Convolutional neural network (CNN) has been leaping forward in recent years. However, the high dimensionality, rich human dynamic characteristics, and various kinds of background interference increase difficulty for traditional CNNs in capturing complicated motion data in videos. A novel framework named the attention-based temporal encoding network (ATEN) with background-independent motion mask (BIMM) is proposed to achieve video action recognition here. Initially, we introduce one motion segmenting approach on the basis of boundary prior by associating with the minimal geodesic distance inside a weighted graph that is not directed. Then, we propose one dynamic contrast segmenting strategic procedure for segmenting the object that moves within complicated environments. Subsequently, we build the BIMM for enhancing the object that moves based on the suppression of the not relevant background inside the respective frame. Furthermore, we design one long-range attention system inside ATEN, capable of effectively remedying the dependency of sophisticated actions that are not periodic in a long term based on the more automatic focus on the semantical vital frames other than the equal process for overall sampled frames. For this reason, the attention mechanism is capable of suppressing the temporal redundancy and highlighting the discriminative frames. Lastly, the framework is assessed by using HMDB51 and UCF101 datasets. As revealed from the experimentally achieved results, our ATEN with BIMM gains 94.5% and 70.6% accuracy, respectively, which outperforms a number of existing methods on both datasets. Understanding and the process to recognize actions of humans in realistic videos remains a challenge due to the diversified objects, ambiguous human motions, and complex relationship between scenes and human beings. From traditional handcraft features  to deep Different with the still image classifying, a special property for action recognition refers to scattered background and dynamic perspective. According to In addition, the other distinct feature exhibited by the video refers to temporal dimension. It is difficult for 3D-CNN architectures  to obtaiNevertheless, in the absence of semantic data guiding at a high level, the representation of actions under the extraction with the use of the mentioned methods fail to have the expression of the frames with the higher relevance inside a video in a selective manner; accordingly, the residual noise is likely to increase unavoidably based on frames with any relevance . The secIn view of the above observations and analysis, a novel framework is developed, termed as temporal encoding network (ATEN) on the basis of attention with background-independent motion mask (BIMM) for video action recognition . InspireWe develop an overall automatic background-independent motion mask (BIMM) for enhancing the moving objects based on sophisticated background by complying with one emerging motion segmenting approach on the basis of boundary priorAn attention-based temporal encoding network (ATEN) is developed for video action recognition. Instead of solving the features at the frame level in an equal manner, one uncomplicated and significant attention mechanism based on long ranges is proposedWe conduct extensive experimental processes on two difficult datasets for demonstrating that the framework here statistically outclasses a number of existing methods by average 7.8% and 4.0%The major contribution here is elucidated as follows:Prior to the extensive CNN application, methods under the handcrafting process are dominant in action-recognizing field. For instance, local spatiotemporal descriptors with the fisher vector (FV)  and clasProgresses for deep learning over the past few years lead to impressive applications for video action recognition. To be specific, pretrained CNN transfer learning with limited training information shows great performance in –30. For Lately, applying models of attention arouses rising attention inside a range of aspects  denotes the i-th pixel in frame Fk. We calculate the apparent edge probability map Estatick(Pik)=Estatick corresponding to k-th frame Fk and pixel Pik using Canny edge detector . Under the saliency value Snk, the coarse saliency map can be generated based on a self-adaptive threshold, dividing the superpixels into background set θk for each frame Fk is computed byμ(·) denotes the mean value of all superpixels within frame Fk by saliency value Snk. Subsequently, the superpixels in the respective frame Fk can be cataloged to background and foreground set:By complying with the definition of geodesic distance dOO, dOB, and dBB are utilized as the measurement for the superpixels Fk:dOO denotes the mean geodesic distance between two foreground superpixels. The higher the geodesic distance value, the closer the relationship between the superpixels. Similarly, dOB and dBB are also adopted as the measurement to describe inter- and intrarelationship among superpixels in one frame. Thus, we define the refined motion object areas Ok of k-th frame asFor obtaining the refined motion object region, we add one dynamic contrast segmentation strategy by comparing both inter- and intrageodesic distance between foreground and background sets. Three kinds of distances, namely, The main rationale behind  is both Yk in each frame Fk, the corresponding BIMM is computed by binarizing the values Snk in the coarse saliency map. If Snk ∈ Bk, then Snk=0; otherwise, Snk=1. Next, we suppress the background pixels in Fk to improve the importance of foreground motion objects. We first transform the Fk in RGB color space to HSI color space, halving the I component of background areas where Snk=0, and then do an opposite operation to reverse the frame back to RGB color space. As a result, a BIMM-based frame can be obtained and denoted as RGB-BIMM. Similarly, to construct the OF-BIMM, the optical flow ωik of each frame Fk is treated in the same way.By complying with the classified superpixels V, we divide it into N segments along the temporal domain, i.e., V={Sk}k=1N, where Sk is the k-th segment. Thus, a sequence of video snippets T1, T2, T3,…, TN is obtained by randomly sampling each frame from the corresponding segment SN. Then, the temporal structure of a video V can be modelled as follows:ℱ is the function of a CNN with parameter W which represents the convolution results of snippet TN. Here, TN={TNRGB−BIMM, TNOF−BIMM}, which represents the two modalities RGB-BIMM and OF-BIMM from the N-th snippet. C is the snippet-level aggregation function, which aggregates all the features learned from the base model via a temporal attention model to obtain a video-level representation.For each video ℱ to represent any given one from the above two modalities (RGB-BIMM and OF-BIMM). A soft attention ei, i = 1,…, N is computed for each segment through one multiple-layer perceptron in the output with the full connection, which is defined aswatt, Watt, and batt are the parameters of the attention model and the soft attention coefficient ei in each watt is then normalized to guarantee the sum of ei is 1. The obtained temporal attention weight wi is used to characterize the importance of the i-th snippet. Specifically, a degenerate case appears if wi=1/N, i.e., all snippets have equal importance.We do not use the single RGB frame or optical flow stacks in our framework, and the proposed ATEN works through the snippets that receive the sampling process in a sparse manner from the overall video. The respective snippet in the sequence generates its own feature representation. The overall framework of the attention-based temporal encoding network is shown in C is formed as C=∑i=1Nwiℱ to obtain a video-level video representation. Finally, the output of the ATEN is modelled as follows:Therefore, the segment-level aggregation function C combines the output from each snippet to obtain a fix-length feature vector, and based on this vector, ℋ aims to predict the probability score of the respective class in terms of the videos. Accordingly, the common multiclass activation function softmax is taken for ℋ. Based on the integration with the set softmax loss, we define the eventual loss function according to the aggregation function C asK is the number of action categories and yi is the action label corresponding to category i. It is worth mentioning that the gradients of the loss function can freely backpropagate, and the whole framework can be trained in an end-to-end manner because the entire ATEN is differentiable with the attention model directly embedded.The HMDB51  dataset The UCF101  dataset N = 6. Meanwhile, we crop 4 corners, 1 centre, and horizontal flipping of them from the sampled frames for assessing the ATEN. Finally, more credits are given to the temporal stream by setting its weight to 1.5 and that of the spatial stream to 1 for the fusion of two streams.At the data preprocessing phase, the TVL1 optical flow algorithm  is emploHere, the effect exerted by ATEN with BIMM on HMDB51 is shown in As is given in Here, for the verification of the effectiveness exhibited by the proposed background-independent motion mask (BIMM) and attention-based temporal encoding network (ATEN), various ablation experiments were performed using a range of settings on 2 datasets: RGB + OF + average fusion , RGB + OF + ATEN (Setting 2), RGB-BIMM + OF-BIMM + average fusion Setting 3), and RGB-BIMM + OF-BIMM + ATEN Setting 4). Tables , and RGB. Tables Finally, the performance of our work is compared with several existing methods on two datasets. To verify the importance of BIMM for classification, watt in the temporal domain. The proposed ATEN prioritizes discriminative video frames  by assigning higher attention values to the specific actions. Naturally, less informative frames are assigned with lower attention weights as expected. As shown in To analyse the effects of the model of attention and to visualize the key snippets from long-term temporal segments proposed in ATEN, the temporal encoding results are visualized from video segments to reveal how the temporal encoding aggregation represents the target actions. For evaluating the computational complexity of the proposed ATEN, we compute the average time consumption per video for our action recognition framework, including preprocessing, CNN-based feature extraction, and feature aggregation on the HMDB51 dataset. The experiment compared the proposed ATEN with TSN in Keras with 16G RAM and GTX1080ti, and the codes do not receive the optimization. The time consumption for the above framework is compared in Here, the attention-based temporal encoding network (ATEN) based on attention is presented with background-independent motion mask (BIMM) for human action recognition which effectively reduces the side effect from both spatial and temporal redundant information and noises. Various experimental processes on 2 thought-provoking datasets verified the superior performance exhibited by the action recognition framework here. It is largely ascribed to the temporal encoding for the sampled snippets, as well as the automatically foreground segmentation method designed here. The former can effectively and efficiently deal with the long-term dependency among frames, whereas the latter makes the convolution focus more on the action-related areas. In the future, we intend to explore the combination of ATEN with some recurrent models such as RNN or LSTM to further exploit the temporal structure in videos to recognize actions of humans.


