Intrinsic Religious Motivations Influencing Advance Care Planning in Japan: A Mixed-Methods Study.

Exploring patient experiences in pre-hospital planning for skin cancer surgery.

Abstract Background Smart glasses might present a promising solution to support older adults with cognitive impairment in maintaining independence. However, there exists a critical gap in smart glasses research that incorporates recently developed models or directly engages older adults with cognitive impairment. Objective This study aimed to use survey and interview techniques to explore the acceptability and usability of smart glasses among older adults with cognitive impairment. Methods This explanatory mixed methods descriptive study was conducted at an independent living older adult apartment building among residents with memory complaints or cognitive impairment. This study consisted of a quantitative survey (N=26), followed by smart glasses beta testing with qualitative interviews (n=14). Results Overall, older participants with cognitive impairment conveyed a generally positive perception of smart glasses and their potential to support memory in daily life. Results suggest that participants prioritized the following smart glasses functions: audio reminders, phone calls, GPS, and distress signals, with audio reminders emerging as the highest-ranked feature. Additionally, participants emphasized the value of an intuitive and quick interface and a preference for audio, rather than visual, information exchange. Conclusions This study supports the development and study of smart glasses for older adults with mild cognitive impairment. Smart glasses developers should place great importance on usability, such as intuitive command interfaces, and equip the smart glasses with functions that are relevant to this population, especially audio reminders. Additionally, future work should examine the integration of smart glasses over a longer period and among a larger sample of older adults with cognitive impairment.

Reproductive coercion, gender role attitudes and fertility desire among married women in Türkiye: a descriptive and explanatory study.

To examine how specific midwife-led continuity of care elements are implemented and sustained in a maternity care system where independent community midwives collaborate with hospital-based care professionals. An explanatory qualitative study was conducted, using the Normalization Process Theory as a conceptual framework. Maternity care networks that had implemented an innovation contributing to midwife-led continuity of care were included in the study. Stakeholders invited to participate in semi-structured interviews included community midwives, hospital-based midwives, obstetricians, managers, an obstetric nurse, and healthcare insurance company employees. Participants were recruited through an initial purposive sampling strategy. As data collection progressed, theoretical sampling was applied. A total of 47 interviews were conducted with stakeholders from nine different maternity care networks. While many participants expressed strong conceptual support for midwife-led continuity of care (coherence), this did not always translate into aligned action in practice (collective action). Trust between stakeholders and financial feasibility were dominant themes across all four constructs of the Normalization Process Theory. Trust was found to develop incrementally through small collaborative steps but remained fragile in competitive or hierarchical networks. Financial structures shaped both engagement and resistance. The implementation process and normalization of midwife-led continuity of care elements are not only shaped by practical or organizational considerations but are also highly dependent on trust between stakeholders and financial feasibility. As dual preconditions, trust and financial alignment must be in place for stakeholders to consider new collaborative models and to be able to act in line with their beliefs. In systems with longstanding institutional divisions and fragmented funding, transformative change requires simultaneous investment in relational infrastructure and financial redesign.

Manual material handling in Indonesia's garment industry, particularly at PT. Mahasuri Utama, poses significant ergonomic risks, evidenced by REBA scores of 9 (high risk) due to repetitive pulling of 15-63 kg loads over 110 cycles per 10-hour shift. This study aimed to design a rail-based push cart using Ergonomic Function Deployment (EFD) to prevent musculoskeletal disorders (MSDs). A mixed-methods explanatory case study was conducted involving six material handlers and anthropometric data from 150 industrial engineering students as local population proxies. Data collection utilized REBA observations, VOC interviews, Likert-scale questionnaires, and SolidWorks/CATIA V5 simulations, analyzed through EFD matrices, HOE relationships, and paired t-tests. Key findings revealed prioritized needs for easy-push aids and shoulder load reduction, addressed by rail systems, ergonomic handles (P5 height 95.5 cm), and optimized wheels, reducing REBA scores to 4 (medium risk). Layout improvements supported neutral postures and minimized pushing forces. This first EFD application in Indonesian garment SMEs provides a replicable prototype enhancing worker safety, productivity, and SDG alignment, though field validation remains needed.

