HIV-positive mothers who face the dual burden of HIV-positive status and motherhood, may benefit from holistic services that include early childhood development (ECD). We evaluated the acceptability and impact of integrated ECD-PMTCT interventions for mothers and their children.We implemented an integrated ECD-PMTCT intervention in 4 health facilities in Malawi for HIV-positive mothers and their infants. WHO/UNICEF Care for Child Development (CCD) education and counseling sessions were offered during routine PMTCT visits between infant age 1.5–24 months. From June–July 2019, we conducted in-depth interviews with 29 mothers enrolled in the intervention for ≥6 months across 4 health facilities. The interview guide focused on perceived impact of the intervention on mothers’ ECD and PMTCT practices, including barriers and facilitators, and unmet needs related to the program. Data were coded and analyzed using constant comparison methods in Atlas ti.8.The vast majority of mothers believed the ECD-PMTCT intervention improved their overall experience with the PMTCT services, strengthened their relationship with providers, and excited and motivated them to attend PMTCT services during the postpartum period. Unlike prior experience, mothers felt more welcome at the health facility, and looked forward to the next visit in order to interact with other mothers and learn new ECD skills. Mothers formed new social support networks with other mothers engaged in ECD sessions, and they provided emotional and financial support to one another, including encouragement regarding ART adherence. Mothers believed their infants reached developmental milestones faster compared to non-intervention children they observed at the same age, and they experienced improved engagement in caregiving activities among male caregivers. Nearly half of women requested additional support with depression or anxiety, coping mechanisms to deal with the stresses of life, or support in building positive dynamics with their male partner.The integrated ECD-PMTCT intervention improved mother’s experiences with PMTCT programs and health care providers, increased ECD practices such as responsive and stimulating parenting, and created social support networks for women with other PMTCT clients.The online version contains supplementary material available at 10.1186/s12913-021-06342-2. Sub-Saharan Africa (SSA) is home to 87% of all HIV infected mothers and children worldwide . HIV expEarly childhood development (ECD) within the first 5 years of life is foundational to an individual’s development, wellbeing, and potential capital throughout the life course .In the past decade, there has been increasing recognition of the importance of ECD, with many countries in sub-Saharan Africa (SSA) adopting national ECD policies . As ECD Prevention of mother-to-child transmission (PMTCT) programs provide a strong, developed infrastructure for reaching nearly all HIV-positive mothers and their infants in SSA. PMTCT strategies have been very effective in reducing HIV transmission to infants . ApproxiIntegrated ECD-PMTCT interventions have several potential benefits. First, ECD interventions have been shown to have the greatest benefit amongst vulnerable or disadvantaged children . ECD strWe used qualitative data from an integrated ECD-PMTCT intervention in Malawi to provide insights into the percieved impact of the intervention among participating women, examining percieved impact on ECD among their youngest child (primary outcome) and women’s experience with and engagemnet in the PMTCT program (secondary outcome). In addition, we examine remaining unment needs for women attending the ECD-PMTCT intervention.Mothers and their young children (aged 0–8 weeks) were recruited in four health facilities in central Malawi to participate in an integrated ECD-PMTCT intervention. Mothers were eligible if they were HIV-positive, enrolled in the PMTCT program at a participating facility, and had a child < 8 weeks of age. Facilities selected for the intervention varied in size, type , and district (see Table Monthly ECD sessions completed during PMTCT waiting times were informed by the WHO-UNICEF “Care for Child Development” (CCD) package  that proIn-depth interviews were conducted from June to July 2019 with a random subset of mothers enrolled in the ECD-PMTCT program for ≥6 months in order to ensure mothers had the opportunity to be exposed to most of the ECD curriculum from CCD package. We selected a random sample of mothers in order to have a representative description of women’s perceptions of the program. – this also ensured there were no biases in sample selection, such as selecting women who were actively engaged in the program or known to think positively about the program. Program enrollment materials were digitized and 32 women were randomly selected by the data manager using a computer-generated random sequence of numbers. Random selection was stratified by health facility to ensure all facilities were represented since implementation and acceptability of the intervention may depend heavily on facility-level factors, such as personnel and characteristics of the community served , as well as by duration on ART. At each facility, 50% of the randomly selected mothers had initiated ART ≤12 months ago and 50% ≥ 12 months ago since newly diagonized mothers may react differently with HIV programs and their infants. Selected women were contacted by the study staff and invited to attend the heatlh facility for an in-depth interview.The interview guide and analysis framework were developed based on existing literature , 12, 13 All interviews were conducted at a participating health facility by a trained female research assistant in the local language (Chichewa), and ranged in duration from 30 to 50 min. Participants were compensated 4000 Malawi Kwacha (approximately US $5) for their transportation costs to attend the interview.Audio recordings were translated and transcribed into English for analysis. A preliminary codebook was generated using deductive coding from existing literature and inductive coding from pilot interviews and novel findings from early transcripts. Two investigators (TT and PK) coded the same five transcripts separately using Atlas.ti (version 1.6). Coding was reviewed with KD and differences in coding were resolved, creating a finalized codebook and code definitions. An additional two transcripts were simultaneously coded, with similar codes between investigators. TT and PK coded all remaining transcripts using the finalized codebook. Data were analyzed using constant comparison methods. In this paper we present dominant themes related to mothers’ perceived benefits of the program and remaining unmet needs.Ethical approval was attained from University of California Los Angeles (UCLA) and the Malawi institutional review board, National Health Sciences Review Committee (NHSRC). The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.Of the 29 mothers interviewed, nearly all were married. Women had a mean of 4 children (range = 1 to 8 children) and mean age of 30 years (range = 18 to 38 years). Half reported informal employment or entrepreneurial activities as the primary household income, with only two participants reporting any formal employment within the household (either for themselves or their husbands). A little less than half of mothers had initiated ART within the past year. The vast majority of mothers attended ECD sessions every month and only one mother stopped attending the ECD-PMTCT program completely (both ART and ECD services). See Table “I am satisfied with everything that is why even when I am late, I make sure to meet with the ECD counsellors.” Mother of 2, age 25–29Nearly all mothers reported that they enjoyed being in the ECD-PMTCT program and prioritized program attendance. Women would ensure they arrived at the PMTCT clinic early in order to attend ECD sessions, and actively engaged in the ECD lessons presented.“My experiences in the ECD program is all good, right now my child is growing up with health [y] and knowledge, I did not know that such things can happen.” Mother of 5, age 30–34“Yes, there are changes, because all my children did not start walking as quickly as my youngest, he started walking with 9 months old. This is because of the program as I was able to teach him everything.” Mother of 4, age 30–34“When my child was six weeks old I started having [ECD] lessons. They told me to make toys, for example a ball, doll and a car, and to call the child’s name and friends’ names. I started seeing change when the child reached five months old. … I will continue to follow what I learn at the hospital because its good. “ Mother of 8, age 30 -34Most mothers believed the integrated ECD-PMTCT program was beneficial for their children and was critical to their own development as caregivers. Mothers identified several tangible ECD-related benefits of being part of the program, including improved parenting techniques  and observed perceived advanced development among their children. Mothers who had multiple children reflected on how their children who participated in the ECD-PMTCT program were more interactive and engaged  when compared with older siblings when they were the same age, and they attributed these changes to the ECD program.“After I told him about ECD, he is active with the child. He makes him porridge, sings to him and plays with him. When the child sees his father, he makes noise indicating that he has seen him.” Mother of 1, age 20–24“Me and my child we are living in harmony because we are raising this child together and the child of the father has just realized that the responsibility is for the both of us.” Mother of 4, age 30–34Women also believed the integrated ECD-PMTCT program improved their male partners' parenting behavior and improved their overall experience as joint caregivers. Of the mothers who reported being in a relationship with the father of their youngest child, the majority reported that since starting the program, the father had increased the time spent with the child, and that he was now implementing ECD lessons learned from the program. Nearly half of mothers in a relationship with the father reported improved communication between the mother and father, attributing this change to having a joint purpose around ECD for their children and responsive parenting.At first we just came and got assisted and left; we did not care about anything else apart from just getting medical help. But now with ECD I am interested in knowing about what I am going to learn about my child through ECD.” Mother of 2, age 35–39““The change is that even when a nurse is alone, we don’t get tired of waiting as we are occupied with the ECD activities, whilst in the past before the program, we thought the happenings [waiting times] were just time consuming.” Mother of 4, age 30–34Mothers cited several benefits of their experiences with PMTCT due to the integrated ECD-PMTCT program. Women believed that having ECD sessions during the PMTCT waiting period improved their overall experience with the ART program and with the health system more broadly. ECD sessions provided additional motivation for attendance and excitement for learning something new as opposed to simply collecting ART medication.“We ask about how their child is or whether they practice the things we have learned on their children … . My friend came here at the hospital for ECD and she told me that she did not have any money on her to help her with the hospital fee, so I gave her the money because in the future I may be in a similar situation and I can be able to be assisted by her as well.” Mother of 1, age 20–24“When you are with the fellow women you are sometimes enlightened … Because you learn a lot from each other. “Mother of 3, age 25-29ECD sessions were also used to form social support networks with other women living with HIV. Mothers provided each other with support and advice regarding everyday life situations, such as emotional encouragement and financial assistance when needed.“We encourage each other about life. Other people are shy, others are afraid that when they have been found with HIV then that is the end of their life not realizing that it is a beginning of another life. We encourage each other about that, that when you accept your status you are able to live a healthy life and that your child can also grow a healthy life and that it’s also possible for the child to be born without HIV as long as the mother follows what the doctor is saying.” Mother of 2, age 25–29Newly founded social networks also encouraged PMTCT activities, as well as encouraged mothers to overcome challenges associated with living with HIV.