Coding Approach Research Articles

Intergenerational transmission or cultural loss? The continuity of ethnic identity among the Yao minority in China

PurposeThis study aims to examine the intergenerational transmission of ethnic culture among the Yao minority in China, focusing on how rapid societal changes and modernization impact cultural identity maintenance. The research seeks to understand the perspectives of different generations of Yao individuals regarding their traditional culture, external influences and ethnic identity. The study aims to identify factors that facilitate or hinder cultural transmission, assess the effectiveness of current cultural preservation efforts and uncover potential strategies for maintaining ethnic identity in a rapidly changing society. Additionally, the research investigates the role of traditional elements, such as ethnic clothing, in connecting younger generations to their cultural heritage.Design/methodology/approachThis study employed a qualitative approach using grounded theory methodology to explore the intergenerational transmission of Yao ethnic culture in China. In-depth, semi-structured interviews were conducted with 30 Yao individuals representing different generations. Participants were purposively selected from two Yao villages in southern China. Data collection also included researcher observations and memos. Interviews were conducted in Chinese, translated to English and analyzed using NVivo12 software. The analysis followed the grounded theory approach of open, axial and selective coding. Triangulation was achieved through discussions with participants' peers and family members. Ethical considerations included obtaining informed consent, ensuring participant anonymity and securing institutional review board approval.FindingsThe study revealed three distinct generational attitudes towards Yao culture: rejection among older generations, semi-openness in middle-aged groups and initiated closeness in younger generations. Despite government policies supporting population growth, ethnic identity is not effectively transmitted across generations. Economic disparities between Yao communities and external society significantly influence cultural preservation, with younger generations prioritizing economic opportunities over traditional practices. However, traditional Yao clothing emerged as a potential link between younger individuals and their cultural heritage, offering a promising avenue for cultural preservation. The research also highlighted the impact of education, technology and media on shaping attitudes towards traditional culture and external influences across different age groups.Originality/valueThis study provides insights into the cultural transmission within the Yao minority in China, a previously understudied ethnic group. It uniquely examines the interplay between economic development, government policies and intergenerational attitudes in shaping ethnic identity maintenance. The research reveals an unexpected potential for traditional clothing to serve as a bridge between younger generations and their cultural heritage, offering a fresh perspective on cultural preservation strategies. By identifying distinct generational attitudes towards cultural identity, this study contributes valuable knowledge to the fields of ethnic studies, cultural anthropology and social psychology, while also informing policymaking for minority cultural preservation in rapidly modernizing societies.

The potential for spatial ability development through the Swedish technology and craft compulsory curricula

AbstractSpatial ability has been demonstrated to be a significant predictor of students’ achievement in science, technology, engineering, and mathematics education. While several studies have focused on offering supplementary or isolated spatial training interventions, this study focuses on spatial ability development through embedded interventions within technology curricula. Specifically, document analysis is adopted in this study to identify the potential areas for spatial ability development within the Swedish compulsory Technology and Craft curricula. A framework consisting of two dimensions has been established by a qualitative coding approach. The first dimension, termed the “visual dimension”, encompasses graphical, property, and manufactured components, reflecting the spatial nature of the information that students engage with. The second dimension, termed the “epistemic dimension”, comprises conceptual and procedural knowledge, representing the types of knowledge students acquire. The framework allows educators to identify potential areas for developing spatial ability within technology curricula. Additionally, it is envisioned that this framework could increase awareness of how to spatialise curriculum and pedagogies among various stakeholders, including policymakers and teacher trainers.

Managing the work of living with heart failure: a qualitative study using the cumulative complexity model from Southeastern Minnesota

ObjectivePatients with heart failure (HF) perform a variety of self-care activities to control symptoms and minimise the risk of HF decompensations. The objective of this study was to understand how...

