This article aims to assess the quality and reliability of the medical information shared on YouTube regarding neck pain.More than 70 percent of the world's population is tortured with neck pain more than once in their vast life, of which 50–85% recur within 1–5 years of the initial episode. With medical resources affected by the epidemic, more and more people seek health-related knowledge We searched on YouTube using the keyword “neck pain” to include the top 50 videos by relevance, then divided them into five and seven categories based on their content and source. Each video was quantitatively assessed using the Journal of American Medical Association (JAMA), DISCERN, Global Quality Score (GQS), Neck Pain-Specific Score (NPSS), and video power index (VPI). Spearman correlation analysis was used to evaluate the correlation between JAMA, GQS, DISCERN, NPSS and VPI. A multiple linear regression analysis was applied to identify video features affecting JAMA, GQS, DISCERN, and NPSS.P = 0.012), JAMA (P < 0.001), DISCERN (P < 0.001), GQS (P = 0.001), and NPSS (P = 0.007). Spearman correlation analysis showed that JAMA, DISCERN, GQS, and NPSS significantly correlated with each other . Multiple linear regression analysis suggested that a higher JAMA score, DISCERN, or GQS score were closely related to a higher probability of an academic, physician, non-physician or medical upload source (P < 0.005), and a higher NPSS score was associated with a higher probability of an academic source (P = 0.001) than of an individual upload source.The videos had a mean JAMA score of 2.56 (SD = 0.43), DISCERN of 2.55 (SD = 0.44), GQS of 2.86 (SD = 0.72), and NPSS of 2.90 (SD = 2.23). Classification by video upload source, non-physician videos had the greatest share at 38%, and sorted by video content, exercise training comprised 40% of the videos. Significant differences between the uploading sources were observed for VPI (YouTube videos pertaining to neck pain contain low quality, low reliability, and incomplete information. Patients may be put at risk for health complications due to inaccurate, and incomplete information, particularly during the COVID-19 crisis. Academic groups should be committed to high-quality video production and promotion to YouTube users. Neck pain imposes a substantial economic burden on patients and renders them handicapped –5. More Classifying neck pain as neurotic or non-neurotic is critical and urgent, as this information is required to guide investigation (imaging necessity) and treatment decisions . There aUnfortunately, the current COVID-19 pandemic and concomitant restrictions have contributed to a severe shortage of conventional medical care –18. GiveTo the best of our knowledge, there currently exist no studies evaluating the reliability and quality of YouTube videos providing medical information to patients with neck pain. Especially against the backdrop of the COVID-19 pandemic, assessing the quality of the relevant videos regarding neck pain is crucial to determining the potential applicability of YouTube tutorials. This article aims to assess the quality and reliability of the medical information shared on YouTube regarding neck pain and to identify factors associated with the overall video quality or reliability.In this cross-sectional study, we used the search item “neck pain” on YouTube (accessed on 25 May 2022) and designed to include relevant videos for patients with neck pain. Search history records were deleted before the search to reduce the impact on search results. In over 50,000 search results, the top 50 videos by relevance were recorded for evaluation, which has been widely adopted as a feasible method of video selection in the literature within orthopedics –29. AddiThe following information was recorded during screening: (1) Title, (2) number of views, (3) number of likes, (4) number of dislikes, (5) video duration, (6) comments, (7) number of subscribers, (8) time since upload and (9) Video Power Index (VPI). The formula for calculating VPI is as follows: [(likes × 100/(likes + dislikes)) × (views/day)/100]. The index used to assess viewers engagement and video popularity has been successfully applied to previous research , 31, 32.According to previous studies , 28, 31,The accuracy and reliability of videos were assessed with the Journal of American Medical Association (JAMA) benchmark criteria, provided by Silberg et al.  Table 1Table 1. Since no assessment tool exists to comprehensively assess the educational content of neck pain, we created a new grading criteria [called the “Neck Pain Specific Score” (NPSS)] based on literature review and expert opinion , 35–39. Two independent orthopedic doctors (XZ and YY) assessed all included videos. Any discrepancies were settled by discussion with a third author for consensus (HL).Since YouTube videos with publicly available data was used, ethics committee approval was not required.post-hoc tests. Spearman correlation analysis was used to evaluate the correlation between JAMA, GQS, DISCERN, NPSS, and VPI. A multiple linear regression analysis was applied to identify video features affecting JAMA, GQS, DISCERN, and NPSS. For the video quality assessment, we use the intraclass correlation coefficient (ICC) to evaluate the scores between reviewers (XZ and YY). A guideline for evaluating ICC values was applied: excellent (>0.90), good (0.75–0.90), moderate (0.50–0.75) and poor (<0.50)  . All repA total of 50 videos were statistically analyzed. The videos occupied a total running time of 23,197 s and an average duration of 464 s (SD = 283). They were viewed an average of 581 times per day (SD = 626) for a total of 29,054 times per day. The mean time since upload was 1,504 days  and the average likes ratio was 96.78 (SD = 2.32). The videos received an average of 0.70 (SD = 1.16) comments per day, with an average of 12.43 (SD = 19.75) likes and 0.24 (SD = 0.28) dislikes per day. The mean VPI was calculated as 566.35 (SD = 613.49) .The included videos are categorized by upload sources and contents covered therein. Non-physician video sources accounted for the largest share , followed by academic sources , commercial sources , medical sources , individual sources  and physicians  .Among all contents, exercise training was the most frequently covered , followed by information about disease , non-surgical treatment , advertisement , and patient experience  .The videos had a mean JAMA score of 2.56 (SD = 0.43), DISCERN of 2.55 (SD = 0.44), GQS of 2.86 (SD = 0.72), and NPSS of 2.90 (SD = 2.23). The reviewers had excellent agreement for the JAMA score , DISCERN score , GQS score , and NPSS score .P = 0.012), JAMA (P < 0.0001), DISCERN (P < 0.0001), GQS (P = 0.001), and NPSS (P = 0.007), with videos from the academic group having the highest VPI, JAMA score, DISCERN, GQS, and NPSS. However, the VPI (P = 0.395), JAMA (P = 0.564), DISCERN (P = 0.869), GQS (P = 0.467), and NPSS (P = 0.329) did not statistically differ between the groups based on video content , the positive correlation between JAMA and GQS was 87.3% (p < 0.0001), the positive correlation was 72.3% the percentage between JAMA and NPSS (p < 0.0001), the positive correlation between DISCERN and GQS was 84.3% (p < 0.0001), the positive correlation between DISCERN and NPSS was 72.0% (p < 0.0001), and the positive correlation between GQS and NPSs was 73.7% (p < 0.0001). However, there existed no significant correlation between the total VPI and the other four scores , physician (P = 0.002), non-physician (P = 0.002) or medical (P = 0.002) upload source compared with an individual upload source. A higher DISECRN was closely related with a higher probability of an academic (P < 0.0001), physician (P = 0.005), non-physician (P = 0.006) or medical (P = 0.006) upload source than of an individual upload source. A higher GQS was closely related with academic (P < 0.0001), physician (P = 0.006), non-physician (P = 0.001) or medical (P = 0.003) upload sources than individuals upload sources. A higher NPSS was more associated with academic (P = 0.001) upload sources than with individual upload sources  is an important influencing factors that can be used to improve the reliability and quality of YouTube videos. This finding is consistent with those of other studies , 51. ThiIn contrast, the reliability and educational quality did not differ significantly among the video contents. The content of the videos included in the study mainly covered exercise training, information about disease, patient experience, and non-surgical and advertisement information. Most videos contain only 1 or 2 of the above categories. Particularly striking is the mean NPSS of 2.90, as the maximum possible score is 18 points, highlighting the dilemma that the current videos lack of discussion of neck pain-specific information. With the lack of availability of in-person medical information exchange during the COVID-19 pandemic, patients suffering from neck pain are at risk of insufficient or inadequate information if they decide to educate themselves regarding neck pain.In our study, the popularity of videos was not significantly related to their quality or reliability, which was in agreement with previous research , 31. AccNeck pain occupies one of the top five chronic pain conditions according to prevalence and years of disability, placing a considerable burden on individuals and the social economy. While most acute episodes resolve spontaneously, more than 30% of patients experience mild symptoms or relapse more than a year later, with genetic and psychosocial factors being persistent risk factors . To makeA previous article recommended that a process of peer review during submission might be an possible solution , but theIn addition, the perception and understanding of the video will depend on the user's level of knowledge of the subject. In our study, we aimed to assess the quality and reliability of the medical information shared on YouTube regarding neck pain with internationally recognized evaluation standards and to identify factors associated with the overall video quality or reliability. According to our results, YouTube videos pertaining to neck pain contain low quality, low reliability, and incomplete information. Even the videos from academics or physicians are inadequate in terms of quality and instructiveness. Therefore, there is a need not only to improve the background