“What has changed is when you come here you are able to talk freely to the nurse about your problems.” Mother of 2, age 35–39“Because of ECD things have changed because even the nurses or patient attendants, we live with them in harmony, unlike if we were just coming here to get drugs and go home. Now we are able to know them by name and talk to them.” Mother of 2, age 30–34Over half of all women reported that facility staff treated them more positively since they joined the integrated ECD-PMTCT program, and that they felt more welcome at the health facility. Among these mothers, most believed client-provider relationships changed because facility staff had taken time to get to know them. They now talked casually and in detail about their personal lives, whereas prior to the intervention client-provider interactions consisted primarily of drug distribution.“We should also be told as women [how] to be happy; something [strategies] that can make us less stressful and have no worries … Teach us to do away with stress and worries.” Mother of 5, age 25–29“Yes, that we would wish is to teach us how to [financially] take care of our families and [communicate] with husbands admirably. This program would be so helpful then.“ Mother of 4, age 30-34Despite valuing the integrated ECD-PMTCT program, over half of the interviewed women reported unmet needs that they would like the program to address. Almost half desired specific sessions to help them cope as mothers living with HIV (ie. caregiver wellbeing), including stress management and marital advice. While women did not directly mentioned post-partum depression, several discussed being sad or overwhelmed with their life circumstances.“I would have loved to learn the sort of nutritious food stuffs that we should be giving our children when they reach six months old.“ Mother of 6, age 35-39Nearly all women reported the need to learn more about nutrition for both themselves and their infants.“Other women consider playing with their child as not important because they think it is too time consuming to suspend what they are doing and play with a child. They think that to make dolls for their child to play with is a waste of time.” Mother of 4, age 30–34“They say that small babies can’t hear anything when you’re chatting with them” Mother of 1, age 20–24The majority of mothers reflected that talking or playing with infants was culturally uncommon, and the benefits of such activities was not intuitive. Participants believed that the program should have explicit, repetitive lessons on why these activities are needed, and how to talk/play with infants.We conducted a qualitative assessment of participants’ perceived impact of an integrated ECD-PMTCT program in Malawi among postpartum mothers living with HIV and their young children. Women believed the intervention had a large impact on both their own experience with PMTCT services, and their infants’ healthy growth and development, along with father’s improved engagement with the childs’ well being and developmental growth. Overall, women prioritized attendance to the program, but still remained with unmet needs such as counseling and mental heatlh support for women who faced multiple stresses in their daily life.To our knowledge, this is only the second study to examine an integrated ECD-PMTCT program . Women’sNotably, mothers believed the ECD-PMTCT program improved their relationships with nurses and faciltiy staff. Negative patient-provider interactions have been documented in other qualitative studies to have profound adverse impact on maternal perception of care and subsequent adherence to ART , 20. MotParticipating mothers believed the ECD-PMTCT program resulted in new social support networks. Within the ECD-PMTCT intervention, women built personal relationships and were able to receive and give support on motherhood, family issues, their HIV-positive status, and adherence to the PMTCT program. Other studies find that social support is directly linked with maternal and infant health outcomes , 22 and ECD programs and their impacts have historically focused on women and children, not men. However, literature indicates that male involvement in ECD can result in improved infant feeding practices , increasMore than half of participants identified unmet needs related implementing ECD and engaging in PMTCT programs, despite their engagement in the intervention. Mothers requested additional counseling and support for their overall mental wellbeing, including strategies to cope with stress, worry, and how to promote positive relationships between themselves and their male partner. Other studies show that postpartum women living with HIV are at high risk of depression, anxiety, and social tensions –33. Such We rely on self-reports from mothers who were actively engaged in the ECD-PMTCT program. Further research is needed with mothers who stop attending either ECD sessions or both ECD and PMTCT sessions in order to further understand unmet needs and barriers to program participation. Second, the study is limited to mothers in central Malawi and may not be representative of other settings, although the structure and barriers related to PMTCT programs are similar throughout the region , suggestAn integrated ECD-PMTCT intervention in Malawi had high perceived impact among postpartum mothers living with HIV. ECD services offered during PMTCT waiting times were perceived to improve women’s experiences with the PMTCT service and patient-provider interactions. Women also believed that their infants demonstrated improved development and that their male partners became more engaged as a result of the program. Similar interventions hold promise for a double benefit for both ECD outcomes for infants and improved PMTCT engagement for mothers.Additional file 1. Interview guide.


During COVID-19, many training programs pivoted to virtual formats. For the Rural Interdisciplinary Team Training (RITT) Program, funded by the Veterans Health Administration as part of the Geriatric Scholars Program, there were unique challenges. Given a history of successful accredited in-person, team-based workshops for staff at rural and remote clinics, program developers needed to quickly devise a plan for an effective virtual training for team members working separately from each other. Without the ability to provide in-person education and training, rapid pivoting to virtual modalities was essential for ongoing education of those providing care for older adults. Using a web-based platform, team members and expert trainer facilitation, participants engaged in lively discussions and reflection using the chat feature. RITT adapted the curriculum to better meet the needs of busy healthcare providers working during the pandemic, including increased discussion of how COVID affects older Veterans. Three virtual RITT workshops were held between March 2020 and February 2021 with 64 participants from 12 rural clinics and medical centers. Over 90% of participants agreed or strongly agreed that they were satisfied with the virtual workshop, comparable to those participating in the in-person workshop in earlier years. Similar to others, we have found that the ability to flex a curriculum has benefits to both learners and educators and increases the reach of educational opportunities in gerontology and geriatrics. Particularly in rural areas where travel may be challenging, a virtual format may be a desirable long-term solution for the RITT program.


It is necessary for the university environment to contribute to the improvement of the attention paid to affective-sexual, bodily, and gender diversity. This research deals with how, by means of a teaching innovation program, competences for affective-sexual diversity were developed. Specifically, negative attitudes towards diversity, knowledge, and degree of empathy on these issues before and after the implementation of the program are compared. The degree of satisfaction, perceived usefulness, and fulfillment of the objectives proposed in the program were also evaluated. An ex post facto design was used. The participants in this study were 129 students belonging to Educational Sciences and Psychology, out of 2400 who benefited from the innovation program. The results showed an increase in competences related to the attention to diversity, with the improvement of attitudes and knowledge about affective-sexual diversity after the application of the program. It is concluded that this type of innovation program, with quality training, contributes to the improvement of coexistence and the prevention of gender violence in university classrooms, eliminating stereotypes and negative attitudes towards diversity. In current undergraduate degrees, the acquisition and/or development of interpersonal skills by students is necessary. Specifically important are those skills related to education that attend to affective-sexual, bodily, and gender diversity, aligning with the Second Plan of Equality of the UGR . Within As recently highlighted , these iThere is still much to be done for gender equality and attention to affective-sexual diversity. Among the autonomous provisions that can be highlighted in Spain are Law 2/2014, of 8 July, comprehensively written for non-discrimination on the grounds of gender identity and recognition of the rights of transgender people in Andalusia . More reThe concept of affective-sexual diversity is what allows individuals to distinguish the different sexual options that exist in society . The conThere are different psychological theories to explain the learning process of sexual and gender identity, such as cognitive–social learning models and psychoanalytic theory. However, since it is not the objective of this work, we will briefly point out some of the specific theories that apply to affective-sexual and gender diversity.The two primary theories underpinning the concepts under analysis and their possible implications are: (1) essentialism, which argues that sexual dimorphism creates fixed male and female identities which are innate in nature and provide unquestionable implications for people’s lives and expectations; and (2) queer theory, emphasizing the influence of the sociocultural relay with freedom for the expression of sexuality and gender . Within One of the consolidated theories, for which there is even an evaluation scale, is the multidimensional theory of , in whicA recent study  shows thFrom a reflexive model using a qualitative methodology, such as interviews with open questions, life histories, and ethnography, other studies can be found which consider the importance of inclusion and respect for diversity, especially in the face of new challenges and changes in gender distinctions, and the tendency towards a less fixed sexual identity in both the social and clinical spheres ,23,24,25With regard to the perception of future teachers towards the LGBTQIA+ community, some studies  point toWith respect to the contributions by previous research, it should be noted that there are more works that call for coexistence with regard to gender equality in secondary education, and even at this level, there are very few which focus on LGBTQ+ communities. However, there are still very few programs, such as the present one, aimed not only at education for gender equality, but also at education for affective-sexual, bodily, and gender diversity in the university environment, in which elements of innovation are introduced and activities are carried out transversally. Non-sexist language guides have been analyzed in this study, and students have also had the opportunity to participate in many joint activities such as workshops, seminars, congresses, conferences, scriptorium conferences, video forums, and exhibitions.Taking the above into account, a successful teaching innovation program was coordinated and developed within the university curriculum  , which aA multidisciplinary group of 25 teachers from various academic disciplines participated. Their students benefited from transversal and specific activities in favor of education for sexual, bodily, and gender diversity. These activities were adapted and blended into the contents of respective teaching programs. The implementation and adaptation of advanced learning methodologies encouraged autonomous learning, active participation, and the use of information and communication technologies (ICT) to raise awareness of these issues in university classrooms.The project was developed over two academic years. The first year was aimed at raising awareness and training students with crosscutting and subject-specific activities. In the second year, together with the previous activities, joint activities were developed with the voluntary participation of students trained in the previous academic year.