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Evaluating Functional Recovery in Stroke Patients: Neurostimulation-Assisted Walking Device in Stroke Patients with Drop Foot

DOI: 10.31038/JCRM.2025834

Abstract

Background: Walking recovery is a key concern for post-stroke patients, with up to 46% of first-ever stroke survivors initially unable to walk and 40% of all post-stroke patients requiring rehabilitation. Regaining a more physiological walking pattern can lead to improved gait performance and, consequently, greater independence in activities of daily living.

Materials and methods: 18 post-stroke patients with drop foot completed a treatment program comprising a neurostimulation-assisted walking device (BTL WALK). Functional gait measurements, including the 10-Meter Walk Test (10MWT), 6-Minute Walk Test (6MWT), Stair Climb Test (SCT), and Manual Muscle Grading scale (MMT) were assessed both before and after the program. Additionally, the Barthel Index was used to evaluate the impact of the treatment on independence in daily activities.

Results: Statistically significant improvements were observed in all monitored parameters, with changes of -17.7% in the 10-Meter Walk Test (10MWT), 14.6% in 6-Minute Walk Test (6MWT), -37.0% in Stair Climb Test (SCT), 8.86% in Barthel Index, and 27.8% in Manual Muscle testing scale (MMT). No significant relationship was found between any parameter or its change and the time since stroke onset.

Conclusions: This study highlights the potential of BTL WALK training in mitigating drop foot in post-stroke patients. Improvements in walking speed, distance, and stair-climbing enhanced independence in daily activities and increased muscle strength, serving as a key motivational factor for continued rehabilitation, especially for patients several years post-stroke.

Keywords

Stroke, Drop foot, Neurostimulation-assisted walking, Gait training, Independence in daily activities

Introduction

Stroke remains a leading cause of mortality and long-term disability, with up to 40% of survivors requiring active rehabilitation [1]. Lower extremity motor impairment is present in 44.1% of individuals experiencing a first-ever stroke, and 46.0% are initially unable to walk [2]. Walking recovery is often one of the first concerns raised by post-stroke patients when consulting medical staff, highlighting its critical role in rehabilitation [3]. Among those who regained some walking ability within 3 to 5 days post-stroke, 76.4% were discharged to home care, compared to only 21% of non-ambulatory patients [1]. Walking is not only a key factor in determining discharge to home care but also a fundamental component in restoring independence in daily life [3].

Up to 20% of stroke survivors experience drop foot, a condition characterized by an impaired ability to dorsiflex the foot during the swing phase of gait. This persistent distal weakness in the hemiparetic leg may be associated with weakness of the anterior muscles, spasticity of the posterior leg muscles, or both. Additionally, the condition can be further complicated by the development of plantar-flexion contracture at the ankle [4]. Drop foot leads to disability by promoting undesirable compensatory movement patterns, restricting mobility, and increasing the risk of falls [4,5]. One potential treatment for drop foot in individuals with hemiparesis is Electrical Stimulation (ES) applied to the peroneal nerve and the tibialis anterior muscle [5].

The most common therapeutic strategies for drop foot are ankle-foot orthosis (AFO) and electrical stimulation [6]. Ankle-foot orthoses (AFOs) are frequently prescribed for individuals with drop foot to maintain ankle neutrality and enhance limb clearance during the swing phase [4,7]. However, this intervention presents several limitations. Restricted ankle mobility associated with AFO use may contribute to contracture development. Furthermore, AFOs do not actively promote dynamic function or facilitate motor recovery [4,6]. Challenges in sit-to-stand transitions and patient discomfort are also commonly reported [4]. Electrical stimulation presents an alternative therapeutic modality for drop foot, targeting branches of the common peroneal nerve distal to the knee. In contrast to AFOs, ES permits physiological ankle range of motion and facilitates active dorsiflexion and eversion without mechanical constraint [4,6]. Clinical evidence indicates that ES, by unrestricted ankle motion, may offer superior functional outcomes compared to AFOs, particularly in complex environments characterized by inclines, uneven terrain, and pedestrian traffic [6,7].

Studies evaluating the immediate effects of ES during therapy have reported positive impacts on walking quality. However, research investigating its long-term effectiveness has yielded divergent results [8,9]. Guzel et al. observed statistically significant improvements in gait quality following a combined conventional physiotherapy, ES, and balance-weighting rehabilitation program in post-stroke patients. Similarly, Street et al. reported positive outcomes in individuals with multiple sclerosis [10,11]. In both patient populations, significant improvements were also observed following ES therapy when compared to the use of AFO [12,13].

This study aims to assess the impact of BTL WALK therapy on post-stroke patients. The research will evaluate the effects on gait parameters, lower limb disability, and the influence of time since stroke on individual outcomes [14,15].

Materials and Methods

The study was conducted at the Hamzova Léčebna Luže-Košumberk rehabilitation center between April and December 2025. Its design adhered to the ethical principles of the 1975 Declaration of Helsinki, as adopted by the Convention on Human Rights and Biomedicine of the Council of Europe and endorsed by the General Assembly of the World Medical Association [17].

Inclusion criteria required participants to be first-time stroke survivors, medically stable, with no cognitive impairment, and presenting with lower extremity involvement in the form of drop foot. Exclusion criteria included febrile conditions, cachexia of any etiology, tuberculosis or other bacterial infections, suspected malignancy, bleeding disorders, menses, the presence of electronic or metal implants in the treatment area, skin inflammation, trophic skin changes, irritated or damaged skin, cardiovascular diseases, sensation disorders, lower limb fractures, dislocations, or conditions adversely affected by motion, electroanalgesia without a confirmed pain etiology, psychopathological syndromes, and inflammatory conditions in the treatment area.

Participants underwent a 4-week treatment program consisting of neurostimulation-assisted walking (BTL WALK) therapy, administered five times per week. Functional assessments were performed before and after treatment, including the 10-Meter Walk Test (10MWT), the 6-Minute Walk Test (6MWT), and the Stair Climb Test (SCT) to evaluate mobility. Muscle strength was assessed by the Manual Muscle Test (MMT). Additionally, participants completed the Barthel Index questionnaire, which assessed their subjective level of disability related to gait impairment.

Before therapy, the patient was seated with the hip, knee, and ankle positioned at a 90° angle. The BTL WALK Pro device (BTL Industries, Ltd.) was placed on the inner calf, with electrode positioning adjusted to stimulate the common peroneal nerve that innervates the peroneal muscles and the tibialis anterior muscle (Figure 1). Following the initiation of therapy, stimulation intensity was gradually increased until ankle dorsiflexion was achieved. The electrode was then further adjusted to maintain the foot in a neutral position, preventing excessive eversion or inversion. The patient was encouraged to walk, with continuous adjustments made to electrode placement and stimulation intensity based on their response. Once optimized, a walking session was conducted, during which drop foot pathology was mitigated through muscle stimulation.

Figure 1: Image depicting the placement of BTL WALK on the inner calf to treat drop foot. Permission was granted by BTL Industries, Ltd.

To assess objective gait improvements, several functional tests were performed. The 10MWT evaluated gait speed, where the patient was instructed to walk at a comfortable pace over a 10-meter distance. The total time taken to complete the walk was recorded in seconds. No physical assistance was provided unless required for safety reasons. Timing began when the first foot crossed the start line and stopped when the first foot crossed the end line at 10 meters [18].

The 6MWT assessed functional exercise capacity by measuring the maximum distance the patient could walk in six minutes. The test was conducted in a long, straight hallway with cones marking each end of the walking course. The patient was instructed to wear comfortable clothing and non-slip footwear and walk at their own pace. They were allowed to rest if needed, but the timer continued running, and the total distance walked in meters was recorded [19].

Lower limb strength and balance were assessed using the SCT, which measured the time taken to ascend a standard flight of 12–14 steps, each 17–19 cm high. The patient was instructed to climb the stairs at their normal pace, using handrails only if necessary for balance. Timing began at the first step and stopped upon reaching the top, with results recorded in seconds [20].

Strength of the tibialis anterior, peronei, soleus, and gastrocnemius muscles was measured using the 0, meaning no contraction, to 5, meaning normal strength against full resistance, scale of the MMT. Muscle tests were performed by trained examiners following standardized limb positions and stabilization to minimize substitution and optimize repeatability.

In addition to these functional tests, the Barthel Index was used to evaluate the patient’s level of functional independence in performing ten essential daily activities. The assessment was conducted through direct observation and patient interviews, with activities scored based on the level of independence—categorized as independent, partially independent, or dependent. The total score ranged from 0 to 100, with higher values indicating greater independence [21].

The sample size was determined based on the capacity of the rehabilitation center and the minimum required sample size calculation. This calculation was conducted using 6MWT data from a previous study on post-stroke patients, assuming a study power of 80% and an estimated effect size of 15 meters [22,23]. The minimum required sample size of nine patients was increased to 20 to account for facility capacity and potential dropout risk.

For statistical processing and data evaluation, a customized script was developed in the Matlab environment. The data were initially analyzed using the Shapiro-Wilk test to assess normality. Except for the 10-Meter Walk Test (10MWT), the assumption of normal distribution was rejected for all parameters. Consequently, these data were analyzed using the Wilcoxon Signed-Rank test and presented as median values with interquartile range (IQR). In contrast, the 10MWT data, which met the criteria for normality, were compared using a T-test and reported as mean values with Standard Deviation (SD). The Pearson correlation coefficient was used to determine if there was a correlation between the time since stroke onset and the therapy outcome. P-values less than 0.05 were considered indicative of statistical significance.

Results

A total of 18 post-stroke patients, 16 men and 2 women, with a mean age of 70.22 ± 12.70 years and a mean time of symptom duration of 8.7 years. No adverse events occurred during the program, and none of the patients experienced any discomfort that would have hindered their participation. The therapy was generally well tolerated and resulted in improved walking function in the majority of patients.

Monitored parameters showed statistically significant improvements, mean score change, and mean within-patient percentage change in Table 1. After the treatments, 83.33% of patients improved in 10 MWT, 88.89% of patients improved in 6MinWT, 83.33% of patients improved in SCT, and 50% of patients improved in BI. These patients showed mean improvements in the aforementioned parameters of -18.41%, +23.06%, -28.46%, and 21.61%. The changes in MMT measurements showed the number of patients that improved after the therapies was 22.22% in the tibialis anterior, 33.33% in the peronei muscle, 27.78% in the soleus muscle, and 27.78% in the gastrocnemius muscle. The average change for the MMT score was 27.78%.

Table 1: Results of functional tests and functional independence questionnaire obtained before and after the treatment program. P values lower than 0.05 were considered statistically significant.

 

Before

After Diff %Diff %Mean within-patient percentage change P (0.05)
Mean (SD) Mean (SD) Mean score change (SD)

T-test

Other: Wilcoxon Signed Rank test

10MWT (seconds)

24.86 (13.50)

20.44 (10.43) -4.43 (5.41) -17.77% -14.20% 0.006

6MWT (meters)

166.17 (75.37) 190.50 (80.67) 24.33 (39.10) 14.64% 19.53%

0.002

SCT (seconds)

68.00 (63.54)

42.83 (20.55) -25.17 (51.53) -37.01% -22.69% 0.006

Barthel Index

75.28 (11.13) 81.94 (5.18) 6.67 (8.91) 8.86% 10.80%

0.035

IQR: Interquartile range, Diff: difference, 10MWT: 10-Meter Walk Test, 6MWT: 6-Minute Walk Test, SCT: Stair Climb Test.

The bar graph in Figure 2 visually represents the improvements achieved. The 6MWT and Barthel Index showed increases in the distance covered and the degree of independence in activities of daily living, respectively. Conversely, both the 10MWT and SCT showed decreases in the time needed to walk a set distance or climb a flight of stairs. These results all suggest an overall improvement in lower limb function over the course of the BTL WALK treatment program.

Figure 2: The baseline and post-treatment values of the 10-Meter Walk Test (10MWT), the 6-Minute Walk Test (6MWT), and the Stair Climb Test (SCT) to evaluate mobility.

Table 2 displays the Pearson correlation coefficients, which show the relationship between the time since stroke onset and individual outcome measures. The results indicate that time since stroke onset did not have a statistically significant effect on any of the indicators.

Table 2: P-value and Pearson correlation coefficient between time since stroke onset and individual outcome measures obtained before starting and after completing the treatment program, and the difference between them.

 

Time vs 10MWT

Time vs 6MWT Time vs SCT Time vs Barthel Index
P (0.05) r P (0.05) r P (0.05) r P (0.05)

r

Before

0.928

0.027 0.662 -0.128 0.355 -0.268 0.578 0.163

After

0.873 0.047 0.57 -0.166 0.591 -0.157 0.757

-0.091

Diff

0.934

0.024 0.711 -0.109 0.358 0.266 0.336

-0.278

Time: Time since stroke onset, r: Pearson correlation coefficient, Diff: difference, 10MWT: 10-Meter Walk Test, 6MWT: 6-Minute Walk Test, SCT: Stair Climb Test.

Discussion

The present study documents statistically significant changes in post-stroke patients’ gait as a result of a rehabilitation program based on BTL WALK gait training. These conclusions are supported by existing evidence, both in terms of statistical significance and the extent of the changes achieved [16,22,24]. Comparing the recalculated 10MWT values for speed (before: 0.51 m/s, after: 0.59 m/s) with similar studies, it is evident that the absolute values of gait speed differ significantly across publications. This may be due to variations in measurement methodology (patient instruction, use of aids, treadmill, etc.) and the different composition of patients in terms of indication, age, time from onset of stroke, severity, or brain damage, etc. Patients in the acute and subacute post-stroke phase tend to be more limited in movement and their gait speed reaches an average of around 0.25 m/s [25]. The current research includes patients who are a few weeks post-stroke, but also those who have been suffering from the consequences of stroke for many years. Correlation analysis did not reveal a statistically significant relationship between time since stroke and any outcome measure or its change. The main influence on walking limitation is likely the extent of brain damage [26].

The observed improvements in walking speed, functional exercise capacity, balance, and lower limb strength, as demonstrated through various functional assessments, can be further explained by the underlying mechanism of BTL WALK in post-stroke drop foot rehabilitation. BTL WALK facilitates neuromuscular activation by delivering electrical impulses to the dorsiflexor muscles, inducing muscle contraction, and enabling ankle dorsiflexion during the swing phase of gait. In post-stroke patients experiencing drop foot or impaired foot clearance, this timely and coordinated muscle activation enhances gait performance, contributing to a more physiological walking pattern [27]. Moreover, intensive and prolonged gait training incorporating ES promotes motor relearning, which, over time, can lead to sustained improvements in gait mechanics, potentially reducing the need for assistive devices [28]. This device can significantly affect the quality of life of patients in everyday life if they use the device as a compensatory aid.

Improvements observed in functional gait assessments were also positively reflected in subjective evaluations of activities of daily living. Although these changes were less pronounced compared to speed and distance-based assessments, they nonetheless reached statistical significance. Future research should consider utilizing more sensitive assessment tools capable of detecting the impact of even minor gait pattern deviations on an individual’s independence in daily activities.