COVID-19 pandemic has changed medical education from offline courses to online formats. Nowadays, offline skill demonstration lessons becomes unfeasible. This study assess the effectiveness of tutorial videos and online classes in delivering knowledge and skill in basic surgical knotting to medical students.https://www.youtube.com/watch?v=WyfOVGhAeVA) while the other group did not watch the video. All participants submitted a demonstration video to show their knotting skill. These videos were graded and made into the first evaluation. Then, all participants attended online classes for the surgical knotting skills via Zoom application. Participants submitted another demonstration video after the online classes. The videos were assessed, and the results were analyzed.A group of medical students (n = 95) was divided into two groups: the first group was allowed to watch the tutorial video that we have been made and uploaded into YouTube  who watched the tutorial video prior to class scored higher in the first video than the control group (n = 39) with a meanscore of 10.850 versus 7.462, The combination of tutorial videos and online classes is the optimal teaching method for surgical knotting skills. •E-learning becomes a favorable learning method in COVID-19 pandemic era.•Combination of tutorial video and live online skill demonstration is proven effective in teaching surgical knotting skills to medical students.•Recording individual skill and individual feedback sessions is the optimal teaching method for surgical knotting skills. Many universities and schools have shifted from on-site classes to online formats to accommodate physical distancing safety protocols. One of the challenges faced by medical education institutions was how to train the procedural skill subjects without the traditional live demonstrations and directly observed skills laboratory. Also in early 2020, Indonesian government imposed a wide scale social restrictions to limit the acceleration of COVID-19 transmission, therefore forbidding on-site learning in school and universities [Some studies showed that video education is at least as good as the traditional methods in teaching medical students. For example, Pilieci et al. found that video education is superior to traditional skill demonstration in providing medical students with knowledge of sterile surgical techniques. McKenny et al. found that video education approaches were as effective as direct demonstrations in teaching nursing students how to change nursery dressing. Additionally, Nageswaran et al. found that the addition of video is better than traditional skills sessions alone, while Weber et al. found that the use of video-based instruction to teach surgical hand disinfection is more effective, efficient, and acceptable than conventional instruction ,4.A good surgical knot is important for loop security to ensure good tissue attachment and healing. A loose surgical knot may result in many complications, such as hemorrhage, anastomotic leakage, incisional hernia, impaired in tissue healing, and poor cosmetic appearance ,6. HowevMany studies presented the advantages and disadvantages of e-learning in general such as using video conference through zoom application. The comparison between the effectiveness of online learning and offline learning has also been reported in few studies. However, our study is slightly different as we observe the effectiveness of online learning in teaching medical students basic surgical knotting. We want to determine wether the combination of online class and tutorial video method in the COVID-19 pandemic setting can be feasible and effective in teaching surgical skills that conventionally taught directly in class or skills laboratory session. This study in line with STROCSS 2019 guideline .2https://www.youtube.com/watch?v=WyfOVGhAeVA) by the author as a digestive surgeon, instructor in charge, and the Basic Suturing Skill Course Director in Indonesia. All the steps and methods are based on the Royal College of Edinburgh standards.A video of basic surgical knotting tutorial was created and uploaded to YouTube  who were given the knotting video prior to the first task, and the control group (n = 42) who were not. All students made a first knotting video before attending online classes with the instructor. After the class, participants made another knotting video. All videos were submitted through Google forms. For the videos, all participants may use any type of ropes and objects that can become core of the knot.This study was approved by the Institutional Review Board of the Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia (KE/FK/0849/EC/2021).The inclusion criteria of this study were: 1) participant was enrolled in surgery clinical rotation, and 2) participant submitted both pre-class and post-class videos. Whereas the exclusion criteria was: 1) the video file was not complete or corrupted in some way. This study was double-blinded. Video assessment was done by two assessors, and the instructor in charge as certified Basic Suturing Skill Course Director in Indonesia.The analyses were made with SPSS Statistics 23 . Data were tested for normality with Kolmogorov Smirnov test. Since the data were not distributed normally, the Mann-Whitney test was used to compare both groups and Wilcoxon test to compare pre and post results between each group.3The video consisted of a step-by-step demonstration to make surgical knotting. The steps shown in video are included in The participants were 95 students registered to the surgery clinical rotation in July to October 2021. The July (n = 26) and August (n = 27) groups were the experimental group whereas the September (n = 24) and October (n = 18) groups were the control group. From the experimental group, 2 participants were not included because 1 participant did not submit the post-class video and 1 participant registered twice, while1 participant was excluded since the post-class video submitted was not surgical knotting. From the control group, 1 participant was not included since the post-class video was not submitted and 2 participants were excluded because the post-class videos were cut and appeared edited .Fig. 2Pap-value of 0.000. However, there was no significant difference in post-test comparison with p-value of 0.706 , such as shoes, chair, rubber band, table, etc., followed by medical instruments , especially stainless-steel instrument set box .Fig. 3Sc4Since the World Health Organization (WHO) declared the COVID-19 outbreak as a global pandemic in late 2019, the restrictions in people's movement to control the spread of the virus have affected all life aspects, especially education, including medical education. As social distancing was adopted, on-site classes and lectures were suspended. Meanwhile, the delayed graduations, especially in medical education, may have negative impacts, especially in this pandemic management setting. Therefore, educational methods have been shifting to online approaches ,9.Online teaching itself has been important in medical education in recent years and has been shown to be on par with offline teaching in examination results . The advHowever, there are some challenges in online medical education, namely student's lack of time management, uneven ability to access and gadgets between students, communication and interaction between lecturers and students, and difficulty in students' assessments ,13. The Basic surgical skills, including surgical knotting, incision, and suturing are normally learned in on-site class and skills laboratory settings, mentored face-to-face by a skilled surgeon ,12,15. RParticipants are allowed to use any kind of rope and other household material to demonstrate the surgical knotting skill. A proper mannequin and knotting media could not be used since the availability of those media is limited to the skills laboratory on the campus. However, the diversity of media, as shown in the above figures, in this study did not hinder the results because the point of the session was the knot formation.In our study, we found that students who watched video lessons of basic surgical knotting excelled in the pre-class examination more than students who did not. After participating in the online class there was no difference in scores for the post-class video assessment between the two groups. This shows that online class is an effective method in teaching surgical knotting skills regardless of prior knowledge and skills. The classes, which are comprised of lectures, live demonstration of skills, and individual feedback sessions, cannot be replaced by tutorial video alone.When looking at the result alone, we can infer that live online classes can give the optimal learning for knowledge and surgical skills. However, in real practice, we believed students that have prior exposure to the tutorial video have less difficulties in following the class and in the end, will produce or replicate the surgical skill with more ease than the students that have no prior knowledge. Our inference in this issue varies and may differ from several studies such as a study by Pilieci et al. which stated that tutorial videos are better than live demonstration of surgical skills . Tutoria5The combination of tutorial videos and online classes comprising of lectures, live demonstration of skills, and individual feedback sessions is the optimal teaching method for surgical knotting skills.This study was approved by Universitas Gadjah Mada Ethical Committee with Ethical Clearance KE/0686/06/2021. This study was registered in Universitas Gadjah Mada research repository with register ID 202107100.This research did not receive any specific grant from funding agencies on the public, commercial, or non-for-profit sectors.Adeodatus Yuda Handaya conceived the study. Joshua Andrew drafted the manuscript. Aditya Rifqi Fauzi, Ahmad Shafa Hanif, Kevin Radinal, and Azriel Farrel Krisna Aditya critically revised the manuscript for important intellectual content. All authors read and approved the final draft.Research Repository Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada Register ID: 202105099.Adeodatus Yuda Handaya is the guarantor of the study.None.