-Using questionnaires focusing attention on affective-sexual, bodily, and gender diversity;-Developing language and guides  for each subject;-Making LGBT people (and those working for LGBT rights) visible;-Debating the importance of initiatives designed to promote respect towards affective-sexual, bodily, and gender diversity in the world today in Spanish and Andalusian schools, with subsequent reflective activities and the possibility of extending these debates to schools at the level of compulsory secondary education ;-Getting the participating students to design everyday life activities for the promotion of affective-sexual, bodily, and gender diversity.The following transversal activities were developed within every subject area:The following specific activities were also carried out: Completing a specific activity based on the corresponding material or subject matter. The teachers participating in each educational activity, which was linked to affective-sexual, bodily, and gender diversity, orientation, and professional ethics, selected the specific activities that would be exclusively carried out within each subject area. These were based on the pedagogical criteria and suitability of the methodology to the content and objectives of the activity. Examples of possible activities included: Watching a short or long-format film followed by a discussion and a debate; a lecture by an expert in the field and completion of follow-up questions on the virtual campus (designed for this purpose); participation in national and international debate forums; construction of a Wiki, chat, or forum for discussion and its use to solve a particular problem or obtain suggestions for everyday ideas to encourage the equality of gender differences; a video or book forum; creation of a glossary of terms related to these issues; asking students to find an LGBT-supportive news item followed by critical reflection upon it in class; creation of a bibliographic file; and analysis of a text.1st Conference on Attention to Affective-Sexual Diversity held at the Faculty of Psychology and the 1st International Congress on Attention to Affective-Sexual Diversity held at the Faculty of Psychology; and the 1st International Congress on Attention to Affective-Sexual Diversity held in Andalusia; (b) Interdisciplinary round tables, such as for the analysis of laws and their development, depathologization, and families; research in education and health. Participation of two experts and other autonomous communities; Legislation and public policies. Participation of two experts and the Andalusian community; Experiences in ESO .The student body also benefited from the following joint activities: (a) Commemoration of anniversaries ; attendance and participation in the The objectives of the present study were: (a) To analyze the descriptive statistics as well as Student’s T-test comparing the initial data at the beginning of the program with the final data once the innovation program had been completed with a series of variables selected to control the effect of the program; (b) To evaluate the degree of satisfaction and perceived usefulness of the activities of the innovation program; (c) To examine the degree of perceived usefulness of the activities carried out to fulfill the objectives of the project; (d) To examine the relationships between the variable attitudes towards equality and affective-sexual diversity and other psychoeducational variables, such as styles of thinking; and e) To assess the degree of fulfillment of the objectives of the teaching innovation program by the teaching staff and students.An increase in the development of socio-emotional skills, such as empathy, is expected to decrease negative attitudes towards affective-sexual, bodily, and gender diversity after the development of the activities of the innovation program. It is also expected that the knowledge about affective-sexual diversity will be greater after the training received in the program.The innovation project benefited 2400 university students from different faculties  who carried out the proposed activities. A total incidental sample of 129 students belonging to the Faculty of Educational Sciences and the Faculty of Psychology of the University of Granada were selected. Most of them belonged to the first year of the Degree in Primary Education and the Degree in Psychology. Of the 129 students, 69% were women. In terms of marital status, most of them were single. They were aged between 18 and 25 years, with an average age of 20.87 years old. A control group was also used with a sample of 95 students  from groups that did not participate in the program but belonged to the same faculties. A multidisciplinary group of 25 teachers from different areas of knowledge participated. The present study protocol was approved by the Ethics Committee of the University of Granada , with the registration number: 2056/CEIH/2021. The participants completed an individual informed consent form to participate in the study.Adaptation of School Doing Gender/Students—Scale of Student Attitudes towards Co-education : This inNegative Attitudes towards Trans People Scale (NATS) . This inModern Homophobia Scale . This inCognitive and Affective Empathy Test (TECA) . This teStenberg–Wagner Thinking Styles Questionnaire ,39   were to An ex post facto design was used. A cross-sectional non-experimental research design was implemented, and convenience sampling was used for selecting student participants. Participants were asked to complete a series of self-report Likert-response scales that were previously outlined. The Ethics Committee of the University of Granada approved the program and the studies derived from it. Evaluations were carried out before starting the program and after ending the program with different variables selected to record the effect of the program. Informed consent was requested, and the confidentiality of the data and the voluntary nature of participation were ensured with participants. The questionnaires were administered collectively with different groups of participants in different classrooms.For the data analysis, the computerized statistical package SPSS V. 22 was used. An examination  of the study variables was carried out to verify compliance with the assumptions of normality, non-collinearity, and Pearson’s correlation.Descriptive analyses were carried out reflecting percentages, means, and standard deviations of the participating sample as well as Student’s T-test for related samples, to determine if there were statistically significant differences in the evaluation of the variables of the questionnaires, including negative attitudes towards transsexual people, empathy in the cognitive and affective dimension, and knowledge about equality and affective-sexual, bodily, and gender diversity.To assess the degree of satisfaction and perceived usefulness associated with the program activities  related to diversity; and a conference or talk. The mean and standard deviation were extracted. Likewise, to evaluate the degree of fulfillment of the objectives of the innovation program it is also extracted the mean, the standard deviation, and extensive information available in print and on the Internet of qualitative comments that have not been presented in this work. Much more information that is not presented in this study is available in the platform used with the participants in the reports delivered, participations and comments in forums, wikis, and glossaries of terms, in addition to the interviews carried out.Analyses of the relationships between the variables—attitudes towards gender equality and affective-sexual diversity and the variable thinking styles/cognitive flexibility—were carried out using Pearson’s correlation analysis.Next, The general objective of this study was to evaluate the knowledge, attitudes in favor of diversity and gender equality, homophobia, transphobia, and the development of socioemotional skills, such as empathy before and after the implementation of the innovation program. The data supported the effectiveness of the teaching innovation program. The data were congruent with other previous programs on education regarding solidarity values and the development of empathy and prosocial behaviors that proved to be successful in university settings ,42,43. HRegarding the objective related to the analysis of the relationship between attitudes towards gender equality with other psychoeducational variables, such as thinking styles, further research is needed. A previous study  demonstrWhen considering the degree of satisfaction and usefulness of the activities, the participants reported a high degree of satisfaction, perceiving them as very useful. They helped them to acquire and develop knowledge, attitudes, and socio-emotional competences in this subject. For example, they developed empathy in the cognitive and emotional/socio-affective dimension to face certain situations. In this sense, participants perceived a high degree of compliance with the objectives of the innovation program. Likewise, they considered that the different types of educational activities carried out contributed in a highly effective and efficient way.It is considered that the university environment constitutes one of the main agents of dynamization for education in gender equality and attention to diversity. Although continuous progress has been made in this area in terms of legislative provisions, such as the Valencian Strategy for Equal Treatment, Non-discrimination, and the Prevention of Hate Crimes 2019–2024, published on 6 February 2019, there is still an immense task to be completed regarding sexual diversity . As 12]12]  that continue to normalize sexual diversity, but these programs should also be launched at a very early age, long before LGBTphobia has settled in people’s minds. Current programs are short, late, and with excessively limited content. We must go beyond the prevention of unwanted pregnancies or the prevention of STIs and start talking about healthy sexuality, affection, autoeroticism, enjoyment, sexual orientation, gender, and sexual freedom. It is essential that we pay more attention to the internalized forms of homo/bi/trans-phobia that can do so much damage to the mental health of the individual who deviates from the norm. We must make a greater effort to make female homosexuality visible, even among LGBTI groups. It is also urgent to take measures that help to reinterpret bisexuality both among the general population and among LGBTI groups themselves so that it is considered as another orientation and not as a state of indecision, transition, or cowardice.”Along these lines, it is necessary that educational centers promote education for the improvement of coexistence and specifically in terms of training or education for affective-sexual diversity ,47,48.One limitation includes the need to employ a longitudinal design that would allow a more comprehensive follow-up than that carried out continuously during the two-year duration of the advanced innovation program. In the future, more robust multivariate designs could be utilized, where more variables or constructs are included, and, in particular, questionnaires with even more inclusive items could be used regarding the assessment of affective-sexual, bodily, and gender diversity.Another limitation is the use of self-report measures. However, it can be noted that much more information that is not presented in this study is available in the platform used with the participants in the reports delivered, participations and comments in forums, wikis, and glossaries of terms, in addition to the interviews carried out.A limitation of the article that must be declared is that the sample consisted of