of the viewer's expertise or to make the expert's videos readable through health education, but most urgently to improve the quality and reliability of the videos and the accuracy and comprehensiveness of the information they contain. Professional associations or credible healthcare organizations should introduce educational videos on relevant diseases that will meet all JAMA criteria, have a GQS of 4 or higher, contain adequate, accurate, and comprehensive information about the patient presentation (symptoms and patients population), evaluation and diagnosis, and treatment alternatives of the disease, and about its possible results and complications, and will not negatively impact the clinician-patient relationship .There are a few inevitable limitations in our study. First, the assessment scoring systems that we used (NPSS) are subjective and unvalidated. The NPSS included comprehensive contents of neck pain, while almost all YouTube videos focused on a specific topic and have a short running time of ~10 min or less. As such, it tended to be intractable to present all NPSS checklists. Nonetheless, considering that existing scoring criteria only non-specifically rate video quality rather than video content and no validated scales existed for assessing the content of video information, we designed quality assessment checklists based on a comprehensive review of relevant expert discussion and neck pain literature. Correlation analysis showed that NPSS was significantly correlated with JAMA, DISCERN, or GQS, which suggested that NPSS has a good application prospect. Second, we searched YouTube for the top 50 videos for “neck pain” by relevant. Actually, a default “relevance” sorting option was adopted by many studies when evaluating the reliability and quality of YouTube videos providing medical information to patients , 57–60. In particular, the current COVID-19 pandemic has highlighted the potential benefits of web-based education for patients suffering from chronic diseases. In light of its high popularity and ease to access, YouTube can be utilized to provide patients with timely medical information and tutorials for neck pain. However, this study suggested that videos concerning neck pain posted on YouTube showed low reliability and quality. The reliability or quality of the video is significantly related to the academic upload source. Video popularity was not associated with video reliability or quality, which suggests that popular videos do not guarantee good content quality. To ensure the dissemination of useful information, YouTube videos must be posted by academics to upload sources and strive to provide high-quality videos that aid in patient diagnosis and treatment.The original contributions presented in the study are included in the article/XZ and HL participated in the conceptualization of the paper. XZ and YY conducted the data searches on the internet. Y-WS, K-RZ, and L-TM extracted relevant and analysis data. CD, B-YW, YM, and HL critically reviewed the manuscript for important intellectual content. XZ structured and wrote the paper. All authors read and approved the final manuscript.This study was supported by the National Natural Science Foundation of China (82172522), Sichuan Province Science and Technology Support Program of China (Nos. 2020YFS0089 and 2020YFS0077), Postdoctor Research Project, West China Hospital, Sichuan University (No. 2019HXBH063), and the Postdoctoral Science Foundation of China (No. 2020M673240).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Attractive targeted sugar baits (ATSBs) control sugar-feeding mosquitoes with oral toxicants, and may effectively complement core malaria interventions, such as insecticide-treated nets even where pyrethroid-resistance is widespread. The technology is particularly efficacious in arid and semi-arid areas. However, their performance remains poorly-understood in tropical areas with year-round malaria transmission, and where the abundant vegetation constitutes competitive sugar sources for mosquitoes. This study compared the efficacies of ATSBs (active ingredient: 2% boric acid) in controlled settings with different vegetation densities.Anopheles arabiensis were released nightly (200/chamber) and host-seeking females recaptured using human landing catches outdoors (8.00 p.m.–9.00 p.m.) and CDC-light traps indoors (9.00 p.m.–6.00 a.m.). Additionally, resting mosquitoes were collected indoors and outdoors each morning using Prokopack aspirators. The experiments included a “before-and-after” set-up , and a “treatment vs. control” set-up (where similar chambers had ATSBs or no ATSBs). The experiments lasted 84 trap-nights.Potted mosquito-friendly plants were introduced inside semi-field chambers (9.6 m by 9.6 m) to simulate densely-vegetated, sparsely-vegetated, and bare sites without any vegetation (two chambers/category). All chambers had volunteer-occupied huts. Laboratory-reared In the initial tests when all chambers had no vegetation, the ATSBs reduced outdoor-biting by 69.7%, indoor-biting by 79.8% and resting mosquitoes by 92.8%. In tests evaluating impact of vegetation, the efficacy of ATSBs against host-seeking mosquitoes was high in bare chambers  but modest or low in sparsely-vegetated  and densely-vegetated chambers . Against resting mosquitoes, the ATSBs performed modestly across settings . Vegetation significantly reduced the ATSBs efficacies against outdoor-biting and indoor-biting mosquitoes but not resting mosquitoes.Anopheles populations or malaria transmission in the first place. Field studies therefore remain necessary to validate the efficacies of ATSBs in the tropics.While vegetation can influence the performance of ATSBs, the devices remain modestly efficacious in both sparsely-vegetated and densely-vegetated settings. Higher efficacies may occur in places with minimal or completely no vegetation, but such environments are naturally unlikely to sustain The online version contains supplementary material available at 10.1186/s12936-023-04625-z. The scale-up of effective vector control tools, notably insecticide-treated nets (ITNs) and indoor residual spraying (IRS), coupled with effective case management and other measures have contributed to significant reductions of malaria burden in sub-Saharan Africa , 2. UnfoFor vector control, there are also concerns of behavioral adaptations of mosquitoes, such as outdoor-biting and day-time biting –6. TheseAttractive targeted sugar baits (ATSBs) are a promising new technology that is increasingly being investigated for expanding the malaria prevention toolbox –17. The ATSBs can be deployed in different ways, e.g. by spraying on vegetation , 25 or sAvailable evidence suggests that current ATSBs have generally been highly efficacious in arid and semi-arid regions , 16, 33.This study was conducted inside the semi-field chambers at the Mosquito City facility of Ifakara Health Institute, in south-eastern Tanzania  , 36. SixMosquito-friendly plants were identified based on published records of feeding and survival rates by malaria vectors . Those tTwo vegetation densities were considered. These included dense vegetation cover in two chambers and sparse vegetation cover in two other chambers. Two other chambers were left bare to simulate settings completely devoid of plants. To achieve the densities of densely-vegetated, sparsely-vegetated and bare chambers, the plants were provided in ratios of 50:5:0 for potted plants, 6:1:0 for directly transplanted vegetation, and 6:3:1 for cut fruit Fig. . To ensuThe candidate ATSBs contained 2% boric acid (active ingredient) prepared in a 10% brown sugar solution. A green food dye was added to enable visual identification of mosquitoes that fed on the ATSBs. Preliminary tests comparing different ATSBs before selecting the test product are provided in Additional file Anopheles arabiensis were used. The mosquitoes were aspirated into small cages and starved for 9 h before being released. The mosquitoes were obtained from a common insectary maintained within the vector biology laboratory, the VectorSphere, at Ifakara Health Institute. This insectary is maintained under controlled conditions of 25–27 °C and 80% relative humidity. The larvae were fed on Tetramin® fish food and adults provided with a 10% sugar solution. A total of 200 mosquitoes were released in each chamber each evening at 6 p.m. and allowed to acclimatize in the environment for 2 h prior to the start of any recapturing. This was done in all chambers, regardless of the presence or absence of ATSBs, by gently opening and shaking the release cages so that no mosquito remained in the cages.Laboratory-reared 3–5 day old nulliparous adult females of In all tests, the process of recapturing host-seeking mosquitoes began 2 h after the starved mosquitoes had been released into the chambers. Human landing catches (HLC) were used to recapture outdoor-biting mosquitoes from 8.00 p.m. to 9.00 p.m. each night, after which the volunteers entered the huts inside each chamber to sleep under intact untreated nets. Thereafter, CDC light traps set beside the volunteer-occupied bed net was used to collect indoor host-seeking mosquitoes from 9.00 p.m. to 6.00 a.m. the following morning. Each morning at 6.00 a.m., Prokopack aspirators were used to collect resting mosquitoes inside and outside the huts for a fixed 20 min each morning. At the end of each test night, the Prokopack aspirators were used to remove any mosquitoes remaining in the chambers as exhaustively as possible, as the chambers prepared for the next trap-night.These mosquito collection procedures were maintained on all experimental nights and in all chambers regardless of presence or absence of ATSBs. To avoid biases in host-attractiveness, the volunteers were rotated between the experimental chambers each night. Each morning, all the recaptured mosquitoes  were killed and their abdomen examined for evidence of having fed on ATSBs. In the initial tests, all the mosquitoes that had fed on the ATSBs died within 24 h , while in the second phase, the ATSBs were introduced in the same chambers .The number of mosquitoes trapped by HLC (outdoor-biting densities), CDC-light traps (indoor-biting densities), Prokopack indoors (indoor-resting densities), and Prokopack outdoors (outdoor-resting densities) were compared between pre-intervention period (no ATSBs) and the intervention period (ATSBs