear guidelines about it. as daniella, a social worker at a boarding school for at-risk youth said: "the staff doesn't have agreed-upon rules, each person does what he wants to and chooses to do." the therapists noted that they are given a "free hand" when it comes to online relationships. the issues that commonly arise are concerned with questions of privacy, authority, and boundaries (for more on these issues, see below). analysis of the interviews revealed four distinct purposes of online communication with alienated youth: (a) technical and organizational purposes; (b) familiarity and connection (c) monitoring potentially dangerous situations, and (d) therapeutic interventions. deepening contact with youth understanding the (online and interpersonal) youth culture defining the treatment time the technical and organizational aspect is particularly seen in the use of whatsapp groups among the therapeutic staff, as well as whatsapp groups that include both professionals and the youth they are treating. eleven interviewees mention that the whatsapp serves as an easy and highly accessible platform for messaging, updating, and scheduling meetings. the diverse functions of whatsapp, such as the ability to create groups and mailing lists, and to switch between interpersonal and group communication, allow for increased control and management. for example, the ability to easily send information and updates to a large number of people frees up valuable time for professionals to engage in educational and therapeutic work. two of the youth care workers noted the feature of whatsapp that allows them to see whether the recipient has read the message (this is a default setting in the application). the feature has become an integral part of their decision-making process about whether it is worth investing additional efforts in an outreach project aimed at recruiting as many youth as possible. a core theme that arose from all of the interviews is the use of social media for purposes of integration, deepening familiarity, and establishing therapeutic relationships with the youth. analysis of the interviews revealed three types of potential therapeutic benefits of social media communication with youth at risk. moreover, young people understand that the ability to use the distinctive language of the internet, for example emojis and new phrases and terms, enables a conversation on equal terms, allowing them to express their feelings in their own language. this creates closeness and opportunities to build trust in their relationships. "i identify a kid who has an easier time expressing himself through messaging. it gives him the time and space to read my message and get back to me when its comfortable for him. it's especially helpful to me especially in the early 'courting' stage of the relationship," (uri, social worker at a non-residential regional center for at-risk youth). one interviewee noted a gender difference when it comes to social media communication: "with boys, let's say, i see that it's easier to communicate with them through whatsapp than in person. for girls, it seems to me the opposite, because they are more verbal. for example, we had a male teen who had a really hard time communicating, but it was easier to talk to him through whatsapp," (ella, coordinator at a youth outreach program). when we asked the interviewees what exactly is on social media that allows the connection they describe, they highlighted specific features and characteristics of social media, such as the availability, accessibility, and computer-mediation of the text that help deepen the relationship and create an open and honest conversation. "there is something about messaging. hiding behind the message allows you to feel comfortable and open, without facial expressions that convey judgment" (leah, media coordinator at the department for youth development). another interviewee mentioned a phenomenon he commonly encounters, a situation in which there is no way to contact the youth, for technical reasons: "i have encountered situations in which youth have a problem with their cellphones, usually because they don't have money to pay for the service, so they turn off their phones, and whatsapp is the only way i have to communicate with them," (david, social worker at a boarding school for at-risk youth). these descriptions recall the quote from uri, about the way online communication helps in the early stages of the relationship. in contrast to classic psychological treatment, therapeutic professionals working with at-risk youth take an approach of gradually getting to know each patient. the characteristics of online communication facilitates this practice and help overcome barriers that may impede success. (b) maintaining relationships. social media enables staff members to keep in touch with youth whom they've worked with in the past. facebook and instagram, in particular, allow them follow the activities, personal lives, and achievements of 'alumni' months and even years after they stop communicating through the more intensive media outlets such as whatsapp groups that were actively used as part of the treatment frameworks. at the same time, three interviewees noted that the whatsapp groups they shared with the youth remained active for years after the formal treatment framework ended. "the group is still active from time to time. i find it moving that they make sure to send happy birthday notes when one of the youth or counselors has a birthday... it's nice to see that they care about each other and that they take a minute or two to send each other birthday wishes," (roni, social worker in the department of youth development). the importance of this connection is twofold. on the part of the staff members, whatsapp allows them to 'stay in touch,' but they indicated that it goes beyond that. they said that being able to follow how alumni are integrating into ordinary life allows them to receive feedback, which one interviewee described as "getting closure." seeing the results, the outcomes, helps reinforce their belief in the challenging work that they do. from the perspective of the youth, the online forum can serve as a mutual support network, and even as a possible opening for them to seek out advice and assistance as they navigate their paths: "[the whatsapp group] helps them keep in touch with the most meaningful group in their lives, that is, the people they were with when they went through a hard time at the very important age of or . we see that even four years later, they'll arrange to meet up, and they share a common language that stays very much alive. it's mainly social, but it can certainly be a platform for therapeutic work like monitoring or ongoing assistance or referrals for help. recently, a lot of the youth who finished [our program] had no framework to be in, and we found jobs for them, we were able to help them," (nurit, director of social welfare division for youth development). (c) understanding the (online and interpersonal) youth culture. the therapeutic staff's online presence helps them to get to know the personal world of the youth, bridging the gap between the adults (the therapeutic professionals) and the young people. six interviewees that highlighted this theme, refer to two levels of acquaintance. this further familiarity with the youth is particular to the online sphere. caregivers see their presence on social media as a way to better understand the online forums and to identify risks, such as bullying and inappropriate discourse. sometimes they can even offer guidance in this new type of social space. social media offers a convenient platform for youth to share emotions and express their thoughts, feelings, and frustrations. therefore, in addition to providing a forum for strengthening connections and becoming familiar with each other, the presence of therapy professionals in online forums has valuable potential for identifying signs of distress prevalent among at-risk youth. interestingly, this theme was raised by all of the interviewees, citing numerous situations in which signs of distress were first exposed online. there was one girl who always posted questions about sexual harassment. it was very worrying. after each such post, i would send her a private message: 'hi, i read your post. i would love to help you.' it was a gentle kind of outreach, because she was already big, years old, which is a stage when they tend to want to share less, when there's a desire for independence. after a few times, she suddenly answered and we developed a connection, and it really helped. (nurit, director of social welfare division for youth development). online communication venues seem to allow youth who are experiencing distress to express their feelings with greater ease, as compared to face-to-face meetings. the interviewees described a wide variety of online posts that drew their attention to the distress of those who wrote them, whether the post was about the pain of a breaking up with a boyfriend or girlfriend, or a crisis with their parents, a depressive episode, social isolation, or even suicidal thoughts. there was a post in which someone expressed signs of distress. naturally, we showed it the social worker, and a tragedy was avoided. the girl wanted to commit suicide, she wrote all kinds of things like "i want to die," "i hate my life." because of facebook, we were able to save her. (ariella, coordinator at a youth outreach program). use of social media is relevant to therapeutic professionals tasked with identifying and reaching out to marginalized youth. in the digital age, this type of work has expanded from the traditional "street search" to a new practice of online searches. indeed, some welfare departments have established media departments and teams that seek to leverage online forums and social media as tools for identifying distress, as means for outreach to at-risk youth, and even to help by providing an initial response, as described in this quote: the orly, who works in the media department of a youth development program, emphasizes the potential of this tool to reach youth who typically avoid exposing their distress or actively seeking mental health support. we can identify situations of distress on social media by spreading posts that reach young people and invite them to contact us. it's there that we see the ones whose pain is more internalized, who don't necessarily look like the ones out in the streets. we're also often approached with questions about sexual identity, which means we are expanding our target audience. using social media to meet the needs of youth and provide them with emotional support was also noted by the most of the interviewees -about in number. "online media helps us locate the youth. there are situations in which we were able to achieve deep therapeutic discourse solely through online correspondence... [the internet] provides us with a vast therapeutic space." (leah, media coordinator, department of youth development). however, it is important to note that while there was considerable consensus among the interviewed professionals regarding the potential uses of online communication described above (technical and organizational purposes, making connections, and monitoring distress), the situation was different regarding its use in therapeutic interventions. even those who to some extent supported such practices presented ambivalent positions, or at least qualified their statements. when leah (quoted above) was asked to give an example of online therapy, she noted a practice that enables youth to sit in the same physical space as caregivers, but chat with them online: choosing to conduct therapy sessions through the chat feature is comfortable for the youth. they feel more secure and more open to talking. meaning, we can actually meet with someone and sit in the same room but still be communicating through the chat. the main thing is to give them the feeling that they are safe and can trust us, and that we are here to help in any way that's comfortable for them, at least in the beginning," of the interviewees strongly emphasize that providing treatment online is a topic of debate among professionals in the field. one of them mentioned a heated discussion among the professional team about whether the word "therapy" should be used to refer to online communication, or whether it is merely a "supportive aid" for therapy. leah stated that she sees an online chat as a first step in the therapeutic process, but not as a practice that can stand on its own. similarly, other interviewees said they did not consider it a replacement for traditional in-person therapy. the in discussions with the interviewees about their actual work in the field, we found almost complete consensus in favor of using online communication as part of their therapeutic work. however, deeper investigation into the issue indicates that they decided to use it both because of its benefits and despite its limitations. most of the interviewees ( of ) noted dilemmas and debates leading up to the decision to adopt online forums as part of their work and some grappled with these questions even while they use online communication. these dilemmas revolve mainly around two issues: the need to protect the privacy of caregivers and patients, and the difficulty of delineating the treatment time. privacy of therapists and youth. some characteristics of social media include personal exposure and sharing by its users. this is the key to its therapeutic potential, and also presents one of the main challenges facing therapists. disclosing caregivers' personal profiles to the youth they treat is seen as problematic. "my facebook page includes family-related things. i don't know if they need to know everything," (samuel, social worker at a youth support center). this concern also relates to the professionals' opinions on current events: "i write a lot about politics on facebook. often, i didn't feel it was right for them to be so aware of my opinions," (david, social worker at a boarding school for at-risk youth). the privacy dilemma also touches on the need to respect the privacy of the youth being treated. monitoring youth online has ethical as well as therapeutic implications. "keeping track of them and being exposed to the things they do is sometimes problematic, because it is an invasion of their privacy. we use it, but are very careful. most of them have trust issues, so i don't want them to think i've been following them [online] all day," (julia, social worker and therapist at a youth development program). various aspects of the privacy dilemma were mentioned multiple times by the interviewees. on the one hand, they expressed a desire to initiate discussions with youth about issues to which the therapist was exposed while viewing their posts on social media. on the other hand, they worry that raising issues the youth did not choose to share directly with the therapist could cause them to avoid treatment, or cause a crisis of trust. the significant therapeutic potential that is inherent in information the therapist sees online must be considered alongside the invasion of the youths' privacy and the danger of violating the therapeutic contract. most of the interviewees said they strive to find the proper balance. on the issue of the online statuses to which we are exposed, there is a lot of information that can help us catch problems in time, such as suicide. we had a girl who showed all kinds of warning signs that she was suicidal, and we prevented it. this can be confusing, but also helpful. it is a question of whether to invade their privacy and whether they want us to do that, while the post is also be a call for help. it's between invasion of privacy and offering help. as we catch up with the gaps in technology advancement, we have to think about how to use online media as an essential tool. (leah, coordinator in the department for youth development) defining the treatment time. another potential disadvantage of using social media that bothered the interviewed professionals pertains to the question of defining the therapeutic setting. the accessibility and ease of sending messages makes it possible for youth to contact therapists beyond working hours, at night or on weekends and holidays. there is a disadvantage in the sense that, for example, they might send messages really late at night. it's more difficult to set limits online, so you need to define the treatment time. i had a case with a girl who asked me 'why were you up at in the morning?' because she saw on whatsapp that i was online. you have to understand that they are on their phones all the time, and they see and pay attention to everything. this has many benefits for adolescents, but you also have to pay it is important to note that the interviewees who mentioned the difficulty in limiting the treatment time were not only relating to their personal experience of how their online presence required them to be available to the youth in their free time; the undefined time also potentially harms the youth. being friends on facebook and instagram with the youth may allow them to deepen and improve their relationship, but it also raises questions about authority and how the relationship is perceived. there is a concern that the caregiver-patient or mentor-mentee relationship will be transformed, in the youth's perspective, into a relationship similar to their other social relationships. this concern is heightened in the case of online contact between therapists and patients of the opposite sex ("if, with boys, i deliberate a few times, with girls i am a million times more cautious," omer, clinical psychologist at a youth development program). in addressing this issue, four interviewees noted that defining the times during which they can be in contact conveys an important therapeutic message and improves patients' ability to accept delayed gratification (despite their potential availability). this skill can be beneficial to the youth in many areas of life. before i told them until what time i'm available, there were situations when i would receive notifications at night as well. i had to make a separation between work and my personal life. it's mostly for myself, but it's also good for the youth, who know i am there for them, but not constantly. this parallels reality, in that they learn that not everything is always accessible to them, and that it may not be possible to help them as soon as they want it, and it's from an empathic place, so they can understand what it's like out there in the world. (julia, social worker and caregiver at a youth development program) one of the interviewers emphasized that when defining their working hours with the youth, they clarified that these limits can be extended in urgent cases: "for example, i specify that i will answer until p.m., and after that only if it is an emergency" (yifat, a coordinator at the department of youth development,). similarly, the very discussion with the youth about what is and is not considered an emergency also serves as a therapeutic opportunity: i had a case a few months ago of a boy calling me at p.m. i sent him a message asking if it was urgent. it turned out that his bike had been stolen, and he was very worried about how his father would respond to the theft (...). that is why i think there are gray areas, and a need for shared thinking about everything. (leah, media coordinator at the department for youth development). another work-related challenge concerns the nature of communication through text messaging. interviewees gave examples of text messages that could be interpreted as more social and intimate than was their original intent. added to this is the fact that such messages sent outside of working hours can diminish the status of the therapist as an authority figure and thus detract from the effectiveness of treatment: "the problem is that it turns into something social, and i am not sure i want to give the relationship that connotation," (menachem, senior coordinator at a youth development program). it emerged that questions related to defining the treatment time are a significant concern to the therapeutic professionals. they repeatedly emphasized that because of the novelty of using online forums, they have no regular use pattern and no definitive answers. the interviewees reiterated that they lack formal guidelines from their workplace about providing treatment to youth online. ("in terms of any general definition or expectation for employees -there is nothing. everyone decides on individual basis," julia, social worker and caregiver at a youth development program.) it is evident that they are eager to receive training on how to effectively and appropriately communicate with youth via social media. instead, their online work activity is characterized by trial-and-error, intuitive decisions, retrospective considerations, and sharing their deliberations with their colleagues. "basically, we are still discovering all the problems and advantages of this tool," (leah). several interviewees mentioned the need to guide the youth regarding proper online communication with therapy professionals as well as a need to develop professional training for therapeutic staff who wish to work (also) through online technologies. this sentiment is summarized by yifat, a coordinator in the department for youth development: there is no doubt that today's technological world is evolving and it is not really under our control. the youth are there, and so we must show our presence there as well. i think, and see, that there are many young people who can only be contacted through online networks. despite the disadvantages communicating through screens, this is the situation, and it should be channeled towards good things. through online networks, trust is also created. there is something very powerful about entering their world and about its ways of reaching them and treating them. even if the relationship ends without them getting frontal treatment, i have been in situations where the communication helped and supported young people who were in distress. the growing popularity of social media raised new opportunities for reaching out and supporting youth at risk. using in-depth interviews with youth counselors and social workers, this study examined the characteristics of online therapeutic relationships between adolescents at risk and their caregivers. the interviews revealed that counselors and social workers generally hold a positive view towards online therapeutic relationships. they acknowledge the benefits of this new type of communication and recount its therapeutic successes. according to the interviewees, social media based communication contributes to maintaining a reciprocal, meaningful, and long-term contact with the at-risk youth under their care. the qualitative analysis of the interviews reveals that online communication can facilitate and even improve the quality of the therapeutic relationship with at risk youth in three key areas: ( ) forming a trustful and positive relationship with detached youth and maintaining it over time; ( ) detecting early signs of dangers and distress; and ( ) providing psychosocial counseling when needed. yet, the clinical picture is more complicated than these noted advantages. the interviewees expressed several concerns regarding the integration of new technologies into the traditional therapeutic practice and some even opposed to use of the word "therapy" in the context of online communication with at-risk youth. the ambivalence regarding the use of new media as a legitimate therapeutic tool might derive from the fact that counselors and social workers usually rely on well-defined, theory-driven therapeutic approaches (e.g., cognitive behavior therapy, psychodynamic therapy). these approaches determine the specific settings that are required for a successful treatment and layout the specific therapeutic strategies that should be applied to achieve beneficial outcomes. nevertheless, it seems that, regardless of their theoretical background, all the interviewees acknowledged the importance of maintaining a continuous relationship with at-risk youth through online communication. this main theme can be understood through the prism of "common factors" in psychotherapy (castonguay, ) . even though different therapeutic approaches incorporate different set of values and practices, they also share common factors that contribute to the successful outcome of the treatment. for example, simply the beginning of a treatment may arouse patient's expectations for symptom relief, which in turn inspire hope and motivation to change (arnkoff, glass, & shapiro, ) . and above all, all approaches highlight the therapeutic alliance as an essential condition for treatment (pilecki, thoma, & mckay, ) . the quality of the relationship between patients and therapists is one of most researched therapeutic component, which has been proven to significantly contribute to outcomes of treatments, independent of the specific type of the examined therapy (norcross & wampold, ) . based on this perspective, it is understood why all the interviewees cherished the online communication. regardless of their guiding approach, they all assume that a positive and trustful therapeutic alliance is a crucial factor in the treatment of at-risk youth. some might even argue that the very relationship between the therapist and the adolescent is the therapy. however, forming a solid therapeutic relationship with at-risk youth is not an easy task. youth at risk are not always inclined to cooperate with conventional therapeutic efforts and may prefer tactics of avoidance and escape (kaim & romi, ) . many of them fear the negative stigma associated with seeking help and are worried that cooperating with the "adult system", will damage their image in the eyes of their peers (ben hur & giorno, ) . these characteristics may explain why the new media attracted both the adolescents and the counselors and social workers. apparently, some of the problematic aspects of online communication, such as the anonymity and the avoidance of direct face-to-face communication, are the very reasons that this form of communication "speaks" to adolescents at-risk. the (partial) anonymity encourages youth to share their inner feelings openly and helps them to overcome the psychosocial barriers mentioned above. it allows them to receive discreet psychosocial support (barak & dolev-cohen, ; dolev-cohen, & barak, ; valkenburg & peter, ), without fearing from real or imagined social sanctions (friedman & billig, ) . some scholars even argue that this type of communication encourages the users to be honest and to express their "true selves" (lapidot, lefler, & barak, ) . moreover, in the digital realm, the adolescent may feel less pressure to participate in the conversation. without the pressure, she/he may feel more comfortable and less shameful (ben hur & giorno, ) . he or she can choose to contact the therapist through textual communication, which in many cases, is perceived as a more convenient and protected channel of communication in which they can express their feelings and thoughts in their own language (barak, klein, & proudfoot, ). indeed, this form of communication requires therapists to let go of some of their rules and theoretical beliefs. yet, it seems that the interviewees agreed that the benefit of online therapeutic relationships with at-risk youth outweighs its potential damage. aside from the potential benefits for the relationship itself, interviewees emphasized the new opportunities that aroused with regard to early detection of dangers and distresses. early detection of distress can prevent worsening of the patient's emotional state and mitigate his or her emotional burden (halfin, ) . this is especially relevant to youth, as many adolescents do not share their negative experiences, such as victimization of bullying or suicidal thoughts, with their adult caregivers (rey & bird, ; velting et al., ) . this finding corresponds with the emerging line of research according to which mental health conditions can be traced from social media activities (for a review see: guntuku, yaden, kern, ungar, & eichstaedt, ) . although most of this research is focused on adults, promising results were also evidenced among adolescent populations (ophir, asterhan, & schwarz, ) . the current study joins these new studies and suggest that social media has become an important source of psychosocial information about atrisk adolescents, offering a rare glimpse into their troubles and pain (ophir, ; ophir, asterhan, & schwarz, ) . finally, the interviewees highlighted the opportunity to provide counseling from a far. despite some reservations from online treatments, there is ample evidence that online counseling has a significant impact on patients, which in many cases is comparable to that of face-to-face counseling (andersson, ; mallen et al., ) . studies showed for example that computerbased treatments are effective for both depressed (kessler et al., ) and anxious patients (barak, hen, boniel-nissim, & shapira, ) . the findings from the current study confirm previous research that claimed that online counseling increases accessibility to treatment (mallen et al., ) . social media seem to increase the accessibility to youth who live in remote geographical areas and to youth who chose to distant themselves from their family and community. the therapeutic relationships that are formed online are especially relevant to these complicated times of social distancing due to the covid- . moreover, aside from overcoming geographic limitations, social media seem to provide the adolescents subjective feelings of ease and comfort. these feelings correspond with a well-acknowledged advantage of online counseling, in which clients may feel less threatened in their natural surroundings and allow themselves to be more exposed with their therapists (gilat, ezer, & sagi, ) . these two factors, accessibility and comfortableness, can be critical when working with at-risk youth who tend to engage in defiant or rebellious behaviors. despite these advantages, online counseling suffers from several principle drawbacks: first, it reduces the ability of patients and therapist to interpret nonverbal communication signs and messages are sometime ambiguous (barak, hen, boniel-nissim, & shapira, ; suler, ) . second, it might diminish the caregiver's ability to provide empathy and warmth. third, it may feel less binding for some patients could easily dropout from the treatment (amichai-hamburger, et al., ) . fourth, it raises practical and ethical dilemmas, especially when the therapeutic relationship is form via social media (rather than video-chats, such as zoom or skype). therapists and counselors may ask themselves: what distinguishes me from other "facebook friends"? should adolescents be exposed to my personal photographs? and will they expect me to be available to them online at all times? these dilemmas are not unique to youth care workers. previous literature that addressed teacher-students online relationships raised similar concerns. although many teachers acknowledge the benefits of social media communication, they are also worried that it will undermine their authority in the eyes of their students (asterhan & rosenberg, ) . even those teachers who used social media to communicate with their students, were concerned about privacy boundaries and were worried that their relationships with the students will become too personal. like teacher, youth caregivers, as shown in this study, are not naïve. they are well aware of the potential pitfalls of social media interactions. despite the inherent informality that characterizes their work with at-risk youth, they do not see their relationships with youth at risk as symmetrical relationships. a primary challenge in this context is the need to understand and define the physical and emotional boundaries between them and their patients (friedman & billig, ; haenfler, ; nagata, ) . several interviewees noted difficulties in defining such boundaries, including the therapeutic space, the duration of the treatment, the availability of the therapist, and the privacy of both patients and caregivers. thus, future training programs should consider intrinsic characteristics of computer-mediated communication, such as the blurred boundaries and its relatively democratic and egalitarian nature (e.g., asterhan & eisenmann, ; hampel, ; weasenforth, biesenbach-lucas, & meloni, ) . without minimizing these concerns, the main conclusion from this study is that youth care workers are well aware of these challenges and yet they all agree that these challenges should not stop them from leveraging the new media for psychosocial purposes. they make considerable efforts to navigate these challenges by clearly defining the online