The conclusions of this study must be interpreted in consideration of its limitations. The primary limitation is the absence of a control group, which would have enabled a direct comparison with patients receiving conventional therapy or no treatment, thereby accounting for the potential effects of spontaneous motor recovery. Additionally, the small sample size may have influenced the findings, particularly in the analysis of the impact of time since stroke onset. Notably, patient inclusion was not stratified based on time post-stroke, which adds a distinctive aspect to the study but also presents a limitation. Future research should aim to investigate specific subgroups of stroke survivors, particularly those several years post-stroke, as clinical evidence in this population remains limited.

Despite its limitations, this study provides valuable insights, particularly by demonstrating the positive effects of BTL WALK therapy on gait in patients undergoing rehabilitation not only in the early post-stroke phase but also several years after stroke onset. The finding that mobility and independence in daily activities can still be improved in chronic stroke survivors may serve as an important motivational factor for continued rehabilitation efforts.

Conclusions

The present study highlights the potential of BTL WALK training in mitigating drop foot in post-stroke patients. The observed improvements in walking speed, distance covered, and stair-climbing ability contributed to enhanced independence in daily activities, which may serve as a crucial motivational factor for continued rehabilitation, particularly for individuals undergoing therapy several years post-stroke. The therapy is an effective intervention for rehabilitating patients with limited mobility and gait impairments resulting from brain damage, promoting functional recovery and improved movement patterns.

References

  1. van de Port IG, Kwakkel G, Schepers VP, Lindeman E (2006) Predicting mobility outcome one year after stroke: a prospective cohort study. Journal of Rehabilitation Medicine 38: 218-223. [crossref]
  2. Louie DR, Simpson LA, Mortenson WB, Field TS, Yao J, et al. (2022) Prevalence of Walking Limitation After Acute Stroke and Its Impact on Discharge to Home. Physical Therapy 102. [crossref]
  3. Preston E, Ada L, Dean CM, Stanton R, Waddington G (2011) What is the probability of patients who are nonambulatory after stroke regaining independent walking? A systematic review. International Journal of Stroke: Official Journal of the International Stroke Society 6: 531-540. [crossref]
  4. O’Dell MW, Dunning K, Kluding P, Wu SS, Feld J, et al. (2014) Response and prediction of improvement in gait speed from functional electrical stimulation in persons with poststroke drop foot. PM & R: The Journal of Injury, Function, and Rehabilitation 6: 587-601. [crossref]
  5. Lairamore CI, Garrison MK, Bourgeon L, Mennemeier M (2014) Effects of functional electrical stimulation on gait recovery post-neurological injury during inpatient rehabilitation. Perceptual and Motor Skills 119: 591-608. [crossref]
  6. Li X, Li H, Liu Y, Liang W, Zhang L, et al. (2024) The effect of electromyographic feedback functional electrical stimulation on the plantar pressure in stroke patients with foot drop. Frontiers in Neuroscience 18: 1377702. [crossref]
  7. Nevisipour M, Honeycutt CF (2020) The impact of ankle-foot-orthosis (AFO) use on the compensatory stepping response required to avoid a fall during trip-like perturbations in young adults: Implications for AFO prescription and design. Journal of Biomechanics 103: 109703. [crossref]
  8. Böhm H, Döderlein L, Dussa U, Ch (2020) Functional electrical stimulation for foot drop in the upper motor neuron syndrome: does it affect 3D foot kinematics during the stance phase of walking? Fuß & Sprunggelenk 18: 115-124.
  9. Robison J, Gibbons R, Achelis D, Bent B, Wajda D, et al. (2022) Augmenting gait in a population exhibiting foot drop with adaptive functional electrical stimulation. medRxiv27.22273623.
  10. Güzel Şükran, Umay Ebru, Ozturk Erhan, ÇAKCI Aytül (2022) The Efficiency of Functional Electrical Stimulation and Balance-Weighted Rehabilitation Therapy in Stroke Patients with Foot-Drop: A Pilot Study. Fiziksel Tıp ve Rehabilitasyon Bilimleri Dergisi 25: 1-10.
  11. Street T, Taylor P, Swain I (2015) Effectiveness of functional electrical stimulation on walking speed, functional walking category, and clinically meaningful changes for people with multiple sclerosis. Archives of Physical Medicine and Rehabilitation 96: 667-672. [crossref]
  12. Renfrew LM, Paul L, McFadyen A, Rafferty D, Moseley O, et al. (2019) The clinical- and cost-effectiveness of functional electrical stimulation and ankle-foot orthoses for foot drop in Multiple Sclerosis: a multicentre randomized trial. Clinical Rehabilitation 33: 1150-1162. [crossref]
  13. Wang He, Li Yaning, Yu Shaohong (2025) Effect of electrical stimulation in the treatment on patients with foot drop after stroke: a systematic review and network meta-analysis. Journal of Stroke and Cerebrovascular Diseases 34: 108279. [crossref]
  14. Friðriksdóttir R (2020) Functional Electrical Stimulation as a treatment option for foot drop, with a focus on gait velocity: A retrospective quality improvement study.
  15. Bethoux F, Rogers HL, Nolan KJ, Abrams GM, Annaswamy TM, et al. (2014) The effects of peroneal nerve functional electrical stimulation versus ankle-foot orthosis in patients with chronic stroke: a randomized controlled trial. Neurorehabilitation and Neural Repair 28: 688-697. [crossref]
  16. Lairamore CI, Garrison MK, Bourgeon L, Mennemeier M (2014) Effects of functional electrical stimulation on gait recovery post-neurological injury during inpatient rehabilitation. Perceptual and Motor Skills 119: 591-608. [crossref]
  17. Hendriks A (1997) Council of Europe-Convention for Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Biomedicine: Convention on Human Rights and Biomedicine. Kennedy Institute of Ethics Journal 7: 277-290.
  18. Peters DM, Fritz SL, Krotish DE (2013) Assessing the reliability and validity of a shorter walk test compared with the 10-Meter Walk Test for measurements of gait speed in healthy, older adults. Journal of Geriatric Physical Therapy 36: 24-30. [crossref]
  19. Agarwala P, Salzman SH (2020) Six-Minute Walk Test: Clinical Role, Technique, Coding, and Reimbursement. Chest 157: 603-611. [crossref]
  20. Gagliano-Jucá T, Li Z, Pencina KM, Traustadóttir T, Travison TG, et al. (2020) The Stair Climb Power Test as an Efficacy Outcome in Randomized Trials of Function Promoting Therapies in Older Men. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 75: 1167-1175. [crossref]
  21. Collin C, Wade DT, Davies S, Horne V (1988) The Barthel ADL Index: a reliability study. International Disability Studies 10: 61-63. [crossref]
  22. Jongbae Ch, Sungryoung M, Jongeun Y (2019) Effect of Electric Stimulation Training on Walking Ability of Patients with Foot Drop after Stroke. J Int Acad Phys Ther Res, Journal of International Academy of Physical Threrapy Research 10: 1903-1906.
  23. Charan J, Biswas T (2013) How to calculate sample size for different study designs in medical research?. Indian Journal of Psychological Medicine 35: 121-126. [crossref]
  24. Wilkinson Hart IA (2016) Team flow: The missing piece in performance [Thesis for the degree of Doctor of Philosophy, University of Southhampton]. Southhampton University Research Repository.
  25. Cheng DK, Dagenais M, Alsbury-Nealy K, Legasto JM, Scodras S, et al. (2021) Distance-limited walk tests post-stroke: A systematic review of measurement properties. NeuroRehabilitation 48: 413-439. [crossref]
  26. Scott JN, Buchan AM, Sevick RJ (1999) Correlation of neurologic dysfunction with CT findings in early acute stroke. The Canadian journal of neurological sciences. Le Journal Canadien des Sciences Neurologiques 26: 182-189. [crossref]
  27. Shin HE, Kim M, Lee D, Jang JY, Soh Y, et al. (2022) Therapeutic Effects of Functional Electrical Stimulation on Physical Performance and Muscle Strength in Post-stroke Older Adults: A Review. Annals of Geriatric Medicine and Research 26: 16-24. [crossref]
  28. Dantas MTAP, Fernani DCGL, Silva TDD, Assis ISA, Carvalho AC, et al. (2023) Gait Training with Functional Electrical Stimulation Improves Mobility in People Post-Stroke. International Journal of Environmental Research and Public Health 20: 5728. [crossref]

Commentary: Rethinking Digital Dating Abuse Through Gendered Perceptions and Lived Experience of Young Adults

DOI: 10.31038/PSYJ.2025762

 

As digital communication becomes ever more embedded in the daily lives of young adults, the dynamics of intimate relationships are increasingly shaped—and strained—by technology. While digital platforms offer constant connection, they also create new contexts in which control, surveillance, coercion, and aggression can emerge [1]. The publication “College Students Perceptions of Digital Dating Abuse: Insights From Gender Schema Theory” advances the field by examining how college students judge the abusiveness of digital dating abuse (DDA) behaviors, how these judgments differ based on gender, and how personal histories of victimization and perpetration influence these views [2]. Although researchers have clearly defined several digital behaviors as abusive, through the increasing norms of online communication and engagement, it is unclear how college students view these behaviors. Situated within the framework of gender schema theory, this publication provides vital insight into how young adults make sense of digital dating behaviors in their relational lives, and why some forms of DDA remain under-recognized despite their documented harm.

Gender as a Lens for Interpreting DDA

A central contribution of the publication is its clear demonstration that gender strongly shapes how college students interpret DDA. Across all behaviors, male-to-female DDA was viewed as more abusive than female-to-male DDA, reflecting longstanding evidence that violence by men against women is perceived as more harmful and threatening [3,4]. Even in digital contexts without physical contact, cultural scripts linking men with physical power and women with vulnerability shape how students assess potential harm and escalation.Women also consistently rated digital sexual coercion and digital monitoring/control as more abusive than men, aligning with research showing that men are generally more tolerant of aggression and less likely to label behaviors as abusive [5,6]. Gender schema theory [7] offers a useful explanation: cultural expectations that associate masculinity with dominance and femininity with nurturance guide how individuals recognize and evaluate relational harm. Women’s heightened perceptions may also stem from their disproportionate exposure to the emotional, psychological, and sexual consequences of DDA [8-10], including fear of escalation, reputational harm, and coercive control [11,12]. Men, by contrast, may normalize persistent messaging or monitoring due to socialization that minimizes relational intrusion and discourages acknowledging vulnerability.A particularly noteworthy nuance is that women also viewed female-to-male digital monitoring/control as more abusive than men did. Female-perpetrated aggression violates cultural stereotypes positioning women as passive or emotionally compliant [13], making such behavior appear more deviant—and therefore more abusive—to female respondents. Men’s lower ratings in these scenarios may reflect norms that downplay male victimization, reinforce emotional invulnerability, and obscure harm when the perpetrator does not match stereotypical images of an aggressor [14]. As a result, male victims may be less visible to peers, less likely to receive support, and less likely to identify their experiences as abuse [15].

Hierarchies of Harm: Why Monitoring Is Under-Recognized

One of the publication’s strongest contributions is its systematic comparison of how different types of DDA are ranked in severity. Students consistently viewed digital direct aggression as most abusive, followed by digital sexual coercion, and finally by digital monitoring/control. This hierarchy parallels findings from broader intimate partner violence research, where overt threats or sexual aggression are more easily recognized as abusive than psychological or controlling behaviors [16,17]. But digital monitoring/control might present unique risks precisely because it is so easily normalized among young adults.

Research shows that a majority of college students engage in at least one digital monitoring/control behavior—such as checking a partner’s social media or sending excessive messages—without labeling these actions as abusive [18]. Adolescents and young adults often view digital access, shared passwords, or location tracking as signs of trust, intimacy, or commitment [19]. In this context, the publication’s results reflect a broader cultural shift in which persistent digital connection is expected and surveillance becomes routine.

Yet digital monitoring/control is not benign. Studies demonstrate strong associations between monitoring behaviors and poor mental health outcomes, attachment anxiety, and eventual escalation to offline aggression [20,21]. The publication’s findings that students consistently under-recognize this category of harm reinforce the need for educational programs that clearly differentiate between healthy connectedness and intrusive control.

Experience Shapes Perception: Minimization Among Victims and Perpetrators

A significant theoretical insight from the publication is the identification of what might be termed a desensitization effect: individuals with prior experiences of DDA—either as victims or perpetrators—rate abusive behaviors as less harmful than those without such histories. This aligns with research on cognitive dissonance, self-justification, and normalization processes in intimate partner violence.

Victims who remain in or return to unhealthy relationships may reinterpret or downplay DDA behaviors to maintain relational coherence. Perpetrators, meanwhile, may minimize the negativity of their actions, especially when DDA behaviors feel mundane or common among their peers. However, the asymmetry noted by the authors, in which perpetrators minimized digital monitoring/control but not necessarily digital direct aggression or digital sexual coercion, might signal a deeper structural issue: digital monitoring/control is so culturally embedded that even those who commit it may not recognize its harm potential.

This has profound implications for prevention programming. Traditional interventions often assume that individuals can identify unhealthy behaviors but struggle with behavioral change. However, if young adults do not interpret their own actions—or their partner’s actions—as abusive, generative dialogue about harm and relational boundaries becomes more challenging. Prevention efforts must therefore address both recognition and reinterpretation: helping students recalibrate their internal thresholds for what constitutes harmful digital conduct.

Conclusion

The publication “College Students Perceptions of Digital Dating Abuse: Insights From Gender Schema Theory” provides an important and much-needed contribution to the evolving discourse on DDA. By grounding its investigation in gender schema theory and foregrounding the diverse and often contradictory ways college students interpret digital behaviors, it illuminates the perceptual landscape that shapes young adults’ responses to DDA. The findings reveal that DDA is not simply a technological phenomenon but a deeply social one—embedded in gendered expectations, cultural narratives, and personal histories. As institutions, educators, and scholars seek to reduce DDA and foster healthier digital relationships, this study offers a foundation for designing prevention efforts that are evidence-based, culturally attuned, and responsive to the realities of young adults. Its insights serve not only as an academic contribution but as a call for more intentional, nuanced, and inclusive strategies to confront the normalization of digital harm in intimate relationships.

