A better understanding of visual performance with Multifocal Contact Lenses (MCLs) is essential, both in young eyes, where MCLs may be prescribed to control the progression of myopia wherein the MCLs optics interact with accommodation, and in presbyopes, where MCLs are increasingly used to compensate the lack of accommodation. In this study, we evaluated the through focus visual acuity (TFVA) with center-near MCLs of three additions  and without an addition (NoLens) in 10 young adults and 5 presbyopes. We studied the effect of accommodation, age and pupil diameter (in cyclopleged subjects) on visual performance. The MCLs produced a small but consistent degradation at far  and a consistent benefit at near in young subjects with paralyzed accommodation (by 1.025 logMAR), and in presbyopes with both paralyzed and natural accommodation . TFVA in young adults with NoLens and all MCLs showed statistically significant differences  between natural and paralyzed accommodation, but not in presbyopes with MCLs. In young adults, VA improved with increasing pupil diameter with the HighAdd MCL (0.08 logMAR shift from 3 to 5-mm pupil size). Visual imbalance (standard deviation of VA across distances) was reduced with MCLs, and decreased significantly with increasing near add. The lowest imbalance occurred in young adults under natural accommodation and was further reduced by 13.33% with MCLs with respect to the NoLens condition. Overall, the visual performance with MCLs in young adults exceeds that in presbyopes at all distances, and was better than 0.00 logMAR over the dioptric range tested. In conclusion, the center-near lenses do not degrade the near high contrast visual acuity significantly but maintains the far vision in young adults, and produce some visual benefit at near in presbyopes. Myopia is one of the most common eye disorders, with increasing prevalence worldwide and considered as a significant global health problem . A variePresbyopia, the age-related loss of the crystalline lens’s ability to accommodate dynamically from far to near, affects 100% of the population over the age of 45. Simultaneous Vision in the form of MCLs ) are increasingly used for correcting presbyopia. These multifocal corrections aim at restoring the near vision functionality lost in the presbyopic eye, while still correcting vision at far. Different studies –6 in preIn progressive myopia, two hypotheses have been postulated for justifying an intervention with MCLs. The first relies on the associations found between myopia and increased accommodative lag , 7–9. ThThe center-distance multifocal lenses are expected to create peripheral myopic defocus for far distances, although it has been observed that the effect is reduced at near . In factThe extent to which MCLs interact with accommodation has been explored in some studies. Petterson et al.  found siIn presbyopes, center-near lenses are more popular than center-distance, as comparative studies have shown a higher performance of center-near lenses , 23. OneIn this study, we evaluated TF visual performance with commercially available center-near multifocal designs of three different magnitudes of addition (low/medium/high) at different foci, both with natural and paralyzed accommodation. The study was performed in a group of young adults and a group of presbyopes.Through focus visual acuity (TFVA) was measured in two groups of subjects with different refractive profiles (young adults and presbyopes), under natural conditions, both with natural and paralyzed accommodation and for different pupil diameters. The measurements were made with the MCLs on the eye and without the MCLs (NoLens) as a control.15 subjects of European origin participated in the study, clustered in two groups: (1) 10 young adults, average age: 26.9±2.2, average spherical equivalent -2.2±0.8D (2) 5 presbyopes, average age: 53±2.0; average spherical equivalent 0.25±0.9D. The study protocols met the tenets of the Declaration of Helsinki, and had been approved by the CSIC Institutional Review Boards. All participants were informed about the study and experimental procedures and signed informed consent prior to the experimental session.The MCLs used in this study was 1-Day Acuvue Moist MCLs  , 37. TheMeasurements were performed in a custom-developed Adaptive Optics (AO) system, described in detail previously . The sysEach subject was measured in two different sessions. The first session was performed under cycloplegia with 1% Tropicamide;  . The second session was performed on non-cyclopleged eyes. Both sessions involved TFVA measurements for 4 conditions ). In session 1, TFVA measurements were performed for 3 different pupil diameters , with the pupil size being controlled by the artificial pupil of the system. In session 2, measurements were done only for the natural pupil . Each session was performed on different days (separated by 1–2 days or less). The duration of session 1 was 7–8 hours, with frequent breaks. The duration of session 2 was approximately 4 hours. The subjects received the contact lenses at the beginning of the session, inserted them and were allowed to settle for 10–15 min prior to the start of the measurements. The subjects were not informed about the addition of the MCLs.All measurements were performed monocularly (dominant eye) in a darkened room. Before starting the measurements, subjects were instructed on the nature of the experiment and performed some trial runs. The subject was then asked to adjust the Badal system position to achieve the best focus for far, for each condition . The zero-defocus setting for each condition was the average of five best-focus readings. Deviations in the best focus with MCLs from the NoLens did not vary more than 0.375/0.50/0.50D across conditions (LowAdd/MediumAdd/HighAdd), consistent with the expected focus shift produced by these MCLs , 39 and 10 [decimal acuity]) ) .Different metrics of analysis , intermediate (1.5D) and near (2.5D) extracted from the TFVA curve as shown in Depth-of-focus (DOF) is defined as the range of defocus over which the VA is 0.2 logMAR or better [r better .Visual Degradation at far & Visual Benefit at near were obtained, respectively, as the difference of VA with MCLs relative from VA with NoLens at far (best focus) and at near (+2.50 D), respectively, as shown in Visual Imbalance is defined as the standard deviation of VA across a TF curve and is illustrated in Visual constancy is estimated from visual imbalance following normalization (by a factor of 0.2) and multiplied by -1.Overall quality metric: This metric is the result of the combination of the visual degradation/benefit and visual constancy metric. The overall metric is defined by Visual benefit at near − Visual degradation at far + Visual constancy. A positive value indicates a high overall visual performance while a negative value indicates a degraded visual performance. We evaluated these metrics in all subjects and conditions and studied differences in visual performance across lenses and age groups.lag k and rho values representing the largest spike of the series when the elements of both TF curves match exactly and the correlation coefficient, respectively.Statistical analysis was performed with SPSS software Statistics 24.0 . The normality assumption was checked using Shapiro-Wilk’s test. A power analysis  was performed. All the comparisons within the group for each condition had a power value greater than 0.8, indicating a sufficiently large sample. Some comparisons across the two groups (young adults and presbyopes) had a power value of 0.4–0.6 which still indicate significant results. Specific non-parametric tests were used: (1) the Mann-Whitney U test to analyze differences between independent samples  (2) the Wilcoxon test to analyze differences between two related samples  within each group, and (3) the Kruskal-Wallis test to analyze differences between NoLens and MCLs conditions. The similarity in the shape of the TF curves between the individual’s native VA and with the MCLs was done using a cross-correlation analysis, with In presbyopes, statistically significant differences were found in VA between far and near both for the NoLens condition and with all MCLs with both natural and paralyzed accommodation . This indicates that VA at near is compromised in presbyopes, as expected, and that MCLs do not produce an improvement in near vision that matches far vision. In the young adults, VA was statistically significantly different between far and near for the NoLens and with all MCLs  with paralyzed accommodation and only for the NoLens condition  with natural accommodation.Under natural accommodation, statistically significant differences in VA were found between young adults and presbyopic groups in all conditions for both far  and near . Under paralyzed accommodation, statistically significant differences between young adults and presbyopes occurred in almost all conditions , MediumAdd (p = 0.003), HighAdd (p = 0.019)) for far and only with the NoLens (p = 0.028) for near.No significant differences were found in presbyopes between VA measured under paralyzed and natural accommodation, as expected due to lack of accommodation and smaller natural pupil diameters. However, statistically significant differences were found in VA measured under paralyzed and natural accommodation in the young adults across all conditions , as a result of operative accommodation.Overall, when comparing the paralyzed  and natuIn young adults, intersubject variability in VA at best focus was lowest with NoLens (0.023logMAR) and increased with MCLs with paralyzed accommodation. Overall intersubject variability was higher with paralyzed than with natural accommodation but differences in intersubject variability did not reach statistical significance in either of the groups.Medium and HighAdd MCLs improved the performance at intermediate and near vision, compared to the NoLens and LowAdd conditions, under paralyzed accommodation in both groups, and also under natural accommodation in presbyopes. On average, under paralyzed accommodation, DOF increased in young adults from 1.95 D (NoLens) to 2.25 D with the HighAdd, and in presbyopes from 1.4D (NoLens) to 1.5D with the HighAdd lens.Partial correlation coefficients between the TFVA curves of the 5-mm pupil with the 3- and 4-mm pupil diameters ranged between 0.464–0.797 and 0.548–0.806 respectively, and were statistically significant in all cases (p<0.001).On average, across all lenses in young adults, DOF increased from 1.5D (3mm) to 2D (5 mm) , and in presbyopes DOF increased from 1D (3mm) to 1.5D (5mm) .In young adults, the TFVA curves tend to be broader for all lenses with the largest pupil (by 42.14% on average). In presbyopes, however, the best performance with the MediumAdd lenses at all distances was found with the 4-mm pupil diameter, whereas for the HighAdd lenses, performance at best focus was better with the 3-mm lens, and the broader curve was found with the 5-mm pupils. Standard deviation across subjects ranged from 0.01 to 0.11.We evaluated the average effect of the multifocal lenses on VA at far (0D), intermediate (1.5D) and near (2.5D) distances, obtained from the TF curve. For natural accommodation, VA was statistically significantly better in young adults than in presbyopes in all conditions at far , intermediate and near . For paralyzed accommodation, VA was statistically significantly better in young adults than in presbyopes for far , intermediate , and near (Mann-Whitney U test NoLens p = 0.028).Young adults showed statistically significantly different VA values between paralyzed and natural accommodation for all conditions at intermediate  and near (p<0.007), but not presbyopes. On average across conditions (lenses and accommodation status), VA at intermediate and near were worse than at far in all cases, by -0.11 and -0.18 logMAR for intermediate and -0.20 and -0.32 logMAR at near, in young adults and presbyopic patients respectively. In young adults under natural accommodation, VA was better than 0 logMAR in all conditions.On average, the MCLs produced a small but consistent degradation of far vision with increasing add in both groups and conditions , and a consistent benefit at near in the young adults with paralyzed accommodation , and in presbyopic subjects with both paralyzed  and natural accommodation .Visual imbalance with natural accommodation was statistically significantly different between young adults and presbyopes in all conditions . Also, statistically significant differences in visual imbalance were found between paralyzed and natural accommodation in young adults in all conditions  but not in presbyopes.