added) to assess the efficacy of the ATSBs in each chamber.Six semi-field chambers were used, two with dense vegetation, two with sparse vegetation, and another two with no vegetation Fig. . The expThe first phase (pre-intervention phase) involved mosquito collections as described above but without any ATSBs in the chambers. This phase lasted 6 consecutive nights. In the second phase, ATSBs containing 2% borate were introduced into one of the two densely-vegetated chambers, one of the two sparsely vegetated chambers and one of the two bare chambers  were controls while the other half had ATSBs. Therefore, in addition to assessing the impact of vegetation cover, the design also enabled valuation of the effects of introducing ATSBs into chambers that previously had none, as well as comparing similar chambers with and without the ATSBs.lme4 package [Data analysis was done using the open-source statistical software, R version 3.6.2 . The ove package , followiThe efficacy of ATSBs was calculated as A separate set of GLMM models were used to compare performance of the ATSBs under different vegetation covers by considering data in the contemporaneous treatment and control chambers. Mosquito catches were used as response variable, while vegetation densities were added as fixed variable. Again, to account for any sampling biases and any unexplained variations between chambers and days, volunteers ID, chamber ID, and experimental day were added as random terms. Odds ratios and respective 95% confidence intervals were reported.ggplot2 package in R [All graphs were created using the age in R . Lastly,Model selection for the inclusion of the random effects  was done using Akaike Information Criterion (AIC), the model with the lowest AIC value was considered as a best model.An. arabiensis females (as measured using HLC) by 69.7% (95% CI 68.3–71.0%). In the same tests, the indoor-biting densities (as measured using CDC light traps) were reduced by 79.8% (78.9–81.1%) and the overall resting densities indoors and outdoors by 92.8% (91.6–94.6%). Full details of the findings are summarized in Table In the initial tests conducted to assess baseline performance of the ATSBs in bare un-vegetated chambers, introduction of the baits reduced the number of outdoor-biting An. arabiensis mosquitoes attempting to bite volunteers outdoors in all chambers, but mostly in the chambers with no vegetation. The catches were reduced by 25.4% (95% CI 24.2–26.6%) in densely-vegetated chambers by 34.5% (31.5–37.6%) in sparsely-vegetated chambers and by 64.1% (57.0–71.2%) in bare chambers without any vegetation , suggesting that vegetation cover reduced the efficacies of ATSBs against mosquitoes biting outdoors  were reduced by 16.1% (95% CI 15.9–16.9%) in densely-vegetated chambers, 26.2% (24.5–28.5%) in sparsely-vegetated chambers and 46.8% (39.7–55.1%) in bare chambers with no vegetation , again suggesting that vegetation cover reduced the efficacies of ATSBs against mosquitoes biting indoors . Similarly, the indoor-resting densities were reduced, in this case by 37.5% (95% CI 36.0–38.7%) in chambers with dense vegetation, 37.5% (36.4–38.7%) in chambers with sparse vegetation, and 38.7% (36.4–41.2%) in bare chambers without vegetation. Here too, there was no differences in impact between the chambers  . The outdoor-resting densities were reduced by 45.5% 95% CI 43.9–45.0%) in the densely-vegetated chambers, by 42.9% 40.9–43.6%) in the sparsely vegetated chambers, and 37.5% (36.7–38.5%) in the chambers without any vegetation. Data obtained from the HLC catches, appeared to show a bimodal distribution though the differences between intervention and control arms were still readily detectable  the efficacy of ATSBs against indoor or outdoor-biting mosquitoes was highest in areas devoid of any vegetation; (ii) while there was a significant effect of varying vegetation densities on the performance of ATSBs, the devices still provided modest protection in both densely-vegetated and sparsely-vegetated settings; and (iii) the vegetation-dependent differences in the efficacy of ATSBs were observed for host-seeking mosquitoes (indoors and outdoors) but not resting mosquitoes due to low recaptures, against which the ATSBs performed modestly regardless of vegetation cover. Collectively, these findings suggest that ATSBs may remain modestly efficacious even in tropical countries where there is moderate to dense vegetation.Mathematical evaluations of the potential impact of ATSBs have previously shown that even with modest mortality rates imparted by ATSBs on mosquito populations, the overall impact on malaria infections may be substantial , 49. TheAnopheles crucians for more 3 weeks. Similarly, Müller et al., showed in a small oasis full of vegetation and small freshwater springs in a desert area that ATSBs reduced the catches of Anopheles sergentii by 39% [An. sergentii over 95%.Published evidence suggests that the modest efficacies observed for ATSBs are not uncommon. In the large scale Mali trial by Traore et al., the application of ATSBs was associated with 26.3% reduction in human-biting densities as measured by HLC, even though the baits appeared to preferentially kill older mosquitoes . This tri by 39% . Interesi by 39%  applied Anopheles populations nor malaria transmission; thus they may not be priority settings for the deployment of ATSBs. In the field studies in Mali by Traore et al. [Another finding from this study was that the reduction in mosquito densities was highest in non-vegetated settings Table , a findie et al. , the popAnopheles gambiae declined by 90% [An. gambiae killed by boric acid were observed to increase with increasing concentrations of boric acid [It was also interesting to observe that the efficacy against resting mosquitoes was similar across all vegetation densities assessed, even though there had been clear differences when considering host-seeking mosquitoes. This lack of statistically-significant differences is partly due to the lower densities of resting mosquitoes collected compared to the densities caught by HLC and CDC light traps. Overall, there were fewer mosquitoes collected resting compared to those collected host-seeking indoors and outdoors. The observations of ATSBs retaining high efficacy despite competing plants and flowers have also previously been recorded in Mali in a semi arid region, where the relative abundance of both male and female d by 90% . One queric acid . Future The application of ATSBs outdoors, as done in this study, appears to have had implications for both indoor and outdoor-densities of mosquitoes. Mosquito densities were also reduced indoors across all vegetation covers Tables  and 3. ITo the best of our knowledge, this is the first study to directly assess the impact of vegetation densities on the performance of ATSBs. While the objectives were broadly achieved, a number of limitations are noted. Notably, the vegetation categories and plant ratios  were broadly arbitrary and might not be fully representative of all malaria-endemic communities. Furthermore, the candidate plants used here were those which had been previously shown to be preferred by mosquitoes . This stThere were some limitations regarding the methods of used. In particular, the vegetation densities were not rotated and instead this study combined a before-and-after design with a “intervention vs. control” comparison. The main reason for repeating the phases was to account for any variation caused by nightly weather changes, as random assignment in such a limited setting could potentially miss such variations and hinder the assessments of ATSBs efficacy. Besides, since some of the larger plants were actually planted in the chambers, rather than being potted, it was not possible to rotate the independent variable (vegetation densities). Instead, it became necessary to rotate the interventions between the chambers with similar vegetation covers. Moreover, since there were only six chambers available in total, the maximum number that could be assigned to any vegetation density was only two. To address these limitations, the study used multiple repeated measures in each semi-field chamber over a total of 84 nights, each time ensuring an appropriate set of controls. Broadly however, it should be noted that these systems remain limited and that such as study would be more realistic if they were: (a) conducted in real field settings in multiple villages having different vegetation densities over multiple seasons, (b) include a placebo treatment for the control arms, as well as appropriate blinding of volunteers to the study phases and interventions and (c) include enhanced statistical evaluations to better fit the data distribution, e.g. bimodal distributions in the HLC catches illustrated in Fig. An. arabiensis, further studies might focus on other species, such as Anopheles funestus, An. gambiae and Anopheles coluzzii, which are also major vectors in Africa.Secondly, it is possible that ATSBs may affect the natural mosquito foraging behaviours, and change the proportions foraging outdoors or indoors. In this study, the ATSBs were located at the eaves level and may potentially have caused a shift between indoor to outdoor feeding proportions. Unfortunately, since there were no comparative trapping observations between the indoor and outdoor locations, it was not possible to evaluate such effects in this study. Lastly, since this study was conducted for only Anopheles mosquitoes nor malaria transmission locally. Additional field studies therefore remain necessary to validate performance of ATSBs in different settings in the tropics. Such studies should also consider investigating the efficacy ATSBs applied indoors and outdoors.Attractive targeted sugar baits control sugar-seeking mosquitoes with oral toxicants and can be used both indoors or outdoors. This study has demonstrated that while vegetation densities can indeed influence the performance of ATSBs, the technology is likely to be at least modestly efficacious in sites with varying vegetation densities including sparsely-vegetated and densely-vegetated settings. It is likely that higher efficacies could be achieved in places with completely no vegetation, but such settings are naturally unlikely to sustain Additional file 1. A additional file to provide details on preliminary studies done prior to and in support of the main study.