Brain-heart conditions disproportionately affect equity-deserving groups. Disparities extend to health decision-making, yet little is known about the decisional needs of people from equity-deserving groups with brain-heart conditions. In this study, we aimed to investigate the decisional needs of equity-deserving patients facing brain-heart health decisions. We conducted an explanatory sequential mixed-methods study. Eligible participants were adults (≥18 years) from an equity-deserving group (eg, racialized; lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and additional sexual orientations [LGBTQIA+]; and living with disability), with a brain-heart condition, and faced a health decision in the past year. We analyzed quantitative survey data using descriptive statistics and qualitative interviews thematically. Data integration occurred at various levels, with results represented through joint displays. We surveyed 23 patients who participated in the parent study between June 2024 and March 2025. Thirteen (56.5%) had a brain-heart condition, 9 (39.1%) had a heart condition with risk factors for a brain condition, and 1 (4.3%) had a brain condition with risk factors for a heart condition. Decisions included lifestyle changes (n = 22, 95.7%), medications (n = 21, 91.3%), and diagnostic tests (n = 14, 60.9%). Seven experienced clinically significant decisional conflict (30.4%) and 6 experienced decision regret (30.0%). Challenges included worrying about choosing the wrong option (n = 12, 52.2%) and feeling that brain implications were never discussed (n = 10, 43.5%). Five participants were interviewed, and themes revealed barriers to decision-making, including information gaps, complex emotions, and poor communication. Unmet decisional needs among equity-deserving patients with brain-heart conditions were decisional conflict, decision regret, and other factors. Decision support interventions tailored to equity-deserving groups could address unmet decisional needs.

In EFL learning, collaborative writing is the joint production of a text in which two or more learners actively contribute to planning, drafting, and revising a shared written product. In multicultural settings such as Indonesia, integrating local cultural content is assumed to enhance engagement and collaboration; however, its effect on learners’ collaborative writing performance within the Sasak cultural context remains underexplored. This study examined the impact of embedding local cultural content into writing instruction on EFL students’ collaborative writing performance. Employing an explanatory sequential mixed-methods design, quantitative data were collected from 134 students in the Department of Computer Science at Bumigora University, and 20 students were purposively selected for semi-structured interviews to provide qualitative insights. Quantitative analyses indicated significant improvement in writing performance, with mean scores increasing from 66.62 to 72.01 (p < .05) and a strong positive correlation between pre- and post-test scores (r = .736, p < .05). The effect size, Cohen’s d = 0.84, confirmed a large improvement. Qualitative findings revealed that cultural familiarity strengthened group engagement, boosted identity-based confidence, and facilitated idea generation. Students reported that working with culturally familiar themes encouraged inclusive participation, reduced communication anxiety, and increased motivation. These findings suggest that integrating local cultural content enhances both language development and collaborative processes. Two key implications emerge: (1) Curriculum designers should incorporate localized cultural materials to increase contextual relevance, and (2) Teachers should design collaborative activities leveraging learners’ cultural knowledge to foster richer interaction, lower participation barriers, and improve overall learning outcomes.

Deficient palliative care coverage and nursing training in Ecuador warrant examining self-efficacy to inform education strategies and strengthen equitable services. To examine Ecuadorian nurses' self-efficacy in Palliative Care. A sequential explanatory mixed-methods study was conducted. Convenience samples of nurses completed the Self-Efficacy in Palliative Care Questionnaire and participated in online semi-structured interviews. Descriptive statistics were used for quantitative data. A side-by-side joint display supported integration. 497 nurses completed the questionnaire (90.4% female; 11.47 years of experience). Teamwork scored highest, while communication scored lowest. Eighteen nurses were interviewed (88.8% female; 11.5 years of experience). Participants reported communication difficulties related to emotions, prognosis, denial, collusion of silence and paediatric cases. They expressed strong confidence in pain management but more difficulty with agitation and dyspnoea. Spiritual care was mainly understood as facilitating access to religious figures. Although teamwork was perceived positively, tensions with physicians and an excessive focus on physical aspects were noted. Quantitative and qualitative findings aligned overall, with dissonances regarding psychological and social communication. Strengthening communication and comprehensive patient management competencies, as well as addressing interdisciplinary tensions, is necessary to improve and consolidate Palliative Care in Ecuador. This study adhered to EQUATOR guidelines and used COREQ for qualitative reporting. No patient or public contribution.