-1; r = 0.65) and in presbyopes with both paralyzed  and natural accommodation . The lowest imbalance occurred in young adults under natural accommodation, although even in this case, visual imbalance was reduced by 13.33% with MCLs with respect to the NoLens condition (averaged across the three near additions).On average, visual imbalance was reduced with increasing add in young adults with paralyzed accommodation  as described in the previous sections. Higher the value higher the overall visual performance of the lens according to the defined metric. Although the metric can also reach negative values, it is noteworthy that overall visual quality was positive in all cases. The best overall performance was found in young adults under paralyzed accommodation . In presbyopes  the highest performance was found with LowAdd lenses (0.22). The overall visual performance metric with MCLs with paralyzed accommodation exceeded the overall performace with natural accommodation (by 76.2% in young adults and by 17.7% in presbyopes).MCLs are well-known solutions for presbyopia. With MCLs becoming a popular strategy to stop myopia progression, evaluating visual quality with these lenses, and identifying various parameters affecting visual performance, becomes important. Although the current state-of-the art favors center-distance designs to treat myopia and specific lenses appear to target this market, some presbyopia MCL designs may be applicable in myopes. Thus, understanding fundamental differences in the performance of MCLs in both young adult and presbyopic populations is of interest.Our study examined a center-near multifocal lens design and evaluated the effect of near add  on visual acuity, as tested in two age groups (young adults and presbyopes) with natural and paralyzed accommodation. In order to reduce the number of variables in the study, all subjects used the same -2 D distance corrected contact lens (independent of their refraction), and the residual defocus was corrected with a Badal system. A previous study with the same MCLs calculated the TF optical performance of the multifocal lenses , which was used as the basis for simulations of the lenses in a Simultaneous Vision Simulator , 45, 46 An important parameter in multifocal lenses is the near add magnitude. We have tested all subjects with MCLs of three additions . In clinical practice with presbyopes, the selection of addition is associated with the remaining accommodation amplitude, and therefore lower additions are prescribed to early presbyopes and higher additions to older presbyopes. The range of addition powers deemed satisfactory for prescribing MCLs to progressing myopes is large , 31, 32,From previous studies, where we used simultaneous vision simulators to investigate the effect of near add in pure simultaneous vision visual acuity , 45 in pPrevious clinical studies in young adults wearing MCLs reported various degrees of visual compromise. Fedtke et al  found a The relative TF Visual performance with paralyzed accommodation is similar in young adults and presbyopes , with consistent performances with increasing near add, indicating that the lens designs prevail over other factors. With natural accommodation, in the same subjects, the curves widen, revealing that accommodation, and not only the lens design, plays a role in the MCL performance in young adults. This could be achieved by fine-tuning the near peak of accommodation to bring the near target in focus with a lower accommodative demand. However, it is most likely that young adults accommodate the full range using the far peak, with the defocused image of the near focus always out of focus (by different amounts). In this case, the combination of a center-near and the natural change of spherical aberration with accommodation could contribute to decreasing accommodative lag and improving performance at near. In our study most of the subjects with Medium and HighAdd lenses  appearedOur results show that MCLs produce a more uniform quality of vision across distances. We can speculate that a higher visual constancy is a preferred scenario than overall better  vision, as achieved in young adults with natural vision, and this may explain the high degree of acceptance of MCLs when prescribed to myopes. Although the selection of multifocal lenses in myopes should be based on their success to control myopia, excellent vision at near and far cannot be compromised. The overall visual quality metric, which takes into account other parameters such as visual constancy, can be used to aid in the selection of the optimal lens design on the basis of performance. In fact, the use of new Simultaneous Vision Simulators would allow non-invasive testing of a range of designs without physically putting them on the eye , 45, 48.In summary, the present study reveals that center-near lenses do not degrade high contrast visual acuity significantly while maintaining far vision in young adults and produce some visual benefit at near in presbyopes. Factors such as visual degradation at far, visual benefit at near and visual constancy (uniformity of vision across distances) should be considered in the management of myopia and presbyopia with MCLs and to gain insights on the mechanism of operation of these lenses. Future studies on visual quality with MCLs may include contrast sensitivity and the Multifocal Acceptance Score metric , 49, whiVA was generally better in the young adult group than the presbyopic group for all conditions (NoLens and MCLs)In young adults, the shape of the TFVA curve was significantly different between paralyzed and natural accommodation conditions. In contrast, presbyopes did not show significant differences between paralyzed and natural accommodation, as expected due to lack of accommodation in the older group.The visual imbalance (variations of VA constancy from far to near) decreased with MCLs, in comparison with the NoLens. This result is consistent with an increase in the negative spherical aberration with the center-near design, which has a favorable effect in decreasing accommodative lagThe MCLs produced a small but consistent degradation at far in all conditions, and a consistent benefit at near in young subjects with paralyzed accommodation and in presbyopic subjects with both paralyzed and natural accommodation. Visual degradation at far increases with more addition in the lenses.Under paralyzed accommodation, both in presbyopes and young adults, the depth of focus of the TF curve increased with increasing pupil diameter (3mm to 5mm).S1 File(DOCX)Click here for additional data file.


This Research Topic covers the neurocognitive aspects of computer gaming and esports. Authors representing a broad spectrum of psychology and neuroscience have contributed, introducing empirical findings as well as conceptual and methodological innovations. In this Editorial we provide a thematic overview of the exciting and diverse contents of this Research Topic.Bera et al. Over the past 20 years, neurocognitive research has demonstrated that habitual competitive video game players appear to display some superior cognitive attributes when compared to their non-video gaming counterparts . However, it is important to note that although classical tests of cognitive inhibition fail to differentiate gaming process, altering the context in which this skill is evaluated may also alter outcomes. For example, a gamified examination of cognitive inhibition may demonstrate performance differences among gamers, where classical standardized stroop tasks have failed to delineate differences. During F1 driving simulations for example, Eckardt et al. found that driving performance was largely tied to adaptive abilities and selective attention/inhibition ability Eckardt et al.A plethora of research has demonstrated that habitual action video gamers demonstrate superior information processing Yuji, , attentiBeavan et al. share the importance of not only evaluating EF ability among soccer players, but also the set-up of consistent protocols and the effective communication of results to players. Traditional sport may also benefit from video games for motor learning too. In addition to the cognitive benefits that can be attained through video game play, video game environments have shown to promote motor skill practice away from the field of play. Michalski et al. demonstrate, in their recent review, that virtual environments (VE) now demonstrate a realism and flexibility that makes them potentially ideal and cost-effective for motor learning and the transfer of skill to the real world Michalski et al. Although work in this area is still sparse, early signs point to a promising role for VE to augment performance in traditional sports as well  abilities can augment motor skill performance. For example, Tabacof et al. In their study, they present solutions that can improve the accessibility of video games to those with spinal cord injury (SCI) and quadriplegia and how doing so significantly improves feelings of social connectedness among these individuals. Overall, this highlights the benefit that the digital nature of video gaming brings as a medium to remove barriers that may exist between individuals of varying sex, race, and physical ability.In addition to the potential for video games to augment cognitive and motor abilities, they have also shown promise as a mental health tool as well (Kowal et al., Martin-Niedecken et al. In fact, new research is now altering the way esports players train, moving away from predominant full emersion training to adopting segmented skill based variable priority training strategies, prevalent in traditional sport (Toth et al., Despite all the benefits to be had from video games, they are not without their pitfall. Their sedentary nature and the fact that users can find themselves staring at bright luminant screens for prolonged periods of time have been well cited as negative attributes (Lanningham-Foster et al., Smithies et al. Furthermore, the cognitive benefits conferred from engaging with video games, further social and physical benefits are likely to manifest as well, in addition to the development of a better understanding of how to mitigate health and performance pitfalls associated with video game play. As we embark on a new decade, we can expect to see a surge of new research on the role video games and virtual environments play in multiple facets of our lives, and this work is welcome now as we continue to place video games at the fore front of entertainment media in our digital world.In conclusion, despite the prevalence and popularity of video games and esports worldwide today, we are still at the frontier of esports science and are only beginning to identify the key features that make elite esports athletes unique AT and MC wrote the first draft. CF and DP edited the draft. All authors contributed to and signed off on the final draft.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.