References

  1. Estévez A, Urbiola I, Iruarrizaga I, Onaindia J, Jauregui P (2017) Emotional dependency in dating relationships and psychological consequences of internet and mobile abuse. Anales de psicología 33: 260.
  2. Weathers MR, Gangel MJ (2025) College students’ perceptions of digital dating abuse: Insights from gender schema theory. Journal of Interpersonal Violence. [crossref]
  3. Allen E, Bradley MS (2017) Perceptions of harm, criminality, and law enforcement response: Comparing violence by men against women and violence by women against men. Victims & Offenders 13: 373-389.
  4. Webster K, Diemer K, Honey N, Mannix S, Mickle J, et al. (2018) Australians’ attitudes to violence against women and gender equality. Findings from the 2017 National Community Attitudes towards Violence against Women Survey.
  5. Bryant SA, Spencer GA (2003) University students’ attitudes about attributing blame in domestic violence. Journal of Family Violence 18: 369-376.
  6. Dardis CM, Edwards KM, Kelley EL, Gidycz CA (2017) Perceptions of dating violence and associated correlates: A study of college young adults. Journal of Interpersonal Violence 32: 3245-3271. [crossref]
  7. Bem SL (1981) Gender schema theory: A cognitive account of sex typing. Psychological Review 88: 354-364.
  8. Dick RN, McCauley HL, Jones KA, Tancredi DJ, Goldstein S, et al. (2014) Cyber dating abuse among teens using school-based health centers. Pediatrics 134: e1560-1567. [crossref]
  9. Reed LA, Tolman RM, Ward LM (2017) Gender matters: Experiences and consequences of digital dating abuse victimization in adolescent dating relationships. Journal of Adolescence 59: 79-89. [crossref]
  10. Reed LA, Conn K, Wachter K (2020) Name-calling, jealousy, and break-ups: Teen girls’ and boys’ worst experiences of digital dating. Children and Youth Services Review 108:104607.
  11. Gracia-Leiva M, Puente-Martínez A, Ubillos-Landa S, González-Castro JL, Páez-Rovira D (2020) Off- and online heterosexual dating violence, perceived attachment to parents and peers and suicide risk in young women. International Journal of Environmental Research and Public Health 17: 3174. [crossref]
  12. Marganski A, Melander L (2018) Intimate partner violence victimization in the cyber and real world: Examining the extent of cyber aggression experiences and its association with in-person dating violence. Journal of Interpersonal Violence 33: 1071-1095. [crossref]
  13. West C, Zimmerman HD (1987) Doing gender. Gender and Society 1(2): 125-151.
  14. Turchik JA., Edwards KM (2012) Myths about male rape: A literature review. Psychology of Men & Masculinity 13: 211.
  15. Felson RB, Paré PP (2005) The reporting of domestic violence and sexual assault by nonstrangers to the police. Journal of Marriage and Family 67: 597-610.
  16. Capezza NM, D’Intino LA, Flynn MA, Arriaga XB (2017) Perceptions of psychological abuse: The role of perpetrator gender, victim’s response, and sexism. Journal of Interpersonal Violence 36: 1414-1436. [crossref]
  17. Masci BSF, Sanderson S (2017) Perceptions of psychological abuse versus physical abuse and their relationship with mental health outcomes. Violence and victims 32: 362-376. [crossref]
  18. Reed LA, Tolman RM, Ward LM (2016) Snooping and sexting: Digital media as a context for dating aggression and abuse among college students. Violence Against Women 22: 1556-1576.
  19. Redondo I, Ozamiz-Etxebarria N, Jaureguizar J, Dosil-Santamaria M (2024) Cyber dating violence: How is it perceived in early adolescence? Behavioral Sciences 14: 1074.
  20. Borrajo E, Gámez-Guadix M, Calvete E (2015) Cyber dating abuse: Prevalence, context, and relationship with offline dating aggression. Psychological Reports 116: 565-585. [crossref]
  21. Gámez-Guadix M, Borrajo E, Calvete E (2018) Abuso, control y violencia en la pareja a través de internet y los smartphones: Características, evaluación y prevención. Papeles Psicólogo 39: 218-227.

Talking to Patients: Part 1 – Using AI to Suggest How to Talk with a Patient Regarding COVID-19

DOI: 10.31038/MGSPE.2025522

Abstract

Using AI (ChatGPT 3.5) and Mind Genomics thinking, the paper shows how the medical professional can learn how to understand and converse with patients on topics such as COVID-19. The approach comprises an initial query to AI about the topic, using the Idea Coach feature on BimiLeap.com. The query can be modified and resubmitted, providing the medical professional with a real-time learning tool based on AI. Once the queries and iterations are completed and the program goes offline, the information generated by AI is subject to additional critical thinking by AI. The output comprises key themes, perspectives, analyses of responses of audiences (positive, negative, alternative viewpoints), as well as suggested innovation. The paper proposes the approach as a just-in-time teaching system for the medical professional who needs an understanding of how patients may think about a condition, and how one might communicate with the patient.

Keywords

Artificial Intelligence; medical communication; Mind Genomics; patient interaction

Introduction

Many medical professionals struggle with the job of communicating with patients. This shortcoming in effective interactions with patients can lead to misunderstandings, misinformation, frustration, and ultimately, the loss of trust in the medical professional. Furthermore, poor communication skills can hinder the diagnostic process, as patients may not feel comfortable sharing important information about their health. As a result, it is crucial for medical professionals, especially students, but also new doctors and nurse practitioners to learn how to talk to patients in a clear, empathic, respectful and ultimately productive manner.

One solution to this problem is the integration of artificial intelligence (AI) technology as a colleague and tutor for medical professionals. AI can provide simulated patient interactions for students to practice and improve their communication skills in a safe environment. AI can also provide real-time feedback and suggestions on how to improve communication with patients, helping the medical professional become more confident and effective in their interactions. In addition, AI can serve as a resource for medical professionals to access information on different communication strategies, cultural nuances, and techniques for building rapport with patients. AI can provide personalized guidance based on the individual needs and preferences of each healthcare provider, helping them to tailor their communication style to better meet the needs of their patients. This personalized approach can lead to more positive patient experiences and ultimately, better health outcomes. Furthermore, AI can assist medical professionals in gathering important information about their patients, such as their medical history, treatment preferences, and communication preferences. This information can help medical professionals build stronger relationships with their patients, as they can better understand and address their individual needs and concerns. By using AI technology, medical professionals can enhance their ability to provide patient-centered care and improve overall patient satisfaction.

Using the Mind Genomics Platform as Access Point to AI

The Mind Genomics platform, with its access to ChatGPT 3.5, is designed to help the medical professional communicate effectively with patients, as will be shown in this paper and the companion paper. With the Idea Coach feature of the Mind Genomics platform, BimiLeap. com, the user can request AI to provide different ways to ask patients about how they are feeling, what concerns them, and so forth. The AI returns with language designed to elicit the necessary information from the patient. The exercise helps the medical professional practice their communication skills in a safe and controlled environment. The happy outcome is that the medical professional ends up learning the nature of insightful and empathic questions, the language which shows compassion, and builds rapport with patients.

The topic of this paper is the interaction with the patient regarding COVID-19 (henceforth abbreviated as COVID). The Idea Coach feature provides a variety of alternative questions, explaining the subtleties of the question where relevant. With the Idea Coach feature, the medial professional can input the specific questions they need help with, and the Idea Coach can provide feedback on the wording, tone, and overall effectiveness of their questions. This personalized coaching can help to refine the medical professional’s communication style and help them learn how to ask relevant and sensitive questions about a complex topic like COVID. For example, the Idea Coach could suggest ways to frame questions about COVID symptoms, exposure history, and vaccination status in a clear and non-judgmental manner. It could also provide guidance on how to address patient concerns and convey important information about the virus and preventive measures. Through repeated practice and feedback from AI. With direct, easy to understand feedback, the medical professional would soon become more confident and skilled in communicating effectively with patients about COVID and other health-related topics.

A Worked Example: How AI can Show Ways for the Doctor to Talk to the Patient.

Table 1 presents the instructions to AI (Idea Coach in BimiLeap. com). The instructions or prompts are written in simple English (the program can work in other languages as well). The instructions are straightforward, simple and direct. At the same time, they convey very little information. All that is known is the topic (COVID), the identity of the respondent (woman, age 25-35), and some simple requests about format (questions 15 words or fewer, simple language). The simplicity of writing the prompt to the AI removes the factor of expertise as a necessity. Anyone can write these simple instructions.

Table 1 first shows the “key idea” and then the question corresponding to that key idea. The question itself is shown in italics. The question itself (in italics) was generated immediately upon request in a so-called iteration. The user typed in the request at the top of Table 1, submitted the requests by selecting the proper “box” on the screen, and the 14 questions emerged immediately. This iteration could be repeated if desired. After the iterations were completed, and the BimiLeap.com program shut down by the user, the underlying program reviewed the results of each iteration through “critical thinking”.The first part of the critical thinking was to state the “key idea” of each question. That “key idea” is presented BEFORE the actual question.

Table 1: Instructions to the AI requesting how the doctor should talk to the patient (top), and the critical thinking and related specific questions emerging from AI (bottom).

During the “critical thinking” period, where AI analyzes its own work “off-line,” AI often comes up with additional questions that were not presented to the user at the time the iteration was occurring, viz., when the user was interacting with BimiLeap. Table 2 shows 12 additional questions suggested by AI that became available when the results of AI’s off-line analyses were completed. The user receives this additional information in the form of an Excel workbook, called the Idea Book.

Table 2: Twelve additional, relevant questions to ask the patient. These questions were generated as part of the AI’s critical thinking analysis of its own work.

Critical Thinking by AI Regarding the 15 Questions

Critical thinking by the Idea Coach feature in BimiLeap is designed to provide deeper insights of a practical nature for the user, insights which teach. Critical thinking begins with the identification of themes and perspectives within the set of questions that the AI had generated. The critical thinking is “built-in.” That is, for every iteration, the critical thinking questions and analyses are done automatically. Thus, for this study, the user actually did eight iterations. We are looking at one iteration. The critical thinking analysis done off- line was done separately for each of the eight iterations, providing a useful compendium of material from which to understand the nature of questions that one could ask. The objective of repeating the critical thinking for each iteration was to create a resource for the medical professional. Table 3 shows the 12 themes and perspectives emerging from the questions. Table 3 goes a bit deeper into the theme, considering different questions that one might ask.

Table 3: Twelve themes and perspectives identified by AI.

AI Suggests Three Audiences: Those Who Accept, Those Who Oppose, and Those Who Think Differently

By hearing different points of view on COVID, medical professionals can learn how each patient reacts and adjust their communication methods accordingly. This helps them handle tough talks and give each patient individualized care. By staying informed about evolving beliefs and attitudes, healthcare providers can identify trends, misconceptions, and misinformation, build trust with patients, and ensure accurate information sharing. Also, seeing things from different points of view prepares the medical professional for possible relationship problems, like language or cultural hurdles. By consistently engaging with diverse viewpoints, medical professionals enhance their ability to dispel myths, address misconceptions, and provide accurate information which resonates with diverse patient experiences.

Table 4 presents possible responses by three populations to the issues surrounding COVID. These populations are those who are interested, those who oppose, and those who “think differently,” because the “facts” that they believe to be true are not true according to orthodox medical belief.

Table 4: Responses of three likely audiences; Interested, Opposing, and Alternative Viewpoints.

Innovations

The feature of critical thinking generated by AI in the Mind Genomics platform are suggested innovations. The AI can only go so far, and the innovations may already be in place. Yet, simply having AI suggest these ideas, and then using AI to expand the interest creates a framework where AI becomes a true collaborator. In this spirit, Table 5 presents 12 innovations as AI conceptualizes them at the early stages [1-15].

Table 5: Twelve innovations suggested by AI for the patients and medical professionals dealing with COVID.

Discussion and Conclusions

Using AI as a coworker and teacher for medical workers is important for improving soft skills like knowing how people with COVID think. AI can model conversations with patients to help workers learn how to understand and talk to patients in tough situations. One of the best things about using AI in medical education is that it can figure out the different ways that people may talk to medical professionals when they need help. AI can help the professional understand and adapt to the different needs and communication styles of patients by giving them specific advice and feedback in real time.

Medical workers can learn how to have tough talks and get along with patients by simulating real-life contacts with patients using AI technology. This can help build trust and make patients happier, which can lead to better results in the long run. Moreover, AI can give doctors information about how patients behave and what they like, which lets them adjust how they talk to each patient to best meet their needs. This personalized method can help people talk to each other better and help patients do better. Finally, AI can help doctors learnmore about the mental and emotional parts of patient care, in addition to making it easier for them to talk to each other.

As a whole, incorporating AI into medical education gives students a one-of-a-kind chance to improve their soft skills and talk to patients more clearly. At the same time, with AI technology, medical workers of all types can learn to understand, connect with, and give patient-centered care which meets each patient’s unique needs.

Acknowledgment

The authors gratefully acknowledge the ongoing support and encouragement of Dr. Rizwan Hamid of the Global Healthcare Management Forum in Brooklyn. Dr. Hamid is a continuing source of encouragement for young medical professionals to create a more patient-focused, knowledge-driven healthcare system.

The authors are grateful to Vanessa A. and Angela A. for their ongoing help in preparing these and other manuscripts for publication.

References

  1. Allen MR, Webb S, Mandvi A, Frieden M, Tai-Seale M, Kallenberg G (2024) Navigating the doctor-patient-AI relationship-a mixed-methods study of physician attitudes toward artificial intelligence in primary care. BMC Primary Care 25(1): 42. [crossref]
  2. Al-Zyoud W, Oweis T, Al-Thawabih H, Al-Saqqar F, Al-Kazwini A, et al. (2021) The psychological effects of physicians’ communication skills on covid-19 patients. Patient Preference and Adherence: 677-90. [crossref]
  3. Casini L, Delnevo G, Mirri S, Monti L, Prandi C, Roccetti M, et (2019) What Do Patients Tell Doctors on the Internet? Ask AI How to Valorize Online Medical Conversations. In2019 28th International Conference on Computer Communication and Networks (ICCCN) IEEE.
  4. Debad SJ, Metcalfe J (2024) DOCTORS AND ARTIFICIAL INTELLIGENCE: WORKING TOGETHER FOR A HEALTHIER FUTURE. SPARK-ing Big Questions: What is the Future of Health Technology? 31: 70.
  5. Delnevo G, Roccetti M, Mirri S (2018) Modeling patients’ online medical conversations: a granger causality approach. InProceedings of the 2018 IEEE/ACM international conference on connected health: applications, systems and engineering technologies.
  6. Gopichandran V, Sakthivel K (2021) Doctor-patient communication and trust in doctors during COVID 19 times—A cross sectional study in Chennai, India. Plos One. 16(6): e0253497. [crossref]
  7. Mehta-Shah, N., S. Mehta, and R. Zemel, in Consumer-based New Product Development for the Food Industry, ed. S. Porretta, H. Moskowitz, and A. Gere,(2021) The Royal Society of Chemistry, 8, pp. 119-131.
  8. Mendel T, Nov O, Wiesenfeld B (2024) Advice from a doctor or AI? Understanding willingness to disclose information through remote patient monitoring to receive health advice. Proceedings of the ACM on Human-Computer Interaction 8(CSCW2): 1-34.
  9. Mheidly N, Fares J (2020) Leveraging media and health communication strategies to overcome the COVID-19 infodemic. Journal of Public Health Policy 41(4): 410-20. [crossref]
  10. Patra M, Hamiduzzaman M, McLaren H, Siddiquee NA (2024) A scoping review of changes to patient-doctor communication during COVID-19. Health Communication. 39(1): 25-48. [crossref]
  11. Reddy BV, Gupta A (2020) Importance of effective communication during COVID-19 Journal of Family Medicine and Primary Care 9(8): 3793-6. [crossref]
  12. Theriot A, Urrutia-Alvarez N, McKinley EM (2021) An analysis of pandemic panic buying motivators among undergraduate college students using mind genomics cognitive Psychology 12(9): 1457-71.
  13. Tripathy AK, Carvalho R, Puthenputhussery A, Chhabhaiya N, Anthony B (2015) MediAssistEdge—Simplifying diagnosis procedure & improving patient doctor In2015 International Conference on Technologies for Sustainable Development (ICTSD) IEEE.
  14. Wittenberg E, Goldsmith JV, Chen C, Prince-Paul M, Johnson RR (2021) Opportunities to improve COVID-19 provider communication resources: A systematic Patient Education and Counseling 104(3): 438-51. [crossref]
  15. Yashar-Gershman SG, Rosenberg AT, Sawhney M, Machicao MF, Moskowitz HR, Bernstein HH (2024) Developing a novel screening tool to address pediatric COVID-19 vaccine hesitancy at point of care. Vaccine 42(9): 2260-70. [crossref]

Chinese T2DM Patients’ Psychological Insulin Resistance: A Comprehensive Structural Equation Model Analysis

DOI: 10.31038/EDMJ.20261014

Abstract

Psychological insulin resistance (PIR) constitutes a significant barrier to achieving timely insulin initiation among adults living with type 2 diabetes mellitus (T2DM). This study utilizes structural equation modeling (SEM) to explore the influence of self-efficacy, social support, diabetes distress, and diabetes stigma on PIR. A cross-sectional survey of 289 T2DM patients demonstrated that PIR is shaped by complex emotional and sociocultural pathways. High self-efficacy and strong social support reduce insulin hesitancy, whereas elevated distress and stigma significantly intensify reluctance toward insulin therapy. These findings provide important guidance for developing psychosocial interventions aimed at improving insulin uptake and long-term glycemic outcomes.