Relations Between Optimism-Pessimism and Loneliness in Sexually Minoritized Men: The Moderating Role of Chronicity-Based Discrimination

ABSTRACT Loneliness has reached epidemic proportions, affecting nearly one-in-two adults in the United States and is particularly potent in sexually minoritized men (SMM). Individual differences in optimism and pessimism may exert protective or maladaptive effects for the impact of discrimination on loneliness. This study investigated interrelationships between optimism/pessimism, discrimination, and loneliness within a sample of sexual minoritized men (SMM). Self-report data from 103 SMM were used from a six-month study from August 2020 to February 2022 in South Florida. A novel chronicity-based coding approach was used to determine whether associations of optimism/pessimism and loneliness vary based on different frequencies of exposure to discrimination. Hierarchical multivariable regression models were conducted to examine associations of optimism-pessimism and the moderating effect of chronicity-based discrimination on loneliness. SMM reporting higher pessimism and lower optimism reported greater levels of loneliness and exposure to discrimination, and chronicity-based discrimination was negatively associated with optimism, and positively associated with pessimism. Associations of optimism, but not pessimism, with loneliness were moderated by discrimination. Among the sample, optimism had a protective effect on loneliness for those experiencing moderate exposure to discrimination. Future research should consider the longitudinal impact of optimism/pessimism and discrimination on loneliness among SMM.

Understanding Healthcare Barriers for Latino/a/e/x Families with Alzheimer's Disease: Insights from Primary Care Provider interviews.

Alzheimer's Disease and Related dementias (ADRD) are disproportionately underdiagnosed, misdiagnosed, and undertreated in Latino/a/e/x populations living in the U.S. Latino/a/e/x families also experience low access to ADRD caregiver support services and high levels of depression. Primary care providers (PCPs) are the first point of contact for patients and their families, and they are critical in understanding the factors associated with disparities in accessing services. This project aims to reflect on the barriers that Latino/a/e/x families experience in accessing and using healthcare services from the perspective of PCPs. The data was collected through structured interviews with 23 diverse PCPs across the US via videoconference or phone calls. Participants were recruited via snowball sampling. Two reviewers used an inductive coding approach to conduct qualitative thematic analysis. The Rigorous and Accelerated Data Reduction (RADaR) technique was used to extract relevant data and organize it into relevant categories. Some of the themes identified reflect the experiences of individuals in the diagnostic process and subsequent care: 1) Family members are usually the first ones to notice the symptoms, 2) Delays in seeking care might be partially influenced by denial from individuals and their families, 3) Language congruency promotes the disclosure of symptoms, 4) Care that is linguistically and literacy appropriate requires additional support of patients and families, and 5) Caregiving expectations and preferences by Latino/a/e/x families do not shield caregivers from feeling burnout. Overall, PCPs reflected that the experiences of individuals are highly influenced by socioeconomic factors, which also influence their care plans. Most Latino/a/e/x older adults with ADRD will be cared for by a PCP at some point during their disease, which means that they require additional support and resources at primary care appointments to address the barriers to accessing care services and enhance health equity in Latino/a/e/x communities.

Exploring recreational hunters’ perspectives on shifting from hunting to working in tourism: Insights from the Push–Pull-Mooring Model

ABSTRACT There are growing pressures on the environment from both natural and human stressors, impacting both protected and unprotected areas. Illegal and irresponsible use of environmental resources harms the health of ecosystems and the well-being of people. Confronting these challenges requires promoting sustainable practices to ensure the long-term health of the environment. In this context, tourism has gained widespread recognition as a tool to enhance local community well-being and conserve environmental resources. Through the lens of the Push–Pull-Mooring model, the study aims to explore the key factors influencing local hunters' perspective on shifting from hunting to working in tourism. Semi-structured interviews were conducted with local hunters residing in the surrounding villages near the Dana Biosphere Reserve in Jordan. Content analysis with an inductive coding approach was used to analyze the data. The findings reveal that the environmental degradation and the environmental concern discourage hunting activities, while financial incentives encourage participation in tourism. However, various institutional, personal, and cultural factors are found to hinder the participation of local hunters in tourism.

Pulses, Their Derivatives and Composite Dishes: A Coding Approach

ABSTRACT Pulses are a key food of the Mediterranean diet, rich in proteins, fiber, complex carbohydrates, vitamins, and minerals essential for health. The inclusion of pulses in the diet can prevent many diseases, including diabetes, cancer, and heart diseases related to their nutrient and bioactive components. Given their importance, the interest in pulses is constantly growing thanks to the possibility of being able to use them in a versatile way as a basis for food products such as flour, pasta, snacks, soups, and vegetable burgers, increasing the frequency of consumption of pulses by consumers with all the benefits that derive. This study aims at demonstrating the effectiveness of the application of LanguaLTM and FoodEx2 classification and description systems to food preparations and ready meals based on pulses for consumption away from home. In particular, they have been used to classify and describe a ready-to-use pulses dish as a case study. In conclusion, the possibility of describing this recipe and others allows us to obtain accessible and useful information, and then obtain data in a standardized format in order to facilitate the exchange and comparison, allowing its classification.