only students pursuing either a degree in primary education or a degree in psychology, since the effects of the program have been analyzed more readily in these two degrees, in which the design of the training plan could be integrated more easily across the different subjects. In other degrees, the training activities were carried out, but due to the enormous changes and adaptations generated by the COVID-19 pandemic, it was not possible to administer the questionnaires on as many occasions as in the aforementioned degrees. In this sense, the idea is to provide continuity for this program in the rest of the degrees, either with this same program or with adapted training activities. Likewise, data from other instruments that have been applied will be analyzed in order to continue evaluating the program’s impact.Future research is needed from an inclusive perspective to fully capture the diversity of the LGBTQIA+ collective . A more precise evaluation of sexual diversity is required of future teachers as well as students, with the construction and validation of new instruments for the specific evaluation of knowledge, procedures, and attitudes towards affective-sexual diversity.This diversity training must be included in new subjects, even if they are optional, and existing curricula and subjects in social sciences, humanities, and health degrees must be able to introduce this type of content more explicitly. Sometimes it is only a question of rethinking or reinventing the same educational activities by introducing elements in favor of affective-sexual, bodily, and gender diversity education.At a socio-community level, there is a need for more awareness and educational programs on affective-sexual diversity in order to aid the prevention of stereotypes and provide greater social support for people who, in this case, sometimes do not have their own support network (such as family) and may even experience internalized homophobia. Even more evidence is needed on the experiences of the wide range of LGBTQ-identified individuals and how their experiences affect them in order to offer necessary support and attention. For example, there are hardly any programs or studies on affective-sexual, bodily, and gender diversity focused on older people, or neurodivergent individuals.In order to provide continuity to this work, in which digital technologies have played a fundamental role in the development of many of the program’s activities, an application (app) is being designed for affective-sexual education.A positive effect of the program was drawn concerning the existence of statistically significant differences before and after the application of the program in the development of socio-emotional competence and for the attention to diversity. Specifically, attitudes and knowledge towards gender equality improved, negative attitudes towards transgender individuals decreased, and there was a clear development of cognitive and affective empathy. Correlations between attitudes towards gender equality and the total score for the thinking styles variable were positive. The program also shows that the participants were extremely satisfied and perceived their participation in this innovative program to be very useful. The teaching staff and participants perceived a very high degree of compliance with the objectives of the project as endorsed in the various reports submitted to the Innovation Unit at the university throughout the process. Statistically, significant correlations were also found between attitudes towards gender equality and the thinking styles variable. At present, it is relevant to continue with this type of innovation program aimed at the construction of coexistence, not only of knowledge in full debate on certain legislative provisions on affective-sexual, bodily, and gender diversity. It is necessary to avoid situations of harassment that still continue to aggrieve certain groups and that can be more serious due to the social and educational impact produced by the pandemic and the confinement necessitated by the coronavirus disease. Diversity education programs and the provision of coping strategies focused on emotional management and social support must be urgently implemented at the university level. Doing so will contribute to the prevention of violence towards the LGBTI collective, especially with regard to the stereotypes and stigma targeting bisexual, intersex, and transgender individuals which can lead to lower self-esteem and self-worth. These impact not only university students’ health, but also the teaching-learning process and student performance. The changes generated by the pandemic and the increased use of Information and Communication Technologies in all areas require competent school leaders to design training programs and activities whose messages aid in the prevention of violence and both overt and subtle discrimination against LGBTQ+ communities. University teaching staff, in collaboration with other educational agents, can significantly contribute to inclusion, diversity and human rights education related to sexual and gender diversity in a way that is more in line with the demands of current society. Likewise, the need for affective-sexual diversity to become more and more visible in mass and interpersonal media, as well as in prevention campaigns carried out by institutions, is also clear.Numerous implications for practice and theory can be derived from this study, such as the fact that the obtained data can contribute to the design of more effective psychoeducational actions promoting the necessary social and educational inclusion in the university environment. This also leads to improved psychosocial well-being, self-acceptance of diversity, prevention of stereotypes and limiting beliefs contrary to equal opportunities, and more generally, the improvement of the climate and quality of life in higher education.This work has practical and professional implications related to its contribution to the 2030 Agenda for Sustainable Development, assuming social responsibility for improving attitudes toward affective-sexual diversity, and the internalization of socio-emotional competences acquired in this program with self-perceptions that translate into less prejudice, LGBTphobia, and fewer violent and discriminatory behaviors towards the LGBTQ collective.With this type of work, we are joining forces to develop more empathetic institutions that contribute to the normalization of diversity and the prevention of LGBTphobia, and advocating for a society more committed to the values of diversity, non-violence, acceptance, solidarity, respect for diversity and human rights. Educational centers must carry out more educational programs for the improvement of coexistence and prevention of violence. Some groups face alarming rates of violence, as in the case of transgender individuals, making the implementation of such programs for awareness and the development of necessary psychoeducational interventions that much more urgent.In addition to generating knowledge, this type of program can contribute to normalizing affective-sexual diversity and improve social support, thereby reducing stigmatization that LGBTQ+ people, in particular, may suffer. Another major opportunity and resource derived from this study is the large amount of educational material that has been provided to future teachers, which will be used to promote diversity and foster more inclusive classrooms.


The AgingPLUS program targets three psychological mechanisms that are known barriers to middle-aged and older adults’ engagement in physical activity (PA): Negative views of Aging (NVOA), low self-efficacy beliefs, and poor goal planning skills. These risk factors are addressed in a 4-week intervention program that is compared to a generic health education program as the control group. Middle-aged and older adults (age 45-75 years) are enrolled in the trial for 8 months, with four assessment points: Baseline (pre-test), Week 4 (immediate post-test), Week 8 (delayed post-test), and Month 6 (long-term follow-up). The major outcome variables are participants’ engagement in PA as assessed via daily activity logs and actigraphs. Positive changes in NVOA, self-efficacy beliefs, and goal planning are the intervention targets and hypothesized mediating variables leading to increases in PA. This trial adopted the experimental medicine approach to assess the short- and long-term efficacy of the AgingPLUS program.


The Wiener-Hopf (WH) method was created in 1931, by Norbert Wiener and Eberhard Hopf, to deliver exact solutions to integral equations with convolution-type kernels on a half-line. It appears that this problem is closely related to that posed by Riemann in 1857 on the problem concerning the construction of a Fuchsian system of differential equations with given singular points and a prescribed monodromy group. This later became known as the 21st Hilbert problem. The WH method is a powerful and long-standing tool that served as a catalyst in broadening the applicability of Fourier analysis, owing to the essential characteristics of analytic functions. Employing the Fourier transform (FT) to the integral equation leads to a Riemann-Hilbert (RH) problem on the real axis:where factorize the given kernel into the form: An essential component of the method is to Then, multiplying equation (1) by Finally, using a combination of Cauchy's integral formula, Liouville's theorem and analytic continuation arguments, explicit evaluation of , was established by Gakhov in 1933.The general factorization procedure for the scalar RH problem (1) on a closed curve A natural generalization of equation (1) assumes this represents partial indices. Considerable challenges arise here and so far a general approach to obtaining equation (3) remains elusive.with In 1958, two seminal papers appeared: one by Krein, dealing with the scalar equationfocusing on the vector case. Both demonstrated direct links between linear operator analysis and the factorization problem.However, in contrast to the scalar case, a general procedure for constructing equation (3) still remains an open problem. The validity of any numerical approximate factorization is also questionable as they proved  that the indices Since then, the theory has undergone significant development in determining classes of matrix functions allowing for constructive factorization. For analytic and rational matrix-functions, a finite factorization algorithm and the method of pole removal have been developed. Important classes of non-rational matrix-functions and piecewise constant matrices, appearing in RH problems related to the construction of complex differential equations with a prescribed monodromy, were studied. Factorization methods for matrix-functions having special properties  have also been developed. Alternative factorization methods  also exist . Waves propagating through (or redirected by) metamaterials may promote high local stress concentrations, making these materials susceptible to failure. The WH technique has already proven its efficacy for such problems . Figure deterministic and usually oscillates around the average value as is shown in Fig. Metamaterials are natural candidates that require matrix factorization due to their complexity and rich multi-scaled response. Examples include the existence of various failure regimes , their The importance of the WH method in bridging and advancing seemingly unrelated fields is illustrated in its application to financially inspired Levi processes or discretely monitored path-dependent option pricing. Other promising directions include the development of hybrid methods, combining analytical modelling, artificial intelligence and experimental testing . PotentiAll these challenging problems face issues concerning possible instabilities of the partial indices and, in the absence of the generalized approach, require significant advancement of matrix factorization techniques. Possible promising directions have been recently reported ,10.Since its conception, the WH technique has remained an enduring analytical tool used broadly in addressing many challenging real-world problems. Its ubiquity, elegance and insight will ensure its continued importance to researchers in a plethora of fields, creating new mathematical research paradigms and enabling scientists to unlock existing and novel industrial and societal challenges.