Requirements for physical distancing as a result of COVID-19 and the need to reduce the risk of infection prompted policy supporting rapid roll out of video consulting across the four nations of the UK—England, Northern Ireland, Scotland and Wales. Drawing on three studies of the accelerated implementation and uptake of video consulting across the four nations, we present a comparative and interpretive policy analysis of the spread and scale-up of video consulting during the pandemic. Data include interviews with 59 national level stakeholders, 55 health and social care staff and 30 patients, 20 national documents, responses to a UK-wide survey of NHS staff and analysis of routine activity data. Sampling ensured variations in geography, clinical context and adoption progress across the combined dataset. Comparative analysis was guided by theory on policy implementation and crisis management. The pandemic provided a “burning platform” prompting UK-wide policy supporting the use of video consulting in health care as a critical means of managing the risk of infection and a standard mode of provision. This policy push facilitated interest in video consulting across the UK. There was, however, marked variation in how this was put into practice across the four nations. Pre-existing infrastructure, policies and incentives for video consulting in Scotland, combined with a collaborative system-level approach, a program dedicated to developing video-based services and resourcing and supporting staff to deliver them enabled widespread buy-in and rapid spread. In England, Wales and Northern Ireland, pre-existing support for digital health  and virtual care, combined with reduced regulation and “light touch” procurement managed to override some  cultural barriers and professional resistance to implementing digital change. In Northern Ireland and Wales, limited infrastructure muted spread. In all three countries, significant effort at system level to develop, review and run video consulting programs enabled a substantial number of providers to change their practice, albeit variably across settings. Across all four nations ongoing uncertainty, potential restructuring and tightening of regulations, along with difficulties inherent in addressing inequalities in digital access, raise questions about the longer-term sustainability of changes to-date. With a view to containing novel coronavirus COVID-19), healthcare organizations across the world rapidly introduced new service models in 2020 intended to help avoid in-person clinician-patient contact and reduce the risk of transmission. Video consulting was a key part of this major service innovation, involving rapid and widespread logistical, cultural and technical change 9, health and redePre-pandemic, adoption of video consulting was slow, time-consuming and resource intensive, with activity limited to specific clinical services and settings . Evidence on the use of video consultations in health services was mixed , 12–14. critical junctures in the lives of systems” , our, our53)]In 1999, the UK devolution settlement created autonomous, elected governments for Northern Ireland, Scotland and Wales and transferred powers for health from the Westminster UK Parliament to the Scottish Parliament, Welsh Assembly, and Northern Ireland Assembly . Many chFirst, we undertook a national evaluation of video consultation services in Scotland in early 2020, funded by the Scottish government. This work involved quantitative and qualitative data collection and the production of narrative case studies to illustrate the successes, failures and partial successes of efforts to use this technology in different settings and services. The Scottish example is interesting because much work was put into building a national infrastructure and branding for the video consultation model . We wereSecond, we conducted a longitudinal analysis of the scaling up of video consultations across the UK during the pandemic. Funded by the Health Foundation, we extended the work already conducted in Scotland to include England, Wales and Northern Ireland by conducting a UK-wide survey on video consulting, along with follow up interviews with NHS staff, and interviews with patients and national-level stakeholders. This allowed us to understand the extent to which the evolving crisis shaped scale-up and gain transferable insights into the development of sustainable service models. It also provided comparisons across the four nations.Finally, we received funding from the UK Research and Innovation emergency response fund to look at “remote by default” primary care in the context of the pandemic. Because COVID-19 is so contagious, patients could no longer walk into a GP surgery and ask to be seen but had to apply online or phone the surgery for an appointment. Our focus in this paper is on the macro  aspects of a remote-by-default service model in primary care that supported these rapid and widespread changes and sought to rapidly strengthen the supporting infrastructure for digital innovation in the NHS. Other elements of the research focused on the micro- , and meso- aspects of remote by default consulting and supporting the change process through action research and are reported elsewhere e.g., , 58]..58)].As detailed in another paper in this special issue , these tWe turned to interpretive policy analysis , 47, 59 This focus on complexity and social action stands in stark contrast to the prevailing view of policy as a formal, rational process that can be planned in advance. This is deliberate. Scholars of health policy have often  alignedAn interpretive approach recognizes policy as negotiated and renegotiated in the social practices and encounters of administrators, regulators and other street level bureaucrats , 59, 72 We identified national level stakeholders through a mix of purposive, snowball and maximum variation sampling. We began by connecting with teams conducting policy relevant work on technology implementation and digitally-enabled care , inviting individuals to participate in interviews and asking for nominations of further people that they recommend we speak with. To spread the net wider, we reviewed policy documents and staff interviews (see below) for mention of individuals, teams or organizations leading work on the spread of video consulting and invited them as further interviewees. This gave a broad sample across civil service, professional and patient groups, regulators and industry. Some interviewees were able to give a UK-wide perspective , others a national perspective. For the latter, we reviewed our sample across the four nations and then actively sought interviewees who were able to fill any gaps . This provided a final sample of 59 interviewees .We tracked evolving policy in the four nations and asked interviewees to suggest relevant documents, resulting in a sample of 20.via social media, with targeted tweets aimed at increasing diversity of respondents . The survey was live for 3 weeks in September 2020.The survey focused on spread and scale-up of video consulting during the pandemic, aimed to capture NHS staff experience across the UK and was designed using SurveyMonkey with input from Barts Health NHS Trust (JM), NHS England, NHS Scotland, NHS Wales and NHS Northern Ireland .A new national program for Technology Enabled Care quickly followed, with TEC Cymru  given a national mandate to roll-out video consulting in 2019, and central government funds available to support NHS organizations to purchase equipment. TEC Cymru's development of video consulting services was modeled on a well-trodden digital innovation blueprint in Wales involving local pilot initiatives, regional spread and national roll-out. Looking to Scotland's Near Me Service as a beacon site , Attend via a new Digital Priorities Investment Fund a year earlier  care; initially focusing on primary and then secondary care. NHS Wales, with support from NWIS, quickly switched the Welsh NHS to Microsoft Teams (via rapid acceleration of the planned program). A government announcement of £50 million recurring funding  earlier , in 2019TEC Cymru provided implementation support to providers taking up the offer to rapidly develop video consultation services, especially in secondary care. Limitations in server capacity during the early emergency period (Attend Anywhere was overwhelmed with demand), combined with kickback from the GP community who felt that Attend Anywhere was not a good “fit” with general practice , meant that the roll-out was not limited to one platform, with others  also in use. Interest in group video consulting grew, with training sessions commissioned to support development and rollout.There is limited detailed evidence on how policy played out on the ground, since national level activity data is hard to come by. Data from the TEC Cymru team , reported over 38,000 video consultations using the Attend Anywhere platform across primary, secondary and community providers from the start of the pandemic to the end of August 2020 . To dateIn sum, the Welsh approach to developing video consulting services seems to have been characterized by tensions between those committed to delivering a national service by driving through Attend Anywhere as the main platform (as Scotland did) and others who favored a more pluralist and flexible approach to technology providers. Digital infrastructure was historically weak but had been quickly updated, allowing rapid roll-out and spread of video consulting, with coordinated national scale-up remaining a longer-term strategic objective.Northern Ireland is a small country, with a population of close to 2 million around a third of whom live in rural areas. It has a rich, if complex, history. Established in 1921 when Ireland was partitioned, Northern Ireland has a turbulent, and at times violent, political history characterized by competing perspectives  on the future of Northern Ireland. The “Good Friday” agreement enabled a coalition government to be established in 1999, though this has since been suspended several times. Relationships between Northern Ireland, the rest of Ireland, and the rest of the UK are complex. Recent Brexit negotiations, which frequently placed border arrangements with the UK and Europe center stage, have not helped. Against this challenging backdrop the health system in Northern Ireland is perhaps the least developed of the four nations.when we talk about virtual consulting in Northern Ireland, we're talking about telephone or video”). Video consulting services were rarely, if ever, identified as a defined area for health policy and remained a fringe activity that was led by a small group of enthusiasts. Beacon sites existed however these developed ad hoc and seemingly with limited central support. With multiple platforms across primary and secondary care and reliance on bottom up, discretionary adoption, spread was limited.Policy on digital technology and innovation is relatively new to Northern Ireland. Pre-pandemic there was a focus on addressing demographic changes, rising demand and significant health inequalities , 100. Prad hoc, locally driven and informed by existing infrastructure and capacity. In this sense, the response to the pandemic revealed significant gaps in national infrastructure and digital readiness, and dilemmas about how best to coordinate, organize and deliver health care at a time of crisis.As the pandemic hit, those leading digital innovation focused on engaging with Trusts and primary care providers to work with the small number of clinicians and their teams who had already successfully set up video consulting, run quality improvement programs to support interorganizational networks and peer-to-peer learning, and provide resources for providers and patients to support the use (and hence spread) of virtual consulting. With diverse video technologies and platforms already procured across the system—largely by individual providers, and with limited central input or guidance—development was via an evolving quality improvement program. Consulting in Northern Ireland involved a mix of telephone and video, with in-person consulting as needed and in line with evolving guidance on physical distancing. A structured and systematic approach to virtual and video consulting remained the ambition however, while progress was clearly made, that ambition has yet to be achieved.As the pandemic evolved, there was a continued emphasis on virtual consulting with support provided carried out 14,000 video consultations”  was needed. What this meant was that, while individual providers were clearly able to  develop video consulting services, the partial infrastructure and the on-going effort required to continually rework it as new resources and products came online, presented a major challenge to scale-up.Recent and rapid investment helped. As a senior policymaker in Wales reflected: “when COVID happened—the red tape seemed to vanish”. This included removal of regulatory blocks to rapid procurement, the use of bespoke software for supporting video consultations , and relaxation of regulatory rules around information governance. As one senior policymaker in England told us in relation to data sharing:One aspect of infrastructure that all four nations focused on at the start of the pandemic was the removal of regulatory and administrative blocks. As one hospital doctor in Scotland put it, “nationally there's been information governance guidance that's gone out…that's been managed through the COVID notice which allows data sharing between [providers]…to make that information for direct care purposes available… traditionally, you know, going through data sharing agreements takes time…. Whereas actually this has been taken on centrally, some of that bureaucracy I suppose has been lightened in this crisis”.“This focus on information governance was critical at the outset of the pandemic, shaping how and when video consulting was adopted and which platforms were used , and enabling spread.opportunity to innovate . However, the challenges allied to developing digital infrastructure and of rapidly reorganizing services at a time of crisis, left few options for policymakers beyond continuing arrangements with multiple suppliers and using existing platforms.In Northern Ireland legacy agreements between suppliers and largely autonomous hospitals placed limits on the potential for national or regional coordination. As one policymaker told us: “In Scotland and Wales the aspiration was to develop national video consulting services. Rather than engaging multiple suppliers (as in England and Northern Ireland), the focus was on establishing and managing central provision. Prior policy and investment in Scotland, along with advanced digital infrastructure and the Near Me service, meant that the immediate pandemic response provided an opportunity to accelerate scale-up, extend successful models of good practice using principles of quality improvement , and rapidly bring many providers to the same level as pre-pandemic exemplar sites.opportunity to become known as a national digital innovator—to build a national video consulting service and gain political and health system currency. The aspiration for a national service was well-received in government and TEC Cymru (see above). However, the reality on the ground was problematic: historic lack of infrastructure, limited resources, collective modes of decision-making and the work required to bring providers across sectors on board with the logistical, technical, material and cultural aspects of video consulting proved challenging. As one policymaker reflected, the pandemic brought opportunities to rethink this approach:In Wales, with one eye on the success of the Scottish service, the overarching crisis response was framed as an How do we move away from having two years to write a business case and that, you know, particularly IT—digital procurement—takes years for us to do and we'll buy some and it'll take seven years to implement. That's not always about procurement, that's about everybody agreeing what they want and how we're actually taking that forward. So, I think there are opportunities in this for us to rethink some of that”.