The coronavirus pandemic has led to an increased reliance on remote patient-clinician interactions, mainly the use of telephone and video consultations. Video consultations are key in psychiatric care, as telephone appointments do not sufficiently allow clinicians to accurately ascertain a patient's mental status and perform a risk assessment. The aim of our quality improvement project was to increase the uptake of video consultations within a community mental health team, focusing on substituting telephone consultations for video.We accessed Electronic Patient Records to retrospectively quantify the method of contact for 130 consultations delivered over a 4-week period. After collecting baseline data, we conducted focused interviews with 10 care providers, identifying the specific clinician and patient barriers to video uptake that informed our intervention design.Our intervention consisted of two 4-week Plan, Do, Study, Act (PDSA) cycles.PDSA 1 involved delivering a focused PowerPoint presentation to the care team, highlighting the benefits of video consultation technology and encouraging clinicians to use it as their primary method of remote communication with patients. Additionally, we conducted qualitative interviews with members of the team to highlight the successes and challenges thus far.PDSA 2 involved creating a video consultation instructional PDF which highlighted how to operate the technological aspects of both Microsoft Teams and WhatsApp Video Call. This included: how to set-up video calls, accept invitations, and overcome common troubleshooting issues.The proportion of remote consultations was quantified retrospectively to compare trends in video consultation uptake from baseline to the conclusion of PDSA 2.Overall, we saw a 15% increase in video consultations with respect to baseline. The greatest change was attributable to PDSA cycle 1, which incurred an 8% increase in video consultation uptake, from 13.85% to 21.9%. PDSA cycle 2 further increased video consultation uptake by 6.97%, from 21.9% to 28.87%. Specifically focusing on remote consultations, the proportion conducted with video rather than telephone increased by 17.3%. Interviewed clinicians reported limited financial access, technological fluency, and issues with patient privacy as the most important barriers to the uptake of video consultations.Our project successfully increased the proportion of consultations conducted by video. This was achieved by targeting interventions to address both patient and clinician barriers to video consultation uptake. Moreover, we understand that motivating and mobilising the care team was a key factor. Possible future work includes improving the sustainability of the interventions and assessing their efficacy in other care teams.


Harmful use of alcohol is highly prevalent around the world and results in a large disease burden. Most people who meet the criteria for an alcohol use disorder do not receive treatment. Those in a person’s social network can be useful in recognizing a problem and encouraging the person to seek treatment. However, many people lack the knowledge and skills to do this effectively. This study reports on the cultural adaptation for Brazil of the 2009 English-language mental health first aid guidelines for helping someone with problem drinking.A Delphi expert consensus study with two expert panels, one comprising health professionals with experience in the treatment of problem drinking and the other comprising people with lived experience was conducted. Participants rated the importance of actions to be taken to help a person with problem drinking.Over two rounds, 60 participants  rated 197 items. A total of 166 items were included in the final guidelines.While there were many similarities with the English-language guidelines for high-income countries, the guidelines also incorporate actions of importance for Brazil, including compulsory treatment and different approaches to dealing with people with problem drinking. Further research is necessary to assess their impact.The online version contains supplementary material available at 10.1186/s12888-022-03709-5. Consumption of alcohol is a widespread phenomenon. In 2016, an estimated 55% of the world’s population over 15 years old had consumed alcohol at some point in their lives, and 43% were current drinkers [Despite the high prevalence of drinking problems, most alcohol-dependent people do not seek professional help or participate in self-help groups, highlighting the need to develop alternative strategies to improve treatment rates . Social In response to low levels of knowledge among the general community about how to assist someone developing a mental health problem or in a mental health crisis, the Mental Health First Aid (MHFA) course was developed to teach these skills . OriginaWhile MHFA training has been widely disseminated, this has mostly been in high-income Western countries with well-resourced health systems . The appSeveral Delphi studies to develop mental health first aid guidelines for middle-income countries have been conducted –23. CompThis Delphi study involved four stages: (1) Questionnaire development for the Round 1 survey; (2) Panel identification and recruitment; (3) Data collection over 2 survey rounds; and (4) Guidelines development.The first step involved translating and adapting the Mental Health First Aid statements on how to help someone with problem drinking into Brazilian Portuguese. This was performed by a senior psychiatrist (AAL) and three medical students . The translated version was checked by AAL and sent to 10 individuals who were asked to check for inconsistencies and readability of the questionnaire. There were a total of 182 statements. These were entered into an online survey website (SurveyMonkey) and grouped into categories to be displayed in sequence. Participants were asked to rate each item on a 5-point Likert scale . At the end of each session, open-ended text boxes were included to allow the participants to add additional comments if they wished.We recruited two expert panels, one comprising mental health professionals with expertise in the field of alcohol use disorders, and another comprising lay people (aged 18 years and over) with lived experience of problem drinking, either as a caregiver or as a patient with an alcohol-related disorder. For mental health professionals with experience in alcohol-related disorders, members of several university centers and hospitals were approached personally, by e-mail, or by telephone, including those of the Institute of Psychiatry of the University of Sao Paulo. For the lay participants, members of the community and of specialized help groups were approached . Brief information about the study was presented to them with a hyperlink to the survey, in which further instructions and explanation were included. They were also asked to send a link on to those who might also be interested. Participants were asked to tick a box indicating consent to participate before starting of the questionnaire. The study was approved by the University of Melbourne and University of Sao Paulo ethics committees.In this study, the Delphi method relies on the agreement of two panels of experts rating the importance of helping statements . We condThe second round also included relevant items suggested in the open-ended comments made by the participants. After the second round, statements that received at least 80% ‘essential’ and ‘important’ ratings from both panels were included, while the remaining statements were rejected  completed round 2 (n = 30); the retention rate was the same for both panels.A total of 60 participants were recruited for the first round of the study—30 professionals and 30 people with lived experience. All participants were born and lived in Brazil. The characteristics of the sample from both the first and second rounds are shown in Table Over the two rounds, 197 items were rated , of which 166 were endorsed and 31 rejected .○ 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.Eight items were approved by the professional panel but rejected by the lived experience panel with a difference of more than 10%:Talking to the person about their drinking○ The first aider should talk to the person when both are in a calm frame of mind.○ The first aider should ask the person how the person feels the day after heavy drinking.○ The first aider should show the person that consuming excess alcohol is not only causing the person itself harm, but also to those around them.General principles for emergencies related to alcohol intoxication○ If the intoxicated person stops breathing, the first aider should be aware they need expired air resuscitation (EAR).What to do if the person unwilling to get professional help○ The first aider should try to convince the person to accept treatment even when the person does not believe they need an intervention.○ The first aider should know that alcohol may undermine the person’s reasoning faculties and should consider compulsory treatment as an option.○ The first aider should proceed with compulsory treatment if the person is a risk to themselves or others.Encouraging other supports○ The first aider should suggest self-help groups to the person.What to do if the intoxicated person becomes aggressive○ The first aider should verify if the person is aggressive due to abstinence.Nine items were approved by the lived experience panel but rejected by the professional panel with a difference of more than 10%:The aim of the study was to culturally adapt the mental health first aid guidelines for helping a person with problem drinking used in English-speaking countries. To our knowledge, this is the first study conducted in Brazil using a systematic process of cultural adaptation to improve supportive behaviours towards people with problem drinking.Many similarities between the Brazilian guidelines and the English-language guidelines were seen. The endorsement rate of initial statements included in the Round 1 questionnaire was high , suggesting a high level of agreement. In the second phase, another 7 items from the English-language guidelines were endorsed resulting in 156 original items being endorsed (84.7%).While both the professional and lay panels opted to endorse statements in agreement with the guidelines of the English-speaking countries relating to taking a calmer, less forceful approach, including avoiding arguing with an intoxicated person, the lay panel rejected the statement pertaining to not labelling the person an ‘alcoholic’ or ‘addict’. This could suggest that although many Brazilians still see people with problem drinking as somehow guilty for their own condition , those tIf the person is unwilling to get professional help, because they don’t want to stop drinking completely, the first aider should explain that the treatment goal may be to reduce alcohol consumption rather than to quit altogether was