Scientific Reports 10.1038/s41598-023-37111-2, published online 21 June 2023Correction to: In the original version of this Article Emiel Schoneveld was incorrectly affiliated with ‘College of Staten Island and the Graduate Center of the City University New York, 2800 Victory Blvd., 4S-108, Staten Island, NY, 10314, USA’, ‘Yale School of Nursing, Orange, USA’, ‘Yale School of Medicine, West Haven, USA’, ‘Nanit Lab, New York, USA’, ‘Brown University, Providence, USA’ and ‘New York University Grossman School of Medicine, New York, USA’. The correct affiliation is listed below:Research Institute of Child Development and Education, University of Amsterdam, Amsterdam, Netherlands.As a result, the Affiliations have been renumbered.The original Article has been corrected.


Therefore, we visualized the spatio-temporal dynamics of Mg2+ in keratinocytes (a skin component) in response to H2O2 (a type of ROS) and found that it increased cytosolic Mg2+ levels. H2O2-induced responses in both Mg2+ and ATP were larger in keratinocytes derived from adults than in keratinocytes derived from newborns, and inhibition of mitochondrial ATP synthesis enhanced the H2O2-induced Mg2+ response, indicating that a major source of Mg2+ was dissociation from ATP. Simultaneous imaging of Mg2+ and MMP revealed that larger Mg2+ responses corresponded to lower decreases in MMP in response to H2O2. Moreover, Mg2+ supplementation attenuated H2O2-induced cell death. These suggest the potential of Mg2+ as an active ingredient to protect skin from oxidative stress.Reactive oxygen species (ROS) are harmful for the human body, and exposure to ultraviolet irradiation triggers ROS generation. Previous studies have demonstrated that ROS decrease mitochondrial membrane potential (MMP) and that Mg 2+ dynamics in keratinocytes shows that a larger Mg2+ response corresponds to lower decreases of mitochondrial membrane potential in response to oxidative stress, suggesting a protective role for Mg2+ on mitochondria.Visualization of Mg ROS generation is attributed to several factors represented by enzyme activities of the electron transport chain in mitochondria2. Oxidative stress induced by ROS constitutes a harmful condition because ROS have high reactivity and cause DNA damage, lipid peroxidation, and protein carbonylation. These forms of oxidative damage increase with age4. Excessive ROS generation also causes mitochondrial dysfunction. In cellular-level experiments, the addition of H2O2 (a type of ROS) decreased mitochondrial membrane potential (MMP)6. Moreover, it has been reported that ROS-induced mitochondrial dysfunction contributes to various diseases, including Alzheimer’s disease, type 1 diabetes, atherosclerosis, and cancer7. Skin in particular is frequently exposed to ROS stress since UV irradiation from sunlight is the main generator of ROS1; ROS stress has been suggested to be involved in aging, inflammation, and pathogenesis of skin cancer, among other conditions9. Therefore, protecting biomolecules and mitochondria from ROS is critical for maintaining normal cellular functions, and cells express antioxidants and several mechanisms to avoid oxidative stress10. Skin cells, such as the keratinocytes and fibroblasts which constitute the epidermis, also have ROS clearance mechanisms11. In our previous study, we suggested that Mg2+ was involved in mechanisms to help cells avoid oxidative stress12.Reactive oxygen species (ROS) are constantly produced in the human body and have harmful effects. Exposure to ultraviolet (UV) irradiation in particular is a notable trigger for ROS generation2+ is the most abundant divalent cation in living cells and is related to more than 600 enzymes as a cofactor15. Recent studies have demonstrated that small changes in intracellular Mg2+ can have large impacts on cellular events, such as cell division, maturation of neurons, and neurodegeneration18. In neurons and cancer cells, intracellular Mg2+ is stored in the mitochondria and constitutes Mg2+ an important factor for sustainable mitochondrial functioning19. The impact of Mg2+ in relation to retaining MMP has been reported at the cellular and isolated mitochondrial levels22. The protective effects of Mg2+ toward oxidative stress have also been reported in various types of cells, such as endothelial cells24, bone marrow mesenchymal stem cells26, and chick embryo hepatocytes27. On the other hand, in monocytes the environment is the determining factor in whether high levels of Mg2+ will increase or decrease ROS levels28. These findings clearly indicate the important role of Mg2+ in protecting cells from oxidative stress. However, it has not been well understood whether cells change intracellular Mg2+ concentrations in response to oxidative stress, nor exactly how Mg2+ protects cells from oxidative stress.Mg2+ concentration in response to ROS in keratinocytes. Keratinocytes were chosen because they are one of the most ROS-exposed cells in the human body, as ROS are generated by UV from sunlight. The dynamics of cytosolic Mg2+ were visualized using fluorescence imaging under H2O2 stress to find that H2O2 induced an increase in cytosolic Mg2+ concentration ([Mg2+]cyto) due to the release of Mg2+ bound to ATP upon the H2O2-induced decrease in ATP level. The effects of Mg2+ on mitochondrial functions were investigated by comparison to changes in MMP to find that the increased Mg2+ attenuated the decrease in MMP. Interestingly, Mg2+ supplementation further suppressed the decrease in MMP and H2O2-induced cell death. Our results suggest that Mg2+ provides robustness to intracellular ATP levels under oxidative stress.In this study, we examined changes in Mg2+ in keratinocytes derived from adults (adult keratinocytes) were visualized with an Mg2+ selective indicator, KMG-104. It was confirmed that H2O2 did not directly react with KMG-104  and two from adults (40 and 57 years old donors: adult keratinocytes). There was large variability in the amplitudes of the H2O2-induced Mg2+ response in each cell, regardless of age  elicited increases in [Mg2+]cyto, even in newborn keratinocytes, indicating that this is not a phenomenon specific to adult keratinocytes, but simply that adult keratinocytes are more sensitive to H2O2 than newborn keratinocytes  decreased [Mg2+]cyto, indicating that inhibition of Mg2+ efflux leads to increase in [Mg2+]cyto in keratinocytes , those induced greater decreases in cellular ATP levels than 2DG alone , strong correlations between Mg2+ increases and MMP were observed; higher levels of cytosolic Mg2+ were correlated with lower decreases in MMP. Interestingly, these two plots appear to line up on the same line, indicating that [Mg2+]cyto is one of the key determinants for protecting the mitochondria from H2O2 damage  from opening, and activating the tricarboxylic acid (TCA) cycle, has been reported previously41. In the present study, MMP levels under oxidative stress were also determined by [Mg2+]cyto, which was perturbed by oxidative stress. This result suggests that the change in [Mg2+]cyto is a mitochondria-protective mechanism under oxidative stress conditions. Previous studies have also demonstrated the long-term effects of Mg2+ on cell protection in keratinocytes42 and other cells24. [Mg2+]cyto changes the activity of phosphatases, such as mTOR, CREB, and ERK16, and leads to cell protection under stress conditions in keratinocytes42 and neurons22. Therefore, Mg2+ has both acute and long-term protective effects for cells.In keratinocytes, oxidative stress changes metabolism drastically and acutely. Glucose usage changes from glycolysis to the pentose phosphate pathway within seconds of oxidative stress and decreased ATP levels occurrence2+. However, little has previously been known about the role of the dissociated Mg2+. It has been reported that an increase in [Mg2+]cyto, which is probably dissociated from Mg-ATP, is required for DNA condensation during mitosis in HeLa cells18, indicating that increased [Mg2+]cyto resulting from ATP consumption is not a byproduct but instead plays an important role in cellular events. In the present study, we demonstrated that increasing levels of Mg2+ during the process of ATP level decrease protected the mitochondria, an organelle that is responsible for ATP generation, under oxidative stress in keratinocytes. This suggest that Mg2+ acts as a negative feedback signal to maintain ATP level against stress on cells. Some studies have already demonstrated that mitochondria was protected from oxidative stress under Mg2+ rich conditions, but these studies have not referred to changes in [Mg2+]cyto levels42. Our data reveal that [Mg2+]cyto increases in response to oxidative stress and that Mg2+ that dissociated from Mg-ATP is not a byproduct but instead acts as a mechanism to protect the mitochondria. Since the protective effect of Mg2+ supplementation against oxidative stress has been reported in other cell types27, the mechanism revealed here might be common in mammalian cells to protect cells against cellular stress.Dissociation from ATP is a well-known source of Mg2O2 induced an increase in [Mg2+]cyto due to dissociation from Mg-ATP, and the increased [Mg2+]cyto protected mitochondria from ROS damage. Moreover, supplementation of Mg2+ to extracellular medium further suppressed the decrease in MMP and attenuated H2O2 toxicity. The skin is always exposed to oxidative stress from UV, so Mg2+ would play an important role in maintaining the robustness of energy metabolism and protecting the skin from oxidative stress. Moreover, the addition of Mg2+ from an external source showed an additive effect for cell protection, suggesting that Mg2+ is a candidate active ingredient to protect skin from oxidative stress.In conclusion, we demonstrated that HTM medium  supplemented with insulin (10 μg mL−1), human recombinant epidermal growth factor (0.1 ng mL−1), hydrocortisone (0.67 μg mL−1), gentamicin (50 μg mL−1), amphotericin B (50 ng mL−1), and bovine pituitary extract , all of which were sourced from Kurabo, at 37 °C in a CO2 incubator. Undifferentiated keratinocytes between passage 2 and passage 6 were used for experiments. EPILIFETM medium contains Mg2+, but the concentration is not disclosed.Normal human epidermal keratinocytes were purchased from Kurabo . To compare the response of keratinocytes from newborn babies and adults, four different batches of newborn keratinocytes vials from different donors  and two different batches of adult keratinocytes vials (donors aged 40 years and 57 years) were used  at a concentration of 6–8 × 104 cells mL−1.For fluorescence imaging, keratinocytes were seeded on glass bottom dishes  coated with 5 μg mL2+ imaging, cells were stained with an Mg2+-selective fluorescent probe, KMG-10443. Keratinocytes were incubated with 20 μM KMG-104-AM and 200 μg mL−1 Pluronic F-127 (Thermo Fisher Scientific) at 37 °C. After 30 min, the keratinocytes were washed twice with Ca2+-free HBSS  and incubated for a further 15 min in Ca2+-free HBSS to allow the complete hydrolysis of acetoxy methyl (AM) groups. To avoid differentiation of keratinocytes, all experimental procedures were performed in Ca2+-free medium.For Mg2+ and MMP, keratinocytes that had been