Keywords

Insulin reluctance, Self-efficacy, Diabetes distress, T2DM, China, SEM

Introduction

Type 2 diabetes mellitus (T2DM) is a rapidly escalating public health challenge in China, with the country representing the largest diabetic population globally. Despite therapeutic advancements, maintaining glycemic control remains difficult for many individuals due to progressive β-cell dysfunction. Insulin therapy is often required as the disease advances; however, psychological insulin resistance (PIR) frequently delays the transition to insulin. PIR refers to a complex spectrum of emotional fears, misconceptions, perceived burdens, stigma, and cultural beliefs surrounding insulin therapy.

In China, sociocultural dynamics play a profound role in shaping patient perceptions of insulin therapy. Many individuals view insulin as an indicator of treatment failure or severe disease progression. Fear of injections, hypoglycemia, lifestyle disruption, dependency, and judgment from others further heighten psychological resistance. The collectivist nature of Chinese society places significant influence on family beliefs, which can either support or hinder insulin acceptance. Additionally, limited diabetes education and inadequate emotional counseling exacerbate misunderstandings about insulin, reinforcing PIR [1].

Existing research highlights key psychosocial determinants of PIR, including self-efficacy, social support, diabetes distress, and diabetes stigma. Individuals with high self-efficacy exhibit stronger confidence in diabetes self-management and are more open to initiating insulin [2]. Social support provides emotional and practical assistance, buffering anxiety associated with insulin therapy. In contrast, elevated diabetes distress increases emotional burden and avoidance behaviors, while stigma contributes to internalized shame and negative self-perception. Few studies, however, have examined these factors within a unified analytical framework in Chinese populations.

Structural equation modeling (SEM) offers a comprehensive statistical method for examining direct and indirect effects across multiple interrelated psychosocial constructs. This study aims to employ SEM to explore how self-efficacy, social support, distress, and stigma interact to shape PIR among Chinese adults with T2DM [3]. Understanding these pathways is crucial for designing culturally sensitive interventions to reduce PIR and facilitate timely insulin initiation.

Methods

Study Design and Setting

This cross-sectional study was carried out between March and September 2023 in the Endocrinology Department of a tertiary teaching hospital in Anhui Province, China. The hospital serves as a major referral center for diabetes management, providing access to a large and diverse patient population. Ethical approval was obtained from the institutional review board prior to study commencement.

Sampling and Recruitment

A convenience sampling method was used to recruit adults attending outpatient diabetes clinics. Inclusion criteria were: age ≥18 years, confirmed diagnosis of T2DM for at least one year, and ability to independently complete questionnaires. Patients with severe psychiatric illness, cognitive impairment, terminal illness, or short-term insulin use for acute conditions were excluded. A total of 289 participants met eligibility criteria and completed the study.

Data Collection Procedures

Written informed consent was obtained from all participants. Trained research assistants supervised questionnaire completion, ensuring accuracy and minimizing missing data. Clinical information including HbA1c levels, treatment regimens, and diabetes duration was extracted from electronic medical records [4].

Measures

Participants completed validated Chinese versions of the following instruments: the Psychological Insulin Resistance Scale (PIR), the Diabetes Management Self-Efficacy Scale, the Multidimensional Scale of Perceived Social Support (MSPSS), the Diabetes Distress Scale (DDS-17), and the Type 2 Diabetes Stigma Scale. All instruments demonstrated high internal consistency with Cronbach’s α > 0.70.

Statistical Analysis

Data analysis was performed using SPSS 26.0 and AMOS 26.0. Descriptive statistics summarized demographic and clinical characteristics. Pearson correlations were computed to examine associations between variables [5]. Structural equation modeling (SEM) was used to evaluate hypothesized relationships, with model fit assessed through χ²/df, RMSEA, GFI, AGFI, CFI, TLI, and IFI indices. Bootstrapping with 5000 iterations tested indirect effects and mediation pathways.

Results

Participant Characteristics

A total of 289 adults with T2DM participated in the study. The mean age was 56.8 ± 10.3 years, with 52% being male. The average duration of diabetes was 8.4 ± 4.2 years. HbA1c levels averaged 8.1%, indicating poor glycemic control across the sample. Approximately 38% of patients reported that their physician had advised insulin initiation, yet they remained reluctant due to psychological barriers [6] (Figure 1).

Figure 1: Conceptual Structural Equation Model.
This figure visually represents the expected directional influences of key psychosocial variables on Psychological Insulin Resistance (PIR).

Psychosocial Profiles and PIR Levels

The mean PIR score was 56.7 ± 11.4, indicating moderate psychological resistance toward insulin therapy. Self-efficacy scores reflected moderate overall confidence in diabetes self-management. Social support was perceived as relatively strong, particularly from family members 7-10]. Diabetes distress scores were elevated, with emotional burden and regimen-related frustration being the most prominent factors. Moderate levels of diabetes stigma were also reported (Table 1).

Table 1: Participant Demographics

Variable

Mean/n SD/%

Interpretation

Age (years)

56.8

10.3

Middle-aged population with chronic disease burden
Gender (Male)

151

52%

Slightly higher male representation
Diabetes Duration (years)

8.4

4.2

Indicates long-term disease progression
HbA1c (%)

8.1

–

Poor glycemic control across sample

Correlation Analysis

Pearson correlation analysis demonstrated significant associations between PIR and key psychosocial variables. PIR was strongly negatively correlated with self-efficacy (r = -0.55) and social support (r = -0.41), indicating that patients with greater confidence and stronger support systems exhibited lower insulin hesitancy. PIR was positively correlated with diabetes distress (r = 0.58) and diabetes stigma (r = 0.32), confirming that emotional burden and stigmatized beliefs contribute substantially to resistance (Figure 2).

Figure 2: Distribution of PIR Scores.
Simulated distribution illustrating typical clustering of PIR scores among T2DM patients.

Structural Equation Modeling (SEM)

The structural model demonstrated excellent goodness of fit, with χ²/df = 1.56, RMSEA = 0.044, GFI = 0.960, AGFI = 0.933, CFI = 0.980, and TLI = 0.972. Standardized path coefficients indicated that self-efficacy (β = -0.61, P < 0.001) and social support (β = -0.39, P = 0.001) significantly reduced PIR. Conversely, diabetes distress (β = 0.61, P < 0.01) and diabetes stigma (β = 0.28, P = 0.001) significantly increased PIR. Bootstrapping confirmed that distress partially mediated the relationship between social support, stigma, and PIR (Table 2).

Table 2: Structural Equation Model Path Coefficients.

Pathway

β Coefficient p-value

Interpretation

Self-efficacy → PIR

-0.61

<0.001

Higher self-efficacy reduces PIR
Social support → PIR

-0.39

0.001

Support systems lower resistance
Diabetes distress → PIR

+0.61

<0.01

Higher distress increases PIR
Diabetes stigma → PIR

+0.28

0.001

Stigma elevates PIR scores

Discussion

This expanded analysis demonstrates the powerful interplay of psychological and sociocultural variables influencing PIR in Chinese T2DM populations. Self-efficacy emerged as the strongest protective factor, emphasizing the necessity of individualized diabetes education and confidence-building strategies. Patients with higher self-efficacy perceive insulin not as a sign of failure but as a therapeutic tool supporting long-term health outcomes. Clinical teams must therefore prioritize training that enhances problem-solving skills, self-management behaviors, and understanding of insulin mechanisms.

Diabetes distress was revealed as a substantial positive predictor of PIR. Emotional burden—including frustration, burnout, and anxiety—magnifies fear of hypoglycemia, perceived complexity of insulin routines, and concerns about lifelong dependency. Interventions such as targeted counseling, diabetes burnout management programs, stress-reduction techniques, and frequent follow-up can meaningfully mitigate distress levels.

Social support demonstrated a significant buffering effect, reducing PIR through emotional, informational, and practical reinforcement. Chinese cultural contexts place high value on family involvement; thus, educating families on insulin benefits and dispelling myths can improve acceptance. Conversely, diabetes stigma was associated with increased PIR. Stigmatized individuals may perceive insulin as an indicator of personal failure or social inadequacy. Addressing stigma through public health communication, peer-support groups, and clinician–patient trust-building is essential.

Conclusion

PIR among Chinese adults with T2DM is shaped by interconnected psychosocial mechanisms. Strengthening self-efficacy, enhancing social support, reducing distress, and addressing stigma collectively improve insulin acceptance. These findings emphasize the need for comprehensive, culturally sensitive interventions integrated into diabetes care pathways. Diabetes distress emerged as one of the strongest predictors of PIR, indicating that emotional exhaustion, frustration with disease management, and fear of future complications significantly undermine patients’ readiness to adopt insulin. Interventions must therefore extend beyond traditional education to include psychological counseling, distress screening, cognitive-behavioral support, and stress-reduction strategies. Addressing distress proactively may not only reduce PIR but also improve glycemic control, treatment adherence, and overall quality of life.

References

  1. Duan J, Li H, Zhang Y, et al. (2025) Type 2 diabetes prediction model in China: a five-year risk assessment study. Chin J Endocrinol Metab 42(2): 112-119. [crossref]
  2. Luo X, Zhang S, Wang Y, et al. (2025) Health management of type 2 diabetes mellitus and its complications in Chinese community settings: a cohort analysis. J Diabetes Res 2025: 998742. [crossref]
  3. Wang R, Li Q, Chen Z, et al. (2025) Disease burden of type 2 diabetes among young adults in China: trends and forecast (1990-2030) Int J Diabetes Endocrinol 12(1): 27-36.
  4. Zeng Z, Wu C, Huang Y, et al. (2023) Health-related quality of life in Chinese individuals with type 2 diabetes: impact of fear of hypoglycaemia and treatment burden. Qual Life Res 32(9): 2451-2462. [crossref]
  5. Deng W, Li M, Zhou Y, et al. (2024) National burden and risk factors of diabetes mellitus in China (1990-2021): analysis of mortality and DALYs. Public Health Rep 139(4): 315-327. [crossref]
  6. Lu X, Zhang D, Wang B, et al. (2024) Type 2 diabetes mellitus in adults: pathogenesis, metabolic dysfunction syndrome and personalized management—A Chinese perspective. Metab Syndr Relat Disord 22(5): 201-214. [crossref]
  7. Zhao X, Li Y, Chen H, et al. (2022) Treatment of type 2 diabetes mellitus using traditional Chinese medicine: efficacy of Jinlida granules in Chinese patients. Chin J Integr Med 28(8): 584-591. [crossref]
  8. Zhang P, Liu Y, Chen D, et al. (2024) Effectiveness of a digital-health intervention for improving T2DM control in rural China: a cluster randomized trial. Chin Prim Health Care 10(3): 145-154.
  9. He Q, Wang J, Li Z, et al. (2023) Diabetes self-management and its correlates among Chinese adults with type 2 diabetes: a cross-sectional study. BMC Endocr Disord 23(1): 107. [crossref]
  10. Wang J, Liu H, Huang Z, et al. (2023) Trends in the burden of type 2 diabetes mellitus attributable to high body mass index in China (1990-2019): a joinpoint regression and age-period-cohort analysis. Front Endocrinol 14: 119388. [crossref]

Behavior of Deuterium on Boric Acid: Raman Spectrometric Measurements: Preliminary Results

DOI: 10.31038/GEMS.2025774

Abstract

We show, in short, using Raman spectroscopy, that upon dissolving boric acid [H3BO3] in heavy water [D2O], all stoichiometric phases form solid crystalline phases and can be detected. The pure D3BO3phase is very rare, but it can be proved. Intermedia forms were not found. Deuterium in higher concentrations in nature is, however, possible in connection with supercritical fluids coming from the mantle region.

Keywords

Raman spectroscopy, heavy water [D2O], solid phases: H3BO3, H2DBO3, HD2BO3, and D3BO3, pegmatites

Introduction

Boron, the fifth element of the periodic table, is relatively rare on Earth, with a concentration of 2.5 ppm in acid rocks. In granite rocks, the average concentration is 15 ppm [1]. Generally, boron is present in the Earth’s crust in its compounds, as tourmaline and other complex minerals. The author has also recently found boron as a mineral in the upper crust [2]. In mineral-forming minerals, especially in pegmatites, boron appears as boric acid [H3BO3], often as a daughter mineral in fluid and melt inclusions in different minerals (quartz, tourmaline, hambergite, beryl, topaz). Raman data of boric acid are difficult for the general public to access. Most publications on this topic are not open access. Therefore, we provide a brief overview of the Raman spectra, including those of deuterium-bearing phases. Because Raman spectroscopy is a relatively straightforward and accurate method for determining the Raman shift by the exchange of hydrogen of boric acid [H3BO3] by deuterium [D], we will show, using the leading Raman bands, the stoichiometric exchange of hydrogen by deuterium.

Methods and Samples

Microscopy, Raman Spectroscopy

Besides a polarization microscope for transmission (JenaLab Pol), we performed all microscopic and Raman spectroscopic studies with a petrographic polarization microscope (BX 43) equipped with an XY- or rotating stage, coupled to the EnSpectr Raman spectrometer R532 (Enhanced Spectrometry, Inc., Mountain View, CA, USA) in transmission. The Raman spectra were recorded in the spectral range of 0–4000 cm−1 using the 30 mW of a single-mode 532 nm laser, an entrance aperture of 20 µm, a holographic grating of 1800 g/mm, and a spectral resolution of 4 cm−1. Solid boric acid (sassolite) crystals are easy to identify under crossed Nicols under the transmission light by their peculiar interference color.