also rejected by the lived experience panel, corroborating the results of the second round. This shows that professional training and experience lead to the belief that alcohol can be consumed in a safe manner even by those with a history of problem drinking [In the second round, many statements about low-risk drinking were rejected, mainly due to low levels of endorsement by the lived experience panel, several of whom came from Alcoholics Anonymous. This suggests that non-professional Brazilians that deal with harmful alcohol use or dependence are more reluctant to use a risk reduction strategy than those from English-speaking countries, while professionals consider it a valid approach. One participant from the lived experience panel stated: “There is no such thing as a use pattern that does not offer risks, therefore, I do not agree with low-risk drinking”. On the contrary, a participant from the professional panel suggested even more risk reduction strategy statements. In the first round, the statement drinking , a countThe first aider should proceed with compulsory treatment if the person offers risk to herself or others and The first aider should try to convince the person to accept treatment even when the person does not believe they need an intervention. This implies that non-professionals are more likely than professionals to see compulsory treatment as a viable option, and to suggest treatment even when the person appears to be unwilling to undergo it, a situation that may reflect the controversies in involuntary treatment in psychiatry [A number of statements about compulsory treatment were endorsed by the lived experience panel but rejected by the professional panel, such as ychiatry . In Brazychiatry , possiblThe major limitation of this study relates to the smaller number of participants when compared to other Mental Health First Aid Delphi studies , 15 due Through the use of the Delphi expert consensus method involving Brazilian mental health professionals and people with lived experience, a culturally adapted set of guidelines for how to provide mental health first aid to someone with problem drinking were produced. While there were many similarities with the English-language guidelines for high-income countries, the guidelines also incorporate actions of importance for Brazil, including the discussion about compulsory treatment, the promotion of alternative activities (e.g. sports and outdoors activities) to prevent drinking and a different approach for talking to the person about their drinking.The guidelines may be disseminated as a stand-alone product or used as the basis for MHFA training in Brazil, thus helping to improve knowledge and helping behaviours of the public towards people with problem drinking. This may contribute to early intervention and better outcomes for people with problem drinking. Further research is necessary to evaluate this.Additional file 1. Statements that were presented to the panels and their ratings across 3 rounds of the survey.Additional file 2. Expert consensus guidelines in Portuguese.


There has been media coverage surrounding the dangers of heavy drinking and benefits of moderation, with TV and radio presenter, Adrian Chiles, documenting his experience of moderating alcohol consumption in an online article for the Guardian. By analysing the comments in response to Chiles’ article, this study aimed to explore (i) posters’ (someone who has posted a comment in response to the article) attitudes or beliefs toward moderating alcohol and (ii) posters’ experiences of moderating or abstaining from alcohol.n = 784) in response to a United Kingdom online news article about moderating alcohol consumption were extracted and inductive thematic analysis was used.A secondary qualitative analysis of online comments in response to an article about moderating alcohol consumption. Main outcome measures: Comments (For aim one, two themes were developed; “general attitudes toward drinking” and “general attitudes toward reducing consumption”. These themes reflect negative perceptions of alcohol and issues around changing attitudes. For aim two, three themes were developed: “moderation vs. abstention”, “reflection on past drinking behaviours”, and “current drinking behaviours”. These themes represent posters’ experiences and implications changing their drinking habits.Our analysis provides a novel insight into perceptions and experiences of moderating or abstaining from alcohol. Alcohol is embedded within United Kingdom culture, creating difficulties for those who choose to moderate or abstain from alcohol. Our analysis highlights the need for public health to focus on shifting the current drinking culture, through clearer drinking guidelines and a wider availability of alcohol-free alternatives. According to a recent United Kingdom (UK) survey of adult drinking behaviour, 28% of males and 14% of females reported drinking at hazardous or harmful levels . HazardoThere is limited research into the experiences of those who abstain or moderate alcohol consumption; understanding their motivations and successful strategies can aid the development of population-level interventions. Qualitative research of Australian adults attempting to moderate found that many experienced stigma for violating social norms, yet adapted their social practices by replacing alcohol with other drinks or choosing other social activities ,b. SimilOnline discussion forums have yielded a rich source of naturalistic secondary qualitative data for health research . There a1, describing his experiences of moderating alcohol consumption since the documentary. There were over a thousand comments in response to the article, from Guardian readers, and this text was used for a secondary qualitative analysis. Using inductive thematic analysis, this study aims to explore (i) posters’ attitudes toward moderating alcohol consumption and (ii) posters’ experiences of moderating or abstaining from alcohol.In 2018, United Kingdom television and radio presenter, Adrian Chiles, made a documentary titled, “Drinkers Like Me”, where he sought medical advice regarding the dangers of his alcohol use. The documentary was also directed at the lobbying power of the alcohol industry and its influence on government policy, yet the government has still not progressed with instituting regulatory measures . Chiles All data were obtained from the comments section of an article titled, “What happened next? ‘Drinking for the sake of drinking. It’s madness’: how Adrian Chiles cut back on booze”, on a United Kingdom news media website, The Guardian (see text footnote 1). Chiles wrote the article as a follow-up to a documentary that he created, titled, “Drinkers Like Me”. In both the documentary and the article, Chiles described his attempts to moderate his alcohol consumption, following medical advice. The documentary and article also explored the impact of not drinking on socialising, alcohol labelling, and problem recognition. The original article was posted at 05.59 GMT on 13th December 2018, with the comment section closing at 20:30 GMT that same day. All comments were obtained for analyses after this date.a priori that irrelevant comments would be removed from the analysis as they would not contribute to the aims of the research, this left N = 784 comments and replies.The initial number of comments including replies in threads was 1128, of which 364 were original comments  and the remainder were responses to comments. Three coders initially coded all comments, including multiple codes for comments which were irrelevant to the aims of the research. Some examples of irrelevant codes included irrelevant support for Chiles , irrelevant abuse/insult , and random exchange . As it had been decided Comments were copied directly from the website into an excel file in chronological order to assist initial coding. Once comments were coded, these were stored and managed in NVivo 10.0 to assist with further analysis.via a unique login, and these were pseudo-anonymised to prevent identification.The Guardian allows the public, including unregistered users, to read articles and comments online. Only registered users may comment on articles, There were a total of 594 individual posters  who responded to the selected Guardian article. Due to the nature of this secondary data, it was not possible to determine socio-demographic characteristics of the posters. However, the average characteristics of Guardian readers were aged over 35, of upper to middle social classes with an even gender split .The University of Liverpool’s ethics committee confirmed that ethical approval was not required for this study and we sought approval from the Guardian for the use of their content and followed the best practice guidelines outlined by the British Psychological Society (BPS). There is limited guidance on the ethics of internet research, as it is relatively novel, therefore it is important to thoroughly address the potential ethical considerations. Most importantly, participants were not able to provide informed consent, as we were unable to identify participants or their personal information to seek consent. However, the BPS states that consent is not needed if the internet communication is considered “public”; the Guardian comments section is publicly available and commenters are made aware that comments can be viewed online and collected by other people . We wereAn inductive thematic analysis was used to identify patterns within the data in relation to the two aims , 2019. IUpon generating initial codes, researchers then developed a codebook, outlining definitions and examples. After initial coding, codes with their associated extracts were read to identify patterns between the data and codes which resulted in the development of themes and sub-themes. Due to the wealth of data, three female second-year doctoral students , who are experienced in conducting qualitative research, each initially analysed a third of all the comments. Data was second coded (10%) to ensure inter-rater reliability. Any discrepancies identified were discussed until all three coders reached a percentage agreement of at least 80%, with Cohen’s kappa above 0.60, indicating at least moderate agreement .JAP reviewed the codes derived from the data and its associated extracts, to develop themes for the two aims. Memos were also used throughout the analysis among the coders to note salient codes, coders’ thoughts on comments, and potential relationships between the different codes and themes. These memos were also discussed at meetings to inform the development of themes and sub-themes. Main themes were developed by JAP and reviewed, defined, and named by PI and JW and are presented in the results section, using quotations to illustrate each theme.For aim one , two themes were developed: “general attitudes toward drinking” and “general attitudes toward reducing consumption”. For aim two , three themes were developed: “moderation vs. abstinence”, “reflections on past drinking behaviours”, and “current drinking behaviours” .within each aim are linked because they answer the same respective research question. Some themes across the aims are linked, as posters discussed general attitudes toward drinking and reducing consumption, alongside sharing their own experiences Moderation and abstinence were frequently discussed with reference to broader general attitudes and personal experiences, hence the “moderation vs. abstinence” theme linking with both themes for aim one.The thematic map  presentsThe two themes developed for this aim  describe posters’ negative attitudes toward alcohol and the culture of drinking within the United Kingdom, as well as highlighting the perceived societal attitudes toward reducing consumption, through either moderating or abstaining. These themes are linked as they reflect posters’ attitudes toward drinking and reducing consumption, without explicitly sharing their own experiences.This theme describes the culture of drinking and how it is normalised within society. Overall perceptions of drinking were negative, with many posters discussing the risks of alcohol, which tend to be ignored.