loaded with KMG-104 were then incubated in Ca2+-free HBSS containing 25 nM TMRE (Thermo Fisher Scientific) for 15 min at 37 °C. Fluorescence imaging was performed in Ca2+-free HBSS with 2.5 nM TMRE.For simultaneous imaging of cytosolic Mg2+ alone, KMG-104 was excited at 488 nm using an Ar laser through a dichroic mirror , and fluorescence at 510–610 nm was detected with a photomultiplier. Images were acquired every 4–6 s. For simultaneous imaging of cytosolic Mg2+ and MMP, KMG-104 and TMRE were simultaneously excited at 488 nm using an Ar laser and 559 nm from a laser diode, respectively, through a dichroic mirror . The emitted fluorescence was separated at 560 nm  and observed at 505–545 nm for KMG-104 and 570–670 nm for TMRE.A confocal laser scanning microscope system, FluoView FV1000 , was used for the measurement of fluorescence. For the imaging of Mg33, was kindly gifted from Dr. Imamura and was used to measure intracellular ATP levels. The plasmids that encoded ATeam were transfected into keratinocytes using Lipofectamine LTX (Thermo Fisher Scientific). These keratinocytes were cultured for 1–2 days after transfection to express the sensor proteins. Before observation, the cells were rinsed with and placed in Ca2+-free HBSS.A fluorescence resonance energy transfer (FRET)-type ATP sensor, ATeam1.03The cells were observed on the confocal laser scanning microscope system Fluoview FV1000. ATeam was excited at 440 nm using a laser diode through a dichroic mirror , and the emitted fluorescence was separated by a dichroic mirror  and observed at 460–500 nm for CFP and at 515–615 nm for YFP.33. The ATP-insensitive ATeam was expressed in the keratinocytes, and it was confirmed that H2O2 at a concentration below 10 mM had no impact on the fluorescent proteins.For the negative control experiments, an ATP-insensitive variant of ATeam was constructed by inducing mutations of R122K and R126K in the ATP-sensing domain, following previous workF) was normalized by the initial value (F0), and the resulting F/F0 values were compared between KMG-104 and TMRE. For ATeam, the ratio (R) of the fluorescence of cyan and yellow fluorescent protein (YFP/CFP) was calculated after subtracting background. The time-course of R was normalized by the initial value (R0), and the resulting R/R0 values were compared.The acquired images were analyzed using the software packages FluoView (Olympus), Aquacosmos , and ImageJ. A region of interest (ROI) was assigned to the whole cell body of each cell, and the average fluorescence intensity in each ROI was calculated respectively. After subtracting the background, the time-course of fluorescence intensity for each cell . KMG-104 was excited at 500 nm and fluorescence intensity at 530 nm was measured and compared. H2O2 in the concentration range of 0–100 mM had no effect on the fluorescence of KMG-104  or Mg2+ +5 mM medium  10 min prior to H2O2 application. The medium was replaced to Mg2+ normal medium or Mg2+ +5 mM medium containing 0 or 1 mM H2O2, and cells were incubated for 24 h in the incubator. Then, the medium was replaced to 0.5 mg mL−1 MTT containing culture medium, and the cells were incubated for 2 h. The medium was discarded, and DMSO was then added to each well to dissolve the precipitate. The absorption at 575 nm was measured on a microplate reader, Valioscan (Thermo Fisher Scientific). The viabilities were calculated as a ratio to the average of H2O2 0 mM condition for each Mg2+ concentration.Keratinocytes were plated at a density of 8.0 × 10t-test was used for comparison of a pair of data. Dannett’s test was used to compare multiple groups to control group. Tukey’s test was used to compare all differences among data group more than three groups.Fluorescence imaging experiments were repeated for 3–4 times for each experiment, and response of all the cells emitting sensor fluorescence in the field of view were analyzed. MTT assay was repeated for six times. Student’s Further information on research design is available in the Peer Review FileSupplementary InformationDescription of Additional Supplementary DataSupplementary data 1Reporting Summary


This study evaluated an attempt to implement video consultations through a novel education intervention in telehealth training and implementation in two middle-sized hospitals in Denmark. Three units tested the education intervention along with a regional decision to strengthen multidisciplinary and cross-sectoral collaboration through technology to improve service delivery by making the process more coherent and saving time and resources. This study aims to identify what contextual factors enable workplace learning, skills acquisition, and utilization of new digital skills to use and routinize video consultations in workplace practice.This qualitative case study draws on the principles of the realist evaluation framework using cross-case comparisons to test and refine program theories by exploring the complex and dynamic interaction among context, mechanism, and outcome. The methods in this study include participant observations, document analysis, semi-structured individual interviews, and focus groups. We performed an interpretive cross-case analysis, which explored the context-mechanism-outcome relationship using the guiding question, “What works, for whom, under what circumstances, and why?”.Two broad mechanisms appeared to enable skills acquisition and routinization of video consultations: informal workplace learning and adjusting video consultations to professional judgment. The three units had different approaches to the implementation and training and, as such, had different outcomes. First, the skills acquired in the units differed; therefore, how and with whom they used video consultations varied. Second, video consultation use was more likely to be adjusted to workflows if unit managers were responsive to staff’s professional judgments regarding patients, as was evident in all three units.Our study shows that a formal training course alone is insufficient to provide healthcare professionals with the skills needed to use video consultations in workplace practice. Informal workplace learning with support on the spot and continuous follow-up seems to equip healthcare professionals with the skills to use video consultations. Video consultations are more likely to be used confidently if novel workflows are adjusted to health care professionals' knowledge, skills, and judgment and their concerns regarding patient soundness.The online version contains supplementary material available at 10.1186/s12913-023-10163-w. Video consultations are one of many telehealth solutions used to exchange medical information through electronic communication between healthcare professionals, patients, and next of kin to improve patient outcomes, reduce travel and costs, improve communication, decrease waiting time and increase accessibility , 2. Due Despite a strong policy push to use video consultations  and evidHowever, in-depth investigations of training measures in the video consultation domain are sparse. Implementing electronic health records can teach important lessons for integrating telehealth, particularly the importance of training to enhance productivity, quality, and safety . EffectiWorking in new ways with telehealth is not a simple transition . A studyIn summary, previous studies report that training is necessary to ensure effective and valuable use of telehealth and that telehealth-related training is essentially about learning a workplace practice skill and, as such, learning how to use telehealth concerns technical skills and adjusting to novel tasks, workflows, and roles. Therefore, it is helpful to investigate training in video consultations through the lens of workplace learning (WPL).Policies on the digital transformation of health systems support the promotion of adequately designed training programs, including greater recognition of on-the-job-practical training measures as an efficient approach to providing healthcare professionals with new skills , 19. PreThe literature on video consultations is growing rapidly across several clinical areas . HoweverTo investigate this, we will employ a realist evaluation (RE)  on an atThis study builds on a qualitative case study drawing on the principles of the RE framework  using crThe study was conducted in two middle-sized hospitals in Denmark alongside an EU innovation project called ‘Digital and Skills Helix in Health’ (DISH). The hospitals were some of several healthcare facilities testing the novel education intervention developed in the DISH project, as there was a regional decision to strengthen the multidisciplinary and cross-sectoral collaboration with technology. The intention was that technology should be used when discharging vulnerable patients with complex diseases from hospital to municipal care, and the technology should make the process more efficient. The aim was that 30% of consultations and meetings should be virtual, and the objective of using the education intervention at the hospitals was to train staff in using video consultations for discharge planning conferences. We defined a case as a unit involved in the training and implementation of video consultations through a novel education intervention. The three cases were a neonatal unit, a cardiology unit, and a neurology unit.The concepts in the education intervention were developed as a part of the DISH project, an EU innovation project comprising seven work packages through which the concepts were developed, tested and evaluated. The first phase of developing the concepts was a needs assessment based on a scoping review that assessed existing digital skills education programs for healthcare staff. One of the triple helix working groups in the DISH project performed this scoping review. The scoping review found that acquiring digital skills is complex and context-dependent and should not be considered in a general and singular way. Therefore, the development of the concepts considered that the concepts should not be standardized and allow openness and flexibility to adapt to the respective contexts.The next phase of the concept development was several workshops where the triple helix partners  in the DISH project collaborated on designing the concepts based on the needs assessment, own experiences, and also influenced by Kotter’s eight steps to change model . The proFirst, the preparation concept consisted of a framework with organizational tasks and tasks related to health care professionals. The tasks were organized into the following eight domains: Objectives, actions, stakeholder involvement, resources, technology adoption, collaboration, costs, and benefits. The preparation concept should help the facilitators to prepare the training and implementation in close collaboration with several levels of management, coordinators and IT staff, and system experts across the hospitals and the municipality. The intention with the preparation concept was to prepare the unit management for the training and implementation, to clarify needs, and to create a mutual understanding through a process characterized by shared decision-making.Second, the on-the-job training concept guided