Sleep- and circadian-related knowledge (pre- and post-program) and the perceived relevance of, and satisfaction with, program content (post-program) were assessed. Before the intervention, most individuals were unaware that 7–9 h of sleep is recommended (72%) and had little understanding of the physiological effects of light; however, knowledge scores increased significantly post-program, from 51% to 88% correct (p < 0.0001). Reception was positive, with high reported satisfaction and relevance. Most individuals reported that they learned something new (89%), planned to use one or more learned strategies (100%), and intended to share learned information with others (85%); the physiological effects of light and circadian rhythms were the content areas most frequently reported as new and useful. The results demonstrate the need for, and feasibility of, the delivery of this program in operational environments.Service members face unique barriers to sufficient and high quality sleep. In the present study, a circadian, light, and sleep skills program for shipboard military personnel (CLASS-SM) was designed to encourage and inform strategies that support optimal sleep and circadian health in the context of those barriers. Phase 1 included program development and refinement via an iterative formative evaluation, including structured interviews with service members and feedback from veterans and experts, resulting in further tailoring to the population. In Phase 2, the highly tailored program was administered to shipboard personnel ( Sleep disruption is pervasive in the military. Recent studies of service members in operational environments indicate that over 50% of deployed service members suffer from chronic sleep restriction ,2,3,4. SThis lack of sufficient sleep has a marked negative impact on performance and health. Specifically, sleep restriction has been shown to impair service member performance on marksmanship and fitness tasks ,19,20, aThe wealth of research demonstrating the significant adverse effects of sleep disruption in the military indicates a critical need for tailored, pre- or non-clinical interventions to prevent or minimize these issues. Additionally, it has been argued that education is a critical component of any shiftwork countermeasure program . In factImportantly, current research suggests that service members are likely to be receptive to educational interventions that aim to support better sleep health. Three recent studies indicate high motivation to improve sleep in U.S. Naval personnel, in particular, with the vast majority (>90%) recognizing that sleep is important to health and performance ,38 and cThe need and support for sleep education programs for service members is clear ,8,41,42.A recent umbrella review of sleep health promotion interventions revealed most health promotion programs do not adequately describe the intervention, including its development, nor do they include health behavior change theories in that development . More coThe study included two phases. Phase 1 consisted of a formative evaluation of initial program content. In Phase 2, the program was delivered to the target population in order to assess feasibility and acceptability, and to determine its effect on the knowledge of sleep and circadian health. GUIDED reporting items for development studies, such as this one, include reporting on the context; purpose; target population; intervention development approach; how existing published theory informed the process; use of any components from an existing intervention; guiding principles; stakeholders; changes in content and format from the start of the process; any changes required or likely to be required for subgroups; uncertainties at the end; and use of the TIDieR framework, all in an open access format ,45.The foundation for the sleep education program was derived from an original slide-based lecture, Circadian, Light, and Sleep Skills, or “CLASS”, developed by the authors (EMH and GLG) to address sleep, circadian rhythms, and the physiological effects of light for college students , many ofThe content and structure were informed by leading sleep therapies . The CLASS program was adapted in the following three ways, through an iterative process that involved receiving feedback from military personnel, described below: (1) the adaptation of existing content and materials, (2) the addition of reinforcing text messages, and (3) the modification of length. The resulting program consisted of a tailored presentation (including PowerPoint slides) and a series of text messages designed to reinforce the content over time.The original program content was tailored in several ways to meet the needs and norms of service members, which have been reported in previous studies ,11,51. FSecond, CLASS-M incorporated information about how to adapt to non-standard sleep schedules and mitigate fatigue, which are critical issues in this shift-working population. Generally, the advice was designed to be brief, practical, and to address operational demands while still remaining as evidence-based as possible. To do this, the presentation began with an explanation of the underlying chronobiological processes that make adjusting to non-standard schedules difficult , then prThird, tips for optimizing sleep quality, given sleep restriction in high operational-tempo settings, were provided. These included strategies for minimizing environmental factors that could impede sleep at bedtime . Fourth and finally, the CLASS-M program was designed to be interactive, with discussion prompts, quizzes, and a participatory introduction to progressive muscle relaxation.Beginning one week after program delivery, four weekly text messages, designed to be brief and to reinforce concepts discussed in the program, were sent to each participant via the phone numbers provided to study staff at consent. The four below were selected out of a list developed by the authors due to their perceived importance and their relative independence from a conceptual standpoint.Week 1: Sleep is important to both physical and mental functioning. Make sleep a priority, as best as you can, wherever you can.Week 2: To help you feel more alert when you wake up, expose yourself to bright light right after waking, using sunlight or artificial blue-enriched light.Week 3: If needed, caffeine is best earlier in the day, and should be avoided (if possible) in the 6 h before bedtime, to prevent trouble falling asleep later.Week 4: Having trouble falling asleep? Try a muscle relaxation exercise, such as the one you learned in the sleep CLASS.The original CLASS and adapted CLASS-M programs were designed to be one hour in length. As noted below, the final in-person, expert-led component of the CLASS-SM program was 30 min, following a formative evaluation (with an intermediary 45 min version that briefly existed during Phase 1).Phase 1 participants were recruited from local Navy Commands via fliers and in-person announcements. For Phase 2, command permission was obtained to board a docked Littoral Combat Ship (LCS) on two consecutive days for recruitment and program delivery. All participants provided written consent to participate, and all study procedures were approved by the Institutional Review Board of the Naval Health Research Center (NHRC.2017.0010).The formative evaluation of CLASS-M consisted of an iterative revision process performed with service members and subject matter experts. First, the program was presented on three separate occasions to approximately 20 veterans, military dependents, and behavioral scientists. After each presentation, participants provided feedback on the content and format in informal group discussions. Feedback was incorporated into the program, and the presentation was repeated with a mixture of new and original audience members. Changes made as a result of the feedback received in these information presentations included: reducing the program time to 45 min, replacing certain scientific jargon with more Navy-relevant expressions and examples, increasing the repetition of key points to maximize knowledge retention, and using “sleep as a tool” to be a better sailor . The refined program was then delivered in a one-on-one setting to five active duty service members, again following an iterative process with the program content tailored after each presentation.The participants completed a brief survey and a one-on-one interview immediately following the presentation. The survey asked participants to rate their satisfaction with the program length, relevance of the material, and program overall; in the interview, open-ended questions included, “What did you think about the presentation?” and “What suggestions do you have for how we could make it maximally relevant to Sailors?” Participants also reported demographic characteristics on the survey.n = 55 total; 6 females). The program was presented twice due to space limitations and to accommodate crew members’ varying schedules. Immediately prior to the program sessions, the participants completed the baseline questionnaire on computer tablets (T1). Then, presentation materials were loaded to a computer monitor provided by the ship, and the study team administered the program in a group setting. Immediately following the completion of the presentation, the crew completed a follow-up questionnaire (T2). Next, in each of the first four weeks following the presentation, a text message reinforcing a different content area was distributed to all study participants who provided contact information.The CLASS-SM program was presented to the crew of a Littoral Combat Ship (LCS) . Post program (T2), participants reported the perceived relevance of the three major content areas of the program . The responses ranged from 1  to 7 (extremely relevant). Additionally, participants reported overall satisfaction with the program as well as its length, format, content, and coverage. The responses ranged from 1 (extremely dissatisfied) to 7 (extremely satisfied). The participants were also asked (free response) if they learned something new, if they were likely to use that information, and if they were likely to share that information. General feedback regarding program improvement was also solicited through a fourth free-response question: “Do you have suggestions for how this program could be improved?”t-tests against neutral values . These test the null hypothesis that scores in the sample are equal to the midpoint (median) of the test variable, in this case a neutral (neither positive nor negative) opinion on program satisfaction or relevance, equal to 4. All statistical tests were evaluated at the alpha = 0.05 level unless otherwise specified.All analyses were conducted in SPSS Statistical Software Version 24  or GraphPad Prism . Descriptive statistics were computed for the questionnaire data, and content analysis of the interview data was conducted for Phase 1. For Phase 2, repeated measures analyses were used to examine potential changes in sleep-related knowledge across time points (T1–2). Degree of satisfaction with and relevance of the program (T2) were determined with one-sample Most (80%) of the five Phase 1 participants were Navy (versus 20% army), on active duty (80% versus 20% reservists), and male (80%). Suggestions received at this point included focusing even more on branch-specific experiences, such as shipboard life, as opposed to the military more generally; making the language less complex; the inclusion of more demonstrations and specific examples; focusing even more on the relationship between performance and sleep; and shortening the program further, to 30 min. As mentioned earlier, the final program was renamed CLASS-SM in light of the increased tailoring for shipboard service members.The majority of participants (86%) were between 25–39 years of age, and most (78%) ranked between E4–E9 (see (50) = 9.39, p < 0.0001; n = 24); see n = 54)).Knowledge increased from baseline to immediately following the program presentation . Participants reported that each of the three major focus areas of the program  were highly relevant , exercise timing (13.5%), and naps 10.8%; A. When pWhen asked if they planned on sharing any of the information learned with anyone, 85% said yes. Of these, 33 said they would share with their spouse, 27 said other family members, 22 said friends, and 15 said coworkers. When asked what information they would share, information about light was the most frequent response 47.1%; C.n = 2), conducting the presentation off-ship (n = 2), speaking more to the military culture (n = 2), and providing more resources (n = 2). Additionally, one individual suggested receiving input from other commands, a second wanted more discussion about sleep deficits, and a third individual made a comment about disliking slide presentations as a format.Additionally, individuals