The rise of artificial intelligence (AI) in the Human Resource Management has allowed organisations to apply cutting-edge analytics in making strategic decisions regarding the workforce. At the same time sustainable workforce planning has acquired significance as firms are pursuing talent continuity, workforce agility and retention in the long term. The current study was based on the topic of the association between AI-based HR analytics capability and sustainable workforce planning through the descriptive and correlational design approach. The cross-sectional survey of HR managers and professionals was used to gather data and analyse them with the help of descriptive statistics and Pearson correlation test. The results showed that AI-based HR analytics capability was positively and significantly related to sustainable workforce planning, and the corresponding aspect like workforce agility and talent retention effectiveness. Based on the findings, AI-based HR analytics can potentially serve as a key facilitator of sustainability-driven workforce planning. Although no causal conclusions are possible, the study offers a starting point of empirical consideration of the strategic value of AI-assisted HR analytics in sustainable labour force overtime and gives new directions of explanatory study.

This article investigates the relevance of selected and adapted representations of Krishna from the broader ISKCON tradition for sustainable and self-sufficient practices within Krishna Valley. Krishna Valley is an ISKCON community established in 1993 in the remote areas of Hungary, and it covers 300 hectares. As a self-sufficient and sustainable community, it is part of the Global Environmental Network, and as an ISKCON community, it belongs to the global movement of the International Society for Krishna Consciousness. The synchronic interconnections of Krishna Valley as an ecovillage and as a religious place intertwine in the same place. In this article, Krishna Valley serves as an explanatory case study to investigate the relevance of ISKCON religious representations for ecological imagination: the process of perceiving relationships through the use of metaphors, images, narratives, symbols, and sematic frames that are central to and constitutive of human ecological thinking. This study uses two units of analysis (cow service and water management) to explore how in Krishna Valley ecological imagination takes shape in the interaction between local sustainable and self-sufficient practices and specific religious representations that are part of the ISKCON tradition. By looking at how the community interprets and treats cows and water pollution from a religious and environmental perspective, this case study answers the question of how ecovillages might benefit from religion-based ecological imagination for their sustainable livelihoods.

BACKGROUND &OBJECTIVE: In Pakistan's undergraduate medical education context, the PERLs (Professionalism, Ethics, Research, and Leadership) module has been introduced to align with modern integrated curricula. This study aimed to explore students' perceptions of the PERLs module and its influence on professional development and clinical practice within a private medical college in Pakistan. METHODOLOGY: A mixed-method sequential explanatory study comprised a cross-sectional survey of 78 medical students, followed by in-depth interviews of 8 participants to gain richer qualitative insights. Survey data were analyzed using descriptive statistics, while interview transcripts underwent thematic analysis. RESULTS: Survey findings demonstrated strong student agreement on the relevance and applicability of the PERLs module to medical practice, with mean ratings ranging from 4.077 to 4.462(out of 5). Students acknowledged the module’s role in preparing them for ethical challenges, enhancing clinical practice skills, and advancing professional development. Qualitative themes reinforced these outcomes, highlighting the module’s practical utility in addressing real-world ethical dilemmas, strengthening research and clinical reasoning, and cultivating teamwork, communication, and leadership. Suggestions for improvement emphasized the need for more accessible resources, expanded practical exposure, and improved time allocation within the module. CONCLUSION: Students viewed the PERLs module as an effective bridge between theory and practice, supporting their growth as competent and ethical future physicians. With targeted enhancements to resources, practical engagement, and time management, the module has strong potential to advance professional identity formation in medical education.

The dual burden of tuberculosis (TB) and diabetes mellitus (DM) presents a growing challenge for health systems in low- and middle-income countries (LMICs), including Pakistan. Despite global and national policies advocating for integrated care, evidence on health facility readiness to operationalize integration remains scarce. This study assessed the readiness of TB basic management units (BMUs) to deliver integrated TB-DM care and explored implementation barriers using the Consolidated Framework for Implementation Research (CFIR). We conducted an explanatory sequential mixed-methods study from September 2024 to February 2025 across 13 TB BMUs in five districts of Pakistan. Quantitative readiness data were collected using a structured tool adapted from the WHO Service Availability and Readiness Assessment (SARA), generating a composite score across four domains. Subsequently, qualitative data were gathered through multi-stakeholder focus group discussions with healthcare providers, facility managers, patients, caregivers, and policymakers. Reflexive thematic analysis was conducted and mapped to CFIR Inner Setting constructs to contextualize quantitative findings. Only one facility demonstrated high readiness, while 12 showed low readiness. Facilities lacked routine comorbidity screening, trained staff, diagnostic capacity, and essential medicines. Key barriers included inadequate infrastructure, workforce shortages, fragmented information systems, and low prioritisation of integrated care. Financial constraints and limited coordination further hindered implementation. This study highlights critically low readiness among TB facilities in different districts of Pakistan to deliver integrated TB-DM care, reflecting systemic weaknesses across core domains. Strengthening systems, building capacity, and improving integration strategies are essential to bridge gaps between policy and practice.