“Cross-national politics also played a role in shaping, at least peripherally, the approach to scaling up video consulting. Several interviewees described longstanding competition across Wales, Scotland and England  and spurred the vision for respective health systems to “lead the way” in technology-enabled care across the UK.It was the operational crisis management , 33 of sIn Scotland and England this often  involved a pragmatic approach to both policy implementation and crisis management , with seIt's very much carrot, not stick, mentality. And we've done some learning on quality improvement and things like that and…I'd say working with [head of directorate] it's been a completely different experience to any other role I've had in the NHS. It's just given the freedom and the space for us to kind of work in a different way and more of a, I guess you'd say more of a creative way”.“Rather than being an explicit set of policy instruments or tools, this approach to “making policy happen” was grounded in practical rationality , coalitiEvaluation and system learning was a key part of strategy in Scotland and England . We were particularly struck by the focus on region-by-region quality improvement in Scotland—and in secondary care in England—grounded in a system-wide approach that involved senior civil servants negotiating both political vision and frontline realities in ways that led to tangible and implementable actions  that, in turn, supported the spread of video consulting.strongly embedded tribal interests from professional groups”. While there were glimmers of system learning (“everybody kind of came together”), there was also tension across local and national interests that made it “difficult to come to an all Wales consensus”. In Northern Ireland, the focus remained largely on virtual (primarily phone) consulting, without an explicit policy on video consulting.In contrast, in Wales the operationalization of policy on video consulting was characterized by what policymakers and professionals described as centralized authority, a rigid approach to rollout and “We've certainly learned from NHS England; we've learnt those lessons [on confidentiality and governance challenges with video group clinics]”. England, Wales and Northern Ireland all turned to the Scottish TEC team—before and during the pandemic—as a site of shared learning and, in England and Wales, a means of gaining additional capacity . These links were not new, but were reinforced in the pandemic and proved critical in progressing rapid spread and scale-up.No matter the approach to making policy happen, cross-national exchange was critical in bolstering spread, enabling trusted relationships and sharing of expertise. As one program manager in Wales told us: “Implementation of policy supporting spread of video consultations was a critical part of service change supporting the pandemic response , 110–112I sometimes invite a patient to engage in a video consultation during a phone consultation, where I feel this would be helpful. I don't do it very often, as I am very used to the telephone consulting and find this adequate for around 90% of encounters” (survey respondent), or how “I mostly use telephone, sometimes use photos…”. This was reflected in activity data, which showed only a small proportion of general practice consultations taking place via video , video consulting made up only a small proportion of general practice consultations. The focus was on digital triage, phone consulting and asynchronous e-consultations. As the same interviewee continued:This “telephone first” approach was reflected across much of our dataset. In Scotland a high volume of GP practices introduced the Near Me service model, but use remained infrequent . A similar picture was evident in England where, despite rapid set up of 99% of practices at the start of the pandemic  from survey respondents across the four nations about choice of platform frequently referred to AccuRx, known to many before the pandemic (who were using it for texting patients), and considered readily available, easy to use and integrated with clinical systems. This resonates with the experience in Wales where the national video consulting service, using Attend Anywhere, was perceived by some to be aligned with secondary care workflows. GPs often reverted to AccuRx, “which offered some really GP specific functionality, and there was…a misunderstanding about what was it GPs wanted or needed from video consulting software; so GPs wanted something to integrate with their practice systems” [senior policymaker]. This made sense given that AccuRx was sold direct to practices (and was freely available during the first few weeks of the pandemic) as a general work support tool: as one industry representative told us, the focus is on “trying to show primary care that it is possible to have software that works and is intuitive and its reliable”.This approach to remote consulting had received a significant policy push several years before the pandemic, with a drive for digital innovation in general practice and central funding to support it , 80, 117Through this lens, policy implementation during the pandemic was unsuccessful. Rather, primary care provides a good example of bottom up, service-led adoption of a technology that was perceived as a good “fit” with existing workflows and clinical systems.the significance, actions and issues of people, social groups, systems, organizations and infrastructure that have previously gone unnoticed” . This interest was often couched in deterministic terms, seeing technology as a “quick fix” to problems of service delivery and redesign and failing to acknowledge the social-technical work involved in spreading and scaling up digital innovation. Work was underway to manage expectations:Our dataset was peppered with similar examples situating video consulting as an integral and on-going part of the NHS offer (rather than a temporary response to the pandemic). This aligned with the renewed interest of politicians who were now: “I spend quite a lot of my time trying to talk people down a little bit… For some things we maybe could aim for five months, but there are also some things that are just inherently complex where we've got a lot of dismantling…and rebuilding to do” .“there's this tension between how much do we maintain the lightweight rapid governance that we had versus how much do we bring back a degree of stability”. Interviewees across all four nations repeatedly told us that this light touch regulatory approach was critical for spread and scale-up.Finally, there was significant concern about a return to pre-pandemic levels of governance and regulation. As one senior decision maker put it, “In this paper we have focused deliberately on policy informing the spread and scale-up of video consulting services across the four UK nations, with the COVID-19 pandemic a burning platform for change. Drawing on data from three studies we have shown the following. First, an interpretive approach to policy analysis combined with theory on crisis management has allowed us to surface the varied national approaches to developing and enacting policy during the pandemic, the challenges faced by national decision makers in negotiating complex systems at a time of crisis, and the varied national policy-level influences aiding progress toward rapidly scaling up video consultation services. Second, following from this, we have shown how different approaches to understanding, negotiating and enacting policy during a time of crisis, variably shape spread and scale-up. Through the combined lens of policy implementation and crisis management, it is clear that those who are able to work flexibly and adaptively in the midst of an evolving crisis appear to be more effective in enabling the spread of video consulting services. Such work involves facilitating the capacity and articulation work needed to enable an iterative approach to implementation; involving multiple actors across the system to work together to solve emergent problems; engaging with processes and actions over time [rather than discrete decisions administered at a particular moment in time ]; and coinfrastructuring involved—i.e., the “continuous collaborative and inherently political process” Fourth, in some settings (often where a more technocratic policy approach was in play) we found a contrast between “work as imagined” by policymakers and “work as done” by frontline practitioners. This was evident in primary care where, in spite of significant policy enthusiasm for video consulting in England, Wales and Scotland, many clinicians reverted to using existing ways of remote consulting , that aligned closely with clinical workflows and practices.Finally, while there has been significant (if varied) spread of video consulting across the UK during the pandemic, findings indicate that sustainability of these services and potential for further spread will only be feasible if questions about the future shape of service delivery and resolution of digital inequalities are addressed.Our data is drawn from three studies that, together, provided a rare opportunity for cross-national analysis, enabled significant insights on evolving policy relating to video consulting, and shone a light on issues of policy implementation that have largely been ignored in literature on telehealth and video consulting to date.via NHSE/I , but no data on use of other platforms, or in primary care. In Scotland, we were able to access national level data on the use of the Near Me service (using Attend Anywhere) but, again, no data on the use of other platforms. This means that, while the activity data we have provides a helpful snapshot, it falls short of providing a full picture of activity and, as different countries use different approaches and criteria for monitoring activity, cannot be used to draw direct comparisons. We only have reported data for Wales and Northern Ireland. Finally, our studies were primarily qualitative, focusing on the experiences and perspectives of those involved in setting up and running video consultation services at multiple levels. We are therefore unable to make a causal link between specific policy initiatives on the one hand and the spread of video consulting on the other.Our dataset brought together national survey and interview data, with analysis of documents and activity data. While every effort was made to identify a diverse group of stakeholders in each of the four nations, the level of engagement from senior politicians at a time of crisis was limited. Those we did interview were able to provide a policy narrative on the spread and scale-up of video consulting. In this sense, we were able to access the national-level perspectives needed in each of the four nations and compare across these. UK-wide activity data was harder to come by. There is no readily available central dataset on consulting activity across the UK; and in England, Wales and Northern Ireland there is no readily available national dataset of consulting activity. In England we were able to access Attend Anywhere data for secondary care within services, rather than knowledge sharing and other learning needed to achieve spread and scale-up of video consulting across settings  and street level bureaucrats . The legacy of Scottish policy supporting video consulting, combined with the explicit focus on developing a national program, clearly enabled a rapid and coherent response in the midst of crisis. That the other three nations turned to Scotland for advice and support is telling in terms of the on-going need for system-level learning and exchange.Our findings add to the literature on video consulting, which has tended to focus on specific clinical setting or condition, pay limited attention to policy initiatives and/or processes, and look at implementation settings . CompariDisruptive technological innovation has been shown to be complex, uncertain, challenging and risky , 120, winot being transformed by the available technology (which may be experienced as unfit for purpose). Findings from our research suggest that this policy narrative, and the mismatch with frontline experiences, has continued during the pandemic: what decision makers viewed as an opportunity to scale up video consulting appeared to be at odds with what many in primary care viewed as disruption in terms of the work involved in “rapidly shifting existing organizational practices to new digital spaces” [. The patients/participants provided their written informed consent to participate in this study.SS leads a work package on the Remote by Default study and is Chief Investigator on the Health Foundation Video Consultation study. She provided theoretical expertise, led senior stakeholder interviews  and documentary analysis, and drafted the paper. TG is Chief Investigator of the Remote by Default study and joint Chief Investigator (with JW) of the Scottish telehealth evaluation study. RR leads a work package on Remote by Default. CP is lead for group video consulting on the Health Foundation study. GH, LM, and JW led on interviews across the four nations. GW led on survey design and reporting, AR on analysis of the Welsh case study, and JM on patient experiences of video consulting. TG, RR, and LM contributed clinical and some social science and technology expertise. SS, GH, JW, CP, AR, JM, GW, and SF contributed social science and technology expertise. All authors contributed to the empirical studies and selected and supplied empirical data that illustrated and shaped the analysis. All authors have read and approved the final manuscript.via ESRC (ES/V010069/1), Wellcome Trust (WT104830MA), and the Health Foundation, an independent charity committed to bringing about better healthcare for people in the UK (2133488).This research was funded from the following sources: Scottish Government (Technology Enabled Care program), National Institute for Health Research (BRC-1215-20008), UK Research and Innovation 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.