were asked if they had any recommendations for improvement for the CLASS-SM program. Twelve individuals (53% of those who responded to the item) endorsed “none;” five of those individuals used the space to provide positive feedback . Eleven individuals had a recommendation for change. These included adding more citations/context for the presentation  consensus study guidelines , this paIn addition to providing evidence of feasibility, the results of this study show that even a very brief educational program, such as CLASS-SM, can address gaps in sleep-related knowledge among service members. Further, the results indicate particular content areas in which knowledge may be lacking in this population; the circadian content of the program was perceived as more novel and salient than the sleep content. For example, members appear to have limited prior knowledge of the importance and effects of light related to sleep but they view light manipulation as a feasible strategy to improve their sleep. Specifically, the importance of light and its timing was the most commonly reported new concept learned (54%), new strategy that would be used to improve sleep (45%), and concept to share with others 47%; . In contLight, noise, temperature, and air pollution were recently identified as primary environmental barriers to sleep in operational contexts ,11,51. AAdditionally, that a majority of the participants reported that they would share new information and strategies with their families, spouses, friends, and/or coworkers is promising and may serve to improve outcomes via indirect reinforcement of newly learned concepts. Delivering the CLASS-SM program to an entire unit or ship may also have a similar reinforcing effect.The results of this study should be interpreted while taking into consideration several limitations. First, all participants were stationed aboard a single ship, which could limit the generalizability of the findings , consideThese results indicate that the CLASS-SM program is both informative and well received—a promising result given the historical perception within the military that sleep is something service members can do without . In the


The partial least squares structural equation modeling PLS-SEM was applied to verify the hypotheses relationships. The findings have confirmed that advertisements substantially predicted brand awareness, brand loyalty, and consumer buying behavior. Furthermore, brand awareness partially mediated the association of advertisement with brand loyalty and consumer buying behavior. Also, perceived quality is significantly moderated on the association of brand awareness with brand loyalty and consumer buying behavior. Based on such findings, this study has contributed to the literature and provided new insights into the practical implications alongside the future roadmap of the survey.Consumer buying behavior is an important aspect in every marketing strategy to produce maximum output from the market. This study aims to determine how advertisement affects consumer buying behavior and brand loyalty by considering a mediator between brand awareness and the moderating role of perceived quality. For this purpose, this study targets the rising cosmetics industry. This study used the purposive sampling technique to collect data from 300 respondents with the help of an online survey method  Fashion Trends is changing rapidly in the international market . ConsumeFurthermore, Similarly, Brand loyalty, brand image, psychical quality and top-of-the-mind brand, and brand recall are ways to measure brand awareness . In the This study examines the functions of advertisement in building company success and its effect on consumers’ buying behavior and brand loyalty. The aim is to know how the brand is perceived, especially the buying behavior of young men and women. To reinstate a product as top-of-the-mind for consumers, organizations from all areas of the world spend huge amounts on advertisement . Given iRQ1: What is the influence of advertisement on brand awareness, brand loyalty, and consumer buying behavior?RQ2: Does brand awareness mediate the relationship between advertisement, brand loyalty, and consumer buying behavior?RQ3: Does quality moderate the relationship between advertisement, brand loyalty, and consumer buying behavior?This study used the theory of reasoned action to support this conceptual model. This theory is proposed by An advertisement is a valuable tool to divert people’s attitudes positively and attract people toward a product . Adverti1.T.V. is the fastest medium of telecommunication for receiving and transmitting multi-colored images and pictures seen by people throughout the world regularly .2.Social Media: Most commonly used by the customers, marketers target their customers by posting links on social sites .3.Magazines: 4.Outdoor Advertisement: It includes billboards, posters, broachers, and banners .Repetition of advertising increases product exposure to increase customer popularity . In prevAdvertisers also use celebrity endorsements in their advertisements to sway customer attitudes . CelebriMarketers’ goal was to make the commercial more glamorous and enticing to persuade customers to buy the goods by pushing its picture in their minds . As a reConsumer behavior involves making a purchase decision based on available resources, i.e., effort, money, and time . FurtherBrand loyalty describes a client’s connection with a brand . Brand lBrand awareness plays a significant role in creating consumer buying decisions by bringing three benefits: learning, consideration, and choice . Sürücü This quality is possessed by an entity capable of specific or indirect desires . Among hAdvertisement is a source that convinces people to purchase the product at least once in their lives. Celebrities or personas used in ads may positively influence peoples’ buying intention . ConsumeConsequently, H1: Advertisement substantially predicts consumer buying behavior.Nowadays, organizations aim to build strong customer relationships rather than provide only products or services to ensure customer loyalty . The proAdvertisement is one of the essential tools to increase the level of identification. Advertisement is a type of cost. According to H2: Advertisement substantially predicts brand loyalty.H3: Advertisement substantially predicts brand awareness.According to According to H4: Brand awareness substantially mediates between advertisement and consumer buying behavior.H5: Brand awareness substantially mediates between advertisement and brand loyalty.In this section, this study discusses the modifying aspect of quality on the association of brand awareness and consumer buying behavior. There is an important relationship between brand awareness and perceived quality . Few resH6: Perceived quality substantially moderates the relationship between brand awareness and consumer buying behavior.In this section, perceived quality has a moderating effect on the relationship between brand awareness and brand loyalty. H7: Perceived quality substantially moderates the relationship between brand awareness and brand loyalty.To identify the impact of advertisement on consumer buying behavior and brand loyalty, as well as the mediating role of brand awareness and moderating influence of quality, we have conceptualized this theoretical model. The current study aims to determine how advertisement affects consumer buying behavior and brand loyalty by considering a mediating role of brand awareness and the moderating role of perceived quality. This study is quantitative and descriptive. However, this study followed deductive reasoning because the foundations of the study are linked with existing literature. Similarly, this study followed a cross-sectional design to gather data from respondents. A questionnaire survey technique was implemented to attain the online feedback of customer responses by using the purposive sampling technique.The target population of the study was consumers of cosmetics brands. Therefore, this study has developed an online questionnaire by using Google docs. The link of the questionnaire has been spread over different social media platforms to gather responses. From this perspective, it can be stated that the present study has followed the purposive sampling method because it allows researchers to request respondents to spread the link to the questionnaire. When the responses of the questionnaire reached 328, the study compiled data in the SPSS file. However, twenty-eight questionnaires consist of empty responses and are considered invalid. Therefore, this study has employed analysis on the valid responses, which are 300 responses with a participation rate of 91%.All the measures were adapted from earlier valid and reliable scales See  here. ToThe brand advertisement was measured using three dimensions, namely repeated exposure, celebrity endorsement, and sex appeal, adapted from the study of Brand awareness was assessed using a five-item scale adapted from the study of Brand loyalty was measured using a three items scale and adapted from the study of To measure consumer buying behavior, we adapted four items scale from the study of Perceived quality was measured using a five items scale and adapted from the study of The measurement model was analyzed through reliability and validity. Construct reliability was assessed using Cronbach’s alpha and composite reliability. Discriminant validity test was assessed using both criteria’s R2. As suggested by R2 should be greater than 0.1 or zero. R2 were acceptable.The structural model was analyzed through Smart-PLS software and partial least squares structural equation modeling technique PLS-SEM was performed using the bootstrap method with 5000 sub-samples. This software was widely used and accepted in the field of management and social sciences studies . The fitQ2 test was performed. According to Q2 must be >0.1 or zero. Q2 exceeded 0.1 and the positive predictive significance level of the model.Additionally, for the predictive relevance of the model, the cross-validated redundancy measure (blindfolding) p < 0.000). It means that if there is a more attractive advertisement about the brand, it will ultimately increase customers’ buying behavior. Therefore, H1 was accepted. Moreover, H2 results illustrate that advertisement has a positive and significant influence on brand loyalty . Increased advertisement creates more brand loyalty among customers to satisfy their needs. Hence, H2 was supported. Moreover, H3 results indicate that advertisement has a positive and significant impact on brand awareness . Hence, H3 was accepted. Furthermore, findings show that brand awareness has a positive and significant impact on consumer buying behavior  and brand loyalty . Additionally, this study also hypothesized that brand awareness plays a mediating role (indirect effect) on the relationship between advertisement, consumer buying behavior, and brand loyalty. The H4 findings illustrate that brand awareness positively and significantly mediates the relationship between advertisement and consumer buying behavior . Therefore, H4 was accepted. Moreover, H5 results show that brand awareness positively and significantly mediates the relationship between advertisement and brand loyalty . Thus, H5 was also supported.The results of the hypotheses were presented in p < 0.000) and also positively moderates the relationship between brand awareness and consumer buying behavior . So, H6 was accepted. Meanwhile, H7 findings indicate that perceived quality has a significant impact on brand loyalty  and significantly moderates the relationship between brand awareness and brand loyalty . Thus, H7 was also supported.To assess the moderating role of perceived quality in the relationship between brand awareness and consumer buying behavior, This study aims to determine how advertisement affects consumer buying behavior and brand loyalty by considering a mediator between brand awareness and the moderating role of perceived quality. The study’s findings have revealed that advertising substantially predicted consumer behavior while brand loyalty mediated it, and perceived quality is moderated on their association. This study has confirmed that buying behavior is substantially predicted by advertisement and brand awareness. Similarly, Furthermore, this study has found that perceived quality moderated the relationship between brand awareness, brand loyalty, and consumer buying behavior. In this regard, several prior research studies have stated that perceived quality attracts potential consumers from the market, and consequently, the company’s growth increases . HoweverThis study has contributed to the literature by evaluating the moderation effect of perceived quality on brand awareness with loyalty and consumer buying behavior. However, The findings of the study