Samples

Deuterium-rich boric acid phases are prepared by dissolving commercial nB-boric acid in pure D2O (heavy water (99.9%) from the PElementeSamples, Belchertown, MA) in surplus. nB refers to boron with natural abundance of the boron isotopes: 80.22% 11B and 19.78% 10B. Droplets of such solutions are placed on the microscope slice, with a deepening in the middle, and the solid boric acid phases slowly crystallize as the heavy water vaporizes at room temperature. Through this slow process, a fractionation of the solid phases occurs according to the schema:

2H3BO3 + 3D2O → 2D3BO3 + 3H2O                             (1)

H3BO3 + D2O → HD2BO3 + H2O                                   (2)

2H3BO3 + D2O → 2H2DBO3 + H2O                               (3)

Besides stoichiometric phases, subordinate phases are theoretically possible as well. However, as we will see clearly, the stoichiometric phases are dominant. The relatively large standard deviations of the D-influenced Raman lines allow them to be incorporated as traces. That means that at low deuterium concentration, we mainly observe it inserting into the Raman main line at 880 cm-1, which results in a slight shift to lower values. In our experiments to produce D-bearing boric acid phases, the formation of small amounts of water [H2O], shown in equations (1) to (3), is detectable [3,4]. In our case, 8% (g/g) water was estimated by Raman.

Results

Gmelin’s handbook (1954) [5] gives only 7 Raman lines for boric acid: 503 (4), 880 (6), 1065 (0), 1155 (0), 3180 (3), 3256 (1), and 3574 (3). The numbers in brackets are relative intensities. Boric acid shows, according to Krishnan (1963) [6], 11 Raman lines (4Ag + 2E1g + 5E2g), including three lines from the lattice spectrum. During our study, we have found all 11 Raman lines/bands (Table 1 and Figure 1).

Table 1: Raman lines of boric acid [H3nBO3 ] according to Krishnan (1963) and own measurements using the 532 nm laser.

H3BO3

Intensity (relative)

Assignment

Krishnan, 1963

This work

Raman band (cm-1)

Species

Raman band (cm-1)

   

60

Ag 76.0 ± 1.6

w

Lattice- oscillation

128

E1g 119.1 ± 3.8

w

Lattice- oscillation

210

E2g 207.8 ± 1.6

m

OH-O bonds

499

E2g 497.2 ± 3.8

m

O-B-O bending

884

Ag 879.8 ± 0.3

vs

B-O stretching

1085

Ag 1092.0 ± 7.2

w

B-O-H bending

1172

E2g 1166.6 ± 2.7

w

O-H stretching

1384

E2g 1383.5 ± 6.3

w

BOH bending

–

  2294.1 ± 2.7

vw

BOH bending

3165

Ag 3173.6 ± 4.2

w

O-H stretching

3251

Ag 3246.4 ± 4.1

w

O-H stretching

Irel – relative intensity: vs – very strong, s – strong, m – medium, w – weak, vw -very weak.

Figure 1: Raman spectrum of boric acid [H3BO3] using nB and the 532 nm Raman excitation in the Raman range from 50 to 4000 cm-1.

The differences in the Raman shift result from the use H3nBO3 and the fractionated crystallization in a droplet of distilled water on the microscope slide. The data in Table 1 are from Krishnan (1963) – [6] and own measurements (mean of 20 measurements per Raman line).

Krishnan (1963) [6] takes the Raman spectrum of crystalline boric acid using the mercury 253.7 nm line.

In a further step, we determined the Raman shift by substituting hydrogen with deuterium. Conspicuously act deuterium on the 880 cm-1 and the 129 cm-1 lines. Figure 2 shows the change in dependence of the substitution degree. Because the 880 cm-1 line (the main line of boric acid) shifts firmly with the substitution of hydrogen by deuterium, the assignment can not be correct – it should be exchanged by B-O-H stretching. As we see from Figure 2, the deuterium substitution influences the lattice oscillation powerfully.

Figure 2: Raman spectrum of boric acid [H3BO3] using nB and the 532 nm Raman excitation in the Raman range from 50 to 4000 cm-1 with the exchange of hydrogen by deuterium.

Figure 2 shows the Raman spectrum of boric acid, where the hydrogen (H) atom is stepwise replaced by deuterium (D), and the extracted results are summarized in Table 2 and Figure 3. In contrast to the Raman spectrum of pure H3BO3 (Figure 1), the spectrum of the deuterium-bearing boric acid is more complex, showing the presence of different D-bearing species (see Table 2 too), especially in the range between 812 – 880 cm-1, and in the range between 75 – 129 cm-1. Conspicuous for the D-bearing boric acid is the Raman band at 2415 cm-1. Pure H3BO3 shows only a very weak doublet in this region at 2235 and 2294 cm-1.

The data in Table 2 are plotted in Figure 3. The correlation coefficient R2 = 0.99914.

Table 2: Position of the main Raman lines at about 880 cm-1 and the Raman shift by including deuterium into the formula (mean of 20 measurements each).

Formula

Raman position Standard deviation

Irel

H3BO3

879.56 0.41 s
H2DBO3 854.43

0.38

s

HD2BO3

834.33 0.80 m
D3BO3 812.78 1.46

vw

Irel – relative intensity: vs – very strong, s – strong, m – medium, w – weak, vw -very weak.

Figure 3: Raman shift of the H3BO3 main line at 880 cm-1 in dependence on the number of deuterium (D) in the formula (subscripted numbers). Raman shift RS =879.236 – 24.729 D + 0.895 D2; SD = 0.9926 (RS – Raman shift, SD – standard deviation).

Table 3 summarizes the data for the low-frequency range, and Figure 4 shows the results plotted.

Table 3: Position of the main Raman lines 129 cm-1 and the Raman shift by including deuterium into the formula (mean of 20 measurements each).

Formula

Raman position Standard deviation Irel
H3BO3 129.0 2.3

vs

H2DBO3

116.8 0.6 vs
HD2BO3 103.9 1.4

m

D3BO3

75.3 0.9

m

Irel – relative intensity: vs – very strong, s – strong, m – medium, w – weak.

Figure 4: Raman shift of the H3BO3 main line at 129 cm-1 in dependence on the number of deuterium (D) in the formula (subscripted numbers). Raman shift RS = 128.25 – 5.1 D – 4.1 D2; SD = 0.99293 (RS – Raman shift, SD – standard deviation).

The Raman lines for all deuterium-bearing species in the lattice oscillation range are all relatively intense. By contrast, the intensity of the Raman bands starting at 880 cm-1 declines very rapidly toward lower frequencies. The band for D3BO3 is, in comparison to H3BO3, very weak (see Figure 5). Sometimes the Raman band of H2DBO3 is significantly intense than the 880 and 129 cm-1 bands of pure H3BO3. This behavior results from the species formed by the exchange reaction of boric acid with D2O.

Figure 5: The four boric acid species (H3BO3 , H2DBO3 , HD2BO3 , and D3BO3 ) around 840 cm-1 . The different intensities result from the concentrations of the species in the measured crystal.

Figure 6 shows a Raman spectrum of nearly pure HD2BO3. The Raman band of H BO is completely missing. Table 4 gives the Raman data.

Figure 6: Raman spectrum of nearby pure HD2BO3. The intensity of the 2402 cm-1 band is strongly dependent on orientation.

Table 4: Raman bands of nearly pure HD2BO3 obtained from fractionated crystallization. Measurements using the 532 nm laser and 30 mW on the sample.

Raman band of HD2BO3

Raman band (cm-1) Species Relative intensity

Nature of vibration

73.5

Ag

m

Lattice-oscillation

116.4

E1g

s

Lattice-oscillation

206.0

E2g

s

OH-O bonds

466.5

E2g

m

O-B-O bending

836.5

Ag

vs

B-O stretching

995.6

 

w

B-O-H bending

1375.8

E2g

w

O-H stretching

2377.2

E2g

m

BOH bending

2402.3

E2g

m

BOH bending

3244.1

Ag

vw

O-H stretching

3251.0

Ag

vw

O-H stretching

Irel – relative intensity: vs – very strong, s – strong, m – medium, w – weak, vw -very weak.

Discussion

In this short contribution, we demonstrate with Raman spectroscopy that by dissolving boric acid [H3BO3] into heavy water [D2O], stoichiometric phases like the equations (1) to (3) forms. The formation of pure D3BO3 after equation (1) is reduced. The formation of the non-stoichiometric mixtures could not be proved. The concentration of deuterium in nature is low; therefore, the different D-bearing phases are only very rare. Higher deuterium concentrations are expected in supercritical fluids that form pegmatites [7]. To obtain Raman spectra of the single D-bearing phases, an expensive separation, for example by fractionated crystallisation, is required.

References

  1. Rösler HJ, Lange H (1975) Geochemische Leipzig. Pg: 700.
  2. Thomas R (2025) Boron in some Variscan deposits in the German Geol Earth Mar Sci 7: 1-5.
  3. Thomas R (2000) Determination of water contents of granitic melt inclusions by confocal laser Raman microprobe spectroscopy. American Mineralogist 85: 868-872.
  4. Thomas R, Kamenetsky VS, Davidson P (2006) Laser Raman spectroscopic measurements of water in unexposed glass inclusions. American Mineralogist 91: 467-470.
  5. Gmelin L (1954) Gmelins Handbuch der anorganischen Chemie: Bor (Ergänzungsband). Verlag Chemie, Weinheim. Pg: 253.
  6. Krishnan K (1963) The Raman spectrum of boric acid. Proceedings of the Indian Academy of Sciences – Sec A. 57: 103-108.
  7. Thomas R (2024) NaHCO3-NaDCO3 and 13CO2-rich fluid inclusion in pegmatite quartz from Bornholm Island/Denmark. Geol Earth Mar Sci 6: 1-5.

The Complex Pathophysiology of Metabolic Dysfunction-Associated SteatoHepatitis (MASH) may Complicate FDA Accelerated Approval Regulatory Paradigm

DOI: 10.31038/EDMJ.20261012

 
 

Metabolic dysfunction-Associated SteatoHepatitis (MASH), previously known as NonAlcoholic SteatoHepatitis (NASH), continues to be the most common cause of chronic liver disease in the industrialized world [1] and can progress to liver fibrosis, as well as end-stage cirrhosis leading to death [2]. MASH is also associated with an increased risk of cardiovascular (CV) morbidity and mortality, as well as obesity and type 2 diabetes mellitus (T2DM) [3]. Cirrhosis associated with MASH increases the risk of hepatocellular carcinoma [4]. Most MASH clinical trials use liver biopsy [5] as the primary endpoint to support regulatory submissions to FDA, based upon the original NIH published guidelines for NASH Clinical Trial Design [6] which influenced the recommendations in the December 2018 Draft NASH FDA Guidance [7]. However, a growing number of trials include imaging and blood based biomarkers as secondary and/or exploratory endpoints, allowing for comparison with liver biopsy for calculations of their sensitivity, specificity and predictive values [8] to help support the move away from liver biopsy to these surrogate assessments for both initial MASH diagnosis and as clinical trial endpoints to support FDA approval [9].

Recent FDA approvals of drugs to treat patients with MASH have been applauded by patient advocacy groups [10] and supported by clinicians [11]. However, lost in the media headlines is the fact that these regulatory actions were “accelerated approvals” by FDA which then must be followed by successful Phase 4 confirmatory clinical outcomes trials in order for these drugs to stay on the U.S. market [12]. One can consider accelerated approvals as a contract between the pharmaceutical company and FDA. Under this initial approval, the agency allows the drug to be sold earlier, allowing broader patient access based upon surrogate or intermediate clinical endpoints (“biomarker”) that is deemed to be “reasonably likely to predict clinical benefit” [12] in confirmatory clinical outcome studies to be conducted post-accelerated approval. FDA expectations are that the pharmaceutical company starts the outcomes trial before accelerated approval is granted, it then is fully enrolled, completed and submits the data to FDA and the submitted clinical data is viewed by the agency as “substantial evidence” [13] adequate to support conversion of the accelerated approval to a traditional (full) approval. Previously the agency had limited authority to withdraw accelerated approvals when confirmatory outcomes studies failed, but in 2022, Congress granted FDA additional authority to rapidly withdraw accelerated approval drugs from the U.S. market, as part of the Food and Drug Omnibus Report Act of 2022 (FDORA) [14]. However, prior to the withdrawal of any accelerated approval, FDA has to provide the pharmaceutical company with due notice and an explanation of the proposed withdrawal. This is followed by an opportunity for the company to have a meeting with the Commissioner or the Commissioner’s designee and an opportunity for written appeal, including an advisory committee meeting on the proposed withdrawal [14]. It was soon after the granting of this new authority that FDA withdrew the accelerated approval of Pepaxto (melphalan flufenamide) [15]. The FDA decision memo stated that “the grounds for withdrawing approval have been met because: (1) the confirmatory study conducted as a condition of accelerated approval did not confirm Pepaxto’s clinical benefit and (2) the available evidence demonstrates that Pepaxto is not shown to be safe or effective under its conditions of use” [16].

FDA Guidance “Noncirrhotic Nonalcoholic Steatohepatitis With Liver Fibrosis: Developing Drugs for Treatment” (December 2018) lists the various endpoints to be utilized to verify clinical benefit after demonstrating positive impact on liver history and receiving accelerated approval [7]. Each element of clinical benefit listed deserves individual analysis. The “Progression to cirrhosis on histopathology” [7] sounds promising on its face. A clinical trial design where the Phase 3 patients which supported accelerated approval are “rolled over” into the Phase 4 confirmatory outcomes trial with the primary endpoint measure by liver biopsy histology. However, a significant question is how long these patients should be treated and should the placebo group be followed for the same interval? The published literature describes various lengths of time for progression of fibrosis from early stages to later stages, with all in years. An article authored by Singh S et al. (2015) described “In this systematic review and meta-analysis of paired liver biopsy studies in patients with NAFLD, contrary to conventional paradigm, we found that both patients with NAFL and NASH develop progressive hepatic fibrosis, progressing by 1 fibrosis stage (from baseline stage 0 fibrosis) over 14.3 and 7.1 years, respectively. A small subset of these patients may develop rapidly progressive hepatic fibrosis” [17]. Will patients want to be part of a placebo group for at best 7 years? Since some companies pushed back on the FDA desire for 18 month endpoints in Phase 3, the willingness to fund a confirmatory study that runs significantly longer than their Hatch-Waxman Exclusivity is less likely. Regardless, this design would require a third liver biopsy to be successful, which many patients do not want to undergo. ”Reduction in hepatic decompensation events” [7] is an appealing endpoint since these are the types of clinical events (e.g., variceal bleeding, portal hypertension, hepatic encephalopathy, ascites, spontaneous bacterial peritonitis (SBP), hepatorenal syndrome, hospitalizations, liver related deaths) that clinicians and patients want to avoid. However, many of these events can be impacted by the amount and quality of care these patients receive. If a patient is in a rural area, the hope is that they receive appropriate supportive care. In contrast, in some tertiary/academic centers, patients could have better outcomes by receiving state-of-the-art procedures and medications that minimize these adverse events [18].