the translation of training needs into concrete training objectives and outcomes through various questions, e.g., value, advantages, barriers, support, involvement, follow-up, and superusers. On-the-job training often used interchangeably with WPL, is characterized as acquiring knowledge or skills in the workplace by formal and informal means . As suchAfter the concepts were developed, several healthcare organizations implemented and tested them within the triple helix partnerships. The DISH project also evaluated the testing and implementation of the concepts; however, this evaluation was not research-based. Our study and the RE were initiated when the testing and implementation phase began. As the concepts were not validated or standardized, and since the concepts were flexible and about adjustments to the respective context, we wanted to find out how the ‘outcomes’ were shaped, enabled, and constrained by the interaction between the context of the education intervention and the change mechanisms. To validate the identified outcomes, we engaged with stakeholders, including DISH project participants, ‘education intervention’ developers, implementers, trainers, project leaders and assistants. Their perspectives have provided valuable insights into the relevance and accuracy of the outcomes.Data were collected from August 2020 to February 2022  mechanisms are underlying and hence often unobservable or hidden , 2) mechAs deriving realist conclusions about the underlying causality of specific CMO configurations is not necessarily a straightforward exercise , we haveThe education intervention resulted from an EU innovation project involving triple helix partners from six different European countries lasting for four years (including 26 months of developing the concepts and 18 months of testing them). The three hospital units drew on several approaches to learning, including formal courses in simulation facilities, formal courses in the units, and informal learning. New approaches emerged as the implementation effort unfolded, and others fizzled out. For example, support and repetitive follow-up meetings and training were added along the way, as the trainers were unsure whether the healthcare professionals used video consultations.We found that two broad mechanisms, each comprising several sub-mechanisms, were evident in the implementation effort. The education intervention unfolded slightly differently across the three units due to organizational structures, routines, and existing workflows across units and sectors, the characteristics and the circumstances of the patient groups and next of kin involved, and the experienced level of responsibility among health care professionals. Taking these and other contextual factors into account, we next present the three cases (including the most prominent quotes), followed by a presentation of the key enabling and constraining factors using the two mechanisms as illustrative examples to demonstrate what appeared to make each mechanism more or less likely to produce the outcome.A neonatal unit is for premature infants and sick or vulnerable newborns with special needs. The staff is trained in caring for and treating premature infants and sick newborns, e.g., helping babies breathe and eat. At the end of the hospitalization period, the unit offers ‘early homestay’ to babies who still need help eating but are otherwise healthy. The parents receive the needed counselling before being discharged to early homestay, and they have consultations with ‘early homestay nurses’ from the unit two times a week. Until COVID-19, these consultations were physical home visits. Due to the COVID-19 pandemic social distancing measures, home visits were no longer possible. Video consultations were therefore proposed to replace these visits. An added value of replacing physical visits with video consultations was the opportunity to save time and resources that could be used in the unit instead. In line with the regional decision to increase the number of video consultations, it was decided that video consultation use should continue even though the social distancing measures were removed. Additionally, the two weekly consultations were reduced to one consultation per week.Before implementing the new workflow, a one-hour preparation meeting was held between the trainers, the unit management, and an IT specialist to plan the training and solve tasks concerning management, workflows, training attendees’ needs, and the value of the training. The training participants were three nurses and one IT specialist from the unit who received two half-day training sessions in the hospitals’ simulation facilities. Additionally, one nurse received informal follow-up training and support the first couple of times she used the video consultations.Through the participant observations of the neonatal unit training session, we got an insight into the training content, which consisted of practical information, hands-on training, troubleshooting, and questions. The hands-on training was based on a case where the trainer took on the role of a parent. The trainer, located in another room, was invited to a video consultation by the nurses. The trainer’s arm was playing the role of the baby, and the nurses asked her to move the camera around so they could detect skin details. During lunch, the trainer sneaked into the training facility and turned off sound and camera or placed black tape on the lens of devices used by the nurses. After lunch, the participants had to ‘trouble-shoot’ and make their devices work again.“That’s where the missing link is. It’s the transition from the training course to the integration in the unit. I can see that we can do something more there. Develop or adjust what we already do. […] We have good experience, and it works really well if they first attended our training course, and then we come out there [to the unit]. They [the staff] appreciate that we come to them and help them further. We’re ready to support and answer questions.” Additionally, the unit had a technology-interested nurse formally assigned as a superuser. However, she did not participate in the training. In hindsight, the unit figured out that she probably should have.The participants expressed that they achieved the digital skills they needed for video consultations and appreciated the possibility of support and follow-up training. The trainers added follow-up training 30–60-90 and 180 days after the initial training course as they were unsure whether the video consultations were used. According to one of the trainers, We feel responsible when we send the patient on early homestay. What if the baby turns yellow [jaundice]? Can we see that through a screen? […] We cannot see whether they [babies] are dirty or if they [the parents] get them washed up and those kinds of things, so there are a lot of things we cannot see”. On the contrary, the nurses were positively surprised about the video quality during the training session. Still, during the hands-on part of the training sessions, they learned that tasks involving bodily and sensuous impressions were not an option. They expressed that they needed to be, e.g., able to feel a hernia or the soft palate with a finger.There was also some resistance to video consultations when nurses' responsibility toward patients and families and their professional knowledge was contested. One nurse said, “We have the permission to consider from time to time whether it should be a video consultation or a physical home visit. But it is okay that half of the visits are physical […]. We think the offer we have now, combining video consultations and physical home visits, is… They [the families] are safe, right?”. The parents found the technology easy to use, which was also important to the nurses.However, video consultations were accepted when unit management was responsive to the nurses’ concerns regarding patient safety and soundness. The responsiveness led to customization of the video consultation use; “if I stayed in the ward, I could help my colleagues because we often have a bad conscience when the ward is busy. I could have had more time to help them the rest of the day, right?”.Despite some resistance, video consultations were used 50% of the time, and the nurses expressed the importance of deciding themselves, based on their professional knowledge, whether a consultation should be physical or on video. An added value of the video consultations was letting go of guilt due to saved time, as one nurse expressed it: “[…] The cardiology unit carries out various outpatient examinations, treatments, care, and specialist rehabilitation of patients with cardiovascular diseases. In 2020, the unit joined a project intending to use video consultations in care transitions to respond to regional and patient expectations. The unit management met with the trainers and planned the implementation and training process.During observation of the training sessions, it was apparent that the training was conducted as in the neonatal unit. As the objective of the video consultations was care transitions, the participants consisted of staff from hospitals and the municipality. The training involved case-based exercises, where staff from the hospital and staff from municipalities were paired and should set up video consultations and discuss a case. The IT specialist who attended the training was needed as it was difficult to set up the devices from the municipalities to log in to the system used by the hospital. Like in the neonatal unit, the trainers sneaked into the training facility during lunch and turned off sound and cameras in various ways. The staff then had to troubleshoot and make their devices work again.