practices that could contribute to the therapeutic process and avoiding or minimizing the ones that could disrupt it. however, they still lack appropriate training and usually work their way to the at-risk youth through trial-anderror. the current study has limitations. the first limitation concerns the fact that we only interviewed adult caregivers and the youth perspective is missing. moreover, the caregivers might have different perspectives and attitudes towards technology-based communications, due to generational difference (zhitomirsky-geffet & blau, ) . in israel most professional caregivers only start their practice in their late twenties. most of the interviewees in this study therefore belonged to generation y (aged - ). they are still considered very technology oriented (compared with previous generations) but they might have more complex attitudes towards internet-based communication, compared with the youth at risk (who belong to generation z and received their first smartphones as children). these differences in attitudes towards technology may have an impact on the online therapeutic relationship. yet, we note that all interviewees emphasized the importance of integrating online communication in their work and declared that digital literacy is a required skill when working with youth. a second limitation concerns the location of the study. two specific contexts may limit the generalizability of the findings: the country (israel) and the socio-geographic location (east border). therapists in israel may differ from therapists in other countries (e.g., in israel, therapists are allowed to provide online counseling, without formal training in this field) and youth in the east border may have different challenges than youth in other places (e.g., ideological crisis that reflects the tension between their conservative upbringing and their new identity). we therefore recommend that further research and future training programs would consider cultural differences. a third limitation concerns the fact that the study is based on qualitative interpretations of interviews with counselors and social workers. the exploratory nature of the study calls for future works that will build upon the current findings and establish the benefits of social media therapeutic interactions. further studies are recommended to quantify these potential benefits and explore their reliability overtime and in additional contexts. studies should also examine the perspectives of the youth themselves and compare them with those of their caregivers. there is also a need to examine potential confounding factors that might impact the online therapeutic relationships, such as gender differences (noguti, singh, & waller, ) , generational differences (hargittai, ) , cultural contexts (mesch & talmud, ) , and religious contexts (rosenberg, blondheim, & katz, ) . these factors might affect the very legitimacy of the online relationship. it is recommended that the current findings will be further examined thorough a quantitative and wide-ranging research. despite these limitations, the current study suggests that the new communication technologies are bringing viable and exciting opportunities to the field of youth at risk. most interviewees believe that online therapeutic relationships are beneficial for at risk youth as they help to maintain a trustful relationship with detached youth and provide a platform for early detection of distress and for delivering psychosocial counseling. yet, as noted above, the clinical picture is more complicated than these advantages. thus, it is advisable to provide special training to youth caregivers to help them bridge the gap between traditional and online practices and help them provide an effective treatment to at-risk youth online. is online communication discussed with you at work? are there certain procedures or guidelines set by the council with regard to social networks? have you undergone training on this topic? what do you do with this information? . do you have joint whatsapp groups with the youths? do you have one group for all of them? what is the role of the group? what do you do there? what interaction takes place there? what are the advantages and disadvantages of these whatsapp groups? ethical issues in the use of in-depth interviews: literature review and discussion the future of online therapy internet-delivered psychological treatments expectations and preferences the promise, reality and dilemmas of secondary school teacher-student interactions in facebook: the teacher perspective does activity level in online support groups for distressed adolescents determine emotional relief a comprehensive review and a meta-analysis of the effectiveness of internet-based psychotherapeutic interventions defining internet-supported therapeutic interventions why shy people use instant messaging: loneliness and other motives manual or electronic? the role of coding in qualitative data analysis narrowing the adolescent service gap: counseling and mental support for adolescents on the internet -yelem as a representative case common factors" and "nonspecific variables": clarification of the two concepts and recommendations for research research design. qualitative, quantitative, and mixed methods approaches adolescents' use of instant messaging as a means of emotional relief teacher-student relationship and snsmediated communication: perceptions of both role-players education, socialization and community: coping with marginal youth in rural frontier communities in israel seeking help among adolescents: their attitudes toward online and traditional sources detecting depression and mental illness on social media: an integrative review learning, teaching, and scholarship in a digital age: web . and classroom research: what path should we take now? educational researcher gender and ethnic differences in formal and informal 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facebook enhances antidepressant pharmacotherapy effects phenomenological research method beyond theology: toward anthropology of "fundamentalism the 'non-aligned' young people's narratives of rejection of social networking sites gender differences in motivations to use social networking sites evidence-based therapy relationships: research conclusions and clinical practices sos on sns: adolescent distress on social network sites unfolding the notes from the walls: adolescents' depression manifestations on facebook the digital footprints of adolescent depression, social rejection and victimization of bullying on facebook in times of war, adolescents do not fall silent: teacher-student social network communication in wartime cognitive behavioral and psychodynamic therapies: points of intersection and divergence sex differences in suicidal behaviour of referred adolescents youth at risk: definition and implication for service delivery whatsapp, teacher?": student perspectives on teacherstudent whatsapp interactions in secondary schools it's the text, stupid! mobile phones, religious communities, and the silent threat of text messages a virtual safe zone: teachers supporting teenage student resilience through social media in times of war. teaching and teacher education techniques to identify themes image, word, action: interpersonal dynamics in a photo-sharing community social consequences of the internet for adolescents: a decade of research. current directions in psychological science parentvictim agreement in adolescent suicide research cross-generational analysis of predictive factors of addictive behavior in smartphone usage characterization of youths with whom he works: what is the youths' background? what is the number of youths; their age range, place of residence; characterization of youths according to the family they came from; in which frameworks did they spend time in the past; do they have a delinquent background; did they undergo molestation as children or another form of victimization. are they in a formal framework, or not? if not, what do they do in their free time? to what extent do the youths reveal their personal lives to you? are they cooperative? what types of problems do you encounter when working with them? are the youths in contact with their families? if so, in what way is this contact expressed? what is the frequency of the youths' contact with their families, do they feel respect towards them or hatred and anger? what types of problems do the youths that you encounter generally suffer from? (e.g., personal problems, family, social, certain extreme behavior.) focus on drugs, crime, behavioral disorders -bullying, attention disorders, depression and anxiety -have they been hospitalized or expressed suicidal tendencies?section b -working with the youths and online communication the nature of the work and dynamics of the connection between the youth and the social workers? where do you actually meet them? are they obliged to attend some of the meetings and what do you do if they fail to come? what are the most common modes of treatment? to what extent are you exposed to what youth at risk do on social networks? what characterizes this use? what applications do they like in particular? what do they reveal on the network? (network advantages and disadvantages for the youth) to what extent are you involved in the youths' social network world and in what ways? (e.g., follow them on instagram, friends on facebook, etc.?) where you work, is it legitimate to communicate with youths via the networks or even make contact with them? (e.g., whatsapp groups or facebook friendship requests? if so -for what purposes? do you learn more about their world thanks to the network? do you use it as a tool for making personal contact with them? are you active on the social media networks, and how much do you know about using these networks for your personal needs?  counselors and social workers hold a positive view towards online therapeutic relationships  social media improve the therapeutic staff's capabilities  positive practices related to distinctive features of online communication channels  significant challenges included dilemmas regarding privacy, authority and boundaries key: cord- -xlyi cnl authors: radic, aleksandar; ariza-montes, antonio; hernández-perlines, felipe; giorgi, gabriele title: connected at sea: the influence of the internet and online communication on the well-being and life satisfaction of cruise ship employees date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: xlyi cnl this study aims to elucidate the idiosyncratic effects of the internet and online communication on the well-being and life satisfaction of cruise ship employees. cross-sectional surveys and covariance-based structural equation modelling tools were used. in addition, univariate variance analysis was used to address the effects of socio-demographic variables (years of service on a cruise ship, working department on a cruise ship, gender, age, educational level and place of residency) on latent variables of the conceptual model. the conceptual model draws on existing theory and previous research and was empirically tested on a sample of cruise ship employee internet users. result show that while being onboard a cruise ship, employees experience strong social pressure to be constantly available and they fear of missing out on important information and life events. thus, relatedness to friends and family needs satisfaction is of paramount importance for cruise ship employees because they are fully aware that they are dispensable and replaceable to cruise ship companies, however to their friends and family, they are indispensable and unique. moreover, employees who engage in other tasks/activities while taking part in online communication with friends and family exhibit reduced performance, which leads to poor interaction and social dissatisfaction. lastly, employees experiencing under-reciprocating exchanges show significant negative effects on their well-being. overall, the results provided several important theoretical and practical implications relevant to cruise tourism and human resource management. cruise tourism growth for predicted by [ ] will not be achieved due to the recent cruise tourism crisis caused by the covid pandemic. on march , all cruise lines suspended their cruise operations for at least days [ ] . however, none of the cruise companies have filed for bankruptcy or cancelled their new builds. therefore, the prediction of the addition of , new crew members and officers each year until remains an achievable possibility [ ] . a recent study by [ ] revealed that cruise ship employees are exposed to long working hours and detachment from friends and family, which leads to poor social interactions and feelings of loneliness. however, advances in information and communication technologies have led to their widespread and increased usage by employees. internet access has become a basic necessity, a more essential element of their mundane ship life with paramount importance on their well-being and life satisfaction. enhanced connectivity is instrumental for bolstering morale and reinforcing job satisfaction, which ultimately strengthens the capability for communication between employees and their significant others back home and hence, reduces the feeling of loneliness [ ] . moreover, maritime labour convention [ ] recommended rational access to the internet with reasonable charges for services. from november to february , only a handful of cruise companies (disney cruise line, holland america, azamara, and princess cruises) have provided free-of-charge specialized cross-platform messaging internet applications for their employees. interestingly, the seafarers happiness index, which covers aspects of job quality, including mental and physical health and relationships at home and onboard, showed significant increases in happiness for cruise ship employees from . to out of [ , ] . given the unique work and life conditions on cruise ships, whereby employees are set apart from their loved ones [ ] , free internet access should be a universal entitlement [ ] because of its ability to enhance seafarer morale, engagement, well-being and life satisfaction [ ] . although significant amounts of research have been done on the positive effects of internet and online communication on social pressure [ ] , fear of missing out [ ] , relatedness to friends and family need satisfaction [ ] , perceived social support [ ] , well-being [ ] and life satisfaction [ ] , these effects were never studied in the peculiar environment of a cruise ship where life and work contexts are so intertwined such that the distinction between one and the other is blurred [ ] . this study aimed to elucidate the idiosyncratic effects of the internet and online communication on the well-being and life satisfaction of cruise ship employees. we reviewed existing theory and previous studies on the effects of the internet and online communication on social pressure, fear of missing out, internet multitasking and relatedness to friends and family need satisfaction. we investigated the influence of social pressure and fear of missing out on relatedness to friends and family need satisfaction and internet multitasking. finally, we proposed relatedness to friends and family need satisfaction and internet multitasking as possible catalyst influencers of perceived social support which, in the end, are the impetus towards the well-being and life satisfaction of employees. the conceptual model draws on existing theory and previous research and was empirically tested on a sample of employee internet users. finally, we addressed the effects of socio-demographic variables (years of service on a cruise ship, working department on a cruise ship, gender, age, educational level and place of residency) on latent variables of the conceptual model. this study is exploratory in nature and presents work addressing a major research gap, given that the effects of internet and online communication on the well-being and life satisfaction of cruise ship employees have never been empirically tested. the results of this study will contribute towards the further development of cruise tourism theory and strengthen existing theories, such as theory of belongingness [ ] , self-determination theory [ ] , uses and gratification theory [ ] , conservation of resources theory [ ] and the paradigm of positive psychology [ ] . while working and living on cruise ships, employees are detached from their family and friends [ ] . primary communication instruments include internet and online communications [ ] , which play significant roles in integrating work and family domains [ ] . these communication instruments provide social capital, information and wider perspectives [ ] . in recent survey conduct by [ ] , the authors concluded that onboard crew members experience strong social pressure for being constantly available to their family and friends. today, almost every cruise ship employee has a mobile device [ ] . although mobile devices allow users to be constantly available, they also create an environment that increases social pressure [ ] . moreover, the social pressure to be constantly available is strongly related to communication load [ ] , with a suppressing effect on well-being via social overload [ ] . based on the social norm of reciprocity in friendship and family ties, psychological tensions and social pressures may arise [ ] . thus, based on the literature review and empirical findings, the following hypothesis is proposed: there is a positive relationship between the internet and online communication and social pressure. in their theory of belongingness, baumeister et al. [ ] argue how human beings have an irresistible need to be a part of a group. the hardest part for cruise ship employees is being away from home and missing so many important life events and quality time with family and friends [ ] . similar results have been reported by [ ] who demonstrated in their comprehensive report how due to being uncontactable at sea, seafarers miss key life events. cruise ship employees are fully aware that work-life on a cruise ship comes with a great burden [ ] . however, they are not willing to tolerate any lack of connectivity [ ] . internet and online communication are closely linked to fear of missing out [ ] . fear of missing out is defined as "a pervasive apprehension that others might be having rewarding experiences from which one is absent" [ ] . thus, we can conclude based on compensatory internet use theory [ ] that individuals who feel that their life needs are not fulfilled and that they are missing important life events and social motivation will experience strong stimulation to use online communication and social networking sites. based on the theoretical background, literature review and empirical findings, the following hypothesis was derived: hypothesis (h ). there is a positive relationship between the internet and online communication and fear of missing out. the internet, social networking sites and online communication have become our liaisons, special amusers, cerberus of our memories and, in times of need, even our counsellors [ ] . based on self-determination theory [ ] , relatedness to friends and family need satisfaction is one of three basic psychological needs that foster healthy self-regulation and promote mental and physical health. opportunities to experience positive feelings of proximity and affection with family and friends at home through the use of online communications benefits seafarers and their friends and family [ ] . interestingly, in the latest survey conducted by [ ] , although provisions of internet access for personal use had positively affected seafarer mental health and morale, home-related anxieties have remained the same, despite speculation that increased communications with family might generate more anxieties. the effects of the internet and online communication and relatedness to friends and family need satisfaction remain unclear [ ] . previous studies have shown that internet and online communication are mainly linked to positive outcomes of relatedness to friends and family need satisfaction [ , ] . few studies have demonstrated the opposite [ , ] . thus, based on literature review, theory and empirical findings, we put forward the following hypothesis: there is a positive relationship between the internet and online communication and relatedness to friends and family need satisfaction. social pressure is conformist behaviour with multiple determinations when an individual or group craves specific social attention; this leads them to behave in certain ways unconcerned of any prestige advantage [ ] . a recent study conducted by [ ] showed how computer-meditated communication is portrayed and influenced by robust rules of conduct, where communication arrangements are under constant social pressure. interestingly, within seafarers, social pressure has shown a strong influence on their work-life at sea due to their social isolation, imbalanced family life, separation from home, family and friends, and lack of free onboard communication facilities [ ] . moreover, relatedness proposes that cruise ship employees need to feel connected with their family and friends at home [ , , ] : when employees feel satisfied with this need, they experience higher levels of work engagement and well-being. most employees own smartphones and experience social pressure to make themselves available to friends and family at home, thereby satisfying needs for relatedness. online communications induced by social pressure and relatedness to friends and family needs satisfaction has been directly linked with significant effects on user life satisfaction [ ] . thus, based on the literature review, theoretical background and empirical findings, we put forward the following hypothesis: there is a positive relationship between social pressure and relatedness to friends and family need satisfaction. the constant occupation with smartphones has created a peculiar mindset in users with specific feelings of being permanently online and connected [ ] . interestingly, online communication and social media are closely linked to fear of missing out [ ] ; % of u.s. social media users suffer from fear of missing out [ ] . thus, tensions related to social relationships may be the prevailing cause for the fear of missing out [ ] . the uses and gratifications theory provides us with pragmatic theoretical lenses instrumental in understanding underlying motives and multitasking behaviours [ ] . the theory proposes that hidden roots of social and psychological needs create certain expectations from various media, which guides users towards specific models of media exposure, culminating in need gratification [ ] . looking at the advantages of online communications to those living and working at sea, fear of missing out has a significant impact; % of crew members need to be connected with the outside world, and % would leave their current company to join some other that would provide better onboard connectivity [ ] . previous research also showed that higher levels of fear of missing out had an impact on a higher tendency to internet multitask [ ] . cruise ship employees have long working hours and rarely go ashore; the tendency to internet multitask leads to some occupational injuries [ ] . consequently, based on theory, literature review and empirical findings, the following hypothesis is derived: there is a positive relationship between fear of missing out and internet multitasking. widespread adoption of the internet, online communication, and social network sites have empowered people across the globe to grow their social network [ ] . however, such a gift comes with responsibility because various social network sites compete for our attention by streaming content based on well-programmed algorithms founded on our likes, fears, and needs [ ] . the digital world is doused with ever-growing social network sites that are changing the online behaviour of digital technology users but also how human beings interact with one another in real life [ ] . moreover, human beings are social animals [ ] in need of relatedness to friends and family, regardless of recent technological advancements. relatedness comes in the form of affective needs, which tend to intensify delightful and affecting experiences, and social needs that tend to bolster existing connections with family and friends [ ] . thus, the need for relatedness is a feeling of satisfaction that comes from being a connected part of a community where individuals manifest a willingness to care about each other [ ] . being away from their homes in an isolated environment [ ] , cruise ship employees are constantly looking for social support [ ] . interestingly, perceived social support, characterized as the tangible or intangible support received from an individuals' social circle, is associated with superior life satisfaction [ ] . consequently, based on theory, literature review and empirical findings, the following hypothesis is derived: hypothesis (h ). there is a positive relationship between relatedness to friends and family need satisfaction and perceived social support. the term internet multitasking refers to "any combination of internet use with other media or non-media activities" [ ] p. . the main reasons for multitasking are social interactions with friends and family and information seeking [ ] . cruise ship employees are most often in different time zones than their friends and family. this leaves them with a limited time frame for online communication and significantly lowers the opportunities for giving and receiving much needed social support. moreover, cruise ship employees are under extreme time pressure due to long working hours [ ] ; this is when individuals perceive that if they engage in internet multitasking, they would be efficient [ ] . however, the effects of internet multitasking on retention of information during online messaging and cognitive load, showed significant retention loss among simultaneous multitasks [ ] . similarly, internet multitasking has been associated with lower gratification and perception memory achievement and sensitivity and moderate standard bias [ ] . moreover, different types of multitasking have robust effects on task performance. task performance significantly decreased when the given task was a secondary task, when a neurological obstruction was high, and when the behavioural reaction was present [ ] . thus, based on literature review and taking in consideration the conflicting empirical results of internet multitasking effect on perceived social support, and bearing in mind the importance of perceived social support for cruise ship employees, the following hypothesis is derived: there is a positive relationship between internet multitasking and perceived social support. the social relationship is flexible and essential for individual vitality because human beings exist within larger social contexts where friends and family play important roles [ ] . moreover, if a persons' social context is supportive of significant relationships, then these individuals encounter elevated feelings towards psychological needs, which can be satisfied through social synergy [ ] . social support has four dominant aspects in the creation of well-being and life satisfaction: main effect (adding particular supplementary function to mental health), mediating effect (intervening in relations between its precursors and health results), indirect effect (preventing disorders by framing mental health) and moderating effect (lowering the risk of any mental health-related components) [ ] . previous studies have shown that the internet and online communication have a positive effect on social capital [ ] where social capital is an antecedent of social support [ ] . internet and online communication are bonding and bridging social capital [ ] , which are of paramount importance for satisfying the social support need of cruise ship employees who tend to use online communication to contact geographically dispersed close friends and family [ ] . thus, social support plays multiple roles in individuals' well-being and life satisfaction [ ] . considering the importance of well-being and life satisfaction of employees, based on literature review and empirical findings, we put forward the following hypotheses: there is a positive relationship between perceived social support and well-being. people should focus on how to be happy, satisfied and filled with positivity [ ] . thus, psychological well-being is an essential part of positive psychology. psychological well-being is related to ones' feelings and evaluations about their life [ ] . moreover, well-being is seen as a psychological well-being that develops based on the eudaimonic dimension of well-being [ ] and as happiness that is built around life satisfaction based on the hedonic dimension of well-being [ ] . in the context of cruise ship employees, well-being is a fusion of eudaimonic (efficiency) and hedonic (thrill) dimensions. interestingly, gibson et al. [ ] argues how due to work-life time constraints, task assignments and job anxiety, employees experience poor well-being. moreover, radić [ ] questions the life satisfaction and well-being of employees who are economic gladiators in pursuit of an unobtainable economic freedom. thus, moore [ ] calls cruise ships "misery machines" where in recent years, as walker [ , ] point out, there has been a substantial increase in suicide rates due to the poor well-being of employees. interestingly, perceived social support from online communication has had a positive effect on well-being [ , ] . social network sites have provided ambient awareness that increases the well-being of its users [ ] . life satisfaction is related to a subjective, comprehensive evaluation of one's quality of life [ ] . moreover, life satisfaction draws from the individual's psychological aspects and is related to one's hedonic satisfaction [ ] , where at the same time, perceived social support from an individual's social networks has the potential to strengthen a person's life satisfaction [ ] . in the q / report, seafarers happiness index [ ] showed how free online communications have a significant impact on employee life satisfaction; as ang et al. [ ] argue, computer-mediated communications can enhance life satisfaction. online communication and social network sites can drive a person towards achieving superior life satisfaction and better quality social relationships [ ] . interestingly, although employees use online communication and social network sites to strengthen their close interpersonal connections and enhance their life satisfaction [ , ] argue that weak ties are also valuable due to their potential to positively influence life satisfaction. figure illustrates the research model and hypotheses of this study. freedom. thus, [ ] calls cruise ships "misery machines" where in recent years, as [ , ] point out, there has been a substantial increase in suicide rates due to the poor well-being of employees. interestingly, perceived social support from online communication has had a positive effect on wellbeing [ , ] . social network sites have provided ambient awareness that increases the well-being of its users [ ] . life satisfaction is related to a subjective, comprehensive evaluation of one's quality of life [ ] . moreover, life satisfaction draws from the individual's psychological aspects and is related to one's hedonic satisfaction [ ] , where at the same time, perceived social support from an individual's social networks has the potential to strengthen a person's life satisfaction [ ] . in the q / report, [ ] showed how free online communications have a significant impact on employee life satisfaction; as [ ] argue, computer-mediated communications can enhance life satisfaction. online communication and social network sites can drive a person towards achieving superior life satisfaction and better quality social relationships [ ] . interestingly, although employees use online communication and social network sites to strengthen their close interpersonal connections and enhance their life satisfaction [ , ] argue that weak ties are also valuable due to their potential to positively influence life satisfaction. figure illustrates the research model and hypotheses of this study. the theoretical framework of this study was based on a literature review; the conceptual model and hypotheses were tested based on a convenience sample. the post-positivistic paradigm was adopted in this study because as [ ] argues, the post-positivistic paradigm takes into consideration the fact that in human behaviour studies, observations are imperfect with potential inaccuracies; thus, all theories could be amended. action research strategy allows the research