Why do healthcare workers refuse tuberculosis preventive treatment (TPT)? a qualitative study from Puducherry, South India

BackgroundThe sustainable development goal (SDG) 3.3.2 prompted India to devise the National Strategic Plan 2017–2025, targeting tuberculosis (TB) eradication by 2030. The prevention pillar of this plan emphasises on Tuberculosis...

A ViT‐Based Adaptive Recurrent Mobilenet With Attention Network for Video Compression and Bit‐Rate Reduction Using Improved Heuristic Approach Under Versatile Video Coding

ABSTRACTVideo compression received attention from the communities of video processing and deep learning. Modern learning‐aided mechanisms use a hybrid coding approach to reduce redundancy in pixel space across time and space, improving motion compensation accuracy. The experiments in video compression have important improvements in past years. The Versatile Video Coding (VVC) is the primary enhancing standard of video compression which is also referred to as H. 226. The VVC codec is a block‐assisted hybrid codec, making it highly capable and complex. Video coding effectively compresses data while reducing compression artifacts, enhancing the quality and functionality of AI video technologies. However, the traditional models suffer from the incorrect compression of the motion and ineffective compensation frameworks of the motion leading to compression faults with a minimal trade‐off of the rate distortion. This work implements an automated and effective video compression task under VVC using a deep learning approach. Motion estimation is conducted using the Motion Vector (MV) encoder‐decoder model to track movements in the video. Based on these MV, the reconstruction of the frame is carried out to compensate for the motions. The residual images are obtained by using Vision Transformer‐based Adaptive Recurrent MobileNet with Attention Network (ViT‐ARMAN). The parameters optimization of the ViT‐ARMAN is done using the Opposition‐based Golden Tortoise Beetle Optimizer (OGTBO). Entropy coding is used in the training phase of the developed work to find the bit rate of residual images. Extensive experiments were conducted to demonstrate the effectiveness of the developed deep learning‐based method for video compression and bit rate reduction under VVC.

Supporting Young Learners During Remote Education: How Context and Gender Shape Adolescent Experiences

PurposeThe COVID-19 pandemic prompted a global closing of schools that raised questions on the implications for students. This study examines the impact of remote education, and subsequent social isolation, on adolescent well-being among urban poor young adolescents worldwide. MethodsQualitative data were collected through focus group discussions with urban poor adolescents in 7 countries and 8 sites, for a total sample size of 249 adolescents. Discussion guides addressed attitudes toward remote education strategies and its perceived impact on health, relationships, and learning. Analysis used an inductive thematic coding approach, with comparison by site and gender. ResultsAdolescents experienced opposite extremes of remote education, with those from lower-income sites feeling abandoned by educators and systems and those from higher-income sites feeling increased external pressure and loneliness. Both boys and girls reported declining mental health, although boys reported more access to support structures than girls. All students missed connections with peers and teachers. DiscussionAlthough all adolescents struggled with remote education, their challenges differed by context and gender. School systems should consider conducting a student needs assessment to ensure future remote education is accessible and beneficial to adolescents in each site. Families and teachers should take a gender-equal approach to assistance, ensuring adolescents have equal opportunities and agency to reach out for, and receive, educational and emotional support.

The prognostic reasoning by physiotherapists of musculoskeletal disorders: A phenomenological exploratory study

Question(s)What are the prognostic reasoning practices of physiotherapists towards musculoskeletal disorders? DesignExploratory phenomenological study. Participants15 physiotherapists who currently treat musculoskeletal disorders. Date analysisSemi-structured interviews were implemented to collect data which was analysed using an inductive coding and thematic analysis approach. ResultsThree themes were identified. First, how physiotherapists considered prognosis within clinical practice. Whilst prognosis is an important consideration, in some circumstances it either may not be considered or is implied. Second, how physiotherapists determine prognosis for musculoskeletal disorders. Several factors shaped the ability of physiotherapists to determine prognosis including how they determine prognosis, and the barriers and facilitators towards determining prognosis. Finally, how physiotherapists discuss prognosis with individuals who have a musculoskeletal disorder. These discussions were shaped by the prognostic information provided, as well as the barriers and facilitators towards discussing prognosis. ConclusionThe prognostic reasoning of physiotherapists appears to be influenced initially by whether they consider it or not. It is then shaped by both barriers and facilitators towards determining and discussing prognosis. Facilitators for this prognostic reasoning process appear to be aligned with the biomedical model of health, whilst barriers more aligned with psychosocial factors. To improve prognostic reasoning, physiotherapists should continue to strive to conceptualize prognosis within a biopsychosocial framework. Doing so will improve the ability of physiotherapists to prognosticate, which will subsequently improve outcomes associated with musculoskeletal disorders.