There is hope that the MELD score (Model for End Stage Liver Disease) [7] will be an easy calculation using laboratory data and other patient information to derive a number that has demonstrated correlation with clinical status over time. The original publication by Wiesner R et al. (2003) was intimidating to some clinicians “The MELD equation used to calculate the severity score was as follows: MELD score = [9.57 × loge creatinine mg/dL + 3.78 × loge bilirubin mg/dL + 11.20 × loge INR + 6.43 (constant for liver disease etiology)]” [19]. Currently, this function has been automated and is available for anyone with internet access and the patient’s laboratory values (e.g., bilirubin, serum sodium, INR, serum creatine, albumin0, along with their medical history [20]. In contrast, “Liver transplant” [7] has been a problematic endpoint in the past for FDA to interpret in the context of treatments of other liver diseases given the variability on timing, as well as heterogeneity of the transplant criteria and implementation within the U.S. and around the world. Despite changes to the organ allocation system over the years, continued variability in this transplant process makes it difficult to differentiate an improvement due to drug treatment versus seasonal or other variabilities within transplant centers or heterogeneity across centers [21]. It is possible for a drug to have a positive impact on either NASH Activity Score (NAS) and/ or NASH Clinical Research Network (CRN) fibrosis score [7] but that efficacy signal is lost in the noise of the liver transplant system.

Finally, “All-cause mortality” [7] prized as the most desirable endpoint for support of clinical efficacy in confirmatory drug trials, is the most difficult to obtain. In the case of MASH, the underlying factors that contribute to fatty liver with resulting hepatic inflammation and fibrosis, are also risk factors for hyperlipidemia [22] obesity and T2DM, all of which contribute to cardiovascular (CV) risk, including myocardial infarction (MI) and stroke (CVA) [23]. The specific mechanism of action for any MASH drug may provide either a selective advantage or disadvantage in confirmatory clinical outcome trials depending upon that drugs impact on a patient’s weight, LDL cholesterol, fasting blood glucose, blood pressure and emerging factors related to inflammation and thus the degree to which they are able to “reasonably likely to predict clinical benefit” [12] in confirmatory trials. From a practical perspective, how can such an accurate prediction be made if the drug is effective in a significant percentage over placebo, but under 50% of patients treated? Even if the drug produces complete resolution of NASH and reduction of hepatic fibrosis, what if the many years of untreated risks have produced coronary artery disease (CAD) which remains unaffected by even the most potent MASH drug, resulting in a fatal CV event during the confirmatory clinical outcome study. With the occurrence of a number of such CV events, the confirmatory trial could be labeled a “failure”. This simplistic perspective would do a disservice to MASH patients, since given the complex nature of this disease it is unlikely that any one drug would significantly treat all of its aspects. It is reasonable to assume that combinations of drugs with different mechanisms of action will be necessary to completely treat MASH, just as combinations of various drugs are routinely used for the effective treatment of T2DM [24]. FDA has approved MASH treatments based upon the accelerated approval pathway which has been in effect since the early 1990’s. Given that FDA law undergoes Congressional revision every five years with Prescription Drug User Fee Act (PDUFA) renewals [25] there have been multiple opportunities for Capitol Hill to modify use of the accelerated approval provisions. FDA has used the regulatory tools it has been provided and the results are MASH drug approvals. Although these initial drugs have been described as “modest” and “incremental advances”, their availability on the U.S. market has raised both patient and practitioner awareness, increasing screening programs and thus MASH diagnosis of patients who are then able to enroll in clinical trials to study new therapeutic agents. I hope that these benefits to underserved patients with MASH will not be forgotten during a future “drug failure” news cycle, questioning FDA and their use of the accelerated approval pathway.

The author declares that he has no competing interests.

Funding Information: No Funding Sources

Keywords

U.S. Food & Drug Administration; FDA; Accelerated approval, Confirmatory trials, Clinical outcome study, MASH, NASH, Biomarkers

References

  1. Diehl AM, Day C (2017) Cause, pathogenesis, and treatment of nonalcoholic New England Journal of Medicine. [crossref]
  2. Ekstedt M, Franzén LE, Mathiesen UL (2006) Long-term follow-up of patients with NAFLD and elevated liver enzymes. Hepatology. [crossref]
  3. Targher G, Day CP, Bonora E (2010) Risk of cardiovascular disease in patients with nonalcoholic fatty liver New England Journal of Medicine. [crossref]
  4. Ratziu V, Bellentani S, Cortez-Pinto H (2010) A position statement on NAFLD/ NASH based on the EASL 2009 special Journal of Hepatology. [crossref]
  5. Anania FA, Dimick-Santos L, Mehta R (2021) Nonalcoholic steatohepatitis: current thinking from the FDA Division of Hepatology and Nutrition. Hepatology. [crossref]
  6. Sanyal AJ, Brunt EM, Kleiner DE (2011) Endpoints and clinical trial design for nonalcoholic Hepatology. [crossref]
  7. S. FDA (2018) Noncirrhotic nonalcoholic steatohepatitis with liver fibrosis: developing drugs for treatment. FDA Guidance. [crossref]
  8. Di Mauro S, Scamporrino A, Filippello A (2021) Clinical and molecular biomarkers for diagnosis and staging of NAFLD. International Journal of Molecular Sciences. [crossref]
  9. Harvey BE (2022) NASH: regulatory considerations for clinical drug development and FDA approval, Acta Pharmacologica Sinica. [crossref]
  10. Global Liver Institute (2024) Annual GLI. [crossref]
  11. Harvey BE (2025) Improvements in FDA regulatory process leading to first drug approval for common liver Acta Pharmacologica Sinica. [crossref]
  12. S. FDA (2024) Expedited Programs for Serious Conditions — Accelerated Approval of Drugs and Biologics. FDA Guidance. [crossref]
  13. S. FDA (2023) Demonstrating substantial evidence of effectiveness with one adequate and well-controlled clinical investigation. FDA Guidance. [crossref]
  14. S. Congress (2022) Accelerated Approval Update under FDORA. Federal Report. [crossref]
  15. S. FDA (2024) Final decision to withdraw approval of Pepaxto. FDA Announcement. [crossref]
  16. S. FDA (2024) Final decision on proposal to withdraw approval of Pepaxto. FDA Documentation. [crossref]
  17. Singh S, Allen AM, Wang Z (2015) Fibrosis progression in NAFLD vs NASH: systematic review and meta-analysis. Clinical Gastroenterology and Hepatology. [crossref]
  18. Liu YB, Chen MK (2022) Epidemiology of liver cirrhosis and associated World Journal of Gastroenterology. [crossref]
  19. Wiesner R, Edwards E, Freeman R (2003) MELD and allocation of donor Gastroenterology. [crossref]
  20. OPTN (2025) MELD Calculator. Organ Procurement and Transplantation Network. [crossref]
  21. Goldberg DA, Gilroy R, Charlton M (2016) New organ allocation policy in U.S. liver Clinical Liver Disease (Hoboken). [crossref]
  22. Loomba R, Friedman SL, Shulman GI (2021) Mechanisms and disease consequences of NAFLD. Cell. [crossref]
  23. Khoshbaten M, Maleki SH, Hadad S (2023) NAFLD and carotid intima-media thickness: systematic review and meta-analysis. Health Science Reports. [crossref]
  24. Fleming GA, Harvey BE (2019) Regulatory considerations for early clinical development of drugs for diabetes, obesity, NASH and cardiometabolic disorders. Springer Nature. [crossref]
  25. S. FDA (2025) Prescription Drug User Fee Amendments. FDA Guidance. [crossref]

Personality Traits as the Predictor of Mental Toughness and Competitive Anxiety in Racket Players

DOI: 10.31038/PSYJ.2025761

Abstract

The present study explored the relationship between personality traits, mental toughness, and sports competition anxiety among racket sport athletes. While mental resilience is increasingly recognised as crucial for performance in high-pressure environments, little is known about how specific personality factors shape athletes’ ability to cope with competitive stress. A quantitative, cross-sectional design was employed with purposive sampling. Sixty racket sport athletes (tennis, badminton, and table tennis), aged 18–25 years, participated in the study. Standardised measures assessed six personality dimensions, three components of mental toughness, and levels of competition anxiety. Descriptive and inferential analyses indicated significant associations between personality and psychological outcomes. Emotionality was positively related to competition anxiety, while Extraversion was negatively related. Regression analyses revealed that Emotionality served as a strong predictor of anxiety, whereas Extraversion functioned as a protective factor. Together, these traits explained a meaningful portion of variance in competition-related anxiety, underscoring their independent and combined influence on athlete performance. The findings highlight the importance of incorporating personality-informed interventions in sport psychology. Programs that strengthen emotional regulation for athletes high in Emotionality, and confidence-building for those lower in Extraversion, may enhance resilience and performance. Future research with larger and more diverse samples is recommended.

Keywords

Personality traits, Mental toughness, Competition anxiety, Racket sports, Athletes, Sport psychology

Introduction

In competitive athletics, success is frequently determined not so much by greater skill but by an athlete’s ability to handle pressure and maintain performance when margins are at their thinnest. Among the psychological attributes that allow this, mental toughness is a complex construct of resilience, concentration, and control over emotions has become the bedrock of athletic achievement. Nowhere is this more pronounced than in racket sports like tennis and badminton, where competitors are subjected to prolonged one-on-one battles, quick changes in momentum, and the psychological test of reacting immediately to success or failure. The power to stay composed, self-assured, and focused in the midst of these pressures frequently decides the contest. Although increasing appreciation of its value, the factors that determine mental toughness are still only partly known. Personality traits are considered to have a basic function in determining resilience, but empirical evidence on these associations particularly in racket sports is yet to be known. Similarly, even though research has established that anxiety can both refine and detract from performance, how anxiety interacts with mental toughness and personality traits also needs to be examined. Filling this knowledge gap is critical to creating evidence-based interventions that enhance athletes’ psychological preparedness and improve their competitive performance.

Importance of Mental Toughness

Mental toughness has been used to describe the ability to retain confidence, motivation, and performance under adversity and pressure [1]. It encompasses emotional stability, self-belief, and persistence towards goals even in the presence of failure. Competitors who are mentally tough not only bounce back from mistakes quickly but also see obstacles as learning opportunities instead of success threats. This resilience sets apart top performers who repeat consistently in high- stakes contexts.

Mental toughness is more crucial in racket sports. Games require focused attention, tactical adaptability, and control of feelings over extended durations of play. A loss of concentration at a decisive moment, a return wide in badminton or a double fault in tennis can immediately shift match momentum. Psychological research has repeatedly established that higher-mental-toughness athletes exhibit higher levels of competitive performance. Because of this, coaches and sport psychologists increasingly view mental toughness as a non-negotiable aspect of athlete development rather than an adjunctive quality.

Personality as a Resilience Building Block

Whereas mental toughness has traditionally been conceptualized as something that can be trained, new evidence is pointing toward the fact that it also resides very much in stable personality traits. Two such traits in specific extraversion and conscientiousness, have repeatedly been linked to successful functioning under stress. Extraverted sports performers, being optimistic, assertive, and sociable, are more inclined toward seeking help and the use of active coping styles. These styles enhance resilience, and extraverts are able to bounce back from stress and adversity sooner.

Conscientious athletes, on the other hand, draw on discipline, planning, and long-term goal commitment. They show persistence in training and consistency of performance, skills that are critical to coping with the physical and mental pressures of elite sport. Both extraversion and conscientiousness are thus potentially psychological resources that enable athletes to gain the basis for establishing mental toughness. However, empirical data linking these personality factors directly to mental toughness in racket sport athletes is limited.

Anxiety as a Double-Edged Sword

In addition to resilience, athletes also have to deal with anxiety, the most ubiquitous of psychological performance barriers. Moderate levels of anxiety, on the other hand, can stimulate alertness, enhance concentration, and energize performance, a “facilitative anxiety.” Conversely, excessive anxiety disrupts, impairing choice, heightening doubt, and yielding physical symptoms like muscle tension and tachycardia. The latter are especially disabling in racket sports, in which precision and poise are crucial. Athletes of greater mental toughness do seem more likely to manage anxiety and direct it towards performance gain, not impairment. Low-resilience athletes, on the other hand, see anxiety as overwhelming, leading to decreased performance. This leaves open the possibility of a moderating effect of mental toughness in the link between personality traits and anxiety, a link that has not yet been wholly demystified in empirical studies.

The Case for Racket Sports

Racket sports provide a distinctive window through which to examine these psychological constructs. In contrast to most team sports, victory in tennis or badminton rests largely with the individual athlete. Every point is an independent psychological test, and mistakes cannot be balanced out by teammates. In addition, the speed of play with shuttlecocks reaching over 200 miles per hour in badminton or quick rallies in tennis requires continual focus and the ability to manage emotions in the moment. These circumstances make racket sports an especially insightful setting for exploring the interaction of personality, mental resilience, and anxiety. The high psychological pressure, along with the individual responsibility for performance, heightens the significance of resilience and emotional control. And yet, even under this distinctive setting, most of the current research has either made assumptions from team sports or centred on one psychological aspect at a time.

Rationale of the Present Study

The main focus of this study is to examine the personal experiences of several Indonesian badminton athletes who have excelled at the international level. The study is directed at efforts to reveal personality traits, influential environments, and career stages possessed by athletes. Many things are not known about Indonesian athletes who are high achievers. This issue will never be revealed as long as the study of personal experiences between them is not carried out in-depth.

Although personality traits are important prerequisites for achievement, environmental factors cannot be ignored. Many potential athletes do not develop optimally simply because the environment is less supportive. Therefore, identifying the environment that influences an athlete’s performance and how that environment affects it is an integral part of this study. After the traits and environment have been identified, the research continues by examining the career stages of the athlete. All of these problems will be revealed simultaneously through a qualitative approach. Based on these problems, the objectives of this study are (1) to find the personality traits possessed by Indonesian badminton athletes who are high achievers, (2) to identify and describe the environment that influences the development of personality traits and athlete achievement, 3and (3) to identify and describe the career stages of athletes in achieving high performance. If the problems in this study can be answered, it will have significant implications for sports coaching. Coaches will find it helpful to develop a pattern of coaching athletes from an early age. Scouting talent by paying attention to psychological factors can also be done. The results of this study will be very useful as one of the considerations in selecting athletes in addition to other considerations such as physical and physiological factors.

Objective

The aim of the research is to assess personality traits as the predictors of mental toughness and competitive anxiety in racket players. For the research design the Quantitative Cross-sectional Study Design was employed as it allows the examination of relationships among variables at a single point in time, making it both efficient and practical for the present context.

Hypotheses

H1. There is a significant correlation between Conscientiousness and Extraversion with mental toughness among sports players.

H2. There is a significant correlation between mental toughness and Competitive Anxiety among sports players.

Methods

Participants

Participants were selected from a sports academy in Delhi with an age range from 18 to 25 years. The male participants with Mean 22.6 and SD 1.79 while the female participants had with mean 21.6 and SD 1.79. Skewness and kurtosis tested indicates that the variables are nearly normally distributed since their skewness and kurtosis measures are within the range of –1.0 to +1.0.