to use different models of contemporary knowledge in solving genuine industry issues and applying obtained results outside the boundaries of the study [ ] . thus, action research strategy was used. the research model was evaluated using a cross-sectional survey and covariance-based structural equation modelling the theoretical framework of this study was based on a literature review; the conceptual model and hypotheses were tested based on a convenience sample. the post-positivistic paradigm was adopted in this study because as [ ] argues, the post-positivistic paradigm takes into consideration the fact that in human behaviour studies, observations are imperfect with potential inaccuracies; thus, all theories could be amended. action research strategy allows the research to use different models of contemporary knowledge in solving genuine industry issues and applying obtained results outside the boundaries of the study [ ] . thus, action research strategy was used. the research model was evaluated using a cross-sectional survey and covariance-based structural equation modelling (cb-sem). cb-sem allows testing and validation of current theories and comparisons of different theories [ ] . in summary, this study used a deductive approach followed by a cross-sectional time horizon and quantitative techniques for data collection. a comprehensive self-reported online survey in english was designed at surveymonkey®. possible participants were invited to take part in the survey via facebook group "crew center". the main criteria was that participants had to be onboard and employed by a cruise company. the survey was online from august to december , and the final sample consisted of cruise ship employees (see table ). the sample comprised males and females from different geographical areas ( . % from europe, . % from north america, . % from southeast asia, . % from south america, . % from central america, . % from africa, and . % from australia). most respondents were between - years old ( . %) followed by respondents - years old ( . %) and - years old ( . %). among the participants, . % were employed in the hotel department, . % were from the deck and technical department, and . % were from the entertainment department. most ( . %) had worked in the industry for over six years. a large share of respondents had a bachelor's degree ( . %). this extreme unrepresentative value was related to the convenience sampling method. overall, the sample was a very good representation of employee demographics [ ] . internet and online communication were assessed using a five item scale designed to asses internet and online communication usage (all the measures are included in the appendix a). participants indicated on a five point scale from (once per week) to (several times per week) how often they use the internet for communication; from (less than an hour) to (more than hours per day) how many hours per day (on average) they spend on internet communication; from (once a week) to (several times per day) how often they use a) instant messenger, b) social networking sites, and c) chat rooms. internal consistency in the present sample was acceptable (cronbach's α = . ). social pressure to be permanently available was assessed with an adapted perceived norm scale [ ] that had four items (e.g., "people from my private social environment think that it is important that i'm constantly available") and is rated on a five point scale ranging from (does not apply at all) to (fully applies). internal consistency in the present sample was acceptable (cronbach's α = . ). fear of missing out on important life events and information was assessed with a three item scale (e.g., "if i would use the internet less frequently, i would be missing out on important things") developed by [ ] . participants rated the items on a five point scale ranging from (does not apply at all) to (fully applies). internal consistency in the present sample was good (cronbach's α = . ). relatedness to friends and family need satisfaction was assessed with three item scale (e.g., "i feel that my friends and/or family sincerely care about me") developed by [ ] . participants rated the items on a five point scale ranging from (strongly disagree) to (strongly agree). internal consistency in the present sample was good (cronbach's α = . ). internet multitasking was assessed with a five item scale (e.g., "how often do you use the internet while you simultaneously are in a conversation with another person") developed by [ ] . participants rated the items on a five point scale ranging from (never) to (very frequently). internal consistency in the present sample was acceptable (cronbach's α = . ). perceived social support was assessed by the multidimensional scale of perceived social support [ ] , which consisted of six items (e.g., "there is a special person who is around when i am in need") and was rated by participants on a seven point scale ranging from (strongly disagree) to (strongly agree). internal consistency in the present sample was acceptable (cronbach's α = . ). well-being was assessed by the world health organization well-being index [ ] . it comprises five items (e.g., "i have felt cheerful and in good spirits") and was rated by participants on a six point scale ranging from (all the time) to (at no time). internal consistency in the present sample was good (cronbach's α = . ). life satisfaction was assessed by satisfaction with life scale [ ] . it consists of five items (e.g., "in most ways my life is close to my ideal") and it was rated by participants on a seven point scale ranging from (strongly disagree) to (strongly agree). internal consistency in the present sample was good (cronbach's α = . ). structural equation modelling (sem) was computed using the amos software packet (ibm, chicago, illinois), and the maximum likelihood method was used to estimate the parameters from the conceptual model (see figure ). the kolmogorov-smirnov and shapiro-wilks test showed that none of the variables were normally distributed. thus, a maximum likelihood (ml) estimator with enough resistance capabilities to none-extreme deviations from the normal distribution [ ] was used. model fit was tested based on the χ and cmin/df statistics, the comparative fit index (cfi) and the root mean square error of approximation (rmsea) as recommended by [ ] . the univariate analysis of variances (anova) was used in search of differences among employee demographics and conceptual model variables. the model showed an acceptable fit to the data with the following values: χ ( ) = , , p = . ; rmsea = . , lo = . , hi = . ; cmin/df = . and cfi = . . although the general indicator χ was significant, with such a large number of degrees of freedom, χ is not reliable; it is better to rely on other indicators. rmsea was close to the limit that indicates an excellent model ( . ), cmin/df was within the limits that represent a good model, whereas the cfi was close to the lower limit of acceptability of the model [ ] [ ] [ ] . table shows the hypothesized paths of the conceptual model. the zero-order correlations between social pressure and fear of missing out, demonstrate that these two variables are strongly interrelated. social pressure and fear of missing out show very high correlations (r = . , p < . ). this significant relationship is reasonable: social pressure as a concept is closely connected to the concept of fear of missing out as these social processes on the internet and social network sites are synthesized. because social interaction through the internet and online communication are of paramount importance for cruise ship employees [ ] , accomplishing this pursuit is a way towards well-being and life satisfaction. this conception is supported by results from [ , ] , who reported that a recently developed free-of-charge specialized cross-platform messaging internet application (by a handful of cruise companies) had an immediate impact on the happiness index of employees by increasing to % from q / to q / . except for hypotheses , and , all other hypothesized relationships were supported in the final model ( figure ). hypotheses and were supported showing how the internet and online communication had positive effects on social pressure (β = . ) and fear of missing out (β = . ). interestingly, hypothesis was not supported, demonstrating that the internet and online communication did not have a positive effect on relatedness to friends and family need satisfaction (β = . ). as predicted in hypothesis , social pressure had a positive effect on relatedness to friends and family need satisfaction (β = . ), and fear of missing out has a positive effect on internet multitasking (β = . ) as predicted in and hypothesis . hypothesis predicted that relatedness to friends and family need satisfaction had a positive effect on perceived social support; this hypothesis was supported (β = . ). hypothesis predicted that internet multitasking had a positive effect on perceived social support; however, this hypothesis was not supported (β = − . ). hypothesis predicted that perceived social support had a positive effect on well-being; however, this hypothesis was not supported (β = − . ). lastly, hypothesis predicted that perceived social support had a positive effect on life satisfaction; this hypothesis was supported (β = . ). in pursuit of elucidating the peculiar socio-demographics characteristics of cruise ship employees and unrevealing significant differences on sample and research model variables, anova was used. the results disclosed the following pivotal differences. the hypotheses and were supported showing how the internet and online communication had positive effects on social pressure (β = . ) and fear of missing out (β = . ). interestingly, hypothesis was not supported, demonstrating that the internet and online communication did not have a positive effect on relatedness to friends and family need satisfaction (β = . ). as predicted in hypothesis , social pressure had a positive effect on relatedness to friends and family need satisfaction (β = . ), and fear of missing out has a positive effect on internet multitasking (β = . ) as predicted in and hypothesis . hypothesis predicted that relatedness to friends and family need satisfaction had a positive effect on perceived social support; this hypothesis was supported (β = . ). hypothesis predicted that internet multitasking had a positive effect on perceived social support; however, this hypothesis was not supported (β = − . ). hypothesis predicted that perceived social support had a positive effect on well-being; however, this hypothesis was not supported (β = − . ). lastly, hypothesis predicted that perceived social support had a positive effect on life satisfaction; this hypothesis was supported (β = . ). in pursuit of elucidating the peculiar socio-demographics characteristics of cruise ship employees and unrevealing significant differences on sample and research model variables, anova was used. the results disclosed the following pivotal differences. the cruise ship employees come from various countries around the globe. thus, it is important to determine whether any fundamental differences were present based on country of residence and the research model variables. employee place of residence had prominent effects on internet and online communication (f( , ) = . , p = . ), fear of missing out (f( , ) = . , p = . ), social pressure (f( , ) = . , p = . ), relatedness to friends and family need satisfaction (f( , . ) = . , p = . ), internet multitasking (f( , . ) = . , p = . ), perceived social support (f( , . ) = . , p = . ) and well-being (f( , . ) = . , p = . ). differences between place of residence and fear of missing out (η = . ) were low. differences among place of residence and internet and online communication (η = . ), social pressure (η = . ), relatedness to friends and family need satisfaction (η = . ), internet multitasking (η = . ), well-being (η = . ) and perceived social support (η = . ) were moderate. student's t-test revealed that employees from africa showed significant differences the goal of the current study was to investigate and model complex mutual interactions the internet and online communication had on social pressure, fear of missing out, internet multitasking and relatedness to friends and family need satisfaction, perceived social support, well-being and life satisfaction of cruise ship employees. the results revealed that the internet and online communication have positive effects on social pressure and fear of missing out, whereas social pressure and fear of missing out have positive effects on relatedness to friends and family need satisfaction and internet multitasking. moreover, internet multitasking had a positive effect on perceived social support, which in turn had a positive effect on life satisfaction. while onboard a cruise ship, employees are detached from their family, significant others and friends. thus, employees experience strong social pressure to be constantly available and fear of missing out on important information and life events. due to their rigorous schedule, i.e., working to hours every day of the week in an isolated environment, the internet and online communications are wonderful instruments that can meet the demands of social pressure and reduce the fear of missing out experienced by cruise ship employees. the internet and online communication are essential to employees from collectivistic cultures where friend and family ties are strong. thus, providing these employees instruments to maintain close contacts with friends and family at home will reduce their social pressure and fear of missing out, which in turn will create harmony among employee social groups. moreover, the provision of online communication creates an interactive platform for validation through communication acceptance; validation boosts employee sense of belonging and strengthens their relationships with friends and family at home. these results are supported by the theory of belongingness by [ ] and are in line with previous studies conducted by [ , , , ] . free time is the single most precious commodity for cruise ship employees. tight work schedules, ship itineraries, in-port safety duties, and daily job demands leave employees with very narrow time windows for engagement in social networking sites and online communication. thus, social pressure and fear of missing out effects on relatedness to friends and family need satisfaction force employees to engage in internet multitasking. within the minimal and confined space of a cruise ship, employees lose almost all points of reference to the outside world and friends and family at home; thus, social pressure and fear of missing out fuels the need for relatedness to friends and family and internet multitasking. employees spend on average between four and six months onboard in small shared cabins while working long hours every day of their full contract length and are in desperate need of the support of family and friends. thus, if cruise ship companies provide ad libitum internet access to online social networks and communication, employees will enjoy a strong network of supportive family and friends that can help them enhance life satisfaction. interestingly, employees with bachelor's degrees exhibited high levels of internet multitasking, which correlated positively with their working memory and ability to divert their attention among different tasks. these results are supported by self-determination theory of [ ] as well as uses and gratification theory [ ] . moreover, these findings are in line with previous studies conducted by [ , , , ] . cruise ship employees understand they are dispensable and replaceable to cruise ship companies [ ] . thus, relatedness to friends and family needs satisfaction is of paramount importance for employees because they know that to their friends and family, they are indispensable and unique. moreover, living and working onboard a cruise ship is a lifestyle; while this particular lifestyle may seem to disregard certain employee rights, it does not dehumanize the employee. when employees feel their needs towards relatedness are satisfied, they experience elevated social support through strengthened connections with friends and family. although cruise ship employees work and live on the high seas, they do not thrive alone: donne [ ] pointed out that each man relies on others. however, there are slight differences between employees and their relatedness to friends and family who need satisfaction. experienced employees with + years exhibited stronger needs towards relatedness because they feel lonely and isolated for a significant period of their life. employees working in the entertainment department and employees coming from south america expressed greater needs because they have a wide circle of close ties at home. lastly, the youngest cruise ship employees between - years exhibited greater needs towards relatedness because at their age, friendships are highly complex and offer significant self-disclosure and support. these results are also supported by self-determination theory of [ ] and are in line with previous studies conducted by [ , ] . onboard cruise ship operations are in constant flux, and employees come and go frequently. for many employees these crew changes become the only point of reference. during long contracts, tiredness of employees builds up as physical pain, exhaustion and psychic fatigue. however, cruise ship employees are required to continuously work until the completion of their contracts. experiences like these build highly intense relationships where employees need social support. in such an environment, employees lean on their friends and family at home for support, which comes in many forms most often as empathy, compassion and providing care. social support is the foundation of healthy relationships that improves employee life satisfaction. employees who spent + years living and working on cruise ships are exposed to prolonged periods of loneliness and isolation, which affects them in ways that would require social support to achieve happiness and life satisfaction. male employees look for social support to feel happy and satisfied, whereas female employees engage in social support to pursue increased well-being. employees with master/doctoral degrees enjoy social support from their close ties because they understand the benefits of happiness that comes from such relationships. finally, employees from north america consider deep relationships to have significance in enhancing social support because larger social networks improve life satisfaction. these results are supported by the positive psychology paradigm by [ ] . moreover, these findings are in line with previous studies conducted by [ , , ] . although keeping in touch with family and friends at home is essential for cruise ship employees, the majority of cruise companies charge significant prices for internet and online communication services. thus, due to limitations of internet and online communication use because of high service prices, poor coverage and slow data connection, employees are prevented from satisfying their needs through their friends and family at home. moreover, due to in-port manning duties, employees cannot use free internet services off ship, which leads to chronic emotional distress, frustration, anger, despair, and anxiety. this finding is in line with [ ] who argued that people heavily dependent on social networking sites to satisfy their needs towards relatedness to friends and family may experience a lack of social capital outcomes; this can trigger detrimental impacts on their well-being. employment on cruise ships carries many occupational safety hazards [ ] . to compensate, employees engage in internet multitasking; however, doing so exposes employees to added distractions and prevents them from safely or effectively completing their tasks. moreover, employees who engage in other tasks/activities while taking part in online communication with friends and family exhibit reduced performance, which leads to poor interaction and social dissatisfaction. this finding was in line with [ ] who argued that multitasking is related to reduced enjoyment in messages and reduced recognition memory performance. similarly, Örün et al. [ ] argue that retention of communication content during online messaging is significantly worse while multitasking. lastly, the perceived social support from internet and online communications and social networking sites with family and friends at home is dependent on reciprocity. employees experiencing under-reciprocating exchanges show significant negative effects on their well-being. these results are supported by the conservation of resources theory [ ] and the reciprocity norm [ ] . perceived social support is a multi-dimensional construct highly dependent on personality traits. personality can affect perceived social support relationship with well-being to the point of being non-significant [ ] . overall, our results provided several important theoretical and practical implications relevant to cruise tourism and human resource management. this study contributes to academic literature in several ways. first, working and living on a cruise ship, carries a heavy burden where cruise ship employees are detached from their family and friends at home [ ] and their main communication instruments are the internet, social networking sites and online communications [ ] . thus, although this study is of an exploratory and pioneering nature regarding the effects of internet communication on employee well-being and life satisfaction, this study was founded on well-known theories. overall, the results are consistent with the theory of belongingness [ ] , the self-determination theory [ ] , the uses and gratification theory [ ] and the conservation of resources theory [ ] and confirmed previous studies that reported positive effects of the internet and online communication on social pressure on fear of missing out [ , ] ; relatedness to friends and family needs satisfaction [ ] ; fear of missing out on internet multitasking [ ] ; relatedness to friends and family needs satisfaction and perceived social support [ ] ; and life satisfaction [ ] . intriguingly, the results did not confirm positive effects of internet and online communication on relatedness to friends and family needs satisfaction, internet multitasking on perceived social support, and perceived social support on well-being. however, these findings are supported by previous studies, such as [ , , , ] . a second contribution to the literature is the final model's broad scope and applicability towards achieving life satisfaction of employees who work and live in a specific workplace, as described by [ ] . comprehensive measurement scales (based on previously confirmed scales by [ , [ ] [ ] [ ] [ ] for measuring internet and online communication effects on well-being and life satisfaction of cruise ship employees showed strong reliability and validity. these tools can be used in future studies as instruments for measuring internet and online communication effects on the well-being and life satisfaction of various employees. this study offers valuable practical recommendations for cruise ship companies. unhappy, detached and dissatisfied employees can become unproductive and disengaged, which can lead to high employee turnover, absenteeism, and increased expenses due to health care costs and insurance premium fees [ ] ; this can harm the profitability of cruise ship companies. companies that provide free-of-charge internet and access to social networking sites and online communication, will satisfy employee needs for belongingness. this will allow employees to enjoy a strong network of family and friends to achieve and maintain life satisfaction. moreover, companies who understand and appreciate the value of employees who flourish in life satisfaction should reinforce their core values by setting their "true north" towards providing employees instruments to maintain close contacts with their friends and family at home. such provisions by companies would suppress employee social pressure and fear of missing out. this would create harmony among their close ties and social groups, ultimately leading to life satisfaction of cruise ship employees. this study has several limitations. first, this study utilized a cross-sectional time horizon; there is space for potential causality and reciprocal relationships among components [ ] . future studies should use a longitudinal time horizon to investigate the effects of the internet and online communication on well-being and life satisfaction during various stages of cruise ship employee contracts. second, common method bias is expected in this study due to self-reported answers collected from employees who agreed to participate in the survey. to lessen this challenge, a cautiously composed and validated survey was used following the suggestion of [ ] . as such, participant anxiety related to giving right or wrong answers was at least reduced to its lowest possible level, if not completely avoided. nevertheless, components that were used in this study could only be measured by particular, authentic impressions of employees. third, participants in this study were recruited via the facebook group "crew center". thus, the sample is not representative of the general population of all cruise ship employees who use the internet and online communications because many cruise ship employees are not members of the aforementioned group and as such are underrepresented. the fourth limitation is related to the sampling method, i.e., the convenience sample method. this method could have limited the generalizability of the overall findings. the fifth limitation is related to the research model. even though components showed satisfactory levels of validity and reliability, component constituents should be tested in future work on wider populations of employees. the sixth limitation is the quantitative analyses that were used to evaluate research data. future studies could mix qualitative and quantitative techniques to obtain comprehensive knowledge about the effects of internet and online communication on 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research bentler department of psychology university of california los angeles cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives principles and practice of structural equation modeling dimensionalizing cultures: the hofstede model in context. online readings psychol devotions upon emergent occasions, and severall steps in my sicknes the norm of reciprocity: a preliminary statement the relationship between social support and subjective well-being across age an investigation into hospitality cruise ship work through the exploration of metaphors games researchers play -extreme-groups analysis and mediation analysis in longitudinal occupational health research common method biases in behavioral research: a critical review of the literature and the recommended remedies key: cord- - wb kayl authors: ahmed, sakir; zimba, olena; gasparyan, armen yuri title: moving towards online rheumatology education in the era of covid- date: - - journal: clin rheumatol doi: . /s - - - sha: doc_id: cord_uid: wb kayl the coronavirus disease- (covid- ) pandemic has unsettled conventional medical education, hastening a switch to digital platforms and open-access publishing. rheumatology is a fast evolving academic discipline that stands to gain by this switch. most rheumatology textbooks are now available in digital formats, and these are complemented with live updating educational hubs such as uptodate and clinicalkey. emerging topics of covid- on these proprietary platforms are now freely available to all specialists. social media channels, particularly twitter, are becoming major players in the era of covid- by offering online journal clubs, enabling fast dissemination of influential articles, and facilitating interactive education. indexed rheumatology journals, in turn, aid online education by opening access to recommendations and other materials that are rapidly changing research and practice worldwide. research peer review additionally offers learning experience to novice and seasoned researchers and authors. global rheumatology societies have online learning resources, which are changing their format and geographic reach to meet the changing needs in the times of pandemic. while online teaching lacks emotional connections between mentors and mentees, switch to a more interactive format of education and regular contacts may partly solve the issue. rheumatologists can take the lead in these challenging times and contribute more to online scholarly activities which are aimed to maintain and enrich education. during the first world war, a piece in the lancet had focused on huxley's concept of education [ ] . huxley had said that the primary aim of education should be to give the possessor a chance to be happy and useful in their generation. the unnamed author or authors of the piece lamented that the medical graduates were not exposed to adequate educational key points • disparities in rheumatology education are likely to be widened during the covid- pandemic. • barriers to rheumatology education include limited number of instructors and their limited experience in online teaching. • online textbooks, didactic materials of indexed rheumatology journals, and frequently updated online educational hubs such as uptodate serve as a foundation of online rheumatology education. • online rheumatology education is enriched by peer review and social media activities, which are becoming major players in the time of the covid- pandemic. facilities as advocated by huxley's wisdom. it was pointed out that in certain parts of the uk, scientific training was still hard to come by. more than a hundred years have passed, and the situation is grim again. the current coronavirus disease- (covid- ) pandemic has led to a significant upheaval to all aspects of society including medical education. even before the pandemic, disparities existed in healthcare systems worldwide, including rheumatology education [ ] . these may be widened as the virus erodes through the already weakened health infrastructure, impacting face-to-face education, and the maintaining of clinical skills by practising [ , ] . by mid-august , the global number of covid- cases has crossed million, with the highest number in the usa ( . million crossed), brazil ( . million crossed), and india ( . million) [ ] . while the curve seems to be flattening for the usa and brazil, it is still rising in many other countries. europe is seeing a resurgence of cases, and the second wave of spread is anticipated. rheumatology education across the globe has been disrupted. cancellation of face-to-face educational meetings and conferences and trainee redeployment and postponement of examinations have been seen across the world [ , , ] . rheumatology training hours for undergraduates are limited, but such educational activities often induce a choice to take up rheumatology [ ] . due to the covid- pandemic, basic rheumatology training can be affected unless corrective measures are taken. it should be also kept in mind that many countries attract a large number of medical students and postgraduates from india where the number of aspirants for medical education greatly outnumbers the available seats [ ] . the pandemic can halt indian graduates from attending classes in various medical universities abroad. even two decades back, it was recognised that with the availability of the worldwide web and extensive handheld electronic devices, it was only a matter of time before medical education shifts to virtual platforms [ ] . the pandemic has hastened the evolution. although the mainstay of medical education is practice-based, covid- has forced medical students worldwide to continue their studies online [ ] . residency programmes in new york have been changed to take into account large patient numbers with a higher proportion of critical illness [ ] . care has been taken so that education is not compromised by using virtual casebased conferences. however, is such an approach viable for countries where health infrastructure is currently under tremendous pressure? there are questions of feasibility and acceptance. as a prime example, medical education in india has been following practices established in britain, with a rec e n t s h i f t t o c o m p e t e n c y -b a s e d t r a i n i n g [ ] . r h e u m a t o l o g y p a t i e n t s i n i n d i a h a d a c c e p t e d teleconsultation based on the commonly available whatsapp platform after the onset of covid- [ ] . but rheumatology education maybe a different cup of tea altogether. students from non-anglophone