These were: technical and sporting aspects of handball, highlighting the benefits of this sport in schools relative to other options (n = 7), co-education (n = 8), and results based on differences between the sexes (n = 11). Co-education stresses significant improvements in skills, together with perceived effort, enjoyment, and participation. These lead to improvements in the social climate and group cohesion, thanks to the practice of sports. Handball within schools, seen from a co-educational angle, should be approached with an eye to its predisposition for the development of social and civic skills. These include respect for the rules of a game, teamwork and solidarity, fair play, commitment, and responsibility. This paper lays out precisely and exhaustively the lines of investigation undertaken in the area of co-education, and, more specifically, how this is handled within the practicing of a confrontational team sport like handball.This study aims to address the characteristics presented by the co-educational models that have been put into practice in school handball, showing a general overview, after providing a systematic review of the literature on the topic published over the last ten years on co-educational paradigms in the practice of handball as a school sport. For the description and recording of the process of selection and filtering of documentary sources to be analyzed, use was made of the PRISMA flowchart. After the elimination of duplicates and entries not compliant with the criteria for time limits and type of document, the final sample surveyed was composed of thirty academic articles. The results considered ( Many may think that it is a challenge that has been overcome, but reality shows that, in a number of areas of life, inequality between the sexes continues to be obvious, particularly in the educational context ,2. The gThe strong intrinsic view, based on physiological characteristics, defining sex inequality, is accompanied by other, no less crucial variables, such as socio-cultural and relational factors, and personal beliefs. It is possible to go beyond a merely physical, bodily viewpoint and take into account the part played by the education system, and not just personal sexual characteristics, in terms of the provision of resources and equality, or the lack of it, in the system itself ,8. EducaThe aim would be to achieve an equitable teaching approach of this nature ,11,12, iAs it is a part of Physical Education, this article will go deeper into the field of school sports, and in particular the practice of handball in which physical education teachers indicate that it is an easier sport to teach . This imTo return to the concept of a facilitator, it becomes necessary to analyze the teaching methods employed ,25 or trSuch a male-centered point of view has led to unequal use of spaces for movement and of material ,32, for After this general panorama, the research question addressed was the characteristics presented by the co-educational models that have been put into practice in school handball. A systematic review of the literature has been carried out. This type of study makes it possible to review the literature on a topic, starting from a question and using systematic and explicit methods in the collection and analysis of data with the aim of highlighting the main conclusions on the topic. In this objective, the problem and the research question are clearly and specifically defined. For their definition, the PICO(C) strategy is used. Taking this strategy into account, the population (P) of women in the practice of handball is studied by means of the intervention (I) of a bibliographic search related to the objective in the selected databases, comparing (C) the practice of handball as a school sport, seeking as outcomes (O) to identify which coeducational models have been put into practice in handball in the school context (C). In this way, we will answer the research question: what are the co-educational models that have been put into practice in school handball?The main aim was to present a general overview, after providing a systematic review of the literature on the topic published over the last ten years on co-educational paradigms in the practice of handball as a school sport.A description of the bibliography of studies published in relation to co-education and handball.The presentation of a mind-map of keywords representing the research work considered.An analysis of the purposes of the investigations was selected on the basis of a co-educational perspective of handball as a school sport.A summary of the principal results and conclusion of this analysis of publications relating to co-educational perceptions in school handball.The overview was to be achieved by fulfilling certain objectives, specifically:The method adopted for this study was a systematic review. Such a methodology is characterized by being valid, reliable, and repeatable. A systematic review of relevant literature makes it possible to judge the extent and depth of pre-existent work and to identify any gaps that require investigation .The research followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)  guidelin(i) Definition of the objectives with explicit and reproducible methodology.In the review carried out, consideration was given to academic articles concentrating on the topic under study: handball as a school sport, seen from a co-educational angle.(ii) Systematic search for evidence following eligibility criteria.In order to perform the systematic review, use was made of three major databases: Web of Science , Scopus and ERIC. In the light of the aims of the study, the search chain applied to these databases was the following: AB = (women OR girl * OR gender *) AND  AND school AND handball)Type of document: Academic articles and reviewsTime limit: 2010 to 2021 (up to April of this last year)Language of publication: English, Spanish, or PortugueseThe inclusion criteria for this systematic review were:The number of entries identified in the databases was 123. After the elimination of duplicates and entries not compliant with the criteria for time limits and type of document , 109 entries were filtered. Of these, forty-eight were excluded and one proved impossible to retrieve. The sixty entries that emerged from the filtering stage were evaluated for eligibility, with thirty retained for the review and thirty excluded.In the two phases of filtering, a total of seventy-eight articles were excluded because they did not concentrate on the topic under analysis. Specifically, there were exclusions on the grounds -first phase- of being related to high-level sport, Special Education, or university sport, to the training of teams, to the physiological dimension and injuries, or Conference-Congress-Minutes-Books. Other items -second phase- were discarded because they were connected to different objectives such as “tech-tach” , bullying, refereeing, and the like. Some entries were ruled out because they had no link with education or did not include females among their samples. Hence, the final sample surveyed was composed of thirty academic articles, shown in the bibliographic references section with a prefixed asterisk.Entry selection was carried out using the Mendeley reference manager, while for the analysis of the studies included in the survey the qualitative analytic package MAXQDA Analytics Pro 2020 was employed. Bibliographic data were exported in Research Information Systems (RIS) standardized tag format through Mendeley and imported into MAXQDA, distinguishing the type of reference, title, main author, volume, issue, first and last page, publisher, digital object identifier (DOI), name of the journal, notes, website or uniform resource locator (URL) details, and date of publication.Content analysis of the academic articles was on similar lines to those of . Main an(iii) Assessment of the validity of the findingsThe methodological quality of the included studies was assessed using a risk-of-bias quality form of 7 items validated and adjusted for the specific context of co-educational research : 1. Time(iv) Systematic presentation and synthesis of the characteristics and findings of the included studiesFor the description and recording of the process of selection and filtering of documentary sources to be analyzed, use was made of the PRISMA flowchart. Such a diagram is split into three phases: identification, filtering, and inclusion, as shown in n = 3) and Puente Maxera (n = 2), whilst all the others had only a single article.In view of the inclusion criteria for the systematic review undertaken, all the entries analyzed were articles published in academic journals. n = 4), Physical Education and Sport Pedagogy (n = 4), Research Quarterly for Exercise and Sport (n = 2), Strategies: A Journal for Physical and Sport Educators (n = 2), The Physical Educator (n = 2) and Universal Journal of Educational Research (n = 2).Consideration of the journals in which the academic articles covering the topic under study were published show that there was some concentration in a range of periodicals. Specifically, these were European Physical Education Review (n = 14).In respect of the year of publication, The titles of the items published were also considered from the viewpoint of word frequencies, as shown in n = 138), a consequence of the generic nature of keywords, and in some cases an obligation to select words from among those included in lists imposed as a standard by the journals in which items were published.These details are closely linked to those recovered from the contents of articles and the keywords chosen by their authors. This field of analysis shows a considerable range of varying segments (n = 20), Teaching Techniques (n = 23), Research Methods (n = 