“By now we’ve all been told how carcinogenic and responsible for so many cancers alcohol is. Why then are SO many people choosing to ignore this message?. unlike smoking, which is widely, unquestioningly and utterly frowned upon.”“Alcohol is addictive and that’s the bit that so many people tend to want to ignore (when it comes to themselves anyhow).”This theme consists of two sub-themes: “drinking culture in the United Kingdom vs. other countries” and “perceptions of drinking guidelines and problem drinking”. Posters discussed the current culture of drinking in the United Kingdom, compared to other countries, and how alcohol is normalised, compared to other substances. Misinterpretation of drinking guidelines (0 to 14 units per week) and what constitutes problematic consumption, makes it difficult to address the harms of alcohol and change United Kingdom drinking culture.Posters discussed the drinking culture in the United Kingdom and how it is different to drinking cultures in other countries. Posters described how heavy drinking and binge drinking (to get drunk) are engrained in United Kingdom society and this is perceived as the norm to British people, but in other countries, moderation is more common.“The social culture in the United Kingdom is very heavily centred on alcohol…”“This country has always had a problem with alcohol. It’s almost treated as a rite of passage to get blotted as soon as possible from a young age, then to carry on as though drinking is an Olympic event for which training is obligatory.”“Fortunately, I moved to Switzerland where if you order a bottle of wine for two – everybody stares – this really helps moderate alcohol intake… But it’s true that the drinking culture is very different here than in the United Kingdom (where I’m from) – people enjoy a drink or two without the need to get drunk.”It was also perceived that in the United Kingdom, but not elsewhere, alcohol is used as a method of coping with stress or low mood.The problem is not alcohol, it is that the British are miserable and repressed and drink to excess to drown their sorrows….”“…“The United Kingdom’s problem is not alcohol, it is the shitty stressed lives which the Brits are, quite logically, seeking to escape from.”Others note that while heavy drinking is normalised in United Kingdom society, other illicit substance use is disapproved of.“The attitude to drinking in Britain is something that needs to be looked at and changed, regular heavy drinking is seen as totally normal, and in a lot of cases it’s actively encouraged. Yet mention other recreational drugs, such as marijuana or ecstasy and there’s uproar and lectures on “gateway drugs.”Posters described how United Kingdom drinking culture makes it difficult to change drinking habits, however, making these issues and the benefits of moderation known through the media could help to change this.“I’m Spanish but in England for the last 14 years. I am still shocked remembering friends and colleagues telling their weekend stories in the pub: “It was a great weekend I had 11 pints on Saturday”. I can’t see our culture changing… but it’s good at least that someone has brought the issue out into the open.”Posters discussed current drinking guidelines with perceptions of what constitutes problem drinking. The quotes below illustrate that posters are aware of some drinking guidelines yet disregard them.“I agree that in general, many people drink too much. I would like to know, however, what is truly a reasonable amount. The 14 units thing I don’t accept, simply because most people lie to the doctor when asked how much they drink, so anything based on that is incorrect.”“Binge drinking is defined as 8 units in a single sitting. Or 4 pints, if you like. That’s really just “drinking”. I always associated “binge” drinking with the likes of George Best or Oliver Reed.”While some posters correctly interpreted recommended drinking guidelines, others did not and instead, thought that problem drinking was defined as the frequency and level of alcohol consumption.“50 pints a week? Either I’m totally wrong about how much a pint is or that guy knows nothing about alcohol and health. It’s one unit a day, folks. That would be seven pints a week! Let’s face it: if you drink every day, you have a problem. If you drink around 10 units/beer a week you have a problem.”Others questioned when drinking becomes a problem, particularly if negative effects were not apparent. Some referred to drinking becoming a habit and losing control, and others referred to interferences with work, as tools for identifying problematic drinking.“When is a habit an addiction? Is dependency the same as carrying out a ritual or doing something because you always do? I think Adrian was saying in his documentary that he drank in both social situations and on his own and it was such a habit, that he hadn’t ever questioned whether it was a good or detrimental thing. It was just a repetitive thing, which he clearly enjoyed, but he came to question whether it was having a negative affect on his health, even if he wasn’t dependent as such.”This suggests that while some posters are aware of the recommended drinking guidelines, others are not, and instead, assess the frequency or impact of their drinking to determine problematic consumption. This dissonance between drinking guidelines with beliefs around problem drinking may make it difficult for the general population to know when to reduce their consumption. The implications of this may then be compounded when alcohol is embedded within United Kingdom culture, as shown in the previous sub-theme.Posters discussed general attitudes toward reducing consumption, through moderation or abstinence. This was discussed in terms of the perceived drinking behaviours of others, where some believed that people are beginning to reduce their consumption, but this may be specific to certain sub-populations, such as the middle class.Lately, I’m seeing more and more people taking steps to drink less, much less, so really happy seeing Adrian’s column, however, not sure if my sample of society as middle class adopted Londoner is a true reflection of society.“…via threads.Overall, posters were supportive of those choosing to reduce their consumption and acknowledged difficulties in doing so, particularly due to the United Kingdom drinking culture in. Original comments by those sharing their own difficulties in moderating generated several replies from others, “I’ve a lot of admiration for people who’ve managed to moderate themselves…”“Always amazes me that some people have these strong negative reactions if someone they are with decline a drink or not drink at all.”Others highlighted that alcohol is the only activity to apologise for not partaking in, highlighting the need for changes at a societal level.“Drinking is addictive, it’s a depressant, it decreases your health, causes cancer, ruins your sleep, skin and teeth, it’s expensive and it makes you fat. It really doesn’t have a lot going for it, and it’s the only drug you have to apologise for not taking.”“The culture of implying that non-drinkers are boring certainly doesn’t help!”It was noted that some of the challenges faced when reducing consumption could be addressed by increasing the availability of alcohol-free alternatives or labelling the harms of drinking.“What has made no alcohol easier now, is the wider range of tasty non-alcoholic beers. I can look and feel that I’m part of a drinking group and enjoy it.”“…Maybe this is part the problem and that pub culture should become cafe culture along with a restriction on advertising and ‘alcohol kills’ on their labels. Add to that an easing back on those now massive wine and beer displays in supermarkets and a complete covering up of the hard stuff like they do with cigarettes and tobacco.”Contrasting this, a few comments suggested that the social environment should not change to accommodate those wishing to moderate or abstain. This illustrates some of the complexities of facilitating a culture change.“I’m glad that people who felt that their drinking had become problematic have found a solution but wish that some of them would accept that not everyone who enjoys getting pissed every now and again has a similar problem.”“Open- house on New Year’s Day, a wedding or a birthday party has to be “dry” because an ex-drinker is going to be present? Selfish, or what? Why does the person who can’t do moderation get to dictate things?”This theme shows both overarching positive attitudes toward reducing consumption and the challenges of changing a culture of heavy drinking.For this aim, three themes were developed: “moderation vs. abstinence”, “reflection of past drinking behaviours” and “current drinking behaviours”. These themes reflect posters’ own experiences of drinking alcohol (both past and present) and approaches used to moderate their consumption or abstain.This theme describes posters’ experiences of reducing consumption, through either moderating or abstaining. There were differences in preferences for moderating or abstaining, with some believing that moderating is more difficult than abstaining as it requires constant planning and vigilance.“I went on the wagon for + 100 days and felt f*%king A. Then went back to “moderating” and discovered how shit it made me feel. Now it’s abstention. Moderating doesn’t work for me.”“Moderating, as opposed to abstaining, is seen as a bit of cop out. Trust me, it isn’t. It requires constant thought; hundreds of decisions have to be made every week.”