Sneakerheads for Trump: information flows in the online news media

PurposeThis paper explores information flows in the news media amid ideological polarization, focusing on challenges and opportunities. The case study of Donald Trump’s sneaker line unveiling examines how news agencies navigate objectivity in reporting politically sensitive topics online. It also explores the balance news supply chains must strike between expediency, objectivity and differentiation for diverse audiences.Design/methodology/approachThe study conducts qualitative and quantitative content analysis on mainstream media coverage of Donald Trump’s sneaker unveiling. Meticulous coding and inductive approaches systematically review news stories to uncover trends and variations. Incorporating media bias ratings provides context on potential framing biases. This rigorous methodology aims to locate emergent themes in how news outlets interpret and report on politically charged events, offering reliable insights into the dynamics of reporting on contentious narratives.FindingsThe analysis reveals polarized reactions to Trump’s sneaker unveiling, reflecting societal divisions. Aesthetics underscore manipulative political messaging and ethical dilemmas. Varying press reception mirrors broader tensions across online news media. Coverage suggests a link between media bias and sentiment toward Trump. Theoretical insights explore dynamic capabilities and social identity theory. The study offers practical implications for navigating ideological framing and audience engagement, benefiting news media supply chain professionals.Originality/valueThis paper provides novel insights into online news supply chains, revealing complexities in reporting politically charged events. It contributes theoretical perspectives on dynamic capabilities and social identity theory and offers practical implications for managing ideological framing in online news media, adding significantly to existing knowledge.Peer reviewThe peer review history for this article is available at: https://publons.com/publon/10.1108/OIR-04-2024-0241

A dataset of venture capitalist types in China (1978–2021): A machine-human hybrid approach

Despite escalating interest in distinguishing among various types of venture capitalists (VCs) and their roles in shaping entrepreneurship and innovation, such research remains sparse in the world’s second-largest VC market, i.e., China. To address this important gap, we have devised a machine-human hybrid approach to perform the classification task for VC types. Specifically, we have compiled a list of 49,187 VCs that made investments in China before 2021 from CVSource database, collected VC ownership information from other public sources, developed machine-learning algorithms to predict VC types, and used human coders when machine-learning failed to produce a prediction. Utilizing this hybrid approach, we have classified VCs into one of the following types: GVC (public agency-affiliated, state-owned enterprise-affiliated), CVC (corporate VC), IVC (independent VC), BVC (bank-affiliated VC), FVC (financial/non-bank-affiliated VC), UVC (university-affiliated VC), and PenVC (pension-fund-affiliated VC). We not only provide the most up-to-date database for VC types in the Chinese setting but also demonstrate how to leverage machine-learning algorithms to devise a transparent coding approach for VC-type classifications.

Precise Orientation Estimation for Rotated Object Detection Based on a Unit Vector Coding Approach

Existing rotated object detection methods usually use angular parameters to represent the object orientation. However, due to the symmetry and periodicity of these angular parameters, a well-known boundary discontinuity problem often results. More specifically, when the object orientation angle approaches the periodic boundary, the predicted angle may change rapidly and adversely affect model training. To address this problem, this paper introduces a new method that can effectively solve the boundary discontinuity problem related to angle parameters in rotated object detection. Our approach involves a novel vector-based encoding and decoding technique for angular parameters, and a cosine distance loss function for angular accuracy evaluation. By utilizing the characteristics of unit vectors and cosine similarity functions, our method parameterizes the orientation angle as components of the unit vector during the encoding process and redefines the orientation angle prediction task as a vector prediction problem, effectively avoiding the boundary discontinuity problem. The proposed method achieved a mean average precision (mAP) of 87.48% and an average cosine similarity (CS) of 0.997 on the MVTec test set. It also achieved an mAP score of 90.54% on the HRSC2016 test set, which is better than several existing state-of-the-art methods and proves its accuracy and effectiveness.