countries may tend to be less vocal, and thus, there is a need to address cultural needs while designing medical curriculum [ ] . this article aims to overview the role of online resources for rheumatology education in the era of covid- . the current number of mentors in rheumatology is limited. most resource-constrained countries have an enormous load of rheumatology patients and a vastly derisory number of trained rheumatologists [ ] [ ] [ ] . some countries like korea and iran have done well recently in the field of rheumatology education [ , ] . while countries like mexico still face acute shortage of rheumatologists, others like liberia have practically negligible trained rheumatologists [ , ] . thus, there are disparities between regions. while europe may have a good number of rheumatologists, there is still a felt need for postgraduate level education for various other health professionals associated with rheumatology [ ] . additionally, many newly independent states, such as ukraine, have developed rheumatology as an academic discipline in the last couple of decades [ ] . after gaining independence in , ukrainian rheumatology has gradually progressed with increasing participation in global rheumatology meetings and representation in indexed rheumatology journals. like many large countries, ukraine has a low rheumatologist to patient ratio. the specialisation programme in ukraine takes months, compared with a median of months in other european countries. also, the number of junior specialists is limited as compared with senior rheumatologists. the ukrainian case scenario is an example where properly organised online courses may augment and enrich rheumatology education. three attributes are required to transcend these existing barriers: flexibility, innovation, and safety [ ] . the flexibility should emanate across strata from accreditation bodies to hospital governing bodies, academic faculty, and learners. innovation is a must in building virtual platforms for teaching. and safety, both physical and mental, should set the framework. some examples of the globally recognised rheumatology textbooks for trainees are kelley and firestein's textbook of rheumatology, oxford textbook of rheumatology, current diagnosis and treatment in rheumatology, rheumatic diseases clinics of north america, and european league against rheumatism (eular) textbook on rheumatic diseases. these books are adapted for various online formats compatible with most computer programmes. busy rheumatology residents may also prefer purely internet-based proprietary resources of large publishers, such as uptodate (wolters kluwer) and clinicalkey (elsevier) [ , ] . online resources like uptodate have changed the face of medicine. residents and attending physicians are comfortable with searching uptodate and retrieving validated evidence syntheses [ ] . physicians relying on uptodate are less prone to diagnostic errors [ ] . this is a portable resource that can aid even during clinical rounds [ ] . an evaluation of the evidence presented in uptodate points to the fact that less than % of the recommendations can be inappropriate [ ] . clinicalkey contains various updated guidelines, videos, and images. it also includes collections of online books and journals. the search feature of clinicalkey also queries the medline database [ ] . although the authenticity of data in wikipedia seems less secure, this online encyclopaedia may be non-inferior to uptodate in specific scenarios [ ] . all these online resources are frequently updated. many, if not most, include algorithms for approaching patients with different suspected conditions. importantly, recently drafted and regularly updated covid- items are freely available on uptodate and clinicalkey. many established rheumatology journals have educational sections to carter to the needs of ongoing research fellows and clinicians. eular and american college of rheumatology (acr) recommendations on various clinical conditions and diagnostic procedures are perhaps the most influential sources for trainees and specialists. clinical updates, images, and case-based reviews, which are frequently published and promoted on social media by clinical rheumatology, may also enrich and diversify materials available to rheumatology trainees. to respond to the challenges posed by the pandemic, many didactic articles on covid- have been published by rheumatology journals with subsequent archiving by pubmed central. social media offers various channels to aid online education and dissemination of evidence on rapidly changing subjects, particularly on covid- prevention and treatment modalities [ ] . nowadays, #meded and #medtwitter are widely recognised hashtags, and many scholars are embracing powerful microblogging platforms such as twitter for sharing their comments and arranging online journal clubs [ ] . twitter has emerged as a powerful influencer regarding dissemination of published articles [ ] . twitter journal clubs are growing in popularity; the most well-known in the field of rheumatology are @rheumjc and @eular_jc. the faceto-face discussions can percolate outside the conference halls on to twitter and reach audiences across the globe, making the traditional conference genuinely global. this year has seen most rheumatology conferences, including the eular and the acr annual meetings, going virtual. thus, it is expected that twitter will play a significant role in the discussions and dissemination of educational content of these conferences. additional examples of twitter hashtags for rheumatologists to follow are #foamed, #rheumtwitter, #cbme (competency-based medical education), #somedocs (doctors on social media), and #academictwitter [ ] . the next popular online platform is youtube where variable quality audio and video materials are available for rheumatology trainees and specialists. youtube offers a variety of graphical materials on most rheumatology topics, exemplified by videos on tumour necrosis factor inhibitors and on secukinumab [ , ] . variable quality videos are increasingly posted in the time of the pandemic [ ] . thus, all such materials require curating by experts. importantly, youtube can serve as a platform for live streaming educational meetings and engaging numerous viewers in interactive education [ ] . similar functionality is also offered by facebook [ ] . a landmark eular survey among young rheumatologists, academics, and basic scientists (n = ) has revealed that around % were using various social media platforms for rheumatology clinical and research updates [ ] . in another survey among rheumatologists and allied specialists (n = ), about % of respondents wanted to follow their favourite rheumatology journals on facebook and twitter and preferred images and videos for learning [ ] . complementary social media sites can be instagram and pinterest [ ] . many specialists have a professional presence on instagram, with dermatologists benefiting a lot from highly educational images posted on this platform [ ] . pinterest can also help disseminate visually relevant content related to skin and radiology [ ] . researchgate, academia.edu, mendeley, and some other multifunctional online platforms can also be employed for publicly sharing research and ideas and finding mentors with impressive scholarly profiles [ ] . establishing special interest groups on such online platforms can complement the education process that is interrupted due to the pandemic. the shortcomings of online education can be partially overcome by engaging skilled, ethical specialists aware of misinformation spread on social media [ ] . many rheumatologists with widely visible publications and impressive online profiles are often invited to act as peer reviewers. the list of the most active rheumatologists (more than ) is now available on the publons reviewer crediting platform, which is a part of clarivate analytics [ ] . the reviewers may find the manuscript evaluation process professionally and intellectually enriching. it can contribute to updating their knowledge across various rheumatology and allied fields. additionally, reviewers with access to web of science and scopus may practice with comprehensive searches and provide evidence-based, timely comments contributing to the science growth [ , ] . the emerging eular network (emeunet) has an exemplary online programme for mentoring ongoing research fellows how to review for top journals, filling a void in rheumatology education [ ] . the gained reviewer accomplishments can be listed on publons, honouring the best contributors by certificates of excellence and medals [ ] . several large professional associations have commitments towards furthering and innovating rheumatology education. their exemplary online resources and programmes are summarised in table . young rheumatologist groups such as the emeunet are leading from the front in setting up various educational and mentoring programmes [ ] . similarly, the aplar young rheumatologist (ayr) incorporates rheumatologists below years from within the aplar organisation [ ] . various other rheumatology organisations can take these examples for establishing similar youth wings that will help to promote online rheumatology education. a meta-analysis has found online medical education noninferior versus alternative methods [ ] . a recent us-based survey has revealed that the covid- pandemic resulted in a massive shift of education in physical medicine and rehabilitation to virtual didactics, paralleled with the adaptation of patient care to telehealth [ ] . although there is no evidence whatsoever to guide the transformation, the current crisis has resulted in delivering education in occupational therapy online-only [ ] . nonetheless, evidence on gained practical skills, self-efficacy, and trainee satisfaction is still missing. with libraries and university campuses closed due to the quarantine, some trainees, particularly in resource-constrained countries, may encounter difficulties with access to online tools and platforms, let alone internet access [ ] . conducting online classes is a skill that is honed over time [ ] . the covid- pandemic has forced a change in a short term that is not sufficient for advancing online teaching skills. while various online tools and access options may ensure knowledge acquisition at undergraduate and graduate levels, gaining various clinical competencies may be jeopardised in the current conditions. assessment of rheumatology education is largely based on objective structured clinical examinations and direct observation of practical skills [ ] . both assessment approaches may be insufficient during the pandemic due to the need of a clinical simulation scenario or direct contact with a patient. at the same time, rheumatology trainees may improve their competence in ultrasound and other imaging techniques, which are prioritised in the process of moving towards distance learning [ ] . the impact on mentor-mentee or student-faculty relationships is still unknown. cultivating a passionate approach to patient care can be overlooked in the online education process. also, online classes suffer from an apparent lack of emotional connection. both student and teacher body language provide unspoken feedback that is often processed on a subconscious level. often shy students approach a teacher after the class that can help build a teacher-student relationship [ ] . a virtual platform is devoid of such human touch, and rheumatologists need to formulate strategies to overcome the emerging issues in education. the eular working group on training has identified four core needs [ ] . the first is the need for frequent feedback to the trainees. the second is the developing approaches in close proximity to clinical practices. the third regards providing adequate time for quality observation and feedback, while the last is the systematic approach to incorporate teamwork and professionalism in competence assessments. all these four need to be incorporated into a system of online rheumatology education. online tools that can be employed by educators should include web-based modules, self-assessment tools, social media journal clubs, interactive learning videos, animations of immunological and pathological pathways, and sites for drug targeting. top journals have successfully adapted such tools like the interactive videos in the new england journal of medicine [ ] or the nature group of journals [ ] . rheumatologists managing patients in the era of covid- may benefit a lot from pliable online education curricula and regular updates of bibliographic databases incorporated in the process of scientific reporting. telemedicine is increasingly accepted across the world [ ] , and trainees need to be exposed to this as well. after the onset of the pandemic, most healthcare services, including those of the uk, have shifted all elective patient consultations to online mode [ ] . thus, online training should incorporate training on telerheumatology as well. also, in countries with limited number of rheumatologists, it makes sense to train allied specialists online too. such a model had been successfully attempted in pakistan that has less than trained rheumatologists [ ] . there have been suggestions to apply gandhian philosophy to manage the situation arising out of the pandemic [ ] . "gandhi always has an answer". gandhi's talisman was to think of the poorest and the most helpless face one could recall and ruminate how our current actions would benefit that soul. online rheumatology education has the potential to reach the furthest doctor or healthcare provider in every nook and corner of the world provided there is a critical mass of online users with adequate literacy and advanced access. by increasing rheumatology knowledge and awareness, the quality of life of the underprivileged can be improved. the patient in the periphery may not have access to telemedicine, but if her/his doctor (general practitioner and rheumatologist) has, that may go a long way in alleviating her/his distress. doctors offered well-established online courses from large rheumatology associations that can be tailored to their changing needs [ ] . subsidising and offering these courses freely to doctors from resource-constrained countries may help achieve a global effect and save countless lives. the covid- pandemic has unveiled a new role for the rheumatologist [ ] . now the rheumatologist has to be able to integrate immunology with disease pathogenesis, infectious agents, rehabilitation, public health, and epidemiology [ ] . the knowledge required for modulating the immune system can no longer be confined to autoimmune diseases but also incorporate emerging and prevalent infectious diseases. the rheumatologists can only expand their horizons via networking with and learning from the experts with various professional backgrounds [ ] . despite some technical limitations and accessibility issues, online rheumatology education has the potential to spread the joy of learning as well as expose potentially brilliant minds to the cutting edge rheumatology. like molecular targeted therapies in rheumatology, the rheumatologist needs to implement targeted online teaching for various macro-and micro-goals. a teaching-to-target paradigm shift is required in online education, 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disease covid- ) and potential therapeutic targets a global perspective on the challenges and opportunities in learning about rheumatic and musculoskeletal diseases in undergraduate medical education: white paper by the world forum on rheumatic and musculoskeletal diseases (wfrmd) publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations authors' contributions conceptualisation: ahmed s, gasparyan ay, key: cord- -xan g w authors: butler-henderson, kerryn; crawford, joseph title: a systematic review of online examinations: a pedagogical innovation for scalable authentication and integrity date: - - journal: comput educ doi: . /j.compedu. . sha: doc_id: cord_uid: xan g w digitization and automation across all industries has resulted in improvements in efficiencies and effectiveness to systems and process, and the higher education sector is not immune. online learning, e-learning, electronic teaching tools, and digital assessments are not innovations. however, there has been limited implementation of online invigilated examinations in many countries. this paper provides a brief background on online examinations, followed by the results of a systematic review on the topic to explore the challenges and opportunities. we follow on with an explication of results from thirty-six papers, exploring nine key themes: student perceptions, student performance, anxiety, cheating, staff perceptions, authentication and security, interface design, and technology issues. while the literature on online examinations is growing, there is still a dearth of discussion at the pedagogical and governance levels. learning and teaching is transforming away from the conventional lecture theatre designed to seat to , passive students towards more active learning environments. in our current climate, this is exacerbated by covid- responses (crawford et al., ) , where thousands of students are involved in online adaptions of face-to-face examinations (e.g. online zoom rooms with all microphones and videos locked on). this evolution has grown from the need to recognize that students now rarely study exclusively and have commitments that conflict with their university life (e.g. work, family, social obligations). students have more diverse digitally capability (margaryan et al., ) and higher age and gender diversity (eagly & sczesny, ; schwalb & sedlacek, ) . continual change of the demographic and profile of students creates a challenge for scholars seeking to develop a student experience that demonstrates quality and maintains financial and academic viability (gross et al., ; hainline et al., ) . universities are developing extensive online offerings to grow their international loads and facilitate the massification of higher learning. these protocols, informed by growing policy targets to educate a larger quantity of graduates (e.g. kemp, ; reiko, ) , have challenged traditional university models of fully on-campus student attendance. the development of online examination software has offered a systematic and technological alternative to the end-of-course summative examination designed for final authentication and testing of student knowledge retention, application, and extension. as a result of the covid- pandemic, the initial response in higher education across many countries was to postpone examinations (crawford et al ). however, as the pandemic continued, the need to move to either an online examination format or alternative assessment became more urgent. this paper is a timely exploration of the contemporary literature related to online examinations in the university setting, with the hopes to consolidate information on this relatively new pedagogy in higher education. this paper begins with a brief background of traditional examinations, as the assumptions applied in many online examination environments build on the techniques and assumptions of the traditional face-to-face gymnasium-housed invigilated examinations. this is followed by a summary of the systematic review method, including search strategy, procedure, quality review, analysis, and summary of the sample. print-based educational examinations designed to test knowledge have existed for hundreds of years. the new york state education department has "the oldest educational testing service in the united states" and has been delivering entrance examinations since (johnson, , p. ; nysed, ) . in pre-revolution russia, it was not possible to obtain a diploma to enter university without passing a high-stakes graduation examinations (karp, ) . these high school examinations assessed and assured learning of students in rigid and highsecurity conditions. under traditional classroom conditions, these were likely a reasonable practice to validate knowledge. the discussion of authenticating learning was not a consideration at this stage, as students were face to face only. for many high school jurisdictions, these are designed to strengthen the accountability of teachers and assess student performance (mueller & colley, ) . in tertiary education, the use of an end-of-course summative examination as a form of validating knowledge has been informed significantly by accreditation bodies and streamlined financially viable assessment options. the american bar association has required a final course examination to remain accredited (sheppard, ) . law examinations typically contained brief didactic questions focused on assessing rote memory through to problem-based assessment to j o u r n a l p r e -p r o o f evaluate students' ability to apply knowledge (sheppard, ) . in accredited courses, there are significant parallels. alternatives to traditional gymnasium-sized classroom paper-and-pencil invigilated examinations have been developed with educators recognizing the limitations associated with single-point summative examinations (butt, ) . the objective structured clinical examinations (osce) incorporate multiple workstations with students performing specific practical tasks from physical examinations on mannequins to short-answer written responses to scenarios (turner & dankoski, ) . the osce has parallels with the patient simulation examination used in some medical schools (botezatu et al., ) . portfolios assess and demonstrate learning over a whole course and for extracurricular learning (wasley, ) . the inclusion of online examinations, e-examinations, and bring-your-own-device models have offered alternatives to the large-scale examination rooms with paper-and-pencil invigilated examinations. each of these offer new opportunities for the inclusion of innovative pedagogies and assessment where examinations are considered necessary. further, some research indicates online examinations are able to discern a true pass from a true fail with a high level of accuracy (ardid et al., ) , yet there is no systematic consolidation of the literature. we believe this timely review is critical for the progression of the field in first stepping back and consolidating the existing practices to support dissemination and further innovation. the pursuit of such systems may be to provide formative feedback and to assess learning outcomes, but a dominant rationale for final examinations is to authenticate learning. that is, to ensure the student whose name is on the student register, is the student who is completing the assessed work. the development of digitalized examination pilot studies and case studies are becoming an expected norm with universities developing responses to a growing online curriculum offering j o u r n a l p r e -p r o o f (e.g. al-hakeem & abdulrahman, ; alzu'bi, ; anderson et al., ; fluck et al., ; fluck et al., ; fluck, ; seow & soong, ; sindre & vegendla, ; steel et al., ; wibowo et al., ) . as many scholars highlight, cheating is a common component of the contemporary student experience (jordan, ; rettinger & kramer, ) despite that it should not be. some are theorizing responses to the inevitability of cheating from developing student capacity for integrity (crawford, ; wright, ) to enhancing detection of cheating (dawson & sutherland-smith, and legislation to ban contract cheating (amigud & dawson, ) . we see value in the pursuit of methods that can support integrity in student assessment, including during rapid changes to the curriculum. the objective of this paper is to summarize the current evidence on online examination methods, and scholarly responses to authentication of learning and the mitigation of cheating, within the confines of assessment that enables learning and student wellbeing. we scope out preparation for examinations (e.g. nguyen & henderson, ) to enable focus on the online exam setting specifically. to address the objective of this paper, a systematic literature review was undertaken, following the prisma approach for article selection (moher et al., ) . the keyword string was developed incorporating the u.s. national library of medicine ( ) mesh (medical subject headings) terms: [("online" or "electronic" or "digital") and ("exam*" or "test") and ("university" or "educat*" or "teach" or "school" or "college")]. the following databases dissertations) are not peer-reviewed, and we aimed to identify rigorous best practice literature, we excluded these. we subsequently conducted a general search in google scholar and found no additional results. all records returned from the search were extracted and imported into the covidence® online software by the first author. the online covidence® software facilitated article selection following the prisma approach. each of the , titles and abstracts were double-screened by the authors based on the eligibility criteria. we also excluded non-higher education examinations, given the context around student demographics is often considerably different than vocational education, primary and high schools. where there was discordance between the authors on a title or abstract inclusion or exclusion, consensus discussions were undertaken. the screening reduced the volume of papers significantly because numerous papers related to a different education context or involved online or digital forms of medical examinations. next, the full-text for selected abstracts were doublereviewed, with discordance managed through a consensus discussion. the papers selected following the double full-text review were accepted for this review. each accepted paper was reviewed for quality using the mmat system (hong et al., ) and the scores were calculated j o u r n a l p r e -p r o o f as high, medium, or low quality based on the matrix (hong et al., ) . a summary of this assessment is presented in table . following the process described by braun and clarke ( ) , an inductive thematic approach was undertaken to identify common themes identified in each article. this process involves six stages: data familiarization, data coding, theme searching, theme review, defining themes, and naming themes. familiarization with the literature was achieved during the screening, full-text, and quality review process by triple exposure to works. the named authors then inductively coded half the manuscripts each. the research team consolidated the data together to identify themes. upon final agreement of themes and their definitions, the write-up was split among the team with subsequent review and revision of ideas in themes through independent and collaborative writing and reviewing (creswell & miller, ; lincoln & guba, ) . this resulted in nine final themes, each discussed in-depth during the discussion. there were thirty-six ( ) articles identified that met the eligibility criteria and were selected following the prisma approach, as shown in figure . the selected articles are from a wide range of discipline areas and countries. table summarizes the characteristics of the selected articles. the united states of america held a vast majority ( , j o u r n a l p r e -p r o o f . %) of the publications on online examinations, followed by saudi arabia ( , . %), china ( , . %), and australia ( , . %). when aggregated at the region-level, there was an equality of papers from north america and asia ( , . % each), with europe ( , . %) and oceania ( , . %) least represented in the selection of articles. there has been considerable growth in publications in the past five years, concerning online examinations. publications between the years and represented a third ( , . %) of the total number of selected papers. the majority ( , . %) of papers were published in the last three years. papers that described a system but did not include empirical evidence scored a low-quality rank as they did not meet many of the criteria that relate to the evaluation of a system. when examining the types of papers, the majority ( , . %) were empirical research, with the remainder commentary papers ( , . %). of the empirical research papers, three-quarters of the paper reported a quantitative study design ( , . %) compared to two ( . %) qualitative study designs and two ( . %) that used a mixed method. for quantitative studies, there was a range between nine and , student participants (x̄ = . ) across studies, and a range between two and staff participants (x̄ = . ) in one study. the most common quantitative methods were self-administered surveys and analysis of numerical examination student grades ( % each). qualitative and mixed methods studies only adopted interviews ( %). only one qualitative study reported a sample of students (n = ), with two qualitative studies reporting a sample of staff (n = , n = ). students perceive the online examinations saves time ( . % of students surveyed) and is more economical ( . %) than paper examinations (attia, ) . it provides greater flexibility for completing examinations (schmidt, ralph & buskirk, ) with faster access to remote student papers ( . %) and students trust the result of online over paper-based examinations ( . %: attia, ) . the majority of students ( . %: attia, ; . %: pagram et al., ) perceive that the online examination environment makes it easier to cheat. more than half ( . %) of students believe that a lack of information communication and technology (ict) skill do not adversely affect performance in online examinations (attia ) . nearly a quarter ( %) of students reported (abdel karim & shukur, ) the most preferred font face (type) was arial, a font also recommended by vision australia ( ) in their guidelines for online and print inclusive design and legibility considerations. nearly all ( %) students preferred black text color on a white background color ( %). with regards to onscreen time counters, a countdown counter was the most preferred option ( %) compared to a traditional analogue j o u r n a l p r e -p r o o f clock ( %) or an ascending counter ( %). many systems allow students to set their preferred remaining time reminder or alert, including minutes remaining ( % students preferred), minutes remaining ( %), mid-examination ( %) or minutes remaining ( %). several studies in the sample referred to a lack of score variation between the results of examination across different administration methods. for example, student performance did not have significant difference in final examination scores across online and traditional examination modalities (gold & mozes-carmel, ) . this is reinforced by a test of validity and reliability of computer-based and paper-based assessment that demonstrated no significant difference (oz & ozturan, ) , and equality of grades identified across the two modalities (stowell & bennett, ) . when considering student perceptions, of the studies documented in our sample, there tended to be favorable ratings of online examinations. in a small sample of postgraduate students, the respondents had positive perceptions towards online learning assessments ( . %). the students also believed it contributed to improved learning and feedback ( . %), and percent had favorable attitudes towards online assessment (attia, ) . in a pre-examination survey, students indicated they preferred to type than to write, felt more confident about the examination, and had limited issues with software and hardware (pagram, ) . with the same sample in a post-examination survey, within the design and technology examination, students felt the software and hardware were simple to use, yet many students did not feel at ease from their use of an e-examination . j o u r n a l p r e -p r o o f rios and liu ( ) compared proctored and non-proctored online examinations across several aspects, including test-taking behavior. their study did not identify any difference in the test-taking behavior of students between the two environments. there was no significant difference between omitted items and not-reached items. furthermore, with regards to rapid guessing, there was no significant difference. a negligible difference existed for students aged older than thirty-five years, yet gender was a nonsignificant factor. scholars have an increasing awareness of the role that test anxiety has in reducing student success in online learning environments (kolski & weible, ) . the manuscripts identified by the literature scan, identified inconsistencies of results for the effect that examination modalities have on student test anxiety. a study of psychology undergraduates identified that students who typically experienced high anxiety in traditional test environments had lower anxiety levels when completing an online examination (stowell & bennett, ) . in a quasi-experimental study (n = nursing students), when baseline anxiety is controlled, students in computer-based