“I tried moderation but it was just hell on earth, I was much better quitting completely and I’ve never regretted it.”This theme consists of three sub-themes, outlining the thought processes when reducing consumption and the implications: “motivations for drinking”, “motivations to reduce consumption” and “positive and negative consequences of reducing consumption.”Several distinct motivations for drinking were described, with some posters stating that they drink to be sociable or because they enjoy it, whereas others reported drinking to cope.“But what else is there? I’m Scottish and single. No drink, no life.”“For me, it’s about drinking because I want to enjoy a single drink…”I had a very stressful job in the city, and wine was my relief…”“…Some posters mentioned that drinking had become part of their routine  and they were not motivated to change this. This highlights the contrasting experiences within the sample, as not all posters were motivated to reduce their consumption.“I still feel I enjoy my drinking, so don’t feel the need to stop.”“A lot of it is habit – and over the last year I’ve changed what I’m used to. Going out for a half is now the norm, and it’s impacted my home consumption too.”Some posters discussed the impact of drinking as a mechanism for change, most notably, damages to health.“I realised I needed to moderate after a talking-to from my doctor. I wasn’t obese, or diabetic, or an alcoholic, but if I wasn’t careful, I’d be headed that way, so his warnings were effectively about making life better in future, rather than thinking I could still get away with it all now.”Other reasons included maturing out of drinking or worsening hangovers, which may reflect the demographic of Guardian readers.“I’m 40 next year and the following day has become such a ghastly ordeal that I’ve pretty much been forced by circumstance to moderate.”“I have been fortunate in that I have gradually lost interest in and taste for alcohol without really thinking about it…”Some had relocated abroad which prompted a change, due to differences in drinking cultures, linking with theme 1 .“I find (through no conscious choice) that I drink far less here. I miss hanging out in my local etc., but that just doesn’t tend to happen here , so I don’t find myself in “drinking situations” as often as I did back home in London.”Posters reported experiencing benefits to changing their behaviours, e.g., weight loss, saving money and leading a more fulfilling life, which encouraged posters to sustain these changes.“Just quitting for a matter of weeks has allowed me to see improvements in my health, mood and bank balance. I’ve also taken up jogging and yoga, writing a bit and reading lots. I’m hopeful I can last even longer this time. Good luck to anyone thinking of trying it, well worth it.”Some described the negative impact of changing their drinking habits, though this was less common. This links to theme 2  as it highlights the difficulties in reducing consumption when it is not accepted by peers.“I was happy enough in myself but had almost no social life and my wife didn’t enjoy drinking alone on holiday.”Posters discussed previous drinking habits and acknowledged previously drinking too much, compared with their current drinking habits.“I used to drink 50-plus pints a week and loved, wanted and needed each one. But it wasn’t a good idea to carry on like that.”“Been there, done it, still now fighting it and winning to a certain extent…. 8–10 Stella a night, 6–7 days a week, so that’s easily over 150 units a week.”Other posters acknowledged that watching Adrian Chiles’ documentary resonated with their previous drinking habits and compared this to their current drinking habits.“This was definitely the most important hour of my year, and possibly my life. I saw this programme and recognised myself… Sometimes all you need is a mirror, though I never thought it would be held by Adrian Chiles…”Others described the difficulties of knowing when to change their behaviours, especially if there were no obvious consequences.“I had an unwritten rule never to drink before 6p.m., functioned at work, now and again a thumping headache, but that wasn’t too often. Ate healthily, cycled, walked, exercised, wasn’t objectionable after drinking, no glaring health-related issues, so it wasn’t a problem, was it? On reflection, it was, and since then I’ve counted the units consumed, and it must have ranged between 30–40 per week.”This theme suggests that posters were aware of previous heavy drinking, and this may have informed their current drinking behaviours, hence the link with theme 5 (current drinking behaviours).Several posters detailed current drinking behaviours, describing reductions compared to previous drinking behaviours. These were described in relation to the strategies used to reduce their consumption and maintain these behaviours. This theme consists of two sub-themes: “self-monitoring of drinking behaviours” and “successful strategies to reduce consumption.”Posters reported moderation or abstinence in the context of self-monitoring, relating to themes 3 (moderation vs. abstinence) and 4 (reflection on previous drinking habits). Moderators used different self-monitoring techniques to maintain their reduced consumption, as outlined in the quotes below.“I have a very simple rule now – I allow myself no more than a third of a glass of wine or a small beer on week nights.”“I’ve cut down from 7 days a week to 2 evenings a week. This has taken 6 months of slow reduction.”Others outlined intentions to self-monitor their drinking behaviours, given this article was published in December 2018, and make changes in the New Year.“My plan for next year is to have a fixed number of alcohol free days (thinking of 120 as a target figure) and marking them off as I do them.”This sub-theme highlights that some individuals have good awareness of their drinking behaviours, however, there were marked individual differences in perceptions of what constitutes moderating.Some posters who changed their drinking behaviours reported changing their drink choice or setting. Some posters described alcohol as an indication of the end of the working day, and therefore, found a substitute helped sustain this.“I cut out midweek drinking by having fruit tea, instead. It seemed that was important to me was that a glass of wine signalled that my working day was over… Making a cup of tea replaced that line between the difficult part of the day and the easy part and I found that with that, ditching weekday drinking was really easy.”via threads.Several posters reported drinking alcohol-free beers and there was much discussion surrounding the availability and quality of different alcohol-free beers, “There are some really good alcohol-free beers out there, Adnam’s Ghost Ship 0% does an outstanding impression of a real ale, and if you’re into craft beer BrewDog’s “Nanny State” is really quite nice.”Others used an alcohol mobile application to track the number of units and to prompt posters when consumption is high.“I found the Drink Fee Days app from the NHS to be a great aid. It’s reminders and gentle journey with you help me remember why I am doing this.”This theme highlights several successful strategies used to maintain reduced alcohol consumption e.g., self-monitoring units, alcohol-free days, and alcohol-free drinks.This novel analysis provides an insight into posters’ attitudes toward, and experiences of, moderating or abstaining from alcohol. We identified five key themes and seven subthemes, in response to our two aims. The themes for aim one suggested that posters generally hold negative perceptions of alcohol and were supportive of those choosing to reduce their consumption. Issues surrounding the United Kingdom drinking culture and misperceptions of problematic drinking were discussed. For aim two, the themes represented posters’ own experiences of moderating or abstaining, reflections on previous drinking habits, and the positive and negative consequences of changing such habits. Posters acknowledged the difficulties of reducing consumption, due to normalisation of heavy drinking in the United Kingdom. Misperceptions, or disregard, of current drinking guidelines highlights a need for population-level interventions, to reduce stigma surrounding moderation or abstinence and increase awareness of the dangers of drinking above government guidelines.Historically, the United Kingdom has been characterised as having a binge-drinking culture . This waOur findings provide support for social practice theory , which tThere were comments which expressed a lack of awareness, or disregard, of current United Kingdom drinking guidelines. This reflects what was observed in a study of United Kingdom drinkers, where 71% were aware of new alcohol guidelines but only 8% knew what they were . MoreoveMany posters stated social and enjoyment motivations for drinking, whereas some discussed drinking to cope with a stressful day or drinking because they face pressure from others . ContrarWhen discussing their own experiences of moderating, posters shared their successful strategies. A range of self-monitoring techniques were mentioned , such asThere are several strengths to this secondary analysis of qualitative data. We used a naturalistic method of data collection, as participants were not prompted through questions. The threads of comments can be interpreted as discourse between participants, which occurred naturally without the presence of a researcher, reducing bias . FurtherAlthough alcohol use is heavily embedded within United Kingdom culture, posters were supportive of those who moderate or abstain from alcohol. Posters also acknowledged the difficulties of reducing consumption, particularly from a societal perspective. Adrian Chiles has raised awareness and invoked discussion surrounding alcohol-attributable harms. Future research should investigate the efficacy of celebrity role models in behaviour change interventions, particularly for reducing heavy drinking and encouraging moderation or abstinence within the context of a country’s drinking culture. Our findings highlight the need for public health to focus on shifting alcohol culture, reducing stigma, and increasing availability of alcohol-free alternatives. We present further evidence which can be used to inform government policy and place pressure on the alcohol industry to instate stricter regulatory measures, such as clearer labelling on alcohol products to highlight the associated harms.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.PI and J-AP contributed equally to the conceptualisation of the study design, data collection, qualitative analysis, the interpretation of the findings, the initial write up of the manuscript, and the revisions. JW contributed to the coding and qualitative analysis. LG developed the initial conceptualisation of the study and the analysis plan. MF, AJ, AKR, SG, and LG provided extensive feedback on the study design, the analyses, the interpretation of the findings, and the manuscript. All authors approved the manuscript as submitted.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.