This explanatory sequential mixed-methods study examined how professional social media learning behaviors relate to learning engagement and perceived educational outcomes among Chinese medical students. Survey data from 350 students across four universities were analyzed using confirmatory factor analysis and structural equation modeling, followed by interviews with 18 students. Professional social media learning behaviors included information seeking, observing professional discourse, peer knowledge exchange, and academic discussion participation. Results showed that these behaviors were positively associated with learning engagement, which in turn was positively associated with perceived learning effectiveness, academic confidence, and perceived professional development. Engagement partially mediated the relationship between professional social media learning and perceived outcomes. Interview findings indicated that professional social media functioned as a flexible supplementary learning environment supporting concept clarification, peer interaction, and professional sense-making, while also requiring critical evaluation and selective use. The findings suggest that the educational value of professional social media depends on how students engage with it.

This study aimed to comprehensively examine social and clinical factors contributing to postpartum depression among women in Nepal and identify their perspectives/experiences regarding postpartum mental health. The explanatory sequential mixed-method study was conducted in two phases. In the quantitative phase, data were collected via survey of 200 postpartum women at immunisation clinics of two hospitals in Kathmandu Nepal. Measures included sociodemographic and perinatal factors and the Edinburgh Postpartum Depression Scale. Regression models were conducted to analyse data. In the qualitative phase, in-depth interviews were conducted with 15 participants having depression scores ≥ 10. Data were analysed using the thematic content analysis method. Qualitative and quantitative findings were integrated using the joint display and the narrative weaving approach to generate results. Findings show that 28% of postpartum women screened positive for depressive symptoms, requiring referral for further evaluation. Integrated findings indicate that prenatal mental health problems, low birth weight or medical conditions among infants, intimate partner violence, partner substance abuse, and a lack of postpartum social support were major contributors to postpartum depression. Depression is highly prevalent among women 6-12 months postpartum in Nepal and is associated with several clinical and social factors. These findings have important implications, emphasising the need for routine screening using validated tools for early identification, timely treatment and referral of women at-risk for postpartum depression. Evidence-based clinical and community initiatives are needed to promote positive outcomes for women and their families. External experts were consulted for survey questions and qualitative interview guide, then refined those instruments based on their feedback to improve construct validity. The immunisation clinic staff provided input during study design, for participant recruitment and data collection. Key findings were presented to stakeholders to validate the interpretation of findings.

To explore concerns and coping experiences regarding sexual well-being in inflammatory bowel disease and examine the relationship between these concerns and affected individuals' background factors. Explanatory sequential mixed methods study. Recruitment flyers (n = 1347) were distributed to individuals attending inflammatory bowel disease outpatient clinics in seven facilities. Participants completed a questionnaire assessing demographics, concerns and coping experiences related to their sexual well-being. Those who provided consent participated in semi-structured online interviews. Quantitative data were analysed descriptively, and qualitative data were analysed using content analysis. A total of 551 participants completed the questionnaire, and 21 participated in the interviews. Among them, 251 (45.6%) reported experiences of concerns related to romantic relationships and marriage, sexual life, pregnancy, childbirth and childcare. The nature of these concerns varied by background factors: unmarried individuals more often reported relationship concerns; those with surgical or perianal history more often reported sexual concerns; and women, married individuals and individuals with Crohn's disease more often reported pregnancy-related concerns. Coping experiences were categorized as (1) active barrier management, (2) partner and professional support, (3) passive or resignation coping and (4) cognitive reframing. Sexual well-being is significantly affected among individuals with inflammatory bowel disease. Many participants reported understanding and support from significant others or relied on personal coping strategies; however, others reported an absence of coping experiences. Sharing these findings with individuals with inflammatory bowel disease and healthcare professionals may enhance awareness and promote support strategies to improve these individuals' sexual well-being. Concerns about sexual well-being are influenced by both clinical and psychosocial factors, including treatment history, life stage and partner relationships. Healthcare professionals should provide individualised and comprehensive care that incorporates the partners and families of individuals with inflammatory bowel disease to better address sexual well-being. This study presents the first large-scale mixed methods evidence on how individuals with inflammatory bowel disease experience sexual well-being, providing direct implications for improving quality of life. By illustrating both adaptive and absent coping strategies, the findings contribute essential insight to inform patient-centred clinical practice and psychosocial care. The Good Reporting of a Mixed-Methods Study (GRAMMS) guidelines were followed. No patient or public contribution.