Abortion access barriers shared in “r/abortion” after Roe: a qualitative analysis of a Reddit community post-Dobbs decision leak in 2022

With drastic changes to abortion policy, the months following the Dobbs leak and subsequent decision in 2022 were a uniquely uncertain and difficult time for abortion access in the United States. To understand experiences of challenges to abortion access during that time, we used a hybrid inductive and deductive thematic coding approach to analyse descriptions of barriers and their impacts shared in an abortion subreddit (r/abortion). A simple random sample of 10% of posts was obtained from those shared from 02 May 2022 through 23 December 2022; comments were purposively sampled during the coding process. In this sample of submissions (n = 523 posts, 88 comments), people described structural barriers identified in past research, including state abortion bans and gestational limits, high costs, limited appointment availability, and long travel required. Posters also commonly described known social barriers, including limited social support and abortion stigma. Several impactful barriers not well-described in past research emerged inductively, including wait time for receiving mail-ordered abortion medication, low credibility of online ordering platforms, and concerns about legal risks of accessing abortion or related medical care. The most common consequences of experiencing barriers were adverse mental health outcomes, delayed access to care, and being compelled to self-manage their abortion because of access barriers. This analysis provides timely insights into the experiences and impacts of abortion access barriers in a group of people with a range of engagement with clinical abortion care, lived experiences, and points in their abortion processes, with public health implications for mental health and abortion access.

Qualitative exploration of awareness about risk factors and transformative behaviours among Pakistani patients with coronary artery disease

ObjectivesTo explore patients’ awareness of risk factors for coronary artery disease (CAD) and experiences of the behavioural modifications, they made during their recovery through in-depth semistructured interviews.DesignQualitative exploration was undertaken...

Acceptability and Scalability of a Meditation App Among Adolescents With Type 1 Diabetes Mellitus.

Background Adolescents with type 1 diabetes mellitus (T1DM) experience stress from general life stressors and diabetes-specific stressors. This stress manifests in a range of ways, such as mood swings, heightened frustration, strained familial relationships, and difficulties in T1DM self-management, which then leads to worse health outcomes. There is small to moderate evidence that frequent use of mental health applications (MHapps) improves mental and physical health outcomes. Meditation apps may help reduce some of the stress associated with living with T1DM. This study explores the acceptability and scalability of a self-guided, smartphone-based meditation app, the Healthy Minds Program (HMP) app, among adolescents with T1DM using the Unified Theory of Acceptance and Use of Technology. Methods Eight adolescents ages 15-19 were recruited from a pediatric clinic in a Midwestern state and introduced to the HMP app. After using the HMP app for one week, they were invited to participate in three successive focus group meetings. During the meetings, they shared their perspectives on the content, navigation, and acceptability of the HMP app and strategies to introduce and scale app utilization among adolescents with T1DM. Researchers conducted conventional content analysis using a hybrid coding approach. Data was managed and analyzed using NVivo 10 (Lumivero, Denver, Colorado, USA). Findings Participants believed that the HMP app has the potential to enhance their stress management, mood, and coping abilities when dealing with the challenges of T1DM management. They found the app enjoyable and easy to use but expressed concerns about time constraints as a potential barrier. To address this, they shared recommendations for facilitating app uptake and usage. Conclusions This study's results provide an in-depth understanding of how positively this subset of adolescents with T1DM viewed the HMP app. The participants also offered valuable suggestions that can promote the adoption and sustained use of MHapps by adolescents living with T1DM.