Research has consistently shown that concealing facial features can hinder subsequent identification. The widespread adoption of face masks due to the COVID-19 pandemic has highlighted the critical and urgent need to discover techniques to improve identification of people wearing face coverings. Despite years of research on face recognition and eyewitness identifications, there are currently no evidence-based recommendations for lineup construction for cases involving masked individuals. The purpose of this study was to examine identification accuracy of a masked perpetrator as a function of lineup type  and perpetrator presence . In both experiments, discriminability was superior for masked lineups, a result that was due almost exclusively to higher hits rates in target-present conditions. These data suggest that presenting a masked lineup can enhance identification of masked faces, and they have important implications for both eyewitness identification and everyday face recognition of people with face coverings. This level of sudden and mass-scaled shift in human behavior is extremely rare in human history, and donning face coverings has profound implications for face recognition in everyday situations as well as eyewitness identification. Prior to 2020, wearing a face mask in public places and government buildings was sometimes unlawful Noble,  because Face identification based on memory  and perception  is impaired by mask-wearing , with these features presented as part of a face or as isolated parts. Participants were better at recognizing the old features when they appeared as part of a face than they were at recognizing the features in isolation. In contrast, when participants were asked to encode features in isolation and then recognized those features in a face or as isolated parts, they showed better recognition performance for a feature in isolation rather than as part of a whole face—an effect termed whole-face interference  even if the lineup contains the same culprit. Instead, the appearance of a face varies from moment to moment due to angles of view, lighting, distance, changes in facial expression, slight variations in hair style, and so on. The eyewitness identification task is a person recognition task, not a picture recognition task and within-person variabilities in appearance are critical aspects in the difficulties that can arise in person recognition  and retrospective (post-identification) judgments , and are their prospective and retrospective confidence judgments diagnostic of actual performance?Experiment 1 used a 2  × 2  within-subjects design. All participants saw a masked perpetrator committing a crime and then attempted to identify that individual in either a masked or unmasked photo lineup. Note that we did not present participants with an unmasked perpetrator during the encoding phase and then varied lineup type at retrieval, because we deemed it extremely unlikely that a witness would be shown a masked lineup for an unmasked perpetrator. Manley et al. , howeverParticipants completed one identification trial from each condition . The order of the trials was random, participants were not informed about which type of lineup they would see, and they were not told that they would complete four trials. In Experiment 1, each trial consisted of three phases . Second, participants watched an unrelated, filler video in the Pre-ID Phase, which served as a brief retention interval. Third, participants were given a six-person lineup  in the Lineup Phase. If participants chose the “Not Present” option, the same (but rearranged) lineup was re-presented and participants were asked to choose the person that looked the most like the perpetrator (to equate response criterion). After the Lineup Phase was complete, the next trial began with a new mock crime video. Experiment 2 employed the same design as Experiment 1, except that participants answered three prospective meta-memory questions before they viewed the lineup.Participants were 314 undergraduate students from Iowa State University who participated in exchange for course credit. Table Fs < 1.21, ps > 0.271), so we collapsed across this variable when reporting our data. We determined the sample size based on an exact proportions McNemar analysis which used the most conservative odds ratios and discordant pairs from Manley et al., (n = 282) was computed using G*Power  did not affect our results for either experiment , and the masked perpetrator was on screen for approximately 75 s, with a close-up view that lasted a total of about half a minute (M = 25 s). Assignment of the videos to lineup conditions was counterbalanced across participants.Materials and Procedure. We created four mock crime videos for this study. Each video depicted a different theft. The four videos showed a man stealing a credit card and identity information from a victim, a wallet theft from an unlocked car, a computer theft from an empty office, and bike theft on a college campus, respectively. Each crime featured a different, college-age, male Caucasian perpetrator wearing a black mask that revealed only the area around his eyes  or masked (n = 75), target-absent eight-person lineup. The final lineup members were selected by removing the faces with the highest and lowest selection rates from both lineup types. We chose to implement the above method in lieu of a simpler method in which fillers were chosen based on a verbal description because of the challenge in creating such a description for a masked face .The target-present lineup included five filler faces and the target-absent lineup replaced the perpetrator with an additional filler. The position of the target and each filler face was randomized every trial and for each participant. The filler faces were selected for each perpetrator via pilot testing with 156 participants from Amazon Mechanical Turk. For the pilot, participants watched each of the four videos and immediately attempted to choose the target from either an unmasked  confidence on a 11-interval scale from 0 to 100, with 0 indicating not sure at all or a guess and 100 indicating absolute certainty. If participants selected the “Not Present” option, they received the same lineup again but with a fresh random order for the faces, and they were told to “choose the individual who most closely resembles the thief.” We included this additional trial to simulate a biased lineup procedure , and the results from this procedure resembled those from the initial trial . Therefore, we focused on the initial identification trial, but the forced-choice lineup data are available on the Open Science Framework (OSF) at Q , we analyzed the data from these lineups separately using Cochran’s M = 0.58) compared to an unmasked lineup (M = 0.48), χ2(310) = 6.72, p = 0.010, OR = 0.63, CI  (see top of Table M = 0.28) than an unmasked lineup (M = 0.36), χ2(310) = 6.15, p = 0.013, OR = 1.62, CI . Lastly, lineup type did not affect incorrect rejections , χ2 < 1, p = 0.637.The most important finding is that participants were more likely to identify the perpetrator from a masked lineup (Mmasked = 74%) than in an unmasked lineup (Munmasked = 69%), F = 4.69, p = 0.031, d = 0.23. But the same pattern also occurred for filler identifications (Mmasked = 63% vs. Munmasked = 56%), F = 4.31, p = 0.039, d = 0.28. However, confidence ratings for incorrect rejections from masked lineups (M = 65%) and unmasked lineups (M = 62%) were comparable, F = 0.30, p = 0.585, d = 0.10. Therefore, the masked lineup appeared to have increased confidence when participants chose someone, regardless of whether that person was the perpetrator.Linear Mixed Models (LMM) ANOVAs were used to examine the effects of lineup type on confidence ratings (see bottom of Table M = 0.31) at a slightly higher rate than masked lineups  = 3.14, p = 0.076, OR = 1.40, CI . In a target-absent lineup, filler identifications are complementary to correct rejections , so they were not analyzed separately.Participants correctly rejected target-absent unmasked lineups (M = 64%) and an unmasked lineup (M = 64%), F < 1, p = 0.906, d = 0.02, but they were more confident in their filler identifications made from masked lineups (M = 63%) than unmasked lineups (M = 57%), F = 9.28, p = 0.002, d = 0.25. Once again, these data suggest that the masked lineup increased confidence when participants choose someone from a lineup regardless of accuracy.Participants provided virtually identical confidence ratings for correct rejections made from a masked lineup  at each level of confidence c. Because there were too few observations at each confidence levels, we binned the confidence levels from 11 to four so that each contained a roughly equal number of responses. The four confidence levels corresponded to 0–40, 50–60, 70–80, 90–100. The term nFIDTA-c is the number of filler identifications made from target-absent lineups  at the same level of confidence. Because there was no designated innocent suspect in the current study, nFIDTA-c is divided by the lineup size in the target-absent lineup (n = 6 in the current study) to estimate the innocent suspect frequencies. Suspect identification accuracy is then plotted at each level of confidence to show a CAC curve for each condition. The CAC curve offers a visual inspection of the relationship between accuracy and confidence , and we are particularly interested in whether masked and unmasked lineups affect this relationship.As shown in Fig. In general terms, the data in Fig. someone in target-present lineups and rejecting target-absent lineups) and identification (i.e. choosing the target). The model produces a discriminability (d’) and response bias (c) value for each condition. Negative (c) values indicate a conservative bias and positive values indicate a liberal bias. We adopted the integration decision rule, which offers a good fit for eyewitness identification data  for the model where d' (or c) was constrained is subtracted from the G2 for the model where d' was permitted to differ. For example, if the G2 values were equal to 10 for the fixed model and 5 for the model in which d’ was allowed to vary, the difference of 5 would exceed the critical value for χ2(1) = 3.84, and we can infer that restricting the two lineup conditions to a single d' value significantly impaired model fit and it is unlikely that the two lineup conditions have the same d' value.A compound signal detection model (SDT-CD) examined whether lineup type affected discriminability  compared to an unmasked lineup (d' = 1.32), G2(1) = 6.05, p = 0.014. Response bias, in contrast, did not differ significant across the lineups, and both showed conservative leaning, negative values , G2(1) = 1.68, p = 0.195.Results for Several important results emerged from Experiment 1. First, presenting participant witnesses with a masked lineup improved their ability to identify the target when the perpetrator was present (relative to an unmasked lineup), but it did not affect correct rejections when the perpetrator was absent. Second, identifications made from a masked lineup were associated with greater confidence than those made from an unmasked lineup, regardless of whether