This study examines the effect of Digital Management Accounting Tools (DMAT) on the operational efficiency of Micro, Small, and Medium Enterprises (MSMEs) in Bengkulu City in the era of Industry 5.0. The low adoption of digital accounting applications due to limited digital literacy, human resource quality, and technical support constitutes the main problem underlying this research. A quantitative approach was employed using an explanatory case study design involving 120 MSME owners selected through proportional random sampling. Data were analyzed using Partial Least Squares Structural Equation Modeling (PLS-SEM) with SmartPLS 4.0. The results demonstrate that DMAT has a positive and significant effect on MSME operational efficiency. Furthermore, managerial digital capability is proven to partially mediate the relationship between DMAT and operational efficiency. In other words, the effectiveness of DMAT implementation in improving operational efficiency is optimized when supported by strong managerial digital capabilities. These findings reinforce the relevance of the Technology Acceptance Model (TAM) in the context of MSME digital transformation and provide practical implications for policymaking and strategies to accelerate regional MSME digitalization.

ABSTRACT This qualitative explanatory study investigated risk-taking behaviors of sex practices and drug use associated with HIV-positive status among African American women. This study was conducted using a non-probabilistic sample of 252 African American women aged from 18 to 65. The data was analyzed using a t-test, Pearson correlation coefficient, and stepwise regression. Four research hypotheses were tested: Ha1: The HIV-positive group will exhibit significantly higher risk-taking behaviors compared to the HIV-negative group. Ha2: HIV-negative group will possess significantly greater knowledge of HIV compared to the HIV-positive group. Ha3: Knowledge of HIV is inversely related to risk-taking behaviors. Ha4: Demographic and socioeconomic factors (age, student status, sexual orientation) have a significant effect on HIV risk-taking behaviors and HIV knowledge. The data suggests that hypotheses one and four were supported, and hypotheses two and three were unsupported. Specifically, the data confirms hypothesis one. Respondents have higher HIV risk-taking behaviors than their HIV negative counterparts. Further, the data confirms that HIV risk-taking behaviors were primarily predicted by positive status (b = 3.816, p < .01, sr2 = .03) and bachelor’s education or higher (b = −4.848, p < .01, sr2 = .07). A key finding of this study is that HIV-negative and HIV-positive Black/African American female respondents were similar in their risk-taking behaviors. HIV-negative and HIV-positive Black/African American female respondents were identical in HIV knowledge.

In Confucian-influenced Chinese culture, childbearing is seen not just as a personal decision but a moral and familial duty, especially for younger generations. However, little research has examined how Intergenerational Childbearing Expectations (ICE) impact Childbearing Anxiety (CA) among Chinese LGBTQ+ individuals. This explanatory sequential mixed-methods study (N = 330) found that ICE significantly positively predicted CA for LGBQ+ individuals. Filial piety also significantly and positively predicted CA, yet it buffered the effect of ICE on CA. Different dimensions of filial piety show distinct patterns of association. A thematic analysis of interviews with 12 LGBTQ+ participants revealed four key themes: (a) Social Norms and Structural Exclusion, (b) Intergenerational Dynamics and Familial Conflict, (c) Identity Struggles and Filial Piety Tensions, and (d) Personal Autonomy and Existential Anxiety. These findings show that Confucian family values can both aggravate and soothe childbearing anxiety, creating a distinct psychological dilemma for LGBTQ+ individuals navigating conflicting cultural and personal identities. By proposing a new framework linking ICE, filial piety, and CA, this study highlights the urgent need for culturally sensitive mental health interventions that address the nuanced experiences of LGBTQ+ individuals within traditional Chinese familial structures.

Models of school-based art therapy range widely. School-based professions were established through legislative, legal, and professional advocacy. The advancement of school-based art therapy in the United States lags behind the progress noted by other school professionals and school-based art therapy as practiced internationally. This sequential explanatory mixed methods study aims to identify characteristics to support the advocacy efforts toward national implementation. Survey findings from school-based art therapists (n = 103) are reported. Characteristics describing the education setting, position, format, collaboration, and administration of school-based art therapy models are shared. Disparities in implementation based on state licensing and funding impact the effective inclusion of art therapy in schools. Current models provide recommendations for the expansion of art therapy in schools. Highlighted strategies establish clear parameters for art therapy intervention and encourage effective collaboration with staff and parents. Understanding the nuances of school-based art therapy models may yield greater knowledge toward its national advancement.