8), Life Stages (n = 6), Educational Stages (n = 14), and Physical Education and Sport (n = 53) to Psychological, Physical and Behavioural Aspects (n = 22).This being accepted, the groupings run through Inclusive Education and the Sexes (n = 2), Development of Sex-Based Stereotypes (n = 1), Differences between the Sexes (n = 4), Literal Concepts of Inclusion (n = 1), and Co-education (n = 1), this last aspect being of note if it is recalled what topic of study is proposed here.Those terms coded under the label Inclusive Education and the Sexes can be further broken down. Among other items, there are Roles and Social Status . Among these, some concentrated on fair play and sporting behaviour (n = 3), others on efficiency (n = 1), skill levels (n = 4), education for dynamic equilibrium (n = 1) and tactical game models or TGM (n = 1).n = 7). These articles addressed democratic, inclusive, and participatory models for handball as a school sport, highlighting sex-related differences between males and females (n = 6).The second group of articles considered aspects related to inclusion and co-education (n = 21). Among other matters, there was an exploration of participation by pupils in undertaking this school sport (n = 1), of the transition between stages of education (n = 1), of those involved, or in other words of the role of teachers or coaches (n = 3) and of the interaction between teachers and pupils (n = 1). There were investigations of the part played by spoken interchanges between team-mates when group sports are underway (n = 2), of the basic abilities and concepts to be taught in handball as a school sport (n = 5), and of how these may be reflected in lessons taught (n = 1). Within this range of pedagogical variables, certain aspects relating to motivation stood out (n = 6), whether from the angle of confrontation, or alternatively of cohesion and a motivational atmosphere.Pedagogical variables were extensively analyzed, since handball was being studied in an educational context (n = 4) and was particularly related to handball as opposed to other alternative sports.Preferences for certain sports and trends among children towards given types of activity, as also sporting culture were also scrutinized. Nevertheless, this occurred to a lesser extent (n = 6). Specifically, these investigations referred to its impact on the immune system and psychology, to the development of motor skills, mind, and physical fitness, to cognitive and psychomotor development, and health, especially in relation to obesity and quality of life.Finally, the developmental effects of practicing this school sport were also examined (n = 26) showed a presentational pattern divisible into three segments or groups. These were: technical and sporting aspects of handball, highlighting the benefits of practicing this sport in schools relative to other options (n = 7), co-education (n = 8), and results based on differences between the sexes (n = 11).The results considered (n = 3), whether these related to refereeing or coaching. A second field corresponded to differences of a physical and physiological nature between the sexes (n = 2). Finally, there were differences seen from the angle of psychological and behavioral aspects (n = 6).Such differences between the sexes as were noted, allowance being made for social stereotypes, fell into three areas of analysis. First, there were the repercussions on actions, and technical and sporting roles (n = 8) stresses significant improvements in skills, together with perceived effort, enjoyment, and participation. These lead to improvements in the social climate and group cohesion, thanks to the practice of sports.Co-education  with differences between the sexes being clear in the sports disciplines considered. Second, there is a large group comprising aspects directly linked to co-education and equality (n = 20), specifically views on the merits of educational methods (n = 11) and the physical and psychological benefits for females (n = 6), within an attempt to overcome learned social stereotypes. Among others, Kovács [Moreover, with regard to the conclusions of the articles analyzed, it is possible to establish two major groupings. First, there are those codified segments that offer technical comparisons relative to other sports (, Kovács  concludeAt this point, there should be some reflection on the extent to which the intended objectives of this research were attained. This paper lays out precisely and exhaustively the lines of investigation undertaken in the area of co-education, and, more specifically, how this is handled within the practicing of a confrontational team sport like handball.Handball within schools, seen from a co-educational angle, should be approached with an eye to its predisposition for the development of social and civic skills. These include respect for the rules of a game, teamwork and solidarity, fair play, commitment, and responsibility.This study has pointed up the main fields of analysis of co-education and handball as a school sport. These include a need to enquire into pedagogical variables, an evaluation of approaches, training strategies, educational equality and inclusion as a motor for change, and the beneficial effects of physical activity, whether on a bodily, a psychological, or a behavioral plane.Handball is seen not merely as a sport, but a tool to be used in presenting educational strategies aimed at equality, since the deep-seated conception of taking part in sports is tied up with attitudes that are socially and culturally imposed, because of their competitive nature. Teachers, coaches, and pupils should be aware of a need for change.As for the topic being addressed here, the most important conclusion that can be drawn relates to the positive repercussions of sports education upon co-education and equality in education. This aspect becomes all the more prominent when it is realized that handball is the third commonest physical activity among sports practiced at school, especially by girls, although it must be noted that it is not so often played outside a school context .In respect of the use of materials and equipment in an educational context that would encourage participation by girls, no research was found that addressed this theme. In view of the pioneering work by Oliver, Sosa, and Porras  that poiOn the premise that there is a need for methodological change if heightened awareness on the part of children of equality between the sexes is to be achieved , certainMoreover, the benefits observed from taking part in school sport with regard to psychological, physical, and behavioral aspects have a positive impact on the perceived skills of girls . They alSeveral limitations were noted in this survey, and the chief among them are highlighted hereafter, alongside details of prospective research that would be a means of palliating them. First of all, there was a number of works found and information overload, leading to a need to summarize, which may have caused the loss of some relevant information that should be taken into account in future studies. Likewise, “grey” literature, material not published through conventional academic or commercial routes, has been omitted, even though it might be a suitable object for study in view of the applied nature of the topic.As in all literature reviews, any selection of articles can be seen as introducing a bias that constitutes a limitation. Similarly, there is a constant necessity to update such surveys as time passes.The line taken in this work was intended to diagnose the current state of affairs in co-education. This included investigation of the syllabuses for the compulsory stages of education that have an impact on the Physical Education curriculum and sport outside school. It also looked at real practices in handball, analyzing the methodologies for teaching and learning that are applied and the concepts of facilitators and pupils. As a function of the results, this should permit the development of specific action plans aimed at improving the quality of education from the twofold perspectives of the sexes and of sport. An outcome would be the application of teaching strategies relating to the use of material, modulations in physical contact, groupings, and playing areas. For this, it would be necessary to create methodological guidelines to help teacher-coaches to achieve an attractive sporting experience that includes the specific needs of girls.The curricular trend recorded relates directly to an analysis of co-educational policies. Participation in sports during the school years is linked to the world of work as adults, in which there are parallel roles to those of trainers, managers, and others. Of particular note that one of the major limitations in reaching conclusions was the lack of longitudinal articles showing the evolution of the different aspects analyzed. The effects of the implementation of co-education should be observed over time, among others, by reducing sports drop-out rates and occupying leadership positions in sports that are mostly occupied by the male gender .This paper cannot end without accepting that there is still a long way to go. It has shown that there was an upswing in the amount of literature in existence noted in the survey in relation to the years 2017 and 2018, even though the focus was exclusively on handball. This points to the opening up of a line of action attempting to anchor itself in schools as a basis for social progress. Schools and school sport should inculcate social values, equality, fairness, respect for differences, and in particular an understanding of individuals that goes beyond seeing no more than one distinguishing feature, their sex. In brief, they should reduce inequalities and aim to achieve tolerant societies.