have confirmed that consumers preferred branded cosmetics products because they are more sensitive about their social standards. These consequences have important suggestions for international selling directors. With the increase in the quantity of cosmetics brands, brand managers and selling directors must evolve and understand the promotional activities from the Pakistani point of view. Outcomes would lead cosmetics product brand managers to develop policies to progress their branding decisions to gain a more competitive edge and stability of business through loyal customers. Consequences suggested that managers focus on brand awareness to increase consumer loyalty and consumer buying behavior by using promotional activities like advertisements. Teenagers are spending more time on social media sites like Facebook, Instagram, and Twitter, consequently, it will also be helpful for managers to create awareness in the mind of customers through social media. Meanwhile, to increase loyalty and consumer buying behavior, cosmetics product managers should pay more attention to building trust between their consumers by meeting or going beyond their expectations.The study’s findings are generalizable to the entire cosmetics industry, although this study has some limitations, just like other studies. For instance, one limit was due to the responses of the questions, which depended upon the Likert-type scale. Some people do not give a careful response, and others like to give careful answers. It means the presenter influenced the respondent’s reaction. Future research could be carried out in other sectors, including the telecom sector, banking sector, and textile sector, to show the cross-sector investigation of c consumer buying behavior and their outcome on performance, and the data should be collected using a mixed approach. Using this, the result might change. In the future, sample size should also be increased. Different promotional tools can be considered for further study to evaluate consumer behavior concerning perceived quality and brand awareness.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of the Jiangsu University China. The patients/participants provided their written informed consent to participate in this study.RB and MM proposed the research, analyzed the experimental results, and wrote the manuscript. JZ, FM, and AS designed and carried out the revision of this manuscript and extensively edited the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


We design a prospective control study on the utilization of transbronchial cryobiopsy guided by EBUS-GS (EBUS-GS-TBCB) to diagnose PPLs.  PPLs were defined as pulmonary nodules or masses with a diameter from 10 mm to 50 mm. PPLs were randomly divided into group EBUS-GS-TBCB and transbronchial biopsy by forceps guided under EBUS-GS (EBUS-GS-TBB). t = 0.600, p=0.551). The diagnostic yields of EBUS-GS-TBCB and EBUS-GS-TBB were 75% and 64.52% respectively, and the difference between the two groups was not significant . If only the first specimen was taken into account, the diagnostic yields from EBUS-GS-TBCB and EBUS-GS-TBB were 64.29% (18/28 cases) and 35.48% (11/31 cases), respectively. The difference was statistically significant by Fisher's Exact Test . The total incidence rates of bleeding were 21.43% and 6.45%, respectively, in groups EBUS-GS-TBCB and EBUS-GS-TBB. The total incidence rates of pneumothorax were 7.14% and 0, respectively, in groups EBUS-GS-TBCB and EBUS-GS-TBB.  28 cases were involved in group EBUS-GS-TBCB and 31 cases were in group EBUS-GS-TBB. The mean sizes of PPLs were 30.23 ± 11.10 mm in group EBUS-GS-TBCB and 28.69 ± 8.62 mm in group EBUS-GS-TBB ( The diagnostic yield of EBUS-GS-TBCB was slightly higher than that of EBUS-GS-TBB for the diagnosis of PPLs. EBUS-GS-TBCB might be useful if only the first sample was taken into account. Pulmonary nodules are becoming an increasingly common radiographic finding. The probability of malignancy has to be evaluated according to the management of pulmonary nodules , 2. The We performed a prospective study at a tertiary care academic medical center. Subjects with PPLs detected by chest CT or HRCT in a recent month were collected at the Department of Respiratory and Critical Care Medicine in Dalian Municipal Central Hospital affiliated to Dalian Medical University from March 2019 to June 2020. PPLs were defined as pulmonary nodules or masses with a single, well-circumscribed boundary surrounded by pulmonary parenchyma in which the sizes were measured from 10 mm to 50 mm in diameter. The single dominant nodule or mass accompanied by one or more incidental small nodules was also involved if the dominant lesions were 10 mm to 50 mm in diameter. The enrolment criteria were as follows: (a) the ranges of age were from 18 to 75 years; (b) PPLs with a likelihood of malignancy were solid or part-solid in which solid components were more than 50%; and (c) the bronchus signs on the heart side of PPLs were displayed on chest CT or HRCT . The excThis study followed ethics principles for medical research in the Declaration of Helsinki and was approved by Dalian Municipal Central Hospital Human Ethics Committee (2019-004-10). Written informed consent was obtained from all subjects or their guardians before the examination.Blood clotting function, arterial blood gas, electrocardiography, and cardiac and pulmonary function were evaluated before bronchoscopy. The examination was prohibited in patients with a forced vital capacity of less than 50%, respiratory failure, or cardiac insufficiency. Some anticoagulation agents, such as aspirin, clopidogrel, and warfarin, had to be blocked for five days and be replaced with low molecular heparin. Solids and liquids were withheld before 6 hours. The target pulmonary subsegment in which PPLs located should be confirmed in advance depending on chest CT or HRCT.All examinations were performed by bronchoscopy . Subjects accepted intravenous remifentanil and disoprofol anesthesia and breathed through mechanical ventilation through a size 4 laryngeal mask airway. The examination of bronchoscopy had to be terminated when severe bleeding appeared and a blocking balloon would be inserted into the target segmental bronchus from the working canal.EBUS-GS-TBB was performed by a guiding sheath  under the guidance of R-EBUS  according to the procedures in , 10. The2. Then, the cryoprobe was firmly pulled out with GS and bronchoscopy. The frozen samples on the cryoprobe were separated from PPLs. The cool duration should be computed before each examination depending on the time when the cryoprobe was frozen in a basin. Three pieces of specimens were usually sampled in each subject unless GS could not be placed in the same position again or bleeding hampered biopsy.EBUS-GS-TBCB was performed by a cryoprobe  through a guiding sheath  under the guidance of R-EBUS . The metal head of the cryoprobe must jut completely out of the far end of the sheath and the length was equal to extending part of the ultrasonic probe from the sheath. The total length of extending part of the ultrasonic probe and the sheath should be measured in advance and the equal length on the cryoprobe should be marked. The procedures to search PPLs and indwell GS were the same as EBUS-GS-TBB. Once a typical EBUS image identified with PPLs was obtained, the probe was withdrawn while the GS was left in place. The cryoprobe was inserted into the GS to the marked level and cooled for 4 to 6 seconds at the desired location under 50-bar pressure of COThe positive R-EBUS detection was typical concentric or eccentric images that defined the location of probe within PPLs . The conAll patients were kept horizontal position without pillow, inhaled oxygen, supervised blood pressure and pulse oxygen for 4 hours after examination. X-ray film should be taken 24 hours later for evaluating pneumothorax.All complications were observed during and after examinations. The bleeding was evaluated as light, severe, and fatal degree. Severe bleeding required intravenous hemostatic drug administration, cessation of transbronchial procedure, and inflation of the bronchial blocking balloon. Fatal bleeding was associated with cardiopulmonary instability, transfusion of packed RBCs, or surgical intervention. Pneumothorax was evaluated as light, severe, and fatal degrees. Light means the lung volume was collapsed by less than 50% and severe means pulmonary volume was collapsed, combined with mediastinal emphysema or gas drainage of the pleural cavity. Fatal pneumothorax was associated with surgical intervention. Other complications were also evaluated such as subcutaneous emphysema, vocal cord lesions, and infection of the bronchus and lung.Malignant PPLs were diagnosed by pathology of transbronchial biopsy, EBUS-TBNA, TTCB guided by chest CT, or surgical resection. Benign PPLs needed to be confirmed by either another pathology or follow-up for at least 6 months until the lesions improved radiographically. The stable or growing benign PPLs were defined as unimproved and surgical resection was recommended because of the rising malignant likelihood. Diagnostic yield and incidence rate of the complications were calculated in groups EBUS-GS-TBCB and EBUS-GS-TBB.p values were double-sided, and p < 0.05 meant that differences were significant.The data were analyzed by using SPSS . The measurement data were reported as the mean values ± standard deviations. Count data were analyzed using Pearson Chi-Square tests. The diagnostic sensitivity, specificity, and accuracy were calculated. The diagnostic sensitivity was defined as the probability of true positive subjects in all suffering the same diagnosis. The specificity was defined as the rate of true negative subjects in all nonsuffering diseases. χ2 value = 0.196, p=0.658). The failure of insertion appeared only in superior lung areas in both groups, especially for lesions at areas affiliated with apical pulmonary segments. The total rate of failing to detect by R-EBUS was 8.10% (6/74 cases). The failure of detection was 8.33% (3/36 cases) and 7.89% (3/38 cases), respectively, in groups EBUS-GS-TBCB and EBUS-GS-TBB . The failure of detection appeared equally at superior, middle, and inferior lung areas. All subjects were followed up for more than 6 months and the longest follow-up time was 12 months.74 subjects were enrolled and 15 subjects withdrew because of failing to detect PPLs by R-EBUS or failing to insert the guide sheaths . FinallyThe subjects diagnosed by pathology and follow-up are displayed in As for inflammatory PPLs diagnosed by initial pathology in group EBUS-GS-TBCB, 6 cases were confirmed as malignancy by subsequent other pathology, 2 improved cases were confirmed as pneumonia and 1 stable case did not confirm the diagnosis owing to refusing biopsy again or surgical resection . In grouχ2 value = 0.137, p=0.711). The diagnostic sensitivity, specificity, and accuracy were 76% (19/25 cases), 25% (2/8 cases), and 77.78% (21/27 cases), respectively, in group EBUS-GS-TBCB and 68.18% (15/22 cases), 41.67% (5/12 cases), and 74.07% (20/27 cases), respectively, in group EBUS-GS-TBB. The values by Pearson's chi-squared test in the two groups were 0.357, 0.290, and 0.101, the differences were not significant, and p values were 0.550, 0.590, and 0.750, respectively. If only the first specimen was taken into account, the diagnostic yields from EBUS-GS-TBCB and EBUS-GS-TBB were 64.29% (18/28 cases) and 35.48% (11/31 cases), respectively .Finally, the diagnostic yields of EBUS-GS-TBCB and EBUS-GS-TBB were 75% (21/28 cases) and 64.52% (20/31 cases), respectively. The diagnostic yield in group EBUS-GS-TBCB seemed to be slightly higher. But, the difference was not significant by Pearson's chi-squares test . Pneumothorax rates were 7.14% (2/28 cases) and 0, respectively, in groups EBUS-GS-TBCB and EBUS-GS-TBB . There were 5 and 3 cases, respectively, in groups EBUS-GS-TBCB and EBUS-GS-TBB where the shortest pleural distances were less than 10 mm. The distances were 8.61 mm and 36.84 mm, respectively, in two cases of pneumothorax , virtual bronchoscopic navigation (VBN), thin/ultrathin bronchoscope, and so on , 13, 14.Among PPLs failing to be detected by R-EBUS, cone-beam computed tomography guiding thin bronchoscope might potentially increase both navigation and diagnostic yield . BronchoHowever, the transbronchial biopsy was always by forceps in spite of the many advances achieved in various guiding methods and thin/ultrathin bronchoscopy. TBCB might be a breakthrough on biopsy patterns. Many studies had displayed that samples by TBCB were larger than those by forceps for diagnosis of diffuse parenchymal lung diseases –8. LargeOn the whole, diagnostic yield of EBUS-GS-TBCB was slightly higher than EBUS-GS-TBB for diagnosis of PPLs. EBUS-GS-TBCB might be useful if only the first sample was taken into account.