Recruits for the current study were enrolled from a sports academy that provided training in tennis, badminton, and table tennis. Purposive sampling was used, where participants were intentionally chosen by the feature that was most relevant to the research itself. The non-probability technique allowed for analyzing only those athletes with competitive experience in racket sports, thus making the data more relevant and applicable. By targeting a well-defined group, purposive sampling enabled the study to produce findings that are contextually meaningful and practically relevant in accessing the psychological dynamics of racket players.

To narrow down the sample, strict inclusion and exclusion criteria were used. Participants had to be current racket sport players (tennis, badminton, or table tennis), between 18 and 25 years of age, and have basic English proficiency to allow them to understand the research tools. Both male and female participants were recruited to enable a balanced view per gender.

Measures

The following psychological tests were used in the present study viz. HEXACO–60 [2] was employed to measure personality traits with six broad dimensions: Honesty–Humility, Emotionality, Extraversion, Agreeableness, Conscientiousness, and Openness to Experience. The HEXACO–60 has shown satisfactory internal consistency, with Cronbach’s alpha coefficient, α ≈ 0.75. It has criterion validity r = 0.53. Mental toughness was assessed by the Sports Mental Toughness Questionnaire [3], a 14-item questionnaire examining three subscales: Confidence, Constancy, and Control. Exploratory and confirmatory factor analyses yield a strong three-factor solution, in addition to a higher-order global mental toughness factor. Internal consistency reliability is adequate, with alpha coefficients of over 0.70 on the three subscales. Construct validity evidence is provided by significant correlations with optimism, positive affect, and hardiness, and Criterion Validity r = 0.429. Sports Competition Anxiety Test [4] was used to measure competitive anxiety tailored to assess anxiety in competitive sporting situations. The SCAT has also been extensively validated within athletic groups, as Cronbach’s alpha values are generally above 0.80, reflecting high internal consistency. Test–retest reliability coefficients between 0.77 and 0.89 illustrate temporal stability. Criterion validity is evidenced through correlations with physiological indicators of arousal and performance-stress, with r ≈ 0.45 – 0.70

Procedure

Participants were excluded if they were participating in sports other than racket games, were under 18 or over 25 years of age, or had a diagnosed psychological disorder, likely to bias measures of anxiety and mental toughness. Participants who lacked the necessary English language proficiency were also excluded, as this may influence the validity of self-reported ratings. These measures were taken to create a homogeneous, targeted sample that is representative of the population being studied. These circumstances render racket sports a highly illuminating setting in which to examine the interaction between personality, mental toughness, and anxiety. The heightened psychological pressure, combined with the individual responsibility for performance, heightens the role of resilience and emotional control. However, given this special setting, much previous work has either extrapolated from team sports or concentrated on examining one psychological factor in isolation.

Statistical Analysis

Descriptive and Inferential statistics analyses were carried out on the collected data using the SPSS 22.0 software. The Pearson product- moment correlation was performed to determine the relationships between personality factors and dimensions of Sports Mental Toughness and Sports Competition Anxiety was computed. Further the Multiple regression analysis was used to find out predictors of personality Factor-Emotionality and Extraversion with Sports Competition Anxiety. To test the hypothesis Statistically the level of significance was maintained at 0.05 level and 0.01 level.

Result

The Table 1 shows information gathered using the sixty participants, who were both male and female racket sport players, was initially verified to ensure that it constituted a normal distribution. This was crucial to verify that the values were statistically valid and within acceptable parameters. Descriptive measures such as averages, variation, skewness, and kurtosis all showed that data were good for analysis.

Table 1: Age ranges and Mean and SD of Racket Players

 

N

Minimum

Maximum

Mean

SD

Skewness

Kurtosis

Gender

 

 

 

 

 

 

Std. Error

 

Std. Error

♀Age

22

19

25

22.6

1.79

-0.19

0.49

-0.71

0.95

♂ Age

38

19

26

21.6

1.79

0.38

0.38

-0.35

0.75

♀ & ♂ Age

60

19

26

22

1.83

0.16

0.31

-0.73

0.61

Table 2, there is a significant correlation between personality dimensions and mental toughness at 0.05 and 0.01 significance levels. Results show that there is significant positive correlation of Emotionality with Constancy and sports competition anxiety, (0.33) and (0.44) respectively.

Table 2: Descriptive statistics of study variables

 

Mean

S.D.

Skewness

Kurtosis

MT1

17.7

2.76

-. 00

-0.76

MT2

10.5

1.76

0.34

0.35

MT3

10.9

2.35

-0.35

1

SCAT1

20.27

2.59

-0.4

0.32

HH

33.93

6.54

0

0.58

EMO

31.47

5.64

-0.09

-1

EXT

32.53

5.81

0.23

-1.04

AGR

32.3

6.29

-0.07

-0.36

CON

34.77

6.22

-0.28

-0.69

OPN

36.57

6.43

-0.05

-0.84

Note: MT1=Confidence, MT2=Constancy, MT3=Control, SCAT= Sports Competition Anxiety, HH= Honesty-Humility, EMO= Emotionality, EXT= Extravernsion, AGR=Agreeableness, CON=Conscientiousness, OPN= Openness to experiences.

Of the various characteristics, openness to experience yielded the largest average score, with conscientiousness, honesty-humility, and extraversion close behind. Agreeableness and emotionality were slightly lower but still within range. As for the psychological skills being measured, athletes indicated moderate levels of competitive anxiety, while confidence, control, and constancy each revealed significant but differing levels of mental toughness (Table 3).

Table 3: Correlations between Personality factors, Dimensions of Sports Mental Toughness and Sports Competition Anxiety.

Variables

Mean

SD

MT1

MT2

MT3

SCAT

HH

EM

EX

AG

CON

OPN

MT1

17.7

2.75

 

-0.10

-.28*

-0.02

-0.02

-.28*

.57**

-.32*

.34**

.39**

MT2

10.5

1.76

 

 

0.19

.46**

-0.05

0.24

-0.23

-0.11

-0.11

-0.04

MT3

10.9

2.34

 

 

 

0.15

0.09

.33**

-.37**

0.24

0.00

0.17

SCAT1

20.26

2.59

 

 

 

 

0.20

.40**

-.28*

0.06

0.14

0.22

HH

33.93

6.54

 

 

 

 

 

0.01

-0.21

.48**

.43**

.38**

EMO

31.46

5.64

 

 

 

 

 

 

-0.08

0.16

0.05

-0.03

EXT

32.53

5.81

 

 

 

 

 

 

 

-.43**

0.01

-0.06

AGR

32.3

6.29

 

 

 

 

 

 

 

 

0.23

.38**

CON

34.76

6.22

 

 

 

 

 

 

 

 

 

.70**

OPN

36.56

6.43

 

 

 

 

 

 

 

 

 

 

*p<0.5, **p<0.1
Note: MT1=Confidence, MT2=Constancy, MT3=Control, SCAT= Sports Competition Anxiety, HH= Honesty-Humility, EMO= Emotionality, EXT= Extraversion, AGR=Agreeableness, CON=Conscientiousness, OPN= Openness to experiences.

When looking at the inter-correlations between these traits, some interesting trends emerged. Emotionality was positively linked with both constancy and sports competition anxiety. In simple terms, athletes who were more emotionally reactive also tended to show higher anxiety and a tendency toward persistence. Extraversion, on the other hand, was strongly associated with confidence, suggesting that outgoing players felt more assured in competitive situations. Conscientiousness and openness to experience were also positively related to confidence, suggesting that well-organised, self-disciplined, and open-minded participants were more confident in their sporting skill (Table 4).

Table 4: Regression results of personality Factor-Emotionality and Extraversion with Sports Competition Anxiety

Model

β

ΔR2

Adjusted R2

Std. Error

Emotionality

.400a

0.16

0.14

2.39

Extraversion

.474b

0.224

0.19

2.32

Moving on to the predictive analyses, emotionality was the best predictor of sports competition anxiety. Participants who were higher in emotionality or were more reactive and sensitive to their emotions tended to be higher in anxiety during competition. When emotionality was taken into account together with extraversion, the model revealed that the two attributes strongly predicted competitive anxiety, but in opposite directions. Emotionality heightened anxiety, whereas extraversion lowered it. The two attributes accounted for a significant proportion of differences in anxiety levels between players. Even after controlling for extraversion, emotionality was still a strong predictor, although its impact was weaker. This informs us that emotional sensitivity always increases the risk of competitive anxiety, and extroversion and social self-confidence can perhaps serve as a protective shield (Table 5).

Table 5: Analysis of Covariance of Emotionality and Extraversion Predicting Sports Competition Anxiety.

 

Sum of Squares

df

Mean Square

F

Sig.

 

Emotionality

63.176

1

63.176

11.01

 

0.002

332.557

58

5.734

 

395.733

59

 

 

 

Extraversion

88.814

2

44.407

8.24

 

0.001

306.92

57

5.385

 

395.733

59

 

 

Discussion

The current research focused on the role of personality traits, i.e., Emotionality and Extraversion, in explaining sports competition anxiety among racket sport athletes. Findings affirmed that these personality traits had significant and independent influences on competitive anxiety, as hypothesised by the study. Emotionality was positively correlated with increased anxiety, while Extraversion acted as a buffer to decrease vulnerability to anxiety. Collectively, the results highlight the significance of accounting for individual personality profiles in interpreting athletes’ psychological performance at competition. The findings are consistent with existing research illustrating the negative function of Emotionality under competition. The emotionally sensitive, reactive, and stress-prone athlete is seemingly more susceptible to worry, fearfulness, and instability in the face of pressure [5]. Such traits can undermine attentional control and increase physiological arousal above ideal levels, thus hampering performance. This is in contrast to Extraversion, which had a negative correlation with competition anxiety, a reflection of previous evidence that extraverted athletes, by virtue of their sociability, assertiveness, and approach-oriented coping tendencies, are well-placed to cope with competitive stress. Their ability to perceive challenges as exciting instead of threatening can be a psychological cushion against anxiety [6-8].

From an applied perspective, the consequences are significant. Interventions targeting athletes high in Emotionality need to emphasise emotional regulation, cognitive restructuring, and stress management skills, such as mindfulness training, relaxation techniques, and visualization practices. Interventions for less Extraverted athletes that enhance confidence, encourage positive self-talk, and build social support networks can enhance resilience in high-stress situations. Personality-specific approaches like these will be more successful than standardized psychological preparation packages. The research adds to the increasing literature on personality and sport psychology by placing Emotionality and Extraversion in a focal role in determining athletes’ competitive experiences. Nevertheless, some limitations must be noted. Involving a cross-sectional design excludes causal interpretations, and the comparatively small sample size restricts generalizability. Furthermore, only two dimensions of personality were examined in detail; other personality traits like Conscientiousness or Openness can perhaps also contribute in significant ways to predicting mental toughness and anxiety [9-12].

The current investigation accentuates the dual role of personality traits in competitive anxiety, whereby Emotionality emerges as a risk factor and Extraversion acts as a protective buffer. These results have significant implications for the practice of sport psychology. Personality tests can be used by coaches and practitioners to select athletes who are likely to be susceptible to performance anxiety and develop specific interventions with a focus on emotional control, cognitive behavioral techniques, confidence development, and social support networks. With the understanding that a one-size-fits-all approach may not be effective for every athlete, personality-guided psychological training can develop resilience and enhance performance under extreme pressure [13]. The limitations of the study, such as its cross- sectional nature, small sample, and emphasis on just two personality dimensions, imply strong directions for future research. Longitudinal research involving larger and more heterogeneous groups of athletes is warranted to allow consideration of causal sequences and to determine the roles played by other personality dimensions [14-16].

Future Research Directions

To overcome current limitations, future research should adopt longitudinal and experimental designs to clarify the causal links between personality traits and racket players’ performance, especially during the early stages of talent development. Incorporating multi-source assessments—such as coach ratings, objective performance metrics, and physiological markers (e.g., heart rate variability, VO₂ max)—can enhance measurement validity while minimising potential biases. Researchers are encouraged to statistically account for key confounders, including gender, training history, cultural background, and sport-specific demands, using multivariate models or structural equation modelling. Standardization of both personality instruments and performance indicators is also necessary to improve study comparability and reproducibility [17,18]. Lastly, cross-cultural validation studies are essential to examine sociocultural variability in trait-performance relationships and to support the development of culturally responsive athlete selection frameworks. Future studies would also need to test whether psychological skills training would operate as a moderator of the personality–anxiety relationship. These steps collectively can move toward a more focused and practical knowledge of how personality influences the psychological outcomes of athletes, toward making connections between research and evidence-based sport performance improvement [19-27].

Funding

This research received no external funding.

Author Contributions

Conceptualisation Upasana Yadav and Y. K. Nagle: original draft preparation Upasana Yadav; Writing of review, methodology, presentation of results, discussion and editing Upasana Yadav and Y. K. Nagle. Both the authors have read and agreed to the published version of the manuscript.

Conflict of Interest

The authors declare that they have no competing interests.