“I have to admit that I thought it was too smart because it didn’t even work when we did the training.” Further, the nurses said they “couldn’t log on to the system” during training and did not “get an immediate experience of success.” One of the nurses said to get the video consultations scaled up after the training, "They needed someone to guide them and to be present.” As the unit did not have formal or informal superusers, they appreciated the follow-up and support from the trainers. One of the nurses said: “The follow-up is important because when I’ve been to the training, I thought this could have been done differently”. Despite some bumps on the road, COVID-19 forced them “to try and see if we could start. If not, we wouldn’t have begun with video”.According to the nurses, they appreciated the training. The training was necessary, but they also said: It’s not about being resistant because you don’t want to do anything new. It’s about trying to see the person first”. A nurse said video consultations “can’t reflect empathy […]. What do a nurse and a physician do? It’s not only objective, you know. It’s what comes out of the mouth […]. It has something to do with… We sit in consultation and register signals. We do that with all our senses, including sounds and smells. It’s all. It tells me about many things”. Another nurse agreed and said: “Yes, I think we are really dependent on so many parameters. I have an example […] I had him [a patient] and observed that he was much worse than he thought. Because he told me he was well, and he wasn’t. It turned out at the heart scan that he was in a really bad condition. But he thinks he is well, which is what he tells me. If it were on video, I wouldn’t know. Because his pulse was way too high. One of the scars was infected. There were so many things that he didn’t react to. He did not tell me, and I could not find out. Even though I specifically asked these things, he was not capable of identifying or telling me that this was wrong because he did not know himself”.Some resistance was related to ‘the medical gaze’ and the patient relation. The head nurse said, "“you do not get eye contact in the same way,” “you lose some of the relations”, and you cannot “reach out to someone, comfort, or calm down or […] touch someone”. The nurses expressed that if video consultations should be used with patients, they must make sense and be relevant. The nurses also said that they need training in personal and communication skills and how to monitor a patient behind a screen to feel safe, as well as some positive experiences, a setup for practice, and support on the spot. According to the nurses, it is something else when communicating with peers because “you can easier concentrate on the technical stuff” and “there you don’t have to concentrate on those on the other side of the screen, they understand what you say, compared to patients. Because it’s from peer to peer. That is something else […]. It makes good sense, and I will make it work when things make sense to me”.Further, the nurses expressed that through video consultations, It’s not like it’s time-saving, at least not yet. In fact, quite the opposite. It increases the possibilities you have to handle as an employee. It requires up-to-date knowledge and awareness concerning how to behave when having patients on the phone, how to behave on video, and how to behave in physical consultations.”. Another nurse agrees: “It’s not saving us time yet. It’s an extra task on top of everything else. It might save us some time in the long run or fewer hospital admissions. But the beds will be filled up with other patients anyways”.A year after the initial training, the unit used video consultations weekly to supervise municipal physical therapists responsible for rehabilitation. However, the unit manager stated, "The neurology unit treats patients with neurological conditions caused by trauma, cancer, infections, and chronic and terminal conditions. These conditions often cause complex and long-term problems. As such, the unit collaborates closely with next of kin and the municipality. Whenever a complex patient is admitted, a ‘multidisciplinary consultation’ is held with next of kin and relevant municipal actors to start the rehabilitation process. These consultations would typically occur physically in the units and would often be delayed due to next of kin living far away. In line with the regional decision to strengthen cross-sectoral collaboration with technology, the unit implemented video consultations to replace the existing workflow and make rehabilitation more efficient.Before implementation, the trainers had a preparation meeting with the head nurse, a senior consultant neurologist, and the unit manager to plan the implementation and training. Since the unit was quite busy, they did not have the time and resources to send staff off to training in simulation facilities. As such, the training was held by the trainers in the unit and became quite practice-based. The training was conducted with practical information, case-based hands-on training, troubleshooting, and questions. As the training took place in the hospital unit, municipal actors did not participate. Most of the staff in the unit participated in the training and seemed to have the needed digital skills on the spot.“I won’t say that it is easy to implement – it's not. The staff… Many received training in this, and I heard that when people went from the training, they said, ‘Oh, was it that easy?’, ‘That wasn’t so hard,’ and ‘We will figure that out easily.’ And then we got the iPad, and were going to start and then ‘how was it again?’, ‘I don’t remember,’ you know… And instead of spending 10 min in a busy workday, it’s easy to say, ‘I don’t have time for it today. I’ll do it another day. We succeed in using it now and then, but it really requires a short and precise manual on how to do it […]. It is not because they fear technology or anything… It’s just that… You tend to revert to old habits. Because that is easiest, I think. It requires persistence to say that this is what we want and this is what we do. I also experience, when we succeed, that we get feedback from next of kin where they say, ‘Oh, it is so convenient that we can do it this way,’ ‘Oh, it is so nice,’ and ‘We can see and hear that it works really well.’ I hope this kind of positive feedback can boost the implementation and get the laggards moving”, and that: “There has not been much resistance. Everyone can see that it makes sense in certain situations. But the thing is… To ensure that everyone maintains and uses it in these situations, and not take the line of least resistance, and then do what they normally do”.However, three months after the training, the head nurse stated: “They are good at helping each other. Some remember better, some just used it, and for some it’s a long time since they used it. So, they use each other.” Initially, a secretary was formally assigned to be the unit’s superuser. However, after some time, a nurse “with a flair for technology” returned from sick leave and informally took over as the unit’s superuser.Unlike the other two units, there was no formal or informal follow-up and support from the trainers after the initial training course. Instead, they helped each other and used a short manual describing the process. According to the head nurse, get to clarify the next steps faster, making the hospital stay shorter.” However, according to the head nurse, they “do not look at it as a financial saving, but as a quality boost when communicating with patients, next of kin and other collaborative actors.” Even though the video consultations aimed to strengthen the cross-sectoral collaboration, they strengthened the involvement of next of kin as they “want to use it where it makes sense, and where it can benefit.”Three months after the initial training, the unit had held ten multidisciplinary meetings on video with the next of kin. The unit experienced that they “The nurses at the neonatal unit expressed that they acquired the needed skills to use video consultations with patients and families. However, their willingness to take responsibility for using video consultations depended on being able to decide whether a video consultation would be sufficient to satisfy their responsibility to the patients.The cardiology unit staff needed personal and communication skills and training in monitoring a patient behind a screen to use video consultations with patients. However, they were willing to take responsibility for using video consultations with peers (once a week), where patient soundness was not contested, and the same personal and communication skills were not needed.According to the neurology unit head nurse, the staff acquired the skills to use video consultations to communicate with the next of kin. As the patient was at the hospital, the patient's soundness was not contested. Instead, the patient soundness might have been increased as the hospital admission became more coherent by including the next of kin through video consultations. However, the neurology unit struggled to routinize video consultations and to change existing workflows as they experienced video consultations as being more time-consuming, even though they had the potential to make a hospital stay shorter. Next, we present the mechanisms and contextual factors that generated the various outcomes.After the formal training course, the trainers offered informal support in the units whenever needed. The informal support appeared to be particularly successful in providing a feeling of safety among healthcare staff when using new technology. The need for informal support often occurred the first couple of times when healthcare professionals used the technology.Formally scheduled follow-up meetings 30–60-90 and 180 days after the initial training, along with the spontaneous needs-based support, led to a continuous focus on getting the video consultations implemented and a continuous focus on ensuring that healthcare professionals had the needed competencies to use the video consultations. If the necessary competencies were lacking, healthcare professionals were frequently encouraged to continue practising (with support).Responsible roles were either assigned formally or taken informally. If assigned formally, the roles were given to either willing and technology-interested healthcare professionals or more “senior” staff with other pressing tasks or other areas of responsibility. If the last happened and no one took responsibility, some health care professionals took an informal responsible role. As such, there were formal or informal superusers to provide support. Available support among peers lowered the threshold of testing the new video consultation system.The formal classroom training where staff across sectors were gathered led to unity and knowledge exchange across disciplines and sectors concerning implementation challenges. However, formally scheduled video consultations with the municipality were not always coherent with the unpredictable workflows at the hospital.Figure Healthcare professionals expressed that video consultations increased the coherence with patient soundness when the technology was well functioning with a clear image and adequate sound and when healthcare professionals could decide whether a consultation should be real-life or on video. For example, if the patient had a high-risk condition. On the contrary, if the person on the other end of the video consultation was a peer or next of kin, the patient's soundness was not contested the same way.The staff takes an informal responsibility to use video consultations if they experience video consultations as being coherent with patient soundness and their professional knowledge, and vice versa. The staff takes less informal responsibility if they experience large clinical and administrative workloads.Units with managers responsive to health care professionals' concerns regarding patient soundness were more likely to adjust the video consultations to the existing workflows and routines. Units with managers who were unresponsive, goal-oriented, and technology-pushing managers were more likely to increase resistance among healthcare professionals. The resistance led to video consultations not being used because they were not adapted to existing workflows and were not experienced as coherent with patient soundness.The realist analysis of approaches to adjusting the video consultations to workflows and routines see Fig.  and not The projected shortages in the health workforce and the changing needs of ageing populations have increased the focus