To investigate the value of endobronchial ultrasound (EBUS) and virtual bronchoscopic navigation (VBN) combined with rapid on-site evaluation (ROSE) in diagnosing peripheral pulmonary lesions (PPLs).Between January 1st 2019 to September 1st 2021, EBUS and VBN examination were performed in expected consecutive patients with PPLs who were admitted to Zhangzhou Affiliated Hospital of Fujian Medical University . Finally, based on the calculation of expected diagnostic yield of R-EBUS biopsy and drop out, 198 eligible patients were randomly divided into ROSE group (100 cases) and non-ROSE group (98 cases). The diagnostic yield of brushing and biopsy, the complications, the procedure time, the diagnosis time and expense during diagnosis were analyzed.In the ROSE group, the positive rate of EBUS brushing and biopsy were 68%, 84%, respectively. The average procedure time and diagnosis time were 18.6 ± 6.8 min, 3.84 ± 4.28 days, respectively, and the average expense was 643.44 ± 706.56 US.$ (4093.15 ± 4494.67 yuan ¥). In the controls, the positive rate of brushing and biopsy were 44%, 74%, respectively. The average procedure time and diagnosis time were 15.4 ± 5.7 min, 6.46 ± 3.66 days, respectively. And the average expense during diagnosis was 1009.27 ± 713.89 US.$ (6420.28 ± 4541.33 yuan ¥). There was significant difference in the positive rate of EBUS brushing and biopsy, diagnosis time and expense during diagnosis between both groups. And no significant difference was observed in the complications and the procedure time. Additionally, the impact of ROSE on diagnostic yield in right upper lobe and the size of lesion ≤ 2 cm in diameter was significant.In combination with ROSE, EBUS could significantly improve the positive rate of diagnosing PPLs, shorten diagnosis time and reduce expense during diagnosis. ROSE will be of great importance in the diagnosis of PPLs and medical resource. Peripheral pulmonary lesions (PPLs) refer to lesions that are located in the subsegmental bronchi and cannot be visualized directly by bronchoscopy . With thOn the other hand, rapid on-site evaluation (ROSE) introduced by Park could help to quickly evaluate the satisfied specimen, form a preliminary diagnosis and guide the TBB operation in real time . An emerHowever, little was known about whether the utility of ROSE can affect the diagnostic yield of EBUS TBB in PPLs –14. SubjThe aim of this study was to evaluate the value of R-EBUS in combination with ROSE in diagnosing PPLs and explore factors that can influence the diagnostic yields.https://www.jq22.com/webqd4314).This was a prospective randomized, controlled trial (RCT). Between January 1st 2019 to September 1st 2021, EBUS and virtual bronchoscopic navigation (VBN) examination were performed in expected consecutive patients with PPLs who were admitted to Zhangzhou Affiliated Hospital of Fujian Medical University . According to the endpoint designed before we started the study, based on the expected diagnostic yield of R-EBUS biopsy in ROSE group and non-ROSE group reported previously , 18 and . PPLs were defined as lesions surrounded by pulmonary parenchyma and endoscopically invisible  . InclusiThe study was approved by the ethical committee of Zhangzhou Affiliated Hospital of Fujian Medical University , and all patients provided informed written consent.The location of the bronchus leading to the lesion was designed by VBN in advance . Bronchoscopy was performed applying a fiberoptic bronchoscope  in combination with the R-EBUS  and guide sheath (GS) kit . The scope was inserted through the oral route, and each procedure was performed under local anesthesia with intravenous administration of midazolam for mild sedation. X-ray fluoroscopy  was applied to guide the insertion of the R-EBUS probe with GS through the working channel of the bronchoscope until the target site was reached.After determining the location of the R-EBUS probe and GS within a target lesion, brushing and TBB cytology were performed for specimen collection. When the R-EBUS probe was adjacent to or outside the target lesion, the bronchus closest to the PPLs was meticulously searched under fluoroscopy prior to collecting specimen. X-ray fluoroscopy guidance was applied during biopsy and brushing sampling, as well as during removal of the GS after sampling. The number of R-EBUS attempts per lesion is less than 5 times and the target value for the number of biopsies is less than 3 times . The proThe material obtained from bronchoscopic biopsy or brushing, was immediately expressed onto numbered glass slides. Diagnostic ROSE specimens were characterised as those clearly demonstrating the typical cytological features of malignancy and inflammation. Non-diagnostic specimens were those where ROSE failed to convincingly demonstrate these features, including where specimens demonstrated only the appearance of benign epithelial cells or where specimens demonstrated a paucity of malignant cells (e.g. < 10 groups of ≥ 5 cells). And bronchoscopy was terminated if ROSE demonstrated diagnostic material. Non-diagnostic rapid on-site examination resulted in further bronchoscopic sampling. What is universally noted is that maximal yield is achieved by a combination of techniques , 22. In Diff stain was applied for specimen staining . The stained slide was screened by the same experienced cytopathologist, who continuously reported the findings in real time and announced when sufficient diagnostic material had been obtained for a provisional diagnosis. The bronchoscopist modified or terminated the sampling process according to the information provided by the cytopathologist. Then tissue biopsy samples were placed in 10% formalin and were embedded in paraffin for routine histologic evaluation on hematoxylin and eosin staining.Positive diagnostic criteria for ROSE: (1) The ROSE cytology showed cancer cells and nuclear heterogeneous cells; (2) The ROSE reported neutrophils, and lesions absorbed after anti-infective treatment; (3) The ROSE showed lymphocytes and other inflammatory cells.For those non-diagnostic patients, the final diagnosis was determined through additional medical examinations such as CT-guided percutaneous lung biopsy, surgical biopsy or anti-infection, anti-tuberculosis therapy and follow-up for at least 6 months.Complications are considered as follows: severe bleeding (bleeding volume > 50 ml), pneumothorax, malignant arrhythmia, lidocaine poisoning, monitoring blood oxygen saturation < 90%, blood pressure greater than 180/120 mmHg or less than 90/60 mmHg, consciousness disorder or other adverse events.t test or one-way ANOVA for comparison. Each nodule attempt was characterized as successful or unsuccessful, based on the definitions provided above for the primary and secondary outcomes. Categorical variables including study outcomes were presented as number (percentage). A comparison of study outcomes between ROSE group and non-ROSE group was done using the chi-square test or Fisher’s exact test. Differences were considered to indicate significance if a p value was < 0.05.The Primary outcome was the diagnostic yield of R-EBUS brushing and biopsy. Second outcome was bronchoscopy complications, the procedure time and diagnosis time. Before starting the study, we set the expected diagnostic yield of R-EBUS biopsy in ROSE group and a potential dropout rate based on previous reports. And we used the PASS version 21.0 to calculate the expected sample size. SPSS version 20.0  was applied for statistical analyses. All variables were evaluated for normal distribution prior to analysis. Non-normally distributed continuous variables were expressed as the median (Md) and interquartile range (IQR), using Kruskal–Wallis H (K) for multiple-group comparison. Normally distributed data were expressed as mean ± SD, using a Student’s Table Table Table Table Table Table Combined with VBN, the positive rate of EBUS TBB on PPLs less than 2.0 cm in diameter could reach 44% . Our stuParticularly, ROSE has revealed clinical importance in the diagnosis of lung tumors, lung nodules, mediastinum disease and other diseases . CompareTo the best of our knowledge, limited data are available concerning the application of ROSE during R-EBUS TBB in the diagnosis of PPLs –14, 18. Our findings demonstrated that ROSE could quickly evaluate whether the samples obtained are satisfactory, form a preliminary diagnosis in real time. Based on the good consistency between ROSE and final diagnosis, the positive result supported termination of procedure without further sampling. It is obvious that EBUS combined with ROSE can reduce the operation time , 18. AndThe majority of data suggested that some factors may affect the diagnostic yield of PPLs, such as the size of lesions and the location of lesions and so on . ParticuThere are still some limitations in our findings. Firstly, although our study was a prospective RCT, it was a single-center design, the conclusion need to be interpreted with caution. Secondly, although we have set the expected diagnostic rate from basic study data and calculated the sample size before start of the study, it should be noted that the expected diagnostic rate from fewer previous studies may lead to some bias , 18. MeaIn combination with ROSE, EBUS could increase the diagnostic yield of PPLs, shorten the diagnosis time, leading to a reduction of expense during diagnosis. ROSE would be of importance in diagnosing PPLs and medical burden.