examinations had higher degrees of test anxiety. in postgraduate student interviews, only three opposed online assessment based on perceived lack of technical skill (e.g. typing; attia, ) . around two-thirds of participants identified some form of fear-based on internet disconnection, electricity, slow typing, or family disturbances at home. a participant community college study used proximal indicators (e.g. lip licking and biting, furrowed eyebrows, and seat squirming) to assess the rate of test anxiety in webcam-based examination proctoring (kolski & weible, ) . teacher strategies to reduce anxiety in their students include enabling students to consider, review, and acknowledge their j o u r n a l p r e -p r o o f anxieties (kolski & weible, ) . responses such as students writing of their anxiety, or responding to multiple-choice questionnaire on test anxiety, reduced anxiety. students in the test group and provided anxiety items or expressive writing exercises, performed better (kumar, ). cheating was the most prevalent area among all the themes identified. cheating in asynchronous, objective, and online assessments is argued by some to be at unconscionable levels (sullivan, ) . in one survey, . percent of students felt it was easier to cheat on online examinations than regular examinations (aisyah et al., ) . this is perhaps because students are monitored in paper and pencil examinations, compared to online examinations where greater control of variables is required to mitigate cheating. some instructors have used randomized examination batteries to minimize cheating potential through peer-to-peer sharing (schmidt et al., ). scholars identify various methods for mitigating cheating. identifying the test taker, preventing examination theft, unauthorized use of textbook/notes, preparing a set-up for online examination, unauthorized student access to a test bank, preventing the use of devices (e.g. phone, bluetooth, and calculators), limiting access to other people during the examination, equitable access to equipment, identifying computer crashes, inconsistency of method for proctoring (hearn moore et al., ) . in another, the issue for solving cheating is social as well as technological. while technology is considered the current norm for reducing cheating, these tools have been mostly ineffective (sullivan, ) . access to multiple question banks through effective quiz design and delivery is a mechanism to reduce the propensity to cheat, by reducing the stakes through multiple delivery attempts (sullivan, ) . question and answer j o u r n a l p r e -p r o o f randomization, continuous question development, multiple examination versions, open book options, time stamps, and diversity in question formats, sequences, types, and frequency are used to manage the perception and potential for cheating. in the study with mba students, perception of the ability to cheat seemed to be critical for the development of a safe online examination environment (sullivan, ) . dawson ( ) in a review of bring-your-own-device examinations including: • copying contents of usb to a hard drive to make a copy of the digital examination available to others, • use of a virtual machine to maintain access to standard applications on their device, • usb keyboard hacks to allow easy access to other documents (e.g. personal notes), • modifying software to maintain complete control of their own device, and • a cold boot attack to maintain a copy of the examination. the research on cheating has focused mainly on technical challenges (e.g. hardware to support cheating), rather than ethical and social issues (e.g. behavioral development to curb future cheating behaviors. the latter has been researched in more depth in traditional assessment methods (e.g. wright, ) . in a study on massive open online courses (moocs), motivations for students to engage in optional learning stemmed from knowledge, work, convenience, and personal interest (shapiro et al., ) . this provides possible opportunities for future research to consider behavioral elements for responding to cheating, rather than institutional punitive arrangements. j o u r n a l p r e -p r o o f schmidt, ralph and buskirk ( ) also examined the perceptions of academics with regards to online examination. academics reported that their biggest concern with using online examinations is the potential for cheating. there was a perception that students may get assistance during an examination. the reliability of the technology is the second more critical concern of academic staff. this includes concerns about internet connectivity as well as computer or software issues. the third concern is related to ease of use, both for the academic and for students. academics want a system that is easy and quick to create, manage and mark examinations, and students can use with proficient ict skills (schmidt et al., ) . furthermore, staff reported in a different study that marking digital work was easier and preferred it over paper examinations because of the reduction in paper (pagram et al., ) . they believe preference should be given to using university machines instead of the student using their computer, mainly due to issues around operating system compatibility and data loss. authentication was recognized as a significant issue for examination. some scholars indicate that the primary reason for requiring physical attendance to proctored examinations is to validate and authenticate the student taking the assessment (chao et al., ) . importantly, the validity of online proctored examination administration procedures is argued as lower than proctored oncampus examinations (rios & liu, ) . most responses to online examinations use bringyour-own-device models where laptops are brought to traditional lecture theatres, use of software on personal devices in any location desired, or use of prescribed devices in a classroom setting. the primary goal of each is to balance the authentication of students and maintain the integrity and value of achieving learning outcomes. in a review of current authentication options (abumansoor, ), the use of fingerprint reading, streaming media, and follow-up identifications were used to authenticate small cohorts of students. some learning management systems (lms) have developed subsidiary products (e.g. weaver within moodle) to support authentication processes. some biometric software uses different levels to authenticate keystrokes for motor controls, stylometry for linguistics, application behavior for semantics, capture to physical or behavioral samples, extraction of some scholars recommend online synchronous assessments as an alternative to traditional proctored examinations while maintaining the ability to manually authenticate (chao et al., ) . in these assessments: quizzes are designed to test factual knowledge, practice for procedural, essay for conceptual, and oral for metacognitive knowledge. a 'cyber face-to-face' element is required to enable the validation of students. the interface of a system will impact on whether a student perceives the environment to be an enabler or barrier for online examinations. abdel karim and shukur ( ) summarized the potential interface design features that emerged from a systematic review of the literature on this topic, as shown in table . the incorporation of navigation tools has also been identified by students and staff as an essential design feature (rios & liu, ) , as is an auto-save functionality (pagram et al., ). none of the studies that included technological problems in its design reported any issues (böhmer et al., ; matthíasdóttir & arnalds, ; schmidt et al., ) . one study stated j o u r n a l p r e -p r o o f that percent of students reported some problem ranging from a slow system through to the system not working well with the computer operating system, however, the authors stated no technical problems that resulted in the inability to complete the examination were reported (matthíasdóttir & arnalds, ) . in a separate study, students reported that they would prefer to use university technology to complete the examination due to distrust of the system working with their home computer or laptop operating system or the fear of losing data during the examination (pagram et al., ) . while the study did not report any problems loading on desktop machines, some student laptops from their workplace had firewalls, and as such had to load the system from a usb. this systematic literature review sought to assess the current state of literature concerning online examinations and its equivalents. for most students, online learning environments created a system more supportive of their wellbeing, personal lives, and learning performance. staff preferred online examinations for their workload implications and ease of completion, and basic evaluation of print-based examination logistics could identify some substantial ongoing cost savings. not all staff and students preferred the idea of online test environments, yet studies that considered age and gender identified only negligible differences (rios & liu, ) . while the literature on online examinations is growing, there is still a dearth of discussion at the pedagogical and governance levels. our review and new familiarity with papers led us to point researchers in two principal directions: accreditation and authenticity. we acknowledge that there are many possible pathways to consider, with reference to the consistency of application, the validity and reliability of online examinations, and whether online examinations enable better measurement and greater student success. there are also opportunities to synthesize j o u r n a l p r e -p r o o f online examination literature with other innovative digital pedagogical devices. for example, immersive learning environments (herrington et al., ) , mobile technologies (jahnke & liebscher, ) ; social media (giannikas, ), and web . technologies (bennett et al., ) . the literature examined acknowledges key elements of the underlying needs for online examinations from student, academic, and technical perspectives. this has included the need for online examinations need to accessible, need to be able to distinguish a true pass from a true fail, secure, minimize opportunities for cheating, accurately authenticates the student, reduce marking time, and designed to be agile in software or technological failure. we turn attention now to areas of need in future research, and focus on accreditation and authenticity over these alternates given there is a real need for more research prior to synthesis of knowledge on the latter pathways. the influence of external accreditation bodies was named frequently and ominously among the sample group, but lacked clarity surrounding exact parameters and expectations. rios ( , p. ) identified a specific measure was used "for accreditation purposes". hylton et al. ( , p. ) specified that the us department of education requires "appropriate procedures or technology are implemented" to authentic distance students. gehringer and peddycord ( ) empirically found that online/open-web examinations provided more significant data for accreditation. underlying university decisions to use face-to-face invigilated examination settings is to enable authentication of learning -a requirement of many governing bodies globally. the continual refinement of rules has enabled a degree of assurance that students are who they say they are. nevertheless, sophisticated networks have been established globally to support direct student cheating from completing quick assessments and calculators with secret search engine capability through to full completion of a course inclusive of attending on-campus invigilated examinations. the authentication process in invigilated examinations does not typically account for distance students who have a forged student identification card to enable a contract service to complete their examinations. under the requirement assure authentication of learning, invigilated examinations will require revision to meet contemporary environments. the inclusion of a broader range of big data from keystroke patterns, linguistics analysis, and whole-of-student analytics over a student lifecycle is necessary to identify areas of risk from the institutional perspective. where a student has a significantly different method of typing or sentence structure, it is necessary to review. an experimental study on the detection of cheating in a psychology unit found teachers could detect cheating percent of the time (dawson & sutherland-smith, ) . automated algorithms could be used to support the pre-identification of this process, given lecturers and professors are unlikely to be explicitly coding for cheating propensity when grading multiple hundreds of papers on the same topic. future scholars should be considering the innate differences that exist among test-taking behaviors that could be codified to create pattern recognition software. even in traditional invigilated examinations, the use of linguistics and handwriting evaluations could be used for cheating identification. the literature identified in the sample discussed with limited depth the role of authentic assessment in examinations. the evolution of pedagogy and teaching principles (e.g. j o u r n a l p r e -p r o o f constructive alignment; biggs, ) have paved the way for revised approaches to assessment and student learning. in the case of invigilated examinations, universities have been far slower to progress innovative solutions despite growing evidence that students prefer the flexibility and opportunities afforded by digitalizing exams. university commitments to the development of authentic assessment environments will require a radical revision of current examination practice to incorporate real-life learning processes and unstructured problem-solving (williams & wong, ). while traditional examinations may be influenced by financial efficacy, accreditation, and authentication pressures, there are upward pressures from student demand, student success, and student wellbeing to create more authentic learning opportunities. the online examination setting offers greater connectivity to the kinds of environments graduates will be expected to engage in on a regular basis. the development of time management skills to plan times to complete a fixed time examination is reflected in the business student's need to pitch and present at certain times of the day to corporate stakeholders, or a dentist maintaining a specific time allotment for the extraction of a tooth. the completion of a selfregulated task online with tangible performance outcomes is reflected in many roles from lawyer briefs on time-sensitive court cases to high school teacher completions of student reports at the end of a calendar year. future practitioner implementation and evaluation should be focused on embedding authenticity into the examination setting, and future researchers should seek to understand better the parameters by which online examinations can create authentic learning experiences for students. in some cases, the inclusion of examinations may not be appropriate; and in these cases, they should be progressively extracted from the curriculum. j o u r n a l p r e -p r o o f as institutions begin to provide higher learning flexibility to students with digital and blended offerings, there is scholarly need to consider the efficacy of the examination environment associated with these settings. home computers and high-speed internet are becoming commonplace (rainie & horrigan, ) , recognizing that such an assumption has implications for student equity. as warschauer ( , p. ) puts it, "the future of learning is digital". our ability as educators will be in seeking to understand how we can create high impact learning opportunities while responding to an era of digitalization. research considering digital fluency in students will be pivotal (crawford & butler-henderson, ) . important too, is the scholarly imperative to examine the implementation barriers and successes associated with online examinations in higher education institutions given the lack of clear cross-institutional case studies. there is also a symbiotic question that requires addressing by scholars in our field, beginning with understanding how online examinations can enable higher education, and likewise how higher education can shape and inform the implementation and delivery of online examinations. this study adopted a rigorous prisma method for preliminary identification of papers for inclusion, the mmat protocol for identifying the quality of papers, and an inductive thematic analysis for analyzing papers included. these processes respond directly to limitations of subjectivity and assurance of breadth and depth of literature. however, the systematic literature review method limits the papers included by the search criteria used. while we opted for a broad set of terms, it is possible we missed papers that would typically have been identified in other this systematic literature review considered the contemporary literature on online examinations and their equivalents. we discussed student, staff, and technological research as it was identified in our sample. the dominant focus of the literature is still oriented on preliminary evaluations of implementation. these include what processes changed at a technological level, and how students and staff rated their preferences. there were some early attempts to explore the effect of j o u r n a l p r e -p r o o f online examinations on student wellbeing and student performance, along with how the changes affect the ability for staff to achieve. higher education needs this succinct summary of the literature on online examinations to understand the barriers and how they can be overcome, encouraging greater uptake of online examinations in tertiary education. one of the largest barriers is perceptions of using online examinations. once students have experienced online examinations, there is a preference for this format due to its ease of use. the literature reported student performance did not have significant difference in final examination scores across online and traditional examination modalities. student anxiety decreased once they had used the online examination software. this information needs to be provided to students to change students' perceptions and decrease anxiety when implementing an online examination system. similarly, the information summarized in this paper needs to be provided to staff, such as the data related to cheating, reliability of the technology, ease of use, and reduction in time for establishing and marking examinations. when selecting a system, institutions should seek one that includes biometrics with a high level of precision, such as user authentication, and movement, sound, and keystroke monitoring (reporting deviations so the recording can be reviewed). these features reduce the need for online examinations to be invigilated. other system features should include locking the system or browser, cloud-based technology so local updates are not required, and an interface design that makes using the online examination intuitive. institutions should also consider how it will address technological failures and digital disparities, such as literacy and access to technology. we recognize the need for substantially more evidence surrounding the postimplementation stages of online examinations. the current use of online examinations across disciplines, institutions, and countries needs to be examined to understand the successes and gaps. beyond questions of 'do students prefer online or on-campus exams', serious questions of how student mental wellbeing, employability, and achievement of learning outcomes can be improved as a result of an online examination pedagogy is critical. in conjunction is the need to break down the facets and types of digitally enhanced examinations (e.g. online, e-examination , byod examinations, and similar) and compare each of these for their respective efficacy in enabling student success against institutional implications. while this paper was only able to capture the literature that does exist, we believe the next stage of literature needs to consider broader implications than immediate student perceptions toward the achievement of institutional strategic imperatives that may include student wellbeing, student success, student retention, financial viability, staff enrichment, and student employability. funding: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. j o u r n a l p r e -p r o o f proposed features of an online examination interface design and its optimal values proposed bio-authentication system for question bank in learning management systems development of continuous authentication system on android-based online exam application developing a new e-exam platform to enhance the university academic examinations: the case of lebanese french university the effect of using electronic exams on students' achievement and test takers' motivation in an english course the law and the outlaw: is legal prohibition a viable solution to the contract cheating problem online course evaluations: review of literature and a pilot study online exams for blended assessment. study of different application methodologies postgraduate students' perceptions toward online assessment: the case of the faculty of education, umm al-qura university education for a knowledge society in arabian gulf countries implementing web . technologies in higher education: a collective case study enhancing teaching through constructive alignment e-exams in engineering education-online testing of engineering competencies: experiences and lessons learned a comparison of online vs. proctored final exams in online classes financial aid and attainment among students in a state with changing demographics exploring the influence of facial verification software on student academic performance in online learning environments changing students, faculty, and institutions in the twenty-first century impeding students' efforts to cheat in online classes immersive learning technologies: realism and online authentic learning the mixed methods appraisal tool (mmat) version for information professionals and researchers. education for information utilizing webcam-based proctoring to deter misconduct in online exams three types of integrated course designs for using mobile technologies to support creativity in higher education history of new york state regents exams college student cheating: the role of motivation, perceived norms, attitudes, and knowledge of institutional policy exams in algebra in russia: toward a history of high stakes testing a decade of adoption: how the internet has woven itself into american life university reform in the post-massification era in japan: analysis of government education policy for the st century situational and personal causes of student cheating online proctored versus unproctored low-stakes internet test administration: is there differential test-taking behavior and performance? student verification system for online assessments: bolstering quality and integrity of distance learning utilizing online exams: a case study have college students' attitudes toward older people changed students' perceptions of byod open-book examinations in a large class: a pilot study an informal history of how law schools evaluate students, with a predictable emphasis on law school final exams e-exams and exam process improvement use of e-exams in high stakes law school examinations: student and staff reactions effects of online testing on student exam performance and test anxiety an integrated approach to preempt cheating on asynchronous, objective, online assessments in graduate business classes objective structured clinical exams: a critical review medical subject headings online and print inclusive design and legibility considerations the paradoxical future of digital learning a pilot study of an electronic exam system at an australian university the efficacy of final examinations: a comparative study of closed-book, invigilated exams and open-book, open-web exams distinguished scholar invited essay: reflections on the role of character in business education and student leadership development the research and design of online examination system key: cord- -w yvp authors: sun, miao; chen, jing; tian, ye; yan, yufei title: the impact of online reviews in the presence of customer returns date: - - journal: int j prod econ doi: . /j.ijpe. . sha: doc_id: cord_uid: w yvp we develop a duopoly model to examine how online reviews influence the decisions of two competing online sellers who sell products of differentiated quality under different returns policies. we derive the competing sellers' optimal decisions on price and returns policy with and without online reviews, and we find that online reviews have greater impact on the high-quality seller than on the low-quality seller. if the salvage value of the product is relatively low, the seller has less opportunity to benefit from online reviews when it offers an mbg, as compared to a no-refund policy. the impact of online reviews on the competition between the two sellers has a “symmetric effect area,” where reviews may either weaken or intensify the price competition between the two sellers when they both offer a no-refund policy, but always intensify the competition if they both offer an mbg. we have identified the conditions under which online reviews lead to a win-win, or benefit one seller, or present a prisoner's dilemma for the two online sellers. we also show that mbgs at both sellers help mitigate the prisoner's dilemma if the net salvage value at both sellers is sufficiently high. return of products by customers is a common phenomenon in the retailing industry, especially in online retailing. as shown in a national retail federation ( ) report, total merchandise returns account for almost $ billion in lost sales for us retailers alone, and the retail returns rate was as high as % in . it has been reported that the returns rate from online sales is two to three times of that of brick-and-mortar retailers (orendorff, ) and is typically between % and % (ratcliff, ) . the major reason for the high level of customer returns in online retail is mismatch between customer expectations and the reality of the product (chen and chen, a; ratcliff, ) . as the customer cannot physically evaluate and experience the product before purchase, there is a j o u r n a l p r e -p r o o f significant chance that the purchased product will fail to match the customer's expectation and taste. online reviews from previous customers reveal additional information about products, enabling customers to adjust their pre-purchase valuations on products and make better purchase decisions, ultimately reducing the rate of customer returns (dellarocas, ; kostyra et al., ; maslowska et al., ) . in practice, bazaarvoice reported that online reviews reduce the number of returned products by % (sahoo et al., ) . in an empirical study by minnema et al. ( ) , online customer reviews were shown to help to form product expectations, and it was suggested that product returns should be considered when examining the effects of online customer reviews. although an attractive returns policy can improve customer satisfaction and thus represent a competitive strength, the lost sales and high cost of handling customer returns significantly affects profitability, and online retailers set their returns policy carefully (mcwilliams, ; chen and chen, b) . furthermore, returns can be managed, and method of handling customers returns may impact the customer's perception and willingness-to-pay (appriss retail, ; pei et al., ) . to reduce costs associated with customer returns, some retailers tighten their returns policies by offering a no-refund policy (su, ; choi et al., ; hsiao and chen, ) .online retailers offer a variety of returns policies (better business bureau; office of consumer affairs (canada)), ranging from the money-back guarantee (for example, amazon.com and walmart.com) to no refund (lcdtvs.com). an mbg returns policy is a widely adopted policy, but no-refund policies can also be observed in practice (especially for digital products like games, music, and software). some sellers specify no-returns policies under certain conditions; the camera store states on its website that any printer in which ink has been installed cannot be returned (https://www.thecamerastore.com). no-returns policies are also common for final sale items. online sales have increased from . billion canadian dollars in to billion in (clement, ) . in the covid- pandemic period, this number has increased to a record $ . billion in may in canada, with a . % increase over february, according to statistics canada (toneguzzi, ) . many, but not all, online retailers (notably amazon.com) allow or encourage customers to leave product reviews on their websites, and there are also third-party sites (such as yelp.com) dedicated to customer reviews. customers can share their opinions on products or services they have experienced, and seek information from others' experience of products they are j o u r n a l p r e -p r o o f interested in. furthermore, there are a variety of types of reviews, including star ratings, pictures, and text description of product details and characteristics. nearly % of consumers read online reviews before purchasing (gilliam, ) , and % of them trust the online reviews as much as personal recommendations; consumers read reviews as part of their pre-purchase research (rudolph, ) . although a number of studies have examined the impact of online reviews on sellers' sales, and several empirical studies have considered the influence of online reviews on customer returns (sahoo et al., ; minnema et al., ) , we are unware of any theoretical study that investigates the impact of online reviews on the decisions of competing sellers on prices and returns policies in the presence of customer returns. to fill this gap, we develop a duopoly model to study how online reviews impact customers' purchases and returns, and how online sellers facing competition can make optimal price and returns policy decisions in the presence of online reviews. online reviews provide customers with additional information on products before purchase, and an mbg provides post-sale service; in principle both should reduce the risk of mismatch of the actual product with customer expectations. we are therefore interested in the interactions between online reviews and returns policies, and the influence of online reviews on competing sellers' price and returns policy decisions. in order to analyze the impact of online reviews in a competitive market with customer returns, we build a three-stage game theoretic model, in which two competing online retailers sell a product at different quality levels. customers are heterogeneous in their valuations on the products, and they make their purchase decisions based on both information provided by the seller and online reviews. not surprisingly, we find that online sellers benefit from favorable reviews (with an increase in both price and demand), and can be hurt by negative reviews (with a decrease in price and demand). comparable reviews of competing products intensify the competition between the two sellers, so the sellers have to reduce their prices, even at the risk of reduced profits, in order to compete. in addition, not unnaturally, in the presence of online reviews, the seller's price, demand, and profit increase with the value of the reviews of its own product and decrease with the value of the reviews of its rival's product. j o u r n a l p r e -p r o o f we identify the condition for a duopoly to offer mbgs. we show that when the net value of the returns service (shared by the customer and an online seller) is positive, the online seller should offer an mbg, no matter what returns policy is offered by its competitor. we also show that online reviews reduce the customer's need for an mbg, as the reviews can reduce the risk of mismatch that is inherent in an online purchase. as a result, sellers are less likely to offer an mbg when online reviews are available than when they are not. online reviews also have several surprising effects. we find that online reviews have greater impact on the high-quality seller than on the low-quality seller. furthermore, the impact of online reviews on the competition between the two sellers has a "symmetric effect area." if online reviews of the two products fall in this area, they have the same influence direction on both sellers, either positive or negative; otherwise, they benefit one but hurt the other. in the symmetric effect area, online reviews may either weaken or intensify the price competition between