Alcohol use disorders have become the second leading cause of death for mental and substance use disorders in China. However, with early diagnosis and timely treatment, the burden can be mitigated. Family and friends of a person with alcohol use problems are well placed to recognize the signs, encourage professional help-seeking and help the person until treatment is received. We aimed to use the Delphi consensus methodology to develop guidelines about how members of the public can provide this “mental health first aid” to someone with problem drinking in China.A Chinese-language questionnaire was developed, comprising statements that were endorsed for inclusion in the English-language problem drinking first aid guidelines for high-income countries. Participants were also encouraged to suggest new statements. These statements were evaluated by two Chinese expert panels – a professional panel and a lived experience panel – on how important they believed each statement was for members of the public providing mental health first aid to a person with problem drinking in China. Three survey rounds were conducted. To be included in the final guidelines, statements had to receive a “very important” or “important” rating from at least 80% of participants from each of the panels.The majority of statements were rated in the first survey round by 30 mental health professionals and 25 lived experience panel members. One hundred and eighty-one statements met the inclusion criteria and were used to form the guidelines. Compared to the English-language guidelines, the importance of family involvement and mutual support were highlighted by both Chinese expert panels, while a number of statements relating to low-risk drinking were rejected by the lived experience panel.The Chinese-language problem drinking first aid guidelines cover a variety of first aid strategies that members of the public can use when providing initial help to a person with problem drinking, such as how to communicate with the person and what to do if the person is intoxicated. These guidelines will be used as a stand-alone document will also inform the content of Mental Health First Aid training in China.The online version contains supplementary material available at 10.1186/s12888-021-03266-3. In Chinese culture, drinking alcohol has long been accepted as an indispensable element, not only in the celebration of special events such as the Chinese New Year, but also in social networking such as building and strengthening one’s relationships with family, friends and colleagues –8. WhileIndeed, heavy drinking is often accepted and encouraged in a wide range of social circumstances in China, such as weddings and business dinners. In such events, repetitive toasting  is a way of showing respect or sharing of joy , 14–16. Similar to physical first aid, mental health first aid is often provided by members of the public , and is defined as “the help offered to a person developing a mental health problem, experiencing a worsening of an existing mental health problem or in a mental health crisis” ,https://mhfa.com.au/mental-health-first-aid-guidelines), can enhance the public’s confidence and competence in providing mental health first aid, and increase both first aid providers’ and receivers’ help-seeking behaviors [There is also evidence showing that using mental health first aid guidelines alone, which are available on the MHFA website  Recognizing problem drinking (4 items); (2) Understanding problem drinking (16 items); (3) Talking to the person about their drinking (23 items); (4) What to do if the person is unwilling to change their drinking behavior (8 items); (5) Professional help (7 items); (6) Discussing professional help with the person (8 items); (7) What to do if the person is unwilling to get professional help (5 items); (8) Understanding low-risk drinking (3 items); (9) How to encourage low-risk drinking (2 items); (10) Practical tips for low-risk drinking (17 items); (11) Encouraging other supports (3 items); (12) Dealing with social pressure to drink (7 items); (13) Recognizing alcohol intoxication (3 items); (14) Understanding alcohol intoxication (8 items); (15) What to do when the person is intoxicated (5 items); (16) Talking to the intoxicated person (5 items); (17) Getting the intoxicated person home (4 items); (18) What to do if the intoxicated person becomes aggressive (10 items); (19) Seeking medical help (3 items); (20) General principles for emergencies related to alcohol intoxication (6 items); (21) What to do if the intoxicated person vomits (4 items); (22) What to do if the intoxicated person falls asleep (2 items); (23) What to do if the person is dangerously intoxicated (13 items); (24) Other alcohol-related emergencies (3 items); and (25) Alcohol withdrawal (7 items). The Round 1 questionnaire also provided an open text box at the end of each section for participants to suggest helping actions and strategies that were not covered in the questionnaire. The questionnaire was administered via a Chinese online questionnaire website, Questionnaire Star.Aged 18 and over;At least secondary school education;Professional expert panel – have more than two years’ working experience as a mental health professional or researcher in the area of problem drinking;Lived experience expert panel – have experience of problem drinking and feel well enough to join (consumers) or have caring experience for someone with problem drinking (carers).Potential participants from organizations such as Chinese Association of Drug Abuse Prevention and Treatment and Alcoholics Anonymous in China (AA) were contacted and invited by YH and YW. We used a snowball sampling method, with participants encouraged to invite others who met the following sampling criteria to join the professional expert panel or the lived experience expert panel:To ensure the confidentiality and anonymity of participants, personal information, including name (or pseudonym), email and mobile number, was excluded from the exported survey data prior to analyses. Online consent was gained from each participant via selecting an “I consent to proceed” option.Between December 2019 and October 2020, data were collected over three survey rounds. Participants rated each statement on a 5-point Likert scale ranging from 1 (very important) to 5 (very unimportant) according to the degree of importance for inclusion in the Chinese-language mental health first aid guidelines for problem drinking. Statements that were given “very important” or “important” ratings by at least 80% of participants from each of the panels were accepted for inclusion in the guidelines. Statements that received “very important” or “important” ratings from 70 to 79.9% of panelists from at least one expert panel were re-rated in the subsequent survey round. Statements were re-rated once only; a re-rated statement was excluded if it did not receive a “very important” or “important” rating from 80% or more of participants from both panels. If a statement received a “very important” or “important” rating from less than 70% of participants from at least one panel, it was excluded.The suggestions for helping actions collected in Round 1 were carefully evaluated by WL, NR and YH, and new statements were generated based on those that contained novel ideas. When generating new statements, similar suggestions from multiple panel members  were combined and reworded. These new statements, together with statements from Round 1 that met the criteria to be re-rated, were rated in the second survey round. The third and final survey round comprised the new statements that were generated from Round 1 feedback and rated for the first time in Round 2 but needed to be re-rated in a further round. Each participant was sent a summary of Round 1 and Round 2 responses including the number of endorsed and rejected statements, and a list of statements that needed to be re-rated in the next round, together with each panel’s previous ratings for the re-rated statements.The first author wrote the statements that were endorsed across the three rounds of questionnaires into a guidelines document. The Chinese working group then met and reviewed this document and finalized the structure and wording. The final draft of the guidelines was also sent to panelists for comments. The final guidelines can be found in online Supplementary material The study was approved by the University of Melbourne Human Ethnics Committee (HREC No.1750853.1) and the Shanghai Mental Health Center Human Ethics Committee (IRB No.2018–62).N = 30) comprised 18 psychiatrists and 12 mental health nurses. Most of the panelists were from Shanghai (N = 16), 4 were from Shandong, 3 were from Yunnan, 2 were from Hunan, and 1 each from Guangdong, Heilongjiang, Liaoning, Sichuan and Xinjiang. The average age was 42.2 years , with 40% males (N = 12) and 60% females (N = 18).A total of 55 participants completed the Round 1 questionnaire. The professional panel (N = 25) comprised 18 consumers and 7 non-mental health professionals who had experiences of caring for someone with problem drinking. The average age was 44.1 years , with 48% males (N = 12) and 52% females (N = 13). Six panelists were from Anhui, 5 were from Shanghai, 2 each from Guangdong and Sichuan, and 1 each from Beijing, Hebei, Heilongjiang, Hubei, Jiangxi, Liaoning, Inner Mongolia, Qinghai, Tianjin and Yunnan.The lived experience panel . In accordance with previous research [Out of the 176 statements rated in the Round 1 questionnaire, 153 statements were endorsed for inclusion in the final guidelines, with 11 rejected and 12 requiring re-rating in the Round 2 questionnaire  and 17 lived experience panelists  completed the questionnaire. Twenty-two statements were endorsed, 9 were rejected, and 6 needed to be re-rated in a further round. As shown in Table The Round 2 questionnaire included the 25 new statements and the 12 needing to be re-rated .○ If the person wants some advice on low-risk drinking, the first aider should advise the person to switch to non-alcoholic drinks when they start to feel the effects of alcohol.○ If the person wants some advice on low-risk drinking, the first aider should advise the person to drink slowly, for example, by taking sips instead of gulps and putting their drink down between sips.○ If the person wants some advice on low-risk drinking, the first aider should advise the person to have one drink at a time.○ If the person wants some advice on low-risk drinking, the first aider should advise the person to think of drinking alcohol as complementary to another activity instead of the sole activity.Practical tips for low-risk drinking○ The first aider should be aware that there is often social pressure to get drunk when drinking.Dealing with social pressure to drink○ The first aider should be aware that only time will reverse the effects of intoxication.Understanding alcohol intoxicationIt is worth noting that, nineteen items, which were endorsed and included in the English-language guidelines , were reMage = 43.7, SD = 10.7, range 27–67) and 11 lived experience panelists  completed the third and final round of the questionnaire. All of the 6 statements, which were generated from panelists’ feedback in Round 1 and rated for the first time in Round 2 but needing to be re-rated, were endorsed, giving a sum total of 181 statements that formed the basis of the Chinese-language problem drinking first aid guidelines.A total of 19 professionals  were endorsed by mental health professionals, they were rejected by members of the lived experience panel. It is possible that, unlike professionals, who understand the benefits of low-risk drinking in reducing the harmful effects of alcohol well, the lived experience panel may be worried that suggesting low-risk drinking may make the person believe that they are authorized to drink . Indeed,“保持滴酒不沾”) (http://www.aa-china.org/), which contradicts the low-risk drinking recommendations, those lived experience panel members who were recruited from AA may have disagreed with the statements relating to low-risk drinking and given lower endorsement ratings. Furthermore, it is noteworthy that of the 19 statements, which were included in the English-language problem drinking first aid guidelines but rejected by Chinese expert panels, 16 were about low-risk drinking. Unlike Australia and other English-speaking high-income countries, there are no national guidelines for alcohol use in China, therefore, lack of knowledge and awareness of low-risking drinking may be common in Chinese populations. Future research would benefit from exploring how different Chinese populations  understand low-risk drinking, including their beliefs, attitudes and knowledge. The central government could consider providing funds to develop national guidelines for alcohol intake  to improve the Chinese public’s understanding of alcohol use.Moreover, some members of the lived experience panel were recruited through AA in China. As the primary purpose of AA is to stop drinking completely and stay sober  can help a person recover from an alcohol use problem and enhance treatment outcomes –44.The current findings must be interpreted in the context of a few limitations we encountered. First, despite our best efforts to recruit the recommended number for each panel  , there wUsing the Delphi consensus method, we developed culturally appropriate mental health first aid guidelines for members of the public helping people with alcohol problems in China. These guidelines provide a range of mental health first aid strategies, such as how to communicate with a person with problem drinking, what to do if the person is intoxicated, and how to deal with emergencies related to alcohol intoxication and alcohol withdrawal. Improving the public’s knowledge of mental health has consistently been mentioned in China’s mental health policies, such as the two National Mental Health Plans , 48. TheAdditional file 1.Additional file 2.