those identifications were correct  or not , but lineup type did not affect confidence for rejections. Third, both the masked and unmasked lineup produced overlapping, positive CAC curves, such that lineup types did not affect the diagnosticity of confidence.In the Introduction, we noted that Manley et al.  showed tboth lineup types.Experiment 2 has two purposes. First, we wanted to replicate the findings from Experiment 1. Second, we wanted to examine whether participant witnesses had a preference for lineup types, and if not, whether they would develop such a preference once they have experienced the eyewitness identification task. We also examined whether prospective confidence judgments (similar to judgments of learning) can predict identification accuracy, given the positive diagnosticity of retrospective confidence judgments. Immediately before the presentation of each lineup in Experiment 2, participants were first asked to indicate their lineup preference ; they were then asked to make prospective confidence judgments for n = 13), because they indicated that they knew one of the actors or fillers (n = 5), or because total duration spent completing the study was over twice the maximum amount of time  it took in-lab participants (n = 2). Of the remaining 313 participants, 158 completed the study in the lab and 155 completed the study online through the university SONA system. For more information about participant demographics, see Table Participants were 334 Iowa State University students. Data from 21 of the 334 participants were not included in the analyses because they failed attention checks  compared to the unmasked lineup (M = 0.38), χ2(313) = 14.30, p < 0.001, OR = 0.53, CI  (see top of Table M = 0.31) than from the unmasked lineups (M = 0.41), χ2(313) = 8.53, p = 0.003, OR = 1.73, CI , and there was no significant difference for incorrect rejections across lineup types (Mmasked = 0.16) compared to unmasked lineups (Munmasked = 0.21), χ2(313) = 2.04, p = 0.153. These results replicated those from Experiment 1, except that they favored the masked lineup over the unmasked lineup even more.The most important finding was that participants identified the perpetrator more often from the masked lineup M = 0.5 comparedM = 68%) than from an unmasked lineup (M = 64%), F = 2.88, p = 0.091, d = 0.20. They also rated their filler-IDs from a masked lineup with greater confidence (M = 55%) than those from an unmasked lineup (M = 49%), F = 4.15, p = 0.043, d = 0.27. There was no significant difference in confidence ratings for incorrect rejections made from a masked (M = 56%) compared to an unmasked lineup (M = 49%), F = 2.52, p = 0.115, d = 0.30. These data largely replicated those from Experiment 1.Linear mixed models ANOVA were performed to examine differences in retrospective confidence ratings for target identifications, filler identifications, and incorrect rejections as a function of lineup type  as they were an unmasked lineup , χ2(313) = 0.30, p = 0.587, OR = 1.10, CI [0.76–1.60]. Once again, we did not analyze the data for filler identifications separately because they are the mathematical complement of correct rejections in a target-absent lineup.When the perpetrator was absent, participants were similarly likely to reject a masked lineup , F < 1, p = 0.556, d = 0.07, but filler identifications made in a masked lineup were associated with greater confidence (M = 58%) than those made in an unmasked lineup (M = 53%), F = 4.38, p = 0.037, d = 0.22. These data once again showed that the masked lineup increased confidence for identifications but not for rejections.Retrospective confidence ratings for correct rejections did not differ across lineup types  than the unmasked lineup  = 18.05, p < 0.01; see Table cmasked = − 0.33, SE = − 0.02, cunmasked = − 0.30, SE = 0.02; G2(1) = 0.26, p = 0.611).The masked lineup led to greater discriminability  when analyzing lineup preference and prospective confidence, because these measures were taken before participants saw the lineup (see Table M = 53%) and unmasked lineup (M = 47%) were preferred by roughly half of the participants, respectively, χ2(313) = 1.41, p = 0.235. However, from the second trial onward, participants developed a preference for the masked lineup (M = 72%), χ2(313) = 58.23, p < 0.001, which persisted for Trial 3 (70%), χ2(313) = 51.53, p < 0.001, and Trial 4 (72%), χ2(313) = 59.97, p < 0.001. Intriguingly, this pattern occurred regardless of whether participants received an unmasked or masked lineup during their first trial , t(312) = 0.56, p = 0.567, d = 0.04. However, by Trial 2, participants began reporting higher prospective confidence for the masked lineup (M = 56%) than the unmasked lineup (M = 51%), t(312) = 4.23, p < 0.001, d = 0.24, and this difference was maintained on Trial 3 (54% vs. 48%), t(312) = 5.61, p < 0.001, d = 0.32, and Trial 4 (52% vs. 47%), t(312) = 4.55, p < 0.001, d = 0.26.The prospective confidence ratings also demonstrated the same preference development. On Trial 1, participants rated their likelihood of a correct decision as virtually identical between a masked lineup and an unmasked lineup  = 39.92, p < 0.001, such that participants provided higher prospective confidence ratings for the lineup that they chose (M = 55%) relative to the one they did not choose (M = 48%). There was not a significant effect of lineup or an interaction, Fs < 1, ps > 0.534. Importantly, whether participants were presented with the lineup they chose or did not choose did not impact accuracy as performance patterns were similar to those presented above for all four lineup types .We conducted an additional 2  × 2  LMM ANOVA to assess the relationship between lineup preference and prospective confidence. If participants’ preference for lineup type was driven by, or associated with, the perceived efficacy of the lineup, then they should report a higher prospective confidence for their preferred lineup over their non-preferred lineup. This was indeed the case, hose M = 5% relatiFinally, CAC curves for prospective confidence were plotted using dotted lines in Fig. To assess if the specific actors impacted the pattern of results, we combined the data from Experiments 1 and 2. This was to ensure adequate power as the data will be split four ways, decreasing reliability, and increasing variability.F = 4.89, p = 0.002. Specifically, for the computer thief , the identity thief , and the wallet thief , participants made more target identifications for masked-face lineups  compared to full-face lineups ; however, for the bike thief , participants made fewer target identifications from masked-face lineups compared to full-face lineups. This last difference was further examined through a post-hoc comparison which found that the difference in target identifications was not significant, F = 0.86, p = 0.355.For target-present lineups, actor interacted with lineup type, F = 4.11, p = 0.007. Specifically, for the bike thief , the identity thief , and the wallet thief , participants made more correct rejections from full-face lineups  compared to masked-face lineups ; however, for the computer thief , participants made more correct rejections from masked-face lineups compared to full-face lineups.For target-absent lineups, actor interacted with lineup type, The purpose of Experiment 2 was to replicate the data from Experiment 1 and to gain insight into participant’s beliefs about their own memory for a masked perpetrator. Would participants have a preference for a masked lineup or for an unmasked lineup, and would their preference change with experience? Our results showed that participants did not have a preconceived notion of the superiority of the masked lineup over the unmasked lineup, but they developed a preference for the former with experience. Moreover, although prospective confidence ratings were indicative of preference, they were not indicative of identification accuracy  during encoding . Rather, we tested a predicted locate a match between their memory and the lineup members. In a target-absent lineup, no such matches exist, which would explain the null effect in this condition. To be clear, this explanation is post-hoc, so further research needs to be conducted to test this account. From an application perspective, however, the null effect for target-absent lineups is positive because it suggests that there is little to no drawback to administering a masked face lineup when the target is absent, but there is much to be gained when the target is present.Our reasoning is that holistic processing at retrieval triggered whole face interference  or high (70–100) prospective confidence rating. Flat CAC curves are rare in eyewitness memory studies, except when participants’ memories have been contaminated by misleading information . In an investigative setting, the interval between a witnessed event and an identification can range from minutes to years , not to mention the popularity of surgical masks due to COVID-19. Depending on the degree of occlusion and/or distortion of the facial features, the masked-lineup superiority effect is likely to vary. For instance, masks that cover fewer regions of the head  might produce a masked-lineup superiority effect that is smaller than masks that cover more regions . Moreover, it is unclear whether sequential exposures to both the masked and unmasked versions of a face would alter the effect . In sum, many relevant variables remain unexplored regarding this effect.Both of our experiments showed a masked lineup superiority when the perpetrator was in the lineup. This increase in target identification has important implications in a judicial context, given that an eyewitness identification is one of the strongest forms of evidence Wells, . Manley Prior to COVID-19, head and face coverings were common only amongst people from Muslim cultures  and in countries in which mask wearing was a widespread practice to prevent the spread of respiratory illnesses . In the context of criminal justice, face masks were worn only by people committing premeditated crimes. But with face coverings having become an essential and global practice, far more unfamiliar face identifications will occur under situations in which a person has previously seen a masked face .Given that eyewitness misidentification contributes heavily to wrongful convictions, it is important to examine methodologies that may increase identification accuracy. The ultimate goal of eyewitness identification research is to encourage investigative approaches that improve the probative value of eyewitness evidence. One way to do this is to leverage cognitive theories and principles to inform better lineup construction strategies. In the present study, we showed that when a witness encounters a masked perpetrator, administering a masked lineup increases identification accuracy compared to an unmasked lineup. Moreover, with experience, the majority of participants actually prefer a masked lineup. The idea of matching the perceptual appearance of lineup members to the perceptual appearance of the originally encoded face when disguises were involved was vaguely considered decades ago Cutler, . With th