the two sellers when both offer a no-refund policy, but always intensify the competition if both offer an mbg. even so, salvage value matters; when the salvage values of the two products are both sufficiently high, both sellers are more likely to benefit from online reviews when they offer an mbg. our contributions to the literature are two-fold. first, we extend the extant studies on the influence of online reviews to include the effect of reviews on competitive online sellers' choice of customer returns policies. our study suggests that online sellers should respond strategically to reviews, not only in pricing but also in returns policies. we demonstrate that online reviews reduce the motivation of online sellers to provide an mbg; this is a new insight in the literature on customer returns. second, we analyze the interactions between online reviews and returns policies in view of the duopoly's competition in prices and returns policies (for products of different qualities). we find that online reviews have greater impact on the high-quality seller than on the low-quality seller, and may have different impacts on the competition. the rest of this paper is organized as follows. section briefly reviews the relevant research. section describes the setting and game sequence of our duopoly model. section examines the two online sellers' pricing and returns policy decisions under the influence of online reviews, and presents equilibrium results for returns policies with and without online reviews. section j o u r n a l p r e -p r o o f examines the impact of online reviews on online sellers' optimal prices and profits, and the duopoly's market when online sellers both offer either a no-refund policy or an mbg. section concludes the paper and proposes possible extensions for future work. all proofs are presented in the appendix. there are two streams of literature related to this study, on online product reviews and customer returns. online product reviews have attracted considerable attention recently, as the growing popularity of reviews has potentially important implications for a wide range of management activities (dellarocas, ; li and hitt, ) . extensive empirical studies have examined the impact of online reviews and shown that they indeed have an effect on firms' sales (chevalier and mayzlin, ; duan et al., ; luca, ; zhou and duan, ) . from an analysis of book reviews at amazon.com, chevalier and mayzlin ( ) find that online reviews have a significant influence on product sales. similarly, luca ( ) finds that an increase in ratings on yelp.com leads to an improvement in the revenues of restaurants. in addition, a large body of detailed work has considered the impact of different characteristics of online reviews, including the association between the variance and volume of product ratings (clemons et al., ; kostyra et al., ; maslowska et al., ) , the review text (archak et al., ) , and professional ratings and sales (zhou and duan, ) . differing from those studies, we develop a theoretic model to study the impact of online reviews on customers' purchasing decisions and on competing online retailers' customer returns and pricing strategies. the existing theoretical studies on online reviews focus on the impact of online reviews on customers' pre-purchase evaluations of products. online reviews are viewed as an information source and have an effect on customers' purchase behaviors (chen and xie, ; li and hitt, ; markopoulos et al., ; sun, ) . chen and xie ( ) argue that online reviews can serve as a new element in market communications and as free "sales assistants" to help customers to make purchase decisions. li and hitt ( ) model the self-selection bias in early online reviews, which impacts later consumers' purchases and later product reviews. sun ( ) models both ratings and j o u r n a l p r e -p r o o f variance of product reviews, and examines the impact of the level of variance on products' subsequent price, demand, and profit. consumers may have different perceptions of either positive or negative reviews (pekgün et al., ) . with the effect of online reviews on customers' utility, kwark et al. ( ) and cai et al. ( ) examine the pricing strategies of different players in a supply chain. some studies show that online reviews can be a promotional device, and provide marketing strategy suggestions to sellers (chen and xie ; dellarocas ; mayzlin ; kuksov and xie ) . all these studies focus on the effect of online reviews on customers' behavior before purchase; in the present paper we also consider the effect of online reviews on customer returns after purchase and on online retailers' decisions on returns policies. several empirical studies have examined the impact of online reviews on customer returns (sahoo et al., ; lohse et al., ; minnema et al., ) . sahoo et al. ( ) show that unbiased online reviews help customers make better purchase decisions, leading to fewer product returns. minnema ( ) and lohse ( ) find that online reviews affect customers' purchase decisions as well as returns decisions. de et al. ( ) find that the technologies used for customer reviews have different effects on returns. in contrast to these empirical studies, we develop a game theoretical model for two online retailers who sell quality-differentiated products, to examine the impact of online reviews on the sellers' pricing and returns policy decisions in a competitive market. this paper is also related to studies on customer returns. to reduce customers' risk and improve customer satisfaction, many sellers offer a lenient returns policy, even though it may lead to high costs (che, ) . the effect of returns policy on customers and retailers has been extensively studied in the economics and marketing literature. some studies have found that returns policy can act as a source of product quality information (moorthy and srinivasan, ; shieh, ) . moorthy and srinivasan ( ) use a signaling theory to analyze how an mbg signals a high-quality product. some studies focus on retailers' strategy in returns policy, and argue that an appropriate returns policy can enhance profits (chen and bell, ; davis et al., ) . others studies pay attention to the influence of returns policy on customer purchase decisions (anderson et al., ; suwelack et al., ; wood, ) . suwelack ( ) argues that mbgs can increase customers' purchase intentions and willingness to pay a price premium. griffis et al. ( ) examine how customers' returns experiences impact their future purchases. in addition, extensive j o u r n a l p r e -p r o o f studies in operations management have focused on firms' strategies facing customers' returns, including pricing, ordering, and returns strategy decisions in either a monopolistic or a competitive market (mcwilliams, ; su, ) . the optimal strategies of each player in supply chains with different structures have been discussed and analyzed (ai et al., ; chen and chen, a; liu et al., ) . none of these studies have examined the impact of online reviews on retailers' returns policies in a competitive market, as we do in this paper. to fill this gap, in this study we develop a model to analyze the online retailers' optimal decisions in a competitive market in the presence of customer returns and online reviews. we consider two sellers who compete on an online platform in the presence of online reviews, selling products with differentiated quality. customers will decide whether or not to buy the product, and from which seller to buy, after reading the online reviews. for example, the customer looking for a blender might consider vitamix and oster, which both sell blenders on amazon.com, but the blender from vitamix may be of higher quality than the blender from oster. in the presence of online reviews, we examine how two competing sellers should offer returns policies, and study the impact of online reviews on the sellers' choice of policy. in practice, companies have to make plans based on projections. our stylized model will allow a company to envision the effects of reviews and returns policies to optimize operations decisions accordingly. the two online sellers are vertically differentiated in their ability to provide product quality and customer returns service to their customers. as in mcwilliams ( ) and chen and chen ( b) , who follow the assumption in moorthy and srinivasan ( ) that mbgs can be offered by high-quality firms to signal product quality (where quality is defined as the likelihood of product return) to uninformed consumers (based on signaling theory), high product quality is reflected in a high customer satisfaction rate. we assume that the high-quality retailer has a customer satisfaction rate and the low-quality retailer has a customer satisfaction rate , where , and satisfaction rate is reflected in returns rate. therefore, ( ) reflects the customer returns rate of seller , if returns are allowed, where , . the two sellers each set a returns policy ( ), either an mbg ( ) or a no-refund policy ( j o u r n a l p r e -p r o o f ), where , . with a no-refund policy, the product is worth zero to an unsatisfied customer. each seller incurs a unit product acquisition cost ( ), and needs to decide on the selling price ( ). without loss of generality, we assume that . let be the salvage value of a returned product and be the customer's cost of returning the product to retailer (the hassle cost, reflecting shipping cost and/or time spent returning the product). seller incurs a unit handling cost per returned product (ℎ ). we assume that the customer's perceived valuation ( ) on a satisfactory product with an mbg policy is between and , following a uniform distribution, as in mcwilliams ( ) and chen and chen ( a) . if the customer is unsatisfied with the product, its value is . as in chen and bell ( ) and chen and grewal ( ) , we assume that the customer's perceived valuation on a product with a no-refund policy is lower than that with an mbg policy, to account for the risk of having to keep a unsatisfactory product . in practice, a product with a no-refund policy usually has a lower price than one with return service (camera store example in section ). both empirical studies (such as, pei et al., ) and theoretical studies (such as shang et al., ) have found that the customer's valuation on the product with a no-refund policy is lower than that with an mbg. to capture the difference in the customer's perceived valuation of products with different returns policies, we assume that the customer has a disutility ( ) on a product purchased under a no-refund policy, and its perceived valuation is ( ≥ ) (as in shang et al., ) . in addition to providing the infrastructure to sell the products, an online platform may enable customers to post product reviews and feedback on purchased products. we designate an online platform { , }, where reviews are either enabled ( ) or not enabled ( ). online reviews provide public information on the product, including quality, fitness, and ease of usage. as pointed out by sahoo et al. ( ) , it is unclear whether online reviews can help customers in making better purchase decisions that may lead to fewer returns, so we denote the value of online reviews, measured by the star and/or score posted by reviewers, as , where < and , . a potential customer can use this information along with seller-provided information to evaluate the products before purchase. the higher the score or the larger the number of stars, the higher the value of the online review. also depends on additional factors such as the descriptive information on the product provided by the seller and the customer's evaluation of the product after j o u r n a l p r e -p r o o f experiencing the product. the reviewer's valuation on product with online reviews under an mbg or a no-refund policy becomes ! ( " and ( " ! ( " , respectively, where and ( " are the weights on the customer's own valuation of the product and on the information from online reviews, respectively, and where ∈ ( , ". the online reviews give the customer as second source of information from which to value a product. the assumption that the customer weighs the online reviews the same for both products follows the study of kwark et al. ( ) , in which the information precision of online reviews on products sold on a given online platform is assumed to be the same. the main notation that will be used in this paper is summarized in table . in the presence of online reviews and customer returns, we model the duopoly competition as a three-stage game. since a seller's decision on returns policy is relatively long term, as compared to its price decision, the returns policy should be set before the price decision is made. the game j o u r n a l p r e -p r o o f sequence is illustrated in figure . ( ) or no-refund ( ). in stage , both sellers set their optimal selling prices simultaneously. in stage , the customer decides where to buy to maximize utility, based on the returns policy offered (' { , , , }) and selling price. we now derive the optimal equilibriums for the duopoly starting with the stage game. to examine the impact of online reviews, we consider a benchmark case in which the platform does not enable online reviews (subscript ). the customer evaluates the product based on its own valuation on the product. given the sellers' returns policies ' and seller ′ selling price , the utility of a customer with valuation ( " on product is: where { , }. on the right-hand side of eq. ( ), the first and the second terms are the expected valuation when the customer purchases and keeps the product (if the product is satisfactory), and when the product is unsatisfactory and returned (with an mbg from seller ) or kept (with a-no-refund policy from seller ). with online reviews (subscript ), for { , }, the customer with value ( " on product has the utility: ( ) and ( ) capture the impact of the seller's returns policy on the customer's utility. with eqs. ( ) and ( ), for { , }, the customer's utility function ( ) can be generalized as: where Γ < if with online reviews if without online reviews and j with a no refund policy with an mbg policy . the customer will buy the product if the utility is non-negative. in addition, the customer will select a seller, either seller or seller , based on maximizing the utility function. with eq. ( ) in the second stage of the game, the two sellers decide their selling prices simultaneously. given the two sellers' returns policies ' set in the stage game, for { , }, seller 's profit function is: where x : is given by the margin profit multiplied by the demand of seller . we define y : as the highest net valuation of the customer ( ) for product . then \ : table a in the appendix. \ : z [ is referred to as the "maximum net shared value of seller " in this paper. (see also chen and chen ( b) . here we are presenting an extension of that work, with consideration of online reviews.) maximizing the profits of both sellers, the optimal price ( : * ) can be derived, as summarized in the following proposition. proposition . for { , } and any given returns policies of two sellers ' , the duopoly has unique optimal prices for cases with and without online product reviews, as given by: we define c the optimal profits of the two sellers are: lemma implies that as long as the efficiency of seller selling a high-quality product relative to that of seller selling a low-quality product (p : ) is comparable (between c and f ), the duopoly can coexist. this then implies that when p : < c < , seller will be driven out of the market; when p : f , seller will be driven out of the market. here we focus on the case when the two online sellers are in sustained competition, that is, they can coexist. since the boundary values ( c and f ) depend only on the returns rates of the two sellers, they only need to know whether or not their relative efficiency (p : ) falls in the range [ c , f ] to know whether or not they can survive in a competitive market. obviously, the presence of online reviews affects the efficiencies of both sellers, and thus affects their relative efficiency (p : ), where c , f , p : are listed in table a in the appendix. in the first stage of the game, the two online sellers simultaneously decide their own returns policies. we define r : \ : c \ : s as the net value of offering an mbg for product . we have: notice that Γ for (with online reviews) and Γ for (without online reviews). Γ and t ( "( ℎ " represent the impact of seller 's no-refund policy and online reviews, and the expected recovery value of a returned product on the net value of offering an mbg for product , respectively. the net salvage of product (the salvage value after offsetting seller 's costs of handling the returned product and the customer's cost of returning the product) is ∆ ℎ . with the profits of the duopoly in eq. ( ), we have the first-stage game decisions on returns policy, as summarized in proposition , where t , ∆ , and r : are listed in table a in the appendix. here proposition extends this result by considering that the customer's valuation of a product is discounted for a no-refund policy and adjusted by the availability of online reviews. even more than in a physical store, where the customer can visually inspect the product, in online shopping a no-refund policy will decrease the customer's valuation on the product. the implication of proposition is that with the customer's disutility on a no-refund policy, the seller's choice of whether or not to offer an mbg policy depends on several factors: the net salvage value of the product (∆ , reflecting the efficiency of seller in handling the returns product), the quality of the product, the weight the customer assigns to information from online reviews, and the customer's disutility on a no-refund policy ( ). proposition provides an easy-to-implement mechanism for seller 's choice of returns policy, as the decision depends only on the factors/parameters related to its own selling channel and product, independent of the competitor's. the online seller can and should carefully estimate these factors. proposition also suggests that even when ∆ is negative, seller may still offer an mbg. the higher the disutility the customer has on a no-refund policy ( ), the more likely the online seller is to offer an mbg. comparing r and r (eq. ( )), we have a direct result as follows. eq. ( ) gives r < r , implying that the value of offering an mbg is reduced (from to " in the presence of online product reviews. lemma shows that when the customer can obtain information on the product through online reviews before purchase, the value of an mbg is reduced. this is because online reviews provide a customer with additional information on the products before purchase, and reduce the risk of mismatch with expectations, reducing the risk of a need to return the product. lemma also suggests that the more information the online reviews provide, the less dependence a customer has on an mbg policy. the implication is that if the members of the duopoly decide not to offer mbgs, they should make efforts to improve the usefulness of their online reviews to reduce the customer's risk of buying an unsatisfactory product. in this way, the sellers can save the cost of returns service while keeping the customer's loyalty. the impact of online reviews . eqs. ( )-( ) show that a seller's demand and profit increase with its own maximum net shared value (\ : ", but decrease with the competitor's maximum net shared value, for any returns policy (') of the duopoly and both with and without online reviews. in this section, we first discuss the impact of online reviews on \ : . let ∆\ z [ be the difference in seller 's efficiency with and without online reviews if it offers a returns policy . we have the following results: proposition implies that if online seller offers an mbg ( ), online product reviews reduce the seller's efficiency of selling the product. in addition, ∆\ c increases with and , and decreases with . in general, the value of online reviews ( ) reflects the customers' aggregate valuation on product after experiencing the product. an individual customer's valuation of product pre-purchase changes after reading online reviews, in view of other customers' experiences with the product. proposition shows that the presence of online reviews results in a j o u r n a l p r e -p r o o f decrease in the maximum net shared value if an mbg is offered. it is interesting to see that if seller offers a no-refund policy ( ), the presence of online product reviews will not always reduce seller 's efficiency in selling the product; if the value of the online product reviews is sufficiently high, the reviews can increase all customers' expected value on the products, and enhance seller 's efficiency in selling the product. the implication of proposition is that online reviews significantly impact a seller's efficiency in selling the product, as they change the customer's valuation and the decision to purchase and/or return the product. in addition, proposition suggests that sellers with a no refund policy could improve their efficiency in selling products by making efforts to, for example, effectively respond to customers, in order to have favorable reviews on their products. proposition provides a simple condition for a seller when it offers an mbg (r : ≥ ) with and without online reviews. a seller needs to evaluate r : in deciding its optimal returns policies. to examine the impact of online reviews on sellers' decisions with and without an mbg, we first compare the equilibrium prices, demands, and profits of both sellers for the cases with and without reviews, and for both sellers with an mbg (' { }" and with a no-refund policy let w z [ t be seller 's unit acquisition cost (if ) or unit net acquisition cost after offsetting the recovery value of a returned product (if ), where t ( "( ℎ ". we also define x , y , and z as boundary values for Δ , Δs , and Δx , respectively, where we can obtain y < z < x , and x , y , and z are listed in table a in the appendix. table a in the appendix. comparing the optimal prices, demands, and profits with online reviews to j o u r n a l p r e -p r o o f those without online reviews in eq. ( ) to ( ), proposition presents the impact of the values of online reviews on seller i's price, demand, and profit, where , . proposition . for ' { , }, the impact of the online reviews on the optimal prices, demands, and profits of the two sellers are summarized in table and illustrated in figure . figure . the impact of the value of online reviews ( ) on seller 's price, demand, and profit note that in figure , the changes due to online reviews vary with the value of the reviews. y , z , and x are threshold values of online reviews by comparing with the results of seller 's demand, profit, and price without online reviews. proposition shows that as compared to the case without online reviews, if the online reviews heavily favor product ( x ), the profit of seller increases as both the optimal price and market size of product increase. the intuition is that favorable reviews improve the average customer valuation on the product and thus increase the customer's willingness-to-pay, which allows seller to increase its price (positive price effect). in addition, positive online reviews make product more competitive than its competitor. as a result, seller attracts more customers j o u r n a l p r e -p r o o f (positive market share effect). both positive price and market size effects enhance seller 's profit. on the other extreme, when the value of online reviews on product is low ( < y ), the online reviews negatively affect product , due to a decrease in both the optimal price and the demand of product , leading to a reduction in seller 's profit. if the value of online product reviews on product is moderate ( y < < x ), the presence of online reviews has a negative price effect and a positive demand effect. online product reviews will enhance seller 's profit when z < < x (and decrease it when y < < z ) if the positive demand effect can outweigh (not outweigh) the negative price effect. for a given returns policy, in the absence of online reviews, the customer's valuation on the product is only based on its valuation on the product itself and the mbg if offered; with online reviews, the valuation depends on both information provided by the seller and information from online reviews. as a result, the online seller benefits from higher value reviews (high stars/scores), but it is hurt by relatively negative reviews. the implication of proposition is that in the presence of competition and online reviews, when the value of online reviews is moderately low, an online seller can expand its market share by reducing its price. this expansion, however, may not enhance its profit. if expansion of market share is a target for an online seller, this seller should put efforts into improving the value of online reviews by asking reviewers specific questions and enhancing other customer experience operations (online interactions with customers on products and quick delivery). the seller should, however, carefully evaluate when such market expansion can be profitable. the impacts of the value of online reviews of product ( ) on the prices, demands, and profits of the two products are summarized in the following proposition. lemma shows that in the presence of online reviews, for given returns policies of the two sellers ('), positively impacts seller 's own selling price, market share, and profit, and negatively j o u r n a l p r e -p r o o f impacts the competitor's price, market share, and profit. furthermore, the valuation of online reviews on a seller's own product has a larger effect on price, demand, and profit than that of online reviews of the competitor's product. lemma implies that in a market with competition, an online seller should consider customer reviews on both its own and its rival's products. comparing the impact of the value of online reviews ( ) on the price, demand, and profit of product with and without an mbg policy, we summarize the results in lemma . lemma shows that in the presence of online reviews, the impact of review value on the price of product with an mbg is higher than that with a no-refund policy. this suggests that the price with an mbg might be more sensitive to the change of review value than the price with a no-refund policy. the impact of review value on demand, however, is independent of the returns policy, and its impact on the profit of a seller with an mbg depends on the net shared value of the returns service of the seller relative to that of its competitor. when the net shared value of the returns service of seller is relatively higher than that of its competitor, its profit with an mbg is more sensitive to change of online review value than with a no-refund policy. this suggests that as the value of its online reviews increases, whether a seller with an mbg can be more profitable depends on the net shared value of its returns service relative to that of its competitor; furthermore, seller 's net shared value of returns service should be high relative to that of seller for seller l to be more profitable with an mbg. these results suggest that when the two sellers decide to offer mbgs (improving the efficiency of handling customer returns), they can benefit more from an increase in the value of online reviews. let t … y | f t , t … y | c t , t … z | f t ! √ ( " , and t … z | c t ! √ ( ss , if t < t … y ; y cc < y ss and z cc z ss , if t … y < t < t … z ; y cc < y ss and z cc < z ss , if t t … z . proposition shows that when it offers an mbg, online seller should have a higher value of online reviews, such that it can set a higher price than with a no-refund policy. without online reviews, the customer evaluates a product based on its own valuation only, and valuation is lower without returns service than with an mbg (because the returns service reduces the customer's risk of mismatch). online reviews may improve the customer's expected value of the product, if they are favorable enough ( ), and reduce the value of the returns service. in such a case, the seller offering a produce with good reviews and a no-refund policy has more space to increase the retail price. in other words, the more customers value the returns service, the lower the valuation on a no-refund product, and the more likely that price can be increased in the presence of favorable online reviews. favorable online reviews have a higher impact on the price of a no-returns product. as compared to a no-refund returns policy, whether or not online reviews will enable a seller to attract more customers and be more profitable with an mbg depends on t (the expected recovery value of a returned product). if t is low relative to that of its competitor (t < t … y ), online seller needs better online reviews for its product, such that it can attract more demand and be more profitable with an mbg. this means that online reviews have less positive effect on seller 's demand in the case with an mbg ( y cc y ss ). since the lower net salvage value may suggest a higher cost in handling customer returns, the seller who offers an mbg may lose the advantage in competition to gain market share if the reviews are not favorable enough; with the impact on price, it is obvious that seller is less likely to benefit from online reviews with an mbg ( z cc z ss ). this is because seller has less space to raise the selling price in view of positive online reviews, and less chance of expanding the market, due to the high cost of offering an mbg. if t t … y , a seller is likely to expand its demand by offering an mbg in the presence of online reviews. this furthermore suggests that the higher t , the more value the seller can recover from a j o u r n a l p r e -p r o o f returned product and the lower the cost of offering an mbg, which provides more space for the seller to reduce its price to compete with its rival in the presence of online reviews. therefore, by providing a good returns service (an mbg), online seller can attract even more demand. whether or not seller is likely to be more profitable from online reviews with an mbg depends on the strength of the positive effect of the demand increase and the negative effect of the price increase. if and only if t t … z can the advantage due to a higher net expected salvage value offset the lower expected value of an mbg resulting from online reviews, and allow the seller to be more profitable from online reviews with an mbg. the interactions between the impact of online reviews and customer returns in proposition provide some guidance for online sellers in deciding their returns policies. in the presence of online reviews, if the efficiency of handling customer returns is relatively low, they benefit less by offering an mbg; this benefit can be enhanced if the salvage value of a returned product sufficiently high. this result may explain the practice of online sellers in some platforms (such as tmall.com and amazon.com) in setting restrictions on returns (requiring intact tags and/or original packaging) to ensure a high salvage value of the returned product. we now discuss the impact of online reviews on the competition of the duopoly. we define ˆx ( " (where ‰ ‰ when ˆx , see in figure proposition : for ' { , } and ~ , s, x, the impacts of online product reviews on the two competing sellers' prices, demands, and profits are summarized in table . proposition and figure show that if • { ∈ ( c , f ", where ~ , s, x, the presence of online reviews has the same influence trend (either positive or negative) on both sellers' prices, demands, and profits, respectively; otherwise, online reviews positively influence one seller, but negatively influence the other seller. we refer to the range ( c , f " as the "symmetric effect range." now, we discuss the impact of online reviews on both sellers when the ratio of changes due to online reviews is in the symmetric effect range. no-returns case. proposition shows that the impacts of online reviews on sellers' optimal prices, demands, and profits depend on the relative difference in value of the online reviews of the two products. both online sellers will mark down their prices if the values of the online reviews (the scores) of the two products are comparable (in region v) and low ( < ˆx ), leading to intensified price competition (negative price effect on the competition). the intuition is that low values of online reviews for both products reduce the difference in the customer's valuation on the two products, and at the same time reduce the customer's utility overall, resulting in intensified price competition between the two sellers. on the other hand, when the values of online reviews are high for both products ( ˆx in region i), the presence of online reviews softens the price