There are emerging applications, like bridge structural health monitoring, continuous patient condition and outdoor aiding of the elderly and the disabled, where Internet of things (IoT) nodes are used with very limited accessibility and no connection to the main supply network. They may also be exposed to harsh environmental conditions. These are applications where power and available area constraints are of great concern. In this paper, we design a 1.1 V low dropout (LDO) linear regulator in 40  Internet of things (IoT) applications suffer from power constraints because there is limited or no access to the main supply, especially when the nodes are placed at inaccessible locations or in harsh environments. Using a local battery can be considered as an easy and fast solution to this problem. However, today, for widely used IoT applications, where hundreds or even thousand of nodes may be available, the need to change the battery or recharging it imposes a high maintenance cost . The proRFID technology has reached a sufficient level of maturity to provide part of the physical layer of the IoT for multiple applications through low-cost and energy-autonomous sensors . The supIn this paper, we propose a low dropout (LDO) linear regulator that produces 1.1 V DC voltage implemented with a 40 nm commercial technology. Special focus has been put on designing a regulator with very low power and low area, to allow room for other sub-circuits in the node. As is depicted in The paper is organized as follows: In A simplified block diagram of a general linear regulator is shown in Accuracy and efficiency are the main characteristics which are expected from voltage regulators for all intended applications . Efficieriations . Power sThe common drain configuration provides a voltage gain of lower than one for nMOS pass transistors. It means that their gate node voltage should be at least equal to the output voltage. This can be done either by configurations, like the one shown in In common drain configuration of nMOS, the source and the body of the nMOS pass transistor are not at the same potential and the body effect appears. To fix this problem, a twin well nMOS device should be used, that is not provided by all foundries.nMOS pass transistors that have a source follower configuration in linear regulators do not show acceptable noise performance. Any noise which appears at the output of the error amplifier (the gate of the pass transistor) is transferred to the output node through the gate-source of the pass transistor.When a load variation initiates a current step, large ripple appears at the output. To deliver high currents to the load, a large nMOS pass transistor that has large gate-source capacitance should be used. This ripple couples through ate them . IncreasAn nMOS device can be also used as a pass transistor with a common drain configuration, presenting very low output resistance. In this manner, it acts as a buffer having a high current gain that can feed applications that demand great load changes. With this configuration, the pole related to the output node will be located very far from the pole produced by the gate of the pass transistor. This leads to a dominant pole configuration with little stability issues. The high mobility of electron carriers in nMOS devices allows lower device size for a specific current . Despitef noise performance is better, and it shows higher power efficiency performance. These are the features that make an LDO linear regulator a true fit for our target applications. But, because of its common source configuration in the regulator, it has higher output resistance, which creates stability issues and degrades the load regulation performance of the regulator.A pMOS pass transistor, in comparison with its nMOS countrpart, needs lower dropout voltage, it has lower threshold voltage without the body effect problem, its 1/Next, we review some of the main regulator characteristics that are used in their assessment.A key parameter of a regulator is efficiency ISD=IWith the assumption that the load current is much greater than the current taken by the sampling network and considering Equation , we can In LDOs, the voltage drop across the pass transistor gmpasWe also know that the dynamic resistance seen from the drain-source of the pass transistor (ieved by :(9)RDSpaFrom the Equations  and 9),,9), we wEquation , changesAs Equation  changes Regarding Equation , the expThe derived analytical model is used throughout this paper to size the components and to look for the trade-offs that should be made between contrasting performance parameters.The common source configuration of the pMOS pass transistor in LDO linear regulators provides a high output resistance with the consequence of a low frequency pole at the output node of the regulator. The output node of the error amplifier also encounters the large capacitance of the gate-source of the pass transistor that together with other capacitances seen from this node are considered as a parasitic capacitance (Equation ).Including a Miller capacitance across the drain and the gate pins of the pass transistor is an approach that helps to stabilize the regulator specially in applications where it is not possible to include off-chip large capacitors. It provides a negative feedback for the regulator that helps to stabilize the regulator. In this manner, any deviation of the output voltage from its desired value is fed back to the gate of the pass transistor so that its conduction is reversely proportional to the output voltage fluctuations. Therefore, the output voltage will be settled at its nominal value. The feedback gain is frequency dependent, so that, for very high frequencies, the pass transistor acts as a diode connected device having low output resistance. Thus, at high frequencies it remains not much stability issues due to the far output pole.The Miller capacitance stabilizes the regulator at the expense of limiting the bandwidth. Lower bandwidth, although helps to stabilize the regulator and prevents the amount of injected noise, degrades the PSRR performance of the regulator. So, there should be a trade-off between these issues, although the stability has the greatest priority.It is important that the regulator could maintain the nominal regulated voltage even if the load demand changes. This is called load regulation and represents the output resistance of the regulator (fined as :(12)LOR=The same result can be derived from the proposed analytical model (Equation ). EquatiEquation . It is cThe ability of the regulator to withstand against the variations originated from the supply voltage is expressed through the line regulation LLine regulation can be improved by a high error amplifier open loop gain (The line regulation performance of the regulator can be studied by assuming a variable oad (RL)  such thaAs is clear from Equation , the linEquation ) and theFlicker  and theIn a single pole system, if the open loop DC gain of the feedback loop increases while the dominant pole is kept constant, the unity gain bandwidth also increases. This may result in an inclusion of far poles in the bandwidth and jeopardizing the stability of the system. On the other hand, if the open loop DC gain of the feedback loop is decreased, it is possible that the left half plane zero, which is located in the bandwidth of the system to help its stability, is forced to the margin and destabilizes the system. Thus, from the stability point of view, an acceptable error amplifier open loop gain is the one which is neither too low nor too high.In Reference , mixed aIn Reference , a 1 V rIn Reference , a 2 V rIn Reference , 2.8 V rIn Reference , a back In Reference , an AB aIn this paper, a capacitor-free LDO, based on the configuration shown in In our design, we have not used resistors for the sampling network because resistances take much of the die size and become a great source of noise. As the difference between the sampled voltage and the voltage reference is amplified by the error amplifier and the pass transistor, it is critical to confine the noise from these blocks. The proposed configuration is designed such that it does not deteriorate the temperature behavior of the sampled voltage because it is possible to produce a positive coefficient current for the sampling network that can help to cancel out the negative coefficient behavior of the  devices . This isIn our design, we have used a two-stage error amplifier (EA). In literature, EAs with two stages are more often used. In this manner, an acceptable open loop gain is provided, which is needed to fulfill various expected metrics of the regulator, such as stability . The firThe pMOS common source configuration (MP4) also provides a high positive saturation AOe with According to Equation , if we cEquation  and assuAs is clear from Equation , the temThe circuit is simulated using Cadence spectre. In these reported results, the parasitic effects of the layout are also included through the Calibre extraction tools.The circuit is assumed to be supplied by a Dickson charge pump that produces 1.3 V with 40 In our simulation, the focus has been on 110 ve power .The presented regulator drags an average current of 110.8 The circuit is designed to regulate 1.1VDC from 1.3 voltage input source. This results in a 200 The efficiency of the whole configuration of the regulator  current of the whole regulator including the embedded voltage reference decreases by increasing the load current . As far The transient time of the regulator when a load transient happens can be evaluated from The step response of the regulator with 10 egulator . The timThe line regulation of the proposed regulator is shown in The line regulation performance of the regulator on the four corners is shown in The performance of the circuit against the abrupt source voltage changes for both nominal and minimal loads are shown in The regulator peaks include only 1.5 If we look at the PSRR curve of the regulator with respect to the frequency  three diThe noise density of both the regulator and the embedded voltage reference outputs, for the range of frequency of up to 1 /f noise  with a lThe behavior of the regulated voltage under temperature variation for both the nominal and the minimum loads is shown in riations b. The reThe stability performance of the regulator in the form of the loop gain and the loop phase is shown in What is more important than the phase margin is its load and the line step and pulse transient behavior of the circuit, that can ensure the stability of the circuit and are shown in Having a low area chip is one of our objectives to address the low area constraint of the target applications. The area of the layout of the whole regulator including the voltage reference and the load and the Miller capacitors  is:100.5In this work, we have presented an all embedded CMOS-only capacitor-less 1.1 V LDO regulator in 40 The key features of our proposed LDO compared with those extracted from the recently reported works are listed in In this manner, our work was placed in the middle between those mentioned in this table. Providing a high In our configuration, if the load current increases, the quiescent current does not increase. So, if the low active area is not a constraint, it is possible to increase the maximum load current in our circuit and achieve a better FOM1. In order to have a better comparison between our work and the reported ones, we introduced FOM2 as follows:This is a FOM which consists of three important components which are expected to be as low as possible in any capacitor-less LDO regulator. Regarding FOM2, our work has got the second position among the reported works which are mentioned in In the proposed design, an embedded voltage reference is used; although it makes the circuit independent from off-chip devices, it degrades its performance when compared with those mentioned in