Mathematics Teachers’ Experiences of Using Online Teaching Resources for Professional Learning in a Context of Disadvantage

This interpretative phenomenological study adopted the Community of Inquiry framework to explore 30 South African teachers’ experiences of the effectiveness of Grade 9 online mathematics teaching resources. A survey questionnaire with open-ended questions and a semi-structured interview guide were used to obtain data on the teachers' experiences. Data were analysed using an inductive thematic coding approach. The findings were that the teachers positively experienced the efficacy of online teaching materials for their professional development in terms of cognitive, social, teaching and learning presences. Using WhatsApp groups to share and discuss the online materials enhanced a common identity (social presence), deep engagement with the mathematical and pedagogical content knowledge of the materials (cognitive presence), (peer) teaching and (peer) learning from one another via WhatsApp (social media) chat groups (teaching and cognitive presences) that collectively eased curriculum implementation and enhanced student learning. However, limited facilitator teaching presence and limited internet access for both teachers and learners constrained the platform's benefits. Participating teachers reported spending at least three hours per week searching for online teaching resources, sometimes fruitlessly, indicating a need for more digital literacy training. The study makes a valuable contribution to our understanding of the potential benefits of online resources for teaching complex mathematics topics such as fractions and familiarity with the obstacles that need to be overcome. The more teachers and students turn to online resources, the more the findings of this study can inform the development of such resources to improve mathematics learning outcomes for schools in contexts of disadvantage.

Factors influencing physical activity and sedentary behaviour in contact centres during the COVID-19 pandemic and their relevance for the future of hybrid working.

The COVID-19 pandemic changed the way many industries work, including contact centres, with some employees working from home and new on-site restrictions/measures in place representing even greater challenges for employers around staff engagement and wellbeing. This study aimed to understand the interplay of individual, social, environmental and organisational factors influencing physical activity and sedentary behaviour in UK contact centre employees, how the pandemic impacted these factors, and their relevance for the future of hybrid working. Individual interviews (n = 33) were conducted with participants (staff working full and part time, on site and from home) from four UK contact centres. A topic guide based on the ecological model was developed to understand current barriers and facilitators to physical activity and (reducing) sedentary behaviour during and outside of working hours. Thematic analysis was carried out using a codebook and a deductive coding approach to identify themes. Three key insights are provided. First, participants felt they were generally sitting more and moving less since the first UK-wide lockdown. Second, factors which negatively impacted on these behaviours were evident across all levels of the ecological model. These included individual and social barriers (e.g., lack of motivation and preferable physical activity options) as well as environmental and organisational barriers (e.g., poor home office setup, back-to-back virtual meetings). There were a mix of new and existing barriers (exacerbated by the pandemic) and several of these were linked to homeworking. Third, organisational support requirements (e.g., homeworking ergonomic support) and existing facilitators (such as the provision of informational support and flexible working arrangements) were identified. Solutions to reduce sedentary behaviours and increase physical activity in contact centres need to address barriers from the individual to the organisational level. Whilst the study was undertaken in the UK, the results are like to be applicable globally. Clinical trial registration: The trial for the wider project has been registered on the ISRCTN database: http://www.isrctn.com/ISRCTN11580369.

Adult mental healthcare professionals' experiences of family centred conversations with patients who are parents: a qualitative study.

Many parents with a mental illness report a desire for both recognition of their parental role and support for themselves and their children. However, parents are often fearful of negative judgements from professionals about their ability to be a parent, which inhibits raising concerns about their children with clinical teams. Consequently, an essential first step to supporting families is for professionals to proactively identify which patients are parents, although evidence indicates this is not consistently part of services. Professionals could play a pivotal role in guiding parents about how to talk to their children about their mental illness; this in turn can facilitate family functioning and enable children to access evidence-based interventions. This approach is crucial for mitigating the well-documented intergenerational risk of poorer outcomes and mental illness in children of affected parents. This study aimed to explore adult mental healthcare professionals' beliefs and experiences of talking with patients about: i) their role as parents ii) communication with their children about mental illness. Semi-structured qualitative interviews were conducted with 19 adult mental healthcare professionals with 4-30 years' experience of working with adult patients under the care of NHS adult mental healthcare services in England. Audio recordings were transcribed verbatim and analysed using an inductive coding approach following the principles of thematic analysis. All participants recognised their responsibility to identify patients' children through routine safeguarding protocols, but supporting patients around telling their children the diagnosis was less common. Many participants expressed concerns that raising the topic of children with patients could conflict with other parts of their professional role or would not be welcomed. Obstacles to these conversations were identified, across individual, environmental and organisational factors. Potential facilitators included specific staff training and resources for clinical teams and families around how to tell children about mental illness. Adult mental healthcare professionals would benefit from enhanced training on the importance and methods of guiding parents to communicate with their children about mental illness. This should include routine identification of which patients are parents and recognition of the impact of an adult's mental illness on the wider family system.