competition (positive price effect on the competition). when the value of online reviews of one product is significantly higher than that of the competitor's product, the online reviews have a positive impact on the seller's price and a negative impact on the competitor's price (figure (a) ). the implication of the result is that collaboration between the sellers in improving the value of online reviews could soften the price competition. notice that the dash-lines and solid lines are for the cases ' { , } and ' { , }, respectively, implying that an mbg at both sellers will always intensify the price competition of the duopoly. the impact on the demands of the two products (figure (b) ) depends on whether the value of j o u r n a l p r e -p r o o f product 's online reviews is higher or lower than the net shared cost of the product divided by the customer's satisfaction ( ˆy , "net unit cost"). if the review values of both products are higher than their net unit costs ( ˆy in region i), online reviews can serve as free advertisement for the products, attracting more customers and improving the demand for both sellers. conversely, if the value of online reviews is low ( < ˆy in region v) for both products, both sellers will risk losing customers, and the total market demand will decrease (positive demand effect on the competition). negative reviews may imply that the product is not as good as advertised, and both sellers will lose demand (negative demand effect on the competition). both sellers benefit in terms of profit from extremely positive reviews ( ( " ) ( figure (c)), as good reviews provide an opportunity for them to raise their prices and expand market size (positive effects in both price and demand). they both suffer from very negative reviews ( < ˆy ), due to both negative price and negative demand effects. when online reviews are moderate ( ˆx ˆy ), both sellers will reduce prices due to the lower customer valuation on the products and the intensified market competition, but demands will increase due to the price reduction. if the online reviews are favorable enough ( ˆz in region i), they will enhance both sellers' profits, since the positive effect of online reviews (demand expansion effect) outweighs the negative effect of lower customer valuations and intensified market competition. proposition suggests that under market competition, when the values of the reviews for the two products are comparable and relatively high, online reviews can benefit both sellers; when the values of the reviews are unbalanced only the high value seller will benefit. in addition, when the values are comparable and relatively low, both sellers are worse off, leading to a "prisoner's dilemma." the results suggest that a collaborative effort between the two sellers to improve the quality of online reviews (such as by encouraging answers to questions that customers care most about and rewarding informative reviews), might benefit both sellers. the impact of online reviews on the two sellers is different, however, under different returns policies. we summarize in proposition . proposition . for ~ , s, x and , , j o u r n a l p r e -p r o o f (b) ˆx cc ˆx ss , ˆy cc < ˆy ss , and ˆz cc ˆz ss , if < t < √ ; (c) ˆx cc ˆx ss , ˆy cc < ˆy ss , and ˆz cc < ˆz ss , if t √ . when both sellers offer an mbg, they have to mark down their prices because online reviews reduce the customers' highest valuation on the product (see dash lines in figure (a); recall that good online reviews reduce the risk of product/expectation mismatch and thus reduce the value of the mbg). when both sellers offer a no-refund policy, the customer's valuation on the product is low, and if reviews of both products are favorable enough ( ) the reviews may improve the customer's highest valuation on both products and allow price increases. in other words, online reviews only intensify the competition between two sellers with an mbg, but high value online reviews may soften the price competition between two sellers with a no-refund policy. the results in proposition imply that as compared to offering a no-refund policy at both sellers, offering an mbg at both sellers intensifies the price competition in the market. this result differs from the study of chen and chen ( b) , which shows (without considering online reviews) that offering an mbg at both sellers softens the price competition, as both sellers can raise prices in view of good post-sales service. we show that online reviews mitigate the advantages of an mbg, as they reduce the risk of mismatch before purchase. seller h and l, respectively; solid and dotted lines are for mbg and no-returns cases, respectively. as compared to the case of a no-refund policy (shown in figure ), when the value recovered from a returned product (t ) is negative (t < ), ˆ{ for both demand and profit with an mbg is high ( figures (a) and (c)). the implication of this result is that if seller cannot efficiently handle customer returns, its price and demand, and therefore profit, are more likely to decrease with online reviews. when t is moderate ( v t v √ ), ˆy is low ( figure (b)) while ˆz is high ( figure (c) ). this implies that the overall market is more likely to expand with online reviews. the positive t reduces the net unit cost of the products, leading to more space for the sellers to expand their market. however, since the online reviews cannot improve prices in the market, the revenue due to online reviews decreases, and the reviews are less likely to benefit the sellers. when t is sufficiently high (t ≥ √ ", ˆ{ for both demand and profit are lower (figures (b) and (d)). this suggests that online reviews can have stronger positive impact on the demands and profits of both products. with a high salvage value, the unit cost of a product is lower, and this provides more space for online sellers to overcome the negative effect of online reviews on their prices and thus benefit from the reviews. this implies that a prisoner's dilemma is less likely to happen if both sellers offer an mbg returns policy. j o u r n a l p r e -p r o o f note that the two sellers coexist in the range c v p v f , where p g`€ • g i€ • is the efficiency of seller relative to seller in selling products in the presence of online reviews. interestingly, this range is exactly the "symmetric effect range." in general, online product reviews reduce the customers' highest valuation and then reduce the maximum net shared value of the product with an mbg. when the relative changes of both sellers' efficiencies due to the presence of online reviews is in the relative efficiency range where the two sellers coexist, the customer perception of the difference in value between the two products is affected significantly by the additional information from online reviews. both sellers can either benefit or suffer. online shopping offers customers flexibility and convenience, but the lack of hands-on pre-purchase experience with products increases the risk of dissatisfaction, and causes high rates of customer returns. customers thus rely heavily on online product reviews when they make purchase decisions. online reviews may significantly affect the customer's valuation on products, and online sellers should consider the impact of reviews in their pricing and returns policies decisions. this paper examines the impact of online reviews in a competitive market with customer returns, and provides new insights into online sellers' optimal pricing strategies and returns policies. our research shows that ignoring the effects of reviews on online sellers' strategic responses to customer returns may lead sellers to misunderstand the processes and outcomes of online shopping and sales. we generate several managerial implications for online retailing. we identify the conditions under which both sellers should offer an mbg in the presence of online reviews. we find that this decision depends not only on the net salvage value of a returned product, as previously noted in the literature, but also on the degree to which the customer relies on online reviews. this implies that it is important for online sellers to consider the impact of product reviews when they choose a returns policy. our research also shows that the customer is less likely to rely on an mbg in the presence of online reviews, as online reviews provide additional pre-purchase information and reduce the risk of dissatisfaction. our results suggest that online reviews with comments that contain a lot of information and small variance may be most useful to customers, so the online seller with useful reviews and small variance can reduce the likelihood of customer j o u r n a l p r e -p r o o f returns and reduce the costs (to customer and seller) of returns service. our study also suggests that an online seller who sells a high-quality product is more motivated to generate reviews, and will benefit from relatively favorable reviews, as those reviews have more effect on the high-quality seller than on the low-quality seller. for a competing duopoly, online reviews may present the same trend of influence (either positive or negative) on both sellers, when the reviews of the two products are within a symmetric effect region. it is interesting that price competition is intensified between the two sellers if both offer an mbg. nevertheless, if the salvage value of the product is sufficiently high (for example, durable products), both online retailers are more likely to benefit from online reviews when they offer an mbg. our research provides new insights into the behavior of competitive online sellers facing customer returns and online reviews. in setting its returns policy, an online retailer must of course estimate the cost of handling the returned product, the customer's cost of returning the product, and the salvage value of the returned product. our results emphasize, however, that the online retailer must also evaluate the online reviews posted by customers who have purchased and experienced the products. our study can be extended in several ways. here we consider the impact of online reviews on the customer's valuation on product, but it would be interesting to examine how online reviews can affect the customer's satisfaction rate. the study could also be extended to examine how online reviews impact the decisions of the retailers and manufacturers in a supply chain facing customer returns. finally, the multi-period case, in which both sellers offer an mbg policy for a certain period of time, but a no-refund policy afterwards (final sale), might shed new light on all of the conditions and results discussed here. proof of proposition : with profits of two online sellers in eq. ( ), for { , } and r : ≥ , x : cz i x : sz i <(fe`de i "g`a m de`g ia b i h(fe`de i "g`a ƒ de`g ia b i -(fe`de i ""`a (e`de i "(je`de i " o n ≥ and x : z`c x : z`s e`<(fe`de i "g ia m de i g`a b`h (fe`de i "g ia ƒ de i g`a b`-(fe`de i "" ia e i (e`de i "(je`de i " o n ≥ . proof of lemma : for < , we have r r ( " < . for < fi (f-`di " o (cd‹"(" i€ d" o "`€" (je`de i " o (e`de i "‹ . for | c < | f < , we have x pricing strategies in a supply chain with multi-manufacturer and a common retailer under online reviews canada retail e-commerce sales customer return policies for experience goods implementing market segmentation using full-refund and no-refund customer returns policies in a dual-channel supply chain structure when to introduce an online channel, and offer money back guarantees and personalized pricing? compete in price or service? -a study of personalized pricing and money-back guarantees competing in a supply chain via full-refund and no-refund customer returns policies third-party product review and firm marketing strategy online consumer review: word-of-mouth as a new element of marketing communication mix the effect of word of mouth on sales: online book reviews when online reviews meet hyperdifferentiation: a study of the craft beer industry no refund or full refund: when should a fashion brand offer full refund consumer return service for mass customization products? return policies and the optimal level of "hassle product-oriented web technologies and product returns: an exploratory study the digitization of word of mouth: promise and challenges of online feedback mechanisms strategic manipulation of internet opinion forums: implications for consumers and firms the dynamics of online word-of-mouth and product sales-an empirical investigation of the movie industry demonstrations and money-back guarantees: market mechanisms to reduce uncertainty retailer's rationale to refuse consumer returns in supply chains top ecommerce rating and review tools: an overview decomposing the effects of online customer reviews on brand, price, and product attributes pricing, frills, and customer ratings online product reviews : implications for retailers and competing manufacturers self-selection and information role of online product reviews supply chain coordination with customer returns and refund-dependent demand how online customer reviews affect sales and return behavior -an empirical analysis in fashion e-commerce reviews, reputation, and revenue: the case of yelp product information websites: are they good for consumers? too good to be true: the role of online reviews' features in probability to buy promotional chat on the internet money-back guarantees: helping the low-quality retailer to keep or not to keep: effects of online customer reviews on product returns signaling quality with a money-back guarantee: the role of transaction costs consumer returns in the retail industry. national retail federation the plague of ecommerce return rates and how to maintain profitability office of consumer affairs. innovation, science and economic development canada e-tailer's return policy, consumer's perception of return policy fairness and purchase intention how unequal perceptions of user reviews impact price competition retail returns specialist optoro raises $ million in new funding how fashion ecommerce retailers can reduce online returns the impact of online reviews on customers' buying decisions the impact of online product reviews on product returns how much do online consumers really value free product returns? evidence from ebay price and money-back guarantees as signals of product quality consumer returns policies and supply chain performance how does the variance of product ratings matter? understanding money-back guarantees: cognitive, affective, and behavioral outcomes retail e-commerce explodes in canada amid covid- pandemic remote purchase environments: the influence of return policy leniency on two-stage decision processes do professional reviews affect online user choices through user reviews? an empirical study the authors gratefully acknowledge financial support from the fundamental research funds for the central universities (china) (grant no. jbk ), and the social sciences and humanitiesresearch council and the natural sciences and engineering research council of canada. ai, x., chen, j., zhao, h., & tang, x. ( ) . competition among supply chains: implications of j o u r n a l p r e -p r o o f full returns policy. international journal of production economics, ( ) , - . retail ( ) . consumer returns in the retail industry , https://appriss.com/retail/wp-content/uploads/sites/ / / /ar - -customer-returns-in-t he-retail-industry.pdf (accessed on august , ).anderson, e.t., hansen, k., & simester, d. ( ) . the option value of returns: theory and empirical evidence. marketing science, ( ) , - . archak, n., ghose, a., & ipeirotis, p. g. ( ) . deriving the pricing power of product features by mining consumer reviews. management science, ( ) , - . business bureau. your refund rights with retailers. https://www.bbb.org/new-york-city/get-consumer-help/articles/your-refund-rights-with-retailers/ (accessed on august , ). the boundary values of for Δ , Δs , and Δx , respectively. ˆx , ˆy , and ˆz the boundary values of for ‰ ‰ , ‰s ‰s , ‰x ‰x , respectively.the impact of the value of online reviews on seller 's price, demand, and profit relative to that of seller , where ~ , s, x. fe`e i (e`de i "n < , and for ' { , }, with prices, demands and profits of two online sellers in ( ) (je`de i " o (e`de i " ‹ < ;in addition, , then ˆy cc ˆy ss and ˆz cc ˆz ss . j o u r n a l p r e -p r o o f highlights • we consider two online sellers selling quality-differentiated products on a platform;• the online platform may enable customers to post and search product reviews;• the online seller's returns policy strategy under the impact of reviews is examined;• reviews impact the duopoly's decisions differently under different returns policies;• interactions between online reviews and returns policy are discussed for the duopoly.j o u r n a l p r e -p r o o f key: cord- -tpu oidi authors: sajnani, nisha; mayor, christine; tillberg-webb, heather title: aesthetic presence: the role of the arts in the education of creative arts therapists in the classroom and online date: - - journal: arts psychother doi: . /j.aip. . sha: doc_id: cord_uid: tpu oidi literature about the integral role of the arts in learning is widely available, but much less has been written about how the arts and aesthetics support education in the creative arts therapies, particularly in the online learning environment. this article introduces the concept of aesthetic presence within the community of inquiry pedagogical model in line with values espoused within a universal design for learning framework. the authors contextualize this concept with examples of how attention to the use of aesthetic and multimedia strategies in the classroom and in the online learning environment may foster openness and connection, encourage flexibility, humor, critical thinking, and animate and facilitate conversations about emergent and emotionally difficult themes while increasing accessibility for different kinds of learners. we need to advance our understanding of the role of the arts and aesthetics in the education of creative arts therapists in person and online. a primary contribution of creative arts therapists, as compared to verbal psychotherapists, is that we create an aesthetic framework, embedded in a socio-cultural context, from which to explore and examine experience as it arises between the client as artist, art-making, and a witness, in reference to the client's capacities to witness j o u r n a l p r e -p r o o f themselves, a group's capacity to witness each other, and the therapist's capacity to bear witness to what unfolds. we seek to facilitate aesthetic distance, an encounter within a representational realm that enables both emotional arousal and cognitive reflection (landy, ) . it follows, then, that the arts should play a formative role in training. this is particularly true in online learning environments where, given the absence of a physical encounter and the ubiquity of multimedia, attention to multisensory engagement would have particular relevance. in this article, we introduce the concept of aesthetic presence and discuss its importance in the education of creative arts therapists (cats) with specific attention to the online learning environment. we begin with a synthesis of literature on the arts in education and online learning in the cats. we then argue the relevance of aesthetic presence within a community of inquiry (coi) model of online learning design and pedagogy and connect this to values espoused with the universal design for learning (udl) framework, an inclusive approach to pedagogy that attends to the needs of different kinds of learners (cast, ) . we conclude with practical suggestions on how aesthetic presence may be enhanced in course design and instruction in the creative arts. while the recent coronavirus pandemic has forced us to make a rapid adjustment to how we teach and practice in the creative arts therapies, our hope is that these strategies may be useful going forward as we contend with course design, instruction and practice in blended in-person and online environments. despite the marginal status of the arts in education, many have written about the role of arts in facilitating learning (beardsley, (beardsley, , (beardsley, , berleant, ; clapp & edwards, ; croce, ; dewey, dewey, , duke, ; gardner, gardner, , gardner, , garrison ; goldberg & phillips, ; granger a; greene ; hausman, ; jackson ; maslak ; munro, ; sawyer, ; simmons & hicks, ; shusterman, shusterman, , shusterman, , j o u r n a l p r e -p r o o f webster & wolfe, ) . some literature exists on the pedagogical use of the arts in the training of creative arts therapists (butler (butler , (butler , a (butler , b deaver, ; gaines, butler, & holmwood, ; knight & matney, ; landy, hodermarska, mowers, & perrin, ; landy, mclellan, & mcmullian, ; mcmullian & burch, ; young, ) . even less focuses on online education in the arts therapies (beardall, blanc, cardillo, karman, & wiles, ; blanc, ; pilgrim, ventura, bingen, faith, fort, reyes, richmond, rosenthal-schutt, schwinn, & butler, ; sajnani, beardall, stephensen, estrella, zarate, socha, & butler, ) . the arts, including sound/music, movement/dance, drama/theatre, visual, literary, and media arts, offer teachers and students multiple forms of expression and facilitate skills in sensing, perceiving, observing, listening, thinking, problem-solving, and collaborating (clapp & edwards, ) . the value of attending to the aesthetic dimension of pedagogy has been argued by dewey ( ) , suggesting that learning occurs through experience and that aesthetic encounters deepen reflection and integrate theory with practice. dewey suggested the artist is able to "actively internalize, then externalize in their art, landscapes, events, relationships and ideas," thus facilitating new insights and possibilities (quoted in goldblatt, , p. ) . the artist transfers values from one field of experience to another, attaches them to the objects of everyday life and by imaginative insight make these objects meaningful. therefore, art, as symbolic of lived and potential experience continues to change with every interaction to offer multiple, contextual readings and perspectives. dewey's observations were reflected in contemporary and subsequent ideas about how people learn. for example, jung described the concept of active imagination, where the verbal free association of ideas, images, and beliefs could be expressed in visualizations, written and spoken narratives, drawn and painted images. from a learning perspective, active j o u r n a l p r e -p r o o f imagination creates a bridge by allowing the unconscious mind to teach the conscious body by facilitating new relationships between latent ideas, feelings, and desires (semetsky, ) . building on dewey's ideas, bruner ( ) described a learning process that oscillates between enactive representation (doing), iconic representation (images of real situations), and symbolic representation. working with the arts in education encourages socio-emotional engagement, integrates understanding, and fosters inquiry even in subjects that do not traditionally involve the arts. for example, sutherland ( ) explored the ways in which the integration of arts and nonverbal methods into traditionally "core" classes such mathematics have helped to develop these skills. furthermore, research in this area has demonstrated how symbolic, metaphoric, and poetic thinking shapes reasoning (thibodeau & boroditsky, ) . as webster & wolfe ( ) wrote in a harvard education review survey of the arts in education: aesthetic pedagogy allows students to create connections through imagining ideas and exploring how they relate to everything else one understands and feels. such a 'scenic' appreciation is not a luxury which teachers may indulge in as 'an extra,' but rather we contend that these aesthetic aspects are essential for learning experiences in order to help assist students to make important connections. (p. ) freire ( ) contributed significantly to how we understand the value of the arts in education through a critical lens. he described codification as the gathering of localized information and lived experience in order to create visual images of real situations that could then be used to catalyze dialogue and critical thinking. boal ( ) extended freire's ideas through enactive learning wherein participants act out, replay, apply, and actively seek out, rather than passively receive, information as a means for learning and liberation. lorde ( ) saw the arts, poetry specifically, as a liberatory epistemology of learning and unlearning, particularly for women, j o u r n a l p r e -p r o o f racialized people, and/or members of the queer community. as she wrote, "poetry is not a luxury. it is a vital necessity of our existence [...] poetry is the way we help give name to the nameless so it can be thought. the farthest external horizons of our hopes and fears are cobbled by our poems, carved from the rock experiences of our daily lives" (lorde, (lorde, , p. ). hooks ( has similarly written extensively about her use of expressive writing, storytelling, arts-based experiences, and consideration of the role of the body in the classroom, seeing education as a practice of affective and interpersonal freedom and transgression. the arts have been used in order to engage with and more fully include different kinds of learners (simmons & hicks, ) . bloom's ( ) widely used taxonomy of learning included an affective domain, and gardner's ( ) theory of multiple intelligences included musicalrhythmic, visual-spatial, and bodily-kinesthetic ways of knowing. most recently, the universal design for learning (udl) framework calls attention to the relationship between emotion and learning and the domination of text in pedagogical materials. a udl framework emphasizes the need for multiple means of engagement, expression, and representation so that students have various pathways "for accessing and comprehending information, for demonstrating what they know, and for increasing motivation and persistence" (udl on campus, n.d.) . the arts support these goals by strengthening socio-emotional coping skills, and self-awareness so as to allow students to find the right personal balance of demands and resources, sustain effort, foster collaboration, and self-regulation (farrington et al., ) . it is clear that the aesthetic dimension of learning engages a powerful mix of higher order thinking skills, imagination and creativity, self-regulated learning, interpersonal interaction, and affective, socio-emotional engagement. with the wealth of insight available on the importance of j o u r n a l p r e -p r o o f arts in education, it is imperative that we examine how the arts are integrated in the training of creative arts therapists where the arts are privileged as a way of sensing, knowing, regulating, and representing lived experience. there is a small but growing literature on how the arts are utilized in the teaching and training of cats, whether in person or online. several have written about the essential nature of art making in art therapy education (deaver, ; gerber, ; wix, ) . deaver and mcauliffe ( ) and fish ( ) explored the use of art-making in supervision and internship training. cahn ( ) specifically addressed the use of studio-based art therapy education. julliard, gujral, hamil, oswalk, smyk, and testa ( ) discussed the use of arts-based evaluation in research education. deaver's ( ) mixed-methods study pointed to the personal and professional importance of the consistent use of the arts across the curriculum. in dance/movement therapy, dance has been explored as a source of knowledge (capello, ) , a method for the personal and embodied growth of trainees (federman, ; payne payne , , and as a way to expand an educator's movement repertoire in order to strengthen their approach to teaching future dance/movement therapists (young, ) . in music therapy, the curriculum requires music therapy trainees to first learn a series of musical competencies in a primary instrument/voice, percussion skills, composition, and improvisation, and then practice applying these skills to a music therapy context (goodman, ) . matney ( , ) highlighted the value of teaching functional percussion skills through a simultaneous contextualization of these skills in a music therapy approach. these authors also pointed to the rarity of the term "pedagogy" in music therapy writing and suggest that there is a need for further research into the training of future music therapists due to the lack of empirical studies on the topic. j o u r n a l p r e -p r o o f butler ( butler ( , a butler ( , b ) has written about the use of drama exercises in drama therapy classrooms and asserts that such approaches are necessary in drama therapy education. his qualitative research pointed to the complexity of training students in therapeutic work without it becoming therapy, as well as the importance of learning through arts-based practice. he suggested that drama therapy education must engage students in "continual embodied reflective practice rather than a merely cognitive reflection" (p. ). several have built on landy's ( ) four-part education model, suggesting additional ways to incorporate embodied and drama-based forms of learning (landy et al., ) , including the use of existing theatrical characters and monologues to learn about clinical diagnoses (mcmullian & burch, ) , embodying clients and therapists in supervision (landy et al., ) , and weaving situated, psychodynamic, and enactive learning with experiential activities (butler, a). only six publications to date are known to have explored teaching cats online (beardall et al., ; blanc, ; lagasse & hickle, ; pilgrim et al., ; sajnani et al., ; vega & keith, ) . vega and keith ( ) focused their research on the scope of online learning in music therapy courses and conducted the first in-depth study in the us. their research revealed that many of the music therapy educators who were surveyed had received queries about online learning, suggesting a growing interest in the adaption of music therapy in online and distance settings. this initial survey research provided a snapshot of the state of online learning in music therapy and confirmed that, as of their publication date, no training program was offered fully online. lagasse and hickle's ( ) mixed methods study compared the perception of community and learning for music therapists in an online and residential graduate course. their quantitative results found no significant difference in perceptions of community. their qualitative data suggested that the presence of the instructor, peer interaction, and multiple online tools were important in creating a sense of community for those enrolled in the online course. online students did have a statistically significant higher perception of learning score than their residential peers, which the researchers attribute to the online students having more experience in the field and thus more investment in the learning process. no qualitative or quantitative measures examined the role of music or aesthetics in perceptions of community or learning. beardall et al. ( ) outlined the development of a comprehensive hybrid low-residency training program for dance/movement therapists. the authors described their attempts to develop an "embodied online presence," as a way for students and faculty to create and sustain a kinesthetic and affective presence online. they articulated the importance of creating opportunities for their dance/movement students to develop and trust their "bodily-felt sense" (p. ) through a variety of explicit activities involving filmed and synchronous dance and movement exercises and assignments, as well as instructors' "listening to and observing students' verbal and non-verbal cues and responding sensitively" (p. ). the authors spent a significant part of their article articulating their use of a range of synchronous and asynchronous tools for teaching, discussion, and assignments, which may be helpful for others interested in developing or improving online and hybrid learning options for cats. blanc's ( ) phenomenological pilot study explored more deeply this concept of embodied presence for dmt hybrid students, finding importance in artsbased responses and layered engagement between movement, other arts responses, and cognitive learning. she provided a sample of these layered assignments and indicates the importance of the most recent publication, co-authored by pilgrim et al. ( ) , presented findings on the first low-residency drama therapy cohort at lesley university. this phenomenological study explored this cohort's experiences, finding that virtual methods for creating experiences of embodiment, connection, and relationship using a combination of technology and artistic expression were seen as critically important. the study also found