on implementing video consultations . AlthougThe most reported challenges are the establishment of new workflows and organizational routines and the lack of technical support, resources, and training , 12. ThePrevious research has not been very specific regarding what training and skills healthcare professionals need to utilize video consultations. The preparation meetings in the education intervention in this study were an attempt to deliver needs-based, structured, and contextualized training, as recommended by previous research on telehealth , 15. TheThe initial program theory of the education intervention was that multidisciplinary collaboration between relevant stakeholders (C) should lead to a shared understanding of implementation challenges and training needs (M) and, as such, to a shared understanding of solutions (M), which in turn would lead to tailormade training (C) providing health care professionals with the skills they need to adopt and routinize video consultations (O). However, after the first round of interviews and observations, the initial program theory was refined to spending sufficient time on planning the training and implementation with relevant stakeholders (C), which leads to a better understanding of implementation challenges and training needs (M), and as such, to a better understanding of solutions and contextualized training (M). Contextualized training (C) provides healthcare professionals with the skills to use video consultations immediately after training, but not necessarily in the long run (O).After the last round of interviews, it became apparent that the units that succeeded in implementing and routinizing video consultations succeeded through informal workplace learning, which is also supported by previous research on WPL in organizations outside healthcare, reporting that most of WPL is informal, ranging from 60–90% , 21. As Our study aimed to identify the contextual factors that trigger mechanisms generating workplace learning, skills acquisition and the utilization of new digital skills to use and routinize video consultations. To succeed with workplace learning and skills acquisition, the findings showed that having informal and formal responsible roles in providing informal and formal support on the spot and ongoing focus and follow-up were key sub-mechanisms. These sub-mechanisms were more or less evident in all three units, and the contextual factors that triggered these outcomes were having available trainers or formal or informal superusers ready to provide both planned follow-up and support on the spot whenever necessary. These contextual factors facilitated a continuous, dynamic, situational and informal learning process after the formal course. The neonatal unit had support and follow-up provided by trainers and a formally assigned superuser. The cardiology unit had support and follow-up provided by the trainers. An informal superuser was the only one to provide support and follow-up in the neurology unit. As apparent in the three units and in line with previous research on WPL, learning is relational, and people learn from each other to find solutions for challenges at the workplace –27. FurtAll three units succeeded in acquiring the skills they needed to use video consultations as such. However, the road to success and how and with whom the video consultations were used in the units differed. The neonatal nurses experienced that they had the needed skills to use video consultations with patients and families. In contrast, the cardiology unit lacked the skills to use video consultations with patients. The cardiology unit was the only unit participating in planned classroom training across sectors, triggering the knowledge exchange mechanism across disciplines and sectors. As such, the cardiology unit was the only unit that used video consultations to communicate with peers in another sector. Due to a lack of time and resources, training in the neurology unit was held in the unit and not as a formal course in simulation facilities. As such, the training became more informal, practice-based, and contextualized compared to the other two units. Despite this customization, the unit struggled to change existing workflows and to routinize the video consultations, regardless of clear benefits.Previous research has shown that changing existing workflows requires investments in time to train new workflows and techniques, which affects both efficiency and effectiveness, often leading to resistance , as evidThe sub-mechanisms were evident in all units, but the contextual factors in each unit triggered varying outcomes in the three units. In the cardiology unit, the staff did not feel confident enough to use video consultations with patients. However, in the neurology unit, the patient was admitted to the hospital, still a part of the video consultation, but with next of kin on the other side of the screen. The neonatal unit succeeded in using video consultations with patients and families. However, only in combination with physical visits. The patient soundness was not contested if the technology was well-functioning and the person on the other side of the video consultation was a peer (cardiology unit), next of kin (neurology unit), or a patient with a low-risk condition .Large clinical and administrative workloads have been reported as the primary barrier to WPL , especiaSuccessfully implementing video consultations in healthcare settings goes beyond sufficient funding, supportive policies, and formal training. It involves recognizing the significance of informal learning processes. Video consultation training and implementation requires careful planning, including a) providing planned and informal support and continuous follow-up even after formal training and b) ensuring the availability of trainers, either through formal superusers or knowledgeable peers, for support.Moreover, healthcare professionals often draw on tacit knowledge when deciding whether and how to use video consultations, emphasizing the importance of managers and leaders considering a) acknowledging and addressing healthcare professionals’ concerns and decisions regarding patient soundness and b) adjusting video consultations to novel workflows based on healthcare professionals’ judgments, knowledge, and skills.This study has demonstrated the value of RE in unpacking the complexity when learning how to use and implement video consultations, which can be argued only to have been made possible by using RE. However, unpacking the complexity of skills acquisition and video consultation implementation is not a process driven solely by logical deduction. As others  have poiOur findings showed that mechanisms are indeed underlying, often unobservable or hidden , 39. OurThe RE has proven beneficial to surface how contextual factors interact, constrain, and enable our study's detected mechanisms. However, we argue that the RE would benefit by being supplemented with other theories of change, such as symbolic interactionism, not immediately associated with a realist philosophy of science. Further studies could benefit from delving into social dynamics, how actors change in interaction with other actors, and how they communicate verbally and non-verbally, especially the latter, as many of the detected factors in our study were informal and found in the unsaid.This study covers 18 months of real-world training and implementation, including interviews and observations of a relatively high number of participants. Using RE and CMO configurations to figure out ‘what works, for whom, under what circumstances, and why’ has been a useful approach and has provided us with a deeper understanding of contextual factors and mechanisms that enable workplace learning, skills acquisition, and utilization of digital skills to use video consultations.Still, this research is not without limitations. Transferability to other fields may be challenging since the findings build on a comparative case study. However, the rich case descriptions may enable readers to determine transferability to other fields.As mentioned, identifying mechanisms, contextual factors, and outcomes are not straightforward. However, the cross-case comparisons helped determine how workplace learning and professional judgment played out in the different units and produced the same or different outcomes. Yet, we identified that a constraining factor in one context might be an enabling factor in another. Further, it was sometimes challenging to distinguish between the education intervention and the contextual factors. For example, to decide whether the ongoing informal support in the units was a part of the education intervention itself or a result of the contextual factors. In some situations, the education intervention might co-construct the context and intertwine with the mechanisms.A formal training course alone is insufficient to provide healthcare professionals with the skills needed to use video consultations in workplace practice. Yet, a formal training course in combination with informal workplace learning with formal and informal support on the spot and continuous follow-up seems to acquire the needed skills among healthcare professionals to use video consultations.The study findings contribute to practice by demonstrating that skills acquisition depends on factors such as having available trainers and informal and formal superusers in responsible roles to provide support on the spot. In addition, the findings also contribute to the concept of workplace learning, showing that providing continuous follow-up and focus by having both formal and informal follow-up meetings enables workplace learning. Moreover, a formal training course across sectors can enable knowledge exchange across disciplines and sectors, which in turn may generate collaboration across sectors through video consultations. However, unpredictable work at the hospital inhibits this mechanism.Furthermore, the research contributes to the telehealth field by demonstrating that utilizing new digital skills and routinization of novel workflows with video consultations are more likely to succeed if unit management is responsive and if video consultations are adjusted to professional judgment, knowledge, and skills, as well as concerns regarding patient soundness. Nevertheless, these adjustments depend on contextual factors dependent on each other. The patient soundness is not contested if there is an option to alternate care delivery, if the end-user is next of kin, peers, or a patient with a low-risk condition, and if the video consultations function well. If the patient soundness is contested, healthcare professionals do not take an informal responsibility to use video consultations. Further, large clinical and administrative workloads constrain informal responsibility. However, if unit management is responsive to and adjusts the video consultations to these sometimes informal and invisible contextual factors, healthcare professionals are more likely to feel confident to use and routinize video consultations.Additional file 1. Interview guide for semi-structured focus groups and individual interviews.Additional file 2. Observation guide.