that several students began to shift away from the dramatic medium during the online teaching components of the hybrid program. furthermore, this study reported that the most substantial critiques of the program centered on some course instructors' lack of relational presence and communication. we see this article as a contribution to addressing ways in which instructors might develop an aesthetic presence to support relationship building and artistry in their course design and instruction in order to mitigate the kinds of difficulties that students face in an online learning environment. a foundational model for conceptualizing a successful online learning experience has been the community of inquiry model (coi) (garrison, anderson, & archer, ). the coi model presents three "presences" required in a successful learning experience: teaching presence, cognitive presence, and social presence integrated seamlessly in an online environment (garrison j o u r n a l p r e -p r o o f & cleveland-innes, , p. ). the coi model clarified the importance of the educational experience culminating in more than simply the mastery of content or cognitive engagement. it arose naturally to meet the challenge of creating a strong sense of community within a text-based environment . what follows below is a brief overview of the teaching, social, and cognitive presences articulated by coi, as well as some of the critiques of this model. teaching presence is the "design, facilitation, and direction of cognitive and social processes for the purpose of realizing personally meaningful and educationally worthwhile learning outcomes" (anderson, rourke, garrison, & archer, , p. ). whereas in a traditional classroom environment, teaching presence may be intuitive and communicated strongly through non-verbal cues; teaching presence in the online environment needs to be an intentional process. for example, glazier ( ) conducted a study of rapportbuilding strategies in the online classroom to improve student success, including providing video updates, personal emails, and personalized comments on assignments. students receiving these rapport-building communications from their instructor were observed to have both higher grades and lower attrition rates. social presence. social presence, particularly in the context of computer-mediated communication, is the degree to which the environment can facilitate immediacy. as rourke et al. ( ) describe, social presence includes verbal and nonverbal communication practices that increase closeness and interaction with instructors and students alike. social presence "supports cognitive objectives through its ability to instigate, sustain, and support critical thinking in a community of learners" (rourke et al., , p. ) , facilitating learning that is both socially and emotionally engaged. it has been identified as a key predictor of student satisfaction; in one study, j o u r n a l p r e -p r o o f it accounted for % of satisfaction (gunawardena & zittle, ) . sung and mayer ( ) identify five facets of social presence that impact student success and satisfaction, namely, "social respect (e.g. receiving timely responses), social sharing (e.g., sharing information or expressing beliefs), open mind (e.g., expressing agreement or receiving positive feedback), social identity (e.g., being called by name), and intimacy (e.g., sharing personal experiences)" (p. ). it is important to note that some have argued that social presence does not need to be included as a separate presence in coi and have been critical of its inclusion (annand, ). cognitive presence. finally, cognitive presence is fundamental to a learning environment that cultivates critical thinking skills ) and while it is held by the learner, it is heavily guided by the interactions in the learning experience. the underlying principle of cognitive presence is engagement in the practical inquiry process, and "the extent to which the participants in any particular configuration of a community of inquiry are able to construct meaning through sustained communication" (garrison et al., , p. ). garrison and cleveland-innes ( ) conclude that cognitive presence is reliant on the quality of interactions that occur throughout the instructional experience, and suggest instructors provide clear expectations and structuring of activities, conduct assessment aligned with intended goals, and select manageable and appropriate online content. as garrison et al. ( ) articulate, cognitive presence facilitates students' working through problems or issues that emerge in learning through exploration and meaning making. limits of coi. the coi model by its very nature is reductionist, dissecting the components of a learning community for analysis by instructors and learning designers interested in ensuring a full learning experience. in terms of its comprehensiveness, various authors have explored whether there are other "presences" or gaps. lam ( ) and shea and bidjerano ( ) j o u r n a l p r e -p r o o f observed that coi lacks an explicit focus on the learner. vladimirschi ( ) identified the need to consider cross-cultural implications. cleveland-innes and campbell ( ) suggested a need for developing emotional presence as part of social presence. kang et al. ( ) also explored emotional presence, through the components of perception, expression, and management, arguing it requires its own attention. anderson ( ) suggested agency be added as a fourth presence. agency also is relevant to the often-ignored conative domain (reeves, ) , which emphasizes the development of a learner's self-regulation. beardall et al. ( ) and blanc ( ) our proposed concept of aesthetic presence does not suggest a fourth, separate domain within the coi framework. rather, when deconstructing our online and hybrid graduate learning experience, it became clear that there was something missing in the coi model, both when explicitly teaching cats and other courses. our experience indicated that attending to the aesthetic dimension of online learning enhanced all three domains. the skillful use of images, sound/music, poetry, video and audio logs, and performances, for example, offered teachers and students multiple approaches to communicate and express themselves (teaching presence), open j o u r n a l p r e -p r o o f up and engage with concepts (cognitive presence), and interact with one another (social presence) (see fig ) . by paying attention to the use of arts and aesthetics, learning often resulted in rich dialogue, particularly when students were learning about sensitive topics (e.g., course material focused on privilege and oppression in the therapeutic relationship). indeed, parrish ( ) describes aesthetic experiences as "heightened, immersive, and particularly meaningful ones" and that they are "important to us because they demonstrate the expressive power of life" (p. ). this is not to suggest that text-based feedback cannot build an effective learning community; however, the use of technologies that take advantage of a multi-sensorial learning environment have been shown to increase a sense of community for students online (kumar et al., ) . for example, a study conducted on the use of asynchronous audio feedback in online learning found that audio feedback was more effective than text-based feedback for conveying nuance and was associated with students' feelings of increased involvement and learning community interactions, increased retention of content, and perceptions of care about the student (ice et al., ) . in this study, students were three times more likely to apply content when audio commenting was provided than when text commenting only was provided, suggesting greater engagement with the course's content. to this end, we propose a definition for aesthetic presence and suggest how it might be applied in online learning environments in order to enhance learning experience. aesthetic presence involves a dynamic interplay of symbols, metaphors, and multisensory technologies to facilitate a complex representation of experience wherein imagination, cognition, and affect are optimally engaged. as previous literature has suggested, attention to the use of j o u r n a l p r e -p r o o f enactive, iconic, symbolic, embodied, and other sensory strategies may animate conversation, foster openness and connection, encourage flexibility and critical thinking, and facilitate conversations about emergent and emotionally difficult themes. aesthetic presence can be embodied in the instructor's approach, embedded in face to face, hybrid, and online course design, included in curricular activities and assignments, and fostered in and between students. in this section, we describe the necessary institutional commitment to acquire and use adequate technology to support online learning with a view to enhance aesthetic presence. we then include examples drawn from our own experiences designing and instructing courses to offer possibilities for cultivating an aesthetic presence in the virtual classroom. these serve as examples of how cognitive, social, and teaching presence can be enhanced by the arts. we are living in a visual economy where affect, experience, and content are communicated through animation, video, and biometrics. perhaps it is not surprising then that, while traditional instructional design models and literature are lacking in this area, recent literature in instructional design emphasizes the value of the aesthetic experience. as our capacities to capture and share images and video have become increasingly commonplace, our capabilities in online learning have been transformed (nakamura, ) . the relative ease with which one can now incorporate aesthetic presence into online and blended teaching has directly benefited from available technologies that readily allow for audio recordings, video recordings, image sharing, and live interaction time. today's learners can easily take photos or video and upload those multimedia objects to share with others through an ever-growing number of social media platforms, and can j o u r n a l p r e -p r o o f do so privately within the instructional experience if tools provided by the institution are able to support this. for example, investment in key platforms that integrate with learning management systems to support students and faculty in integrating multimedia and video into the learning experience seamlessly and privately such as voicethread (multimedia), kaltura (video streaming), and livetext (eportfolio) are recommended. because the tools are integrated into the learning management system and were selected because of their intuitive user interface, little technical expertise is required for either instructors or students to use these tools. ensuring that technology decision-making is aligned with instructional needs is a component of the decision-making process for acquiring technology tools to support instruction. and a conceptual and technical skill-set in aesthetics, the online environment is greatly enhanced. for example, learners and instructors need to be attentive to the environment and background in which they are recording video to ensure that it does not distract from their message. similarly, they need basic orientation in framing an image to ensure they capture critical visual data and in basic audio to ensure that the audio is adequate for the instructional audience. finally, a commitment to aesthetic presence should inform the design of the user interface in online learning platforms. from our perspective, a beautifully laid out, intuitive interface communicates care for the learning experience that will unfold and enhances an online community learning environment. when moving from a face-to-face to virtual instructional context, one of the biggest challenges is creating opportunities for immediacy and emotional engagement. the emotions embodied in the learning process can range from: positive emotions that motivate learners and enhance creative thinking, to negative emotions (such as situational anxiety) which, if not managed j o u r n a l p r e -p r o o f well, can undermine the learning process. meyer and jones ( ) articulate the ways in which technology might inhibit affective engagement and, more critically, engagement in the learning process as a whole. they write, "email, for example, works against the individual's ability to perceive accurately the other's emotional state because the other person cannot be seen or felt, thereby muting empathy and perhaps providing an explanation of the "online disinhibition effect," which occurs when one does not deal face-to-face with the effects of one's rudeness (p. ). the use of emojis, emoticons, and other forms of affective representation have recently been assessed for their utility in online learning. as dunlap and colleagues ( ) wrote, one way people make up for the lack of nonverbal behaviors and cues in primarily textbased environments is by using paralanguage, specifically emoticons. [...]for instance, people use :-) to show that they are happy or smiling. when used in text-based emc (e.g., email, threaded discussion forums, texting, social networking), emoticons function as textual representations of the nonverbal behaviors and cues prevalent in face-to-face communication, designed to convey clarity of intent and emotion in efficient, direct, and transparent ways. (p. ) emoticons may serve to facilitate a nuanced exchange between students and may be used to instill a sense of humor in the virtual classroom, as well as provide cues to both instructors and students of embodied, affective aspects of learning. similarly, orr ( ) has also suggested the use of emoticons and textually based description of body language or emotions when providing distance supervision. additionally, meyer and jones ( ) offered a synthesis of the use of humor in online courses in order to increase: learning, motivation for participation, enjoyment, and social bonding, and the sense of "bringing life" to the community. recognizing that laughter is less common online than in a face to face setting, meyer and jones ( ) called for a better understanding in how people "go online and feel emotion, including laughter and anger" (p. ). goodboy et al. ( ) introduced the concept of instructional humor processing theory, which posits that humor connected to course content may be motivating; whereas other types of humor j o u r n a l p r e -p r o o f might be distracting and interfere with learning. rourke et al. ( ) discussed the importance of humor and the expression of emotions in order to help instructors establish a social presence that is ideal for online learning. from a practical standpoint, this involves investing in user interfaces that permit the use of emoticons and avatars. it also means that online education may necessarily need to make use of personalized learning environments (phones, tablets, ipads, etc.) that permit an exchange of advanced personalized emotion technology such as bitmoji which are personalized avatars (dabbagh & kitsantas, ; walton, ) . sajnani ( ) used bitmojis to explore landy's notion of role, counter-role, and guide in drama therapy. in the online classroom, one of the authors (ns), used this strategy to explore identity which seemed to be motivating in that students found it fun to create and share. opportunities to cultivate affective immediacy and humor in online learning begins with the tone set by initial communications and assignments through the modeling of the instructor. when facilitating online learning, we have found that modeling the use of emoticons and/or textual descriptions of nonverbal affective cues early on in the semester helps to facilitate broader adoption of interweaving emotional cues in the online space. the use of icebreakers in online learning is already a best practice (chlup & collins, ; goodyear et al, ; mcgrath et al, ) . however, icebreakers also present an excellent opportunity for students to interact using a full range of multisensory technologies. for example, the instructor might assign a "check in" or introduction assignment in which students are invited to upload a written paragraph along with a video or image of a cartoon, photograph, dance, song, comic strip, or poem that represents something about who they are or why they have chosen to take a particular course. another icebreaker example used by one of the authors (cm) at the beginning of a synchronous virtual class was to ask attendees to make a sound and movement over j o u r n a l p r e -p r o o f video to demonstrate how they were feeling about their capstone research project. members of class portrayed a wide range of movements, sounds, and affect that demonstrated some levels of stress. as they witnessed the others in the class and themselves making these sounds and movements, many burst into spontaneously laughter and verbally reflected feeling both more connected to their classmates and their bodies. this permission for play, embodiment, and affect expression through an icebreaker also allowed students to engage with the research content of that lesson with more presence and engagement. in this example, the instructor also intentionally chose to make a sound and movement from her position teaching the course, which students reflected as important in demystifying the process of research and writing. indeed, instructors are encouraged to create their own arts-based introductions in order to model risk taking and to enhance their teaching and social presence online. having the instructor engage with the same artful assignments asked of students can cultivate a sense of trust. as lowenthal and dunlap ( ) suggest, the distance barriers can, "dull or even nullify online instructors' humannesstheir emotion, humor, sympathy, and empathy. these human qualities, established through personal sharing, help students develop a sense of trust in and connection with an instructor, which is foundational for cultivating the social presence needed" (p. ). their experiments with the use of digital storytelling and self-disclosure from the instructor and embedded throughout assignments in the course facilitated a deeper and more meaningful social presence and served to decrease the sense of isolation often articulated by many online learners. further, humor can forge bonds between classmates, deepen one's curiosity and desire to learn, aid in the retention of information, and help students to tolerate "difficult" or emotionally contentious learning material (anderson, ; bacay, ; shatz & loschiavo, ; stambo, ) . intentionally selecting some materials that include humor as part of the teaching method j o u r n a l p r e -p r o o f can be particularly effective when teaching online about potentially emotionally-loaded topics. for example, in a course that included content learning about racial microaggressions, one of the authors (cm) blended a traditional scholarly article (sue et al., ) with a buzzfeedyellow video that addresses similar content through humor and role reversal (boldly, ) . the instructor asked students to consider reflecting on the difference in their learning when reading the article versus the humorous video. their responses indicated that both were important and that the video made it possible for them to remain focused and able to engage with each other about what many agreed was difficult material. of course, humor and emotional expression are both culturally constructed and embedded, therefore, instructors should approach their use of humor from a critical and cross-cultural perspective in terms of difference, power, and social norms. for further reading on this topic, see bell ( ) , ellingson ( ) , and lu, martin, usova and galinsky ( ). teaching might be best understood through the metaphor of performance, where aspects like role, affect, embodiment, voice, delivery, and play are critical in engaging the imaginations and curiosity of the "audience" of students (lessinger & gillis, ; sawyer, ; timpson & tobin, ) . in an online setting, there is greater risk of the instructor becoming a faceless, lifeless entity, providing little in the way of performance in order to energize and enrich the learning environment. further, because of changes to technology, there is a shift in the expectation from learners about the manner in which they will engage with their instructors and peers. page et al. ( ) noted the shift in user expectation stating, "they do not want to stay in a passive role with different media… they want active participation and emotional engagement, to manipulate the presented objects and expect a degree of emotion and interactivity" (p. ). indeed, we have j o u r n a l p r e -p r o o f observed an increase in the expectations of learners engaging in online and blended instruction who anticipate interacting with the instructor authentically and through a range of media. incorporating improvisation makes it possible to avoid a deadened delivery in online settings where pre-recorded lectures, pre-scripted written materials, and rigidly scheduled online discussions and interactions are the norm. this is not to say that structured practices are not useful. rather, as sawyer ( sawyer ( , observed, disciplined innovation involves an interplay between repeating routines and improvised interaction. expected activities online provide a strong foundation from which creative improvisation and flexibility might emerge. similarly, in improvisation forms (dramatic form, jazz, etc), a set structure (or melody in the jazz metaphor) provides the steady beat against which creative and spontaneous moments can be created. from a practical perspective, aesthetic presence in online teaching includes a range of strategies. having clear expectations and schedules for learners is important, but should not preclude opportunities for improvisation, which keep the energy and engagement high. for example, in one course design, the instructors (ns & cm) created a schedule where a student was designated as a weekly discussion leader on the assigned readings and was responsible for posting a question for their classmates to answer within a designated time frame. by having the students create the questions, rather than the instructor, this structure maintained a sense of "new-ness." this approach also privileges a multiplicity of perspectives and voices, encouraging the instructor to respond in an improvised way to the flow of largely text-based discussions. in another example, students were invited to create an artistic response to the weekly readings and to use that as a common reference point for complex ideas conveyed in the assigned readings. the aesthetics of instruction involve a dance between offering framing or additional thoughts, probing questions, additional perspectives, summaries, and space for others to participate (mazzolini & maddison, j o u r n a l p r e -p r o o f ). depending on the topic of the course, instructors may incorporate additional articles, videos, art-making or news items that are related to the weekly content which also ensure that courses that are repeatedly taught each year are met with a renewed sense of purpose and content. live improvisation through synchronous video also heightens engagement. using programs such as periscope, youtube live, and facebook live make it possible for students to interact immediately with course content. another faculty member at the same university, angelica pinna-perez, held monthly gatherings to enable on-campus and low residency students to form community and interact. these 'create on the th' sessions involved live streaming from a maker space in which on campus students were engaged in making art, writing, singing, and reading their own poetry while other students participated from their respective locations (beardall et al., ) . we suggest that course design and instructors that experiment with ways in which the arts and multi-sensory technologies might offer new possibilities for engaging learners. the arts can encourage students to participate in praxis wherein personal experience is brought to into conversation with the material presented, applied, and reflected upon. in one class, filming weekly video lectures made it possible to not only frame the topic and the required readings for the week, but also modeled self-reflexivity and the use of personal experience as the beginning of learning. when teaching a module on religion and spirituality in the arts therapies, one of the assigned readings discussed the role of music and religion. as part of the introductory video for that module, the instructor (cm) included a brief story about her grandmother who had been quite ill for several months before her death, where playing hymns at her bedside resulted in an increased orientation to time and space, a brightening of affect, and less discomfort. sharing this story with j o u r n a l p r e -p r o o f students provided a concrete example of some of the intersecting dynamics of aging, music, religion, and pain, worked to enhance the instructor's social presence online, and encouraged students to make the material they were reading meaningful. students were invited to share their own stories about religion and music in relation to the assigned readings, with multiple students uploading musical audio clips alongside their video or textual storytelling. in another course pertaining to trauma and recovery in the context of global mental health, the instructor (ns) asked participants, all of whom were health care providers or humanitarian aid specialists, to create a video in which they used images, music, and/or video to communicate how they contributed to a healing environment. despite their initial hesitation, students almost unanimously proclaim this to be one of the best aspects of the course each year, commenting that the creative process of selecting and editing images, sound, and footage facilitated their reflection on this important topic. collaborative art making also facilitates cognitive connections in the online classroom and opportunities should be woven throughout courses. in general, small groups create the opportunity for students to commit to their colleagues and allow learners to problem-solve collectively (fink, ) . group work promotes positive interdependence, social skills, verbal interaction, individual accountability and group processing (kaufman et al., ) , all of which can be better supported in online instruction through the incorporation of aesthetic presence. indeed, part of the work of instructional design and delivery is including opportunities for cognitive capacities to be strengthened alongside social and emotional capacities, which can be enhanced through the use of the arts and aesthetic presence. from an implementation perspective, for team-based learning to work well, teams should be assigned early in order to anticipate and plan for working together on specific assignments. similarly for these types of group projects, it is important to orient learners to a variety of tools j o u r n a l p r e -p r o o f that might aid their collaboration, including, but not limited to, options for their own synchronous collaboration space online (e.g., through zoom, microsoft teams, blackboard collaborate, adobe connect, google docs). ideally, team-based cooperative projects are scaffolded so that there are regular check-ins and adequate time in between those check-ins for groups to convene and make forward progress on their collective work (paulus, ) or students can be guided in strategies for collaboration on project co-creation. if the final product is an academic paper or text-based project, including a visual representation of the work as part of the final deliverables can effectively support learners in demonstrating their own use of aesthetic presence. for example, a hybrid course (designed by ns and taught by ns and cm), included a group project focusing on cultural literacy. groups of - participants were formed during the inperson residency and presented their final work later in the semester online. in this assignment, group members chose a film or television show addressing issues relating to identity and were asked to critically analyze their chosen media through the concepts of power, privilege, and oppression. they were then asked to represent their collaboration and their perspectives through a co-created work of art (music, imagery, video with movement, etc.) and to then present this artwork in a minute presentation using voicethread. this technology made it possible to present their artwork, slides, and an oral presentation in a single platform. other students were able to leave audio feedback which heightened the sense of interactivity in the class. for example, one group (taught by cm) focused their presentation on what is gained and potentially lost in crosscultural communication used their art as a way to engage and demonstrate this learning. one group member created a piece of visual art and sent it to the next member electronically with no explanation of their piece. the next member witnessed this visual art piece and filmed a dance/movement video based on their own reaction to the original film and the visual art piece j o u r n a l p r e -p r o o f they were sent. the third and final member watched this dance/movement video and created their own poem in response to the original film and the film that was created by their teammate. in their voicethread presentation, this group uploaded all three arts pieces and then discussed the intention behind their individual art-making, how they viewed their teammate's piece, and moments of disagreement, surprise, or new learning in hearing what they others had taken from their artmaking, all serving as a beautiful example of what assumptions arise about another and potential challenges and growth opportunities in cross-cultural communication. this assignment required that students not only engage with one another, but also to do so creatively and collaboratively through arts processing, in order to heighten engagement with the material and foster a community of learning. in course evaluations, students regularly highlight this project as a way to interweave new learning with aesthetic processing, as well as an opportunity to connect with other students. what differentiates the creative arts therapies from traditional forms of psychotherapy is that this practice unfolds within an aesthetic frame. aesthetic engagement should, therefore, be reinforced within the process of learning in both in-person and online settings. a stronger integration of the arts in classroom instruction and online may also encourage students to retain their unique aesthetic sensibilities in practice, especially in environments dominated by verbal or textual intervention. the integration of various modes of symbolic communication also increases access to learning for different kinds of learners. while two of the three authors are educators within the creative arts therapies, aesthetic presence should not be seen as limited to courses that explicitly involve the arts. rather, aesthetic presence should be considered in design, instruction, and delivery for any subject area. in the context of remote education, conscious attention to aesthetic presence in online teaching and learning may help to mitigate disengagement and j o u r n a l p r e -p r o o f enhance existing cognitive, social, and teaching presences. finally, we believe that aesthetic presence is something that each of us will need to cultivate in this new era marked by social distance. it is therefore critical that we continue to innovate ways of creating and sustaining holistic, multi-sensory learning environments and assess their impact in the training of creative arts therapists from the perspective of educators, practitioners, students, and those we serve. treated in school-based settings, and the use of the arts as a way of knowing. she is an adjunct professor at wilfrid laurier and in the low-residency program at lesley university. christine is the associate editor of drama therapy review. heather tillberg-webb, phd is the associate vice president of academic resources and technology at southern new hampshire university, where she oversees the strategic implementation 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of inquiry: instructor perspectives and challenges do you even bitmoji? reify media incorporating the aesthetic dimension into pedagogy udl on campus (n.d.). udl in higher education bringing my body into my body of knowledge as a dance/movement therapy educator bct is associate professor and director of the program in drama therapy and the theatre & health lab at new york university. she is the editor of drama therapy review phd candidate, ma, bct/rdt is a drama therapist and phd candidate at wilfrid laurier university where she specializes in the racialization of how trauma is defined and