References

  1. Ford J, Ildefonso K, Jones M, Arvinen-Barrow M (2017) Sport-related anxiety: Current insights. Open Access Journal of Sports Medicine 8: 205-212.
  2. Ashton MC, Lee K (2009) The HEXACO–60: A short measure of the major dimensions of personality. Journal of Personality Assessment 91: 340-345. [crossref]
  3. Sheard M, Golby J, van Wersch A (2009) Progress toward construct validation of the Sports Mental Toughness Questionnaire (SMTQ) European Journal of Psychological Assessment 25: 186-193.
  4. Martens R (1977) Sport Competition Anxiety Champaign, IL: Human Kinetics.
  5. Gucciardi D (2017) Mental toughness: Progress and Current Opinion in Psychology 16: 17-23.
  6. Aditya R, Rahmatika Q, Solikhah F, Almutairi R, Alruwaili A, et (2024) Mental toughness may have an impact on athlete’s performance: Systematic review. Retos.
  7. Akbar A, Karim Z, Zakaria J, Kurniawan R, Dwatra F, et (2024) Understanding mental toughness in student-athletes: Insights from sport psychology. Retos.
  8. Ashdown-Franks G, Sabiston C, Solomon-Krakus S, O’Loughlin J (2017) Sport participation in high school and anxiety symptoms in young adulthood. Mental Health and Physical Activity 12: 19-24.
  9. Bandealy A, Kerr G (2013) Examining the views of sport psychology consultants on mental toughness. 45: 69-69.
  10. Correia M, Rosado A (2019) Anxiety in athletes: Gender and type of sport International Journal of Psychological Research 12: 9-17. [crossref]
  11. Crust L (2007) Mental toughness in sport: A review. International Journal of Sport and Exercise Psychology 5: 270-290.
  12. Crust L, Azadi K (2010) Mental toughness and athletes’ use of psychological European Journal of Sport Science 10: 43-51.
  13. Gumusdag H (2023) Examination of mental toughness in sports. ASEAN Journal of Psychiatry.
  14. Hossein A, Mohd R, Soumendra S, Anwar H, Muzaimi M (2016) Relationship between mental toughness and trait anxiety in International Journal of Pharma and Bio Sciences.
  15. Jannah M, Halimatussa’diyah L, Nabila N, Widohardhono R (2018) Anxiety and mental toughness among athlete students. Proceedings of ICEI 2018.
  16. Ji C, Yang J, Lin L, Chen S (2022) Anxiety and sleep quality amelioration in college students: A comparative study between team sports and individual Behavioral Sciences 12: 50149. [crossref]
  17. Kalinin R, Balazsi R, Péntek I, Duică Ș, Hanțiu I (2019) Relationship between competitive anxiety and mental toughness: A latent regression Health, Sports & Rehabilitation Medicine.
  18. Mahoney J, Gucciardi D, Ntoumanis N, Mallett C (2014) Mental toughness in sport: Motivational antecedents and associations with performance and psychological Journal of Sport & Exercise Psychology 36: 281-292. [crossref]
  19. Miçooğullari B, Odek U, Beyaz O (2017) Evaluation of sport mental toughness and psychological wellbeing in undergraduate student athletes. Educational Research Review 12: 483-487.
  20. Pluhar E, McCracken C, Griffith K, Christino M, Sugimoto D (2019) Team sport athletes may be less likely to suffer anxiety or depression than individual sport Journal of Sports Science & Medicine 18: 490-496.
  21. Pranoto N, Fauziah V, Ockta Y, Zarya F, Iswanto A, et (2024) Comparison of anxiety levels of individual and group athletes. Retos.
  22. Rice S, Gwyther K, Santesteban-Echarri O, Baron D, Gorczynski P, et (2019) Determinants of anxiety in elite athletes: A systematic review and meta-analysis. British Journal of Sports Medicine 53: 722-730. [crossref]
  23. Ryerson M (2018) The relationship between the Dark Tetrad using the HEXACO personality models in relationship to mental toughness in college athletes.
  24. Sofyan W, Nurjaya D (2024) The relationship between mental toughness and competitive anxiety of diving athletes in the training Journal of Physical Education Health and Sport.
  25. Stamatis A, Grandjean P, Morgan G, Padgett R, Cowden R, et al. (2020) Developing and training mental toughness in sport: A systematic review and meta-analysis of observational studies and pre-test and post-test experiments. BMJ Open Sport & Exercise Medicine 6: e000747. [crossref]
  26. Yankov G, Davenport N, Sherman R (2019) Locating mental toughness in factor models of Personality and Individual Differences 151: 109532.
  27. Zubić I (2021) Mental toughness as predictor of state anxiety of Serbian athletes. Exercise and Quality of Life.

Transient Creep of the Lithosphere and Propagation of a Local Vertical Displacement Over the Earth’s Surface

DOI: 10.31038/GEMS.2025773

Abstract

Laboratory experiments with rock samples show that creep at small strains is transient and is described by the linear hereditary rheological model of Andrade. Flows that restore isostasy (in particular, postglacial ones) cause deformations in the lithosphere that do not exceed 10-3 and, therefore, demonstrate transient creep. The effective viscosity characterizing transient creep is lower than the effective viscosity at steady-state creep and depends on the characteristic time of the process under consideration. The characteristic duration of isostatic equilibrium recovery after the initial disturbance of the Earth’s surface relief does not exceed ten thousand years, and therefore the depth distribution of rheological properties differs from the distribution that corresponds to slow geological processes. The perturbations of the Earth’s surface relief caused by an initial small-scale perturbation that disrupts isostasy are considered. The propagation of vertical displacements along the Earth’s surface from the area of the initial perturbation is carried out by diffusion-type waves that arise during the process of isostasy recovery, and by convective waves that arise due to the vertical temperature gradient in the lithosphere. The solutions of the equations of continuum mechanics are obtained using the Fourier transform in the spatial horizontal coordinate and the Laplace transform in time.

Keywords

Transient creep, Isostatic recovery, Vertical movements of the Earth’s surface, Thermoconvective waves, Diffusion-type waves

Introduction

Andrade proposed a law to describe the transient creep he observed experimentally in 1910. This law was later confirmed in numerous laboratory studies of rock creep conducted at high temperatures and pressures typical of the Earth’s interior [1-5]. The well-known concept in mechanics that creep is transient at small deformations was first introduced into geophysics in the work of [6], where the idea was put forward that flows in the mantle associated with small deformations, and, in particular, postglacial flows, occur in the transient creep regime. The concept of transient creep at small deformations of geomaterial was further developed in the monograph [7]. Experimental and theoretical justifications for the applicability of the Andrade rheological model in studying dynamic processes in the lithosphere and mantle are presented in [8]. The lithospheric plate is a cold boundary layer formed by mantle convection, and the thickness of continental plates beneath cratons can exceed 200 km. The rheological model of a power-law non-Newtonian fluid, which describes steady-state creep and is commonly used in modern geophysical studies, leads to a very high effective viscosity characterizing creep at small deformations. With such a high effective viscosity, the lithosphere would be purely elastic even over geological times. Transient creep corresponds to a much lower effective viscosity than steady-state creep. Therefore, transient creep must be taken into account when examining geophysical processes in the lithosphere. The effective viscosity corresponding to transient creep depends on the characteristic duration of the geophysical process under consideration. In [8-11], low-amplitude thermoconvective waves in the lithosphere, the existence of which is due to transient creep, were considered, and it was shown that thermoconvective oscillations (standing waves) lead to the formation of sedimentary basins on continental cratons. The characteristic time of this process is about 108 years. The work [12] considers the recovery of isostatic equilibrium after an initial small – scale disturbance of the earth’s surface relief. As a result of the recovery process, the Earth’s surface returns to a flat position, which corresponds to the equilibrium state with a uniform horizontal density distribution. The characteristic duration of this process does not exceed 1000 years, and therefore the distribution of rheological properties by the depth of the lithosphere and crust differs from the distribution that corresponds to slower processes associated with convective motion. A process with a characteristic time of about 1000 years is a fairly fast process, the study of which does not require taking into account the influence of the vertical temperature gradient present in the lithosphere, since thermal effects are associated with very slowly occurring thermal conductivity. However, this process is slow enough to neglect the elasticity, compressibility, and inertia of the lithosphere.

In this paper, we will consider the movements of the Earth’s surface caused by initial vertical displacements. If a vertical displacement disrupting the isostatic equilibrium of the crust has occurred in some area of the Earth’s surface, then the process of isostasy recovery is reduced not only to a gradual decrease in the initial vertical displacements in this area, but also to the propagation of displacements beyond its boundaries. The processes of displacement propagation in the crust can be called diffusion-type waves. Waves of this type appear when solving parabolic equations of the theory of diffusion or heat conduction. These waves describe the process of propagation of temperature disturbance from the area where the disturbance occurred to the environment. The temperature gradually increases in remote areas, and the temperature in the initially disturbed area decreases. The propagation of the disturbance is accompanied by its strong attenuation, and over time, the temperature disturbance disappears everywhere. This is exactly how the process of displacement propagation occurs in the elastic crust, where the displacement acts as an analogue of temperature disturbance. It will be shown what movements of the Earth’s surface created by diffusion-type and thermoconvective waves caused by the initial vertical displacement of this surface.

Rheological Model

Laboratory studies show that at small deformations transient creep occurs, in which creep deformations depend linearly on the applied constant stresses

where  f(t) is the creep function, which provides an analytical description of transient creep, εij and  is the strain tensor measured from the state at the moment of stress application. For rocks, the creep function at high temperatures is well described by Andrade’s law

where A is the Andrade rheological parameter. At short times, transient creep obeys Lomnitz’s law, but already at times of the order of a day, Andrade’s law becomes valid [13]. Therefore, Andrade’s law will be used in the study of low-frequency waves. The attenuation of high-frequency seismic waves is described by Lomnitz’s rheology [14], but in this paper, although we will talk about Rayleigh surface elastic waves, their attenuation will not be considered. To generalize the results of experiments carried out at constant stresses to the case of variable stresses, we can use the linear Boltzmann theory, valid for sufficiently small deformations. This theory leads to an integral relationship between strains and stresses

where t is the observation time, and K(t) is the integral creep kernel determined by the creep function

As follows from (2) and (4), the creep kernel corresponding to Andrade’s law has the form

The rheological model described by equations (3) and (5) will be called the Andrade model. This model generalizes Andrade’s law to the case of variable stresses. At sufficiently large deformations, transient creep is replaced by steady-state creep, which is described by the rheological model of a power-law non-Newtonian fluid. The value of the Andrade rheological parameter depends on temperature, pressure, and mineralogical composition. The depth distribution of the Andrade parameter was obtained in [11]. Since the Andrade parameter decreases with increasing temperature, and the temperature increases with depth in the lithosphere, this parameter decreases with depth. In the upper crust, the thickness of which is about 20 km, the value of this parameter is estimated as A ≈ 1016 Pa∗ s1/3 . With such a high value of  A, the upper crust behaves as an elastic layer even on times of the order of the age of the Earth. More precisely, the upper crust, the thickness of which is about 20 km, is brittle-elastic, and elasticity dominates only in the lower layer of the upper crust, the thickness of which is about 10 km. In the uppermost layer of the crust, brittleness dominates, and its strength is very low [11]. We will assume that the upper crust with a thickness of 20 km is an elastic layer with a reduced shear modulus due to brittleness. Within the framework of the simplified model of the lithosphere beneath the upper crust used in the paper,we use the depth-averaged estimate A ≈ 1012 Pa∗ s1/3.

Since the total deviatoric deformation of the medium can be represented as the sum of the deviatoric creep deformation (1) and the deviatoric elastic deformation

where μ is the elastic shear modulus, an elastic-creeping medium whose creep is transient is described by the equation

In linear stability theory, it is assumed that the strains and stresses depend on time as exp(λt), where λ is the complex decrement, and the right-hand side of equation (3) takes the form

where the asterisk denotes the Laplace transform, which is used here only to evaluate the integral in equation (8). The Laplace transform of the creep kernel (5) yields

where the gamma function is Γ (1/3)≈3. Linear stability theory considers the behavior of a mechanical system at large times elapsed since the occurrence of a small disturbance. Therefore, in equation (8), the upper limit of integration is t=∞.

Thus, when the time dependence has the form exp(λt), at large times the effective shear modulus of the Andrade medium has the form

and the effective Newtonian viscosity is written as

where  is the characteristic time of the process. As follows from (11), on time scales of the order of 1000 years, small-scale postglacial flows, which are characterized by an average value of the rheological parameter A ≈ 1012 Pa∗ s1/3, correspond to an effective viscosity ℑeff ≈ 1019 Pa∗ s. Such estimate agrees in order of magnitude with the viscosity estimates found when considering small – scale postglacial flows within the framework of the rheological model of a Newtonian fluid [15]. Consequently, the estimates of Andrade parameter obtained on the basis of data from laboratory experiments with rock samples at temperatures and pressures characteristic of the Earth’s interior [11], correspond to the observational data used to estimate the viscosity of the upper mantle [15]. The effective viscosity for the Andrade medium depends on the characteristic time of the process under consideration and, therefore, the effective viscosity found for postglacial flows with a characteristic time of 1000 years cannot be used in the study of slower geological processes [8,13].

Thermoconvective and Elastic Surface Waves

We consider an elastic thin plate lying on a layer with Andrade rheology. The origin of coordinate is placed on the upper surface, and the z-axis is directed vertically upward. The thin plate (z = 0) models the upper elastic crust, and the layer (-1 < z < 0) – the underlying lithosphere. The equations describing the disturbances of the lithostatic equilibrium of an incompressible medium are written as

where p  is the pressure perturbation, σxx, σxz and σzz are the components of the deviatoric stress tensor,  vx and vz are the velocities, θ is the temperature perturbation,  x is the thermal diffusivity,  is the vertical gradient of the unperturbed temperature, which is assumed to be uniform throughout the depth of the lithosphere, ρ is the density, α is the coefficient of thermal expansion, g is the gravitational acceleration. The velocities, stresses, pressure and temperature perturbations are functions of the vertical spatial coordinate, the horizontal coordinate x, and time t. Equations (12) and (13) describe the two-dimensional motion of the medium (the motion occurs in the xz plane) taking into account the Archimedes force. Equation (14) is the condition of incompressibility of the medium, and equation (15) is the heat balance equation. Equations (12) – (15) use the Boussinesq approximation, within which the mechanical compressibility of the medium can be neglected, and thermal compressibility can be taken into account only in the equations of motion. Rheological equations are added to equations (12) – (15)

where F(λ) is the complex viscosity of the Andrade viscoelastic medium (7)

Equations (16) relate deviatoric stresses to strain rates, which are defined as

On the upper surface of the lithosphere (z = 0) the boundary conditions, determined by the force action of the elastic plate, are imposed

where ν is Poisson’s ratio, N is the flexural rigidity of the elastic plate with thickness h. The displacements  ux and uz in the plate are equal to the displacements in the underlying layer at z = 0. The temperature boundary condition is added to the boundary conditions (19) and (20)

The incompressibility condition for a viscous medium, under which equation (14) is valid, is written as

where τ is the characteristic time of the flow under consideration, and K is the bulk modulus. It follows from (23) and (11)

In equations (12) and (13), the inertial terms can be neglected under the condition

from which it follows

Slow flows with a large characteristic time τ are called creeping. Convective flows in the Earth are a typical example of creeping flows. The lithosphere, which exhibits both elastic and viscous properties, is described by the Maxwell viscoelastic rheological model. Elasticity can be neglected for a sufficiently slow flow

where µ is the elastic shear modulus, and ηeff /μ is called the Maxwell time. It follows from condition (27)

To move to dimensionless variables, we introduce the following scales: the length scale is the layer thickness d, the time scale is d2/x , where κ is the thermal diffusivity, the velocity scale is κ/d, the pressure (and stress) scale is kηA /d2, where ηA is the viscosity scale for the Andrade medium. The temperature difference between the hot lower and cold upper surfaces of the layer is taken as the temperature scale. For the Andrade medium ηA = A(d2 /x)2/3, and then with an exponential dependence on time, the dimensionless effective viscosity takes the form

and the Rayleigh number for the Andrade medium is defined as

The lithosphere is characterized by the following values of physical parameters [16]:

The thickness of the continental lithosphere, which is taken as the length scale, is estimated as d = 2∗ 105 m. Since the Andrade parameter for the lithosphere is estimated as 1012 Pa∗.s1/3 m, the Rayleigh number, according to (31), is estimated as Ra ≈ 80.

We will represent the vertical velocity as

where λ is the complex increment, k is the real wave number. We will represent all the physical variables in a similar form. This representation allows us to reduce the system of partial differential equations (12) – (18) to a system of ordinary differential equations, in which all variables characterizing the strain rates, stresses, and pressure depend only on the vertical coordinate z. The characteristic time τ for a flow with a decrement λ can be represented as .

Passing to dimensionless variables and substituting relations (32) into equations (12) – (15), (16) and (18), we obtain relations connecting the amplitudes of pressure, temperature, and components of the deviatoric stress tensor with the amplitude of the vertical velocity

Excluding from the equations the amplitudes of all physical variables, except for the amplitude of the vertical velocity Vz , we arrive at an ordinary differential equation, valid for small values of λ, for which we can neglect elasticity and inertia of the layer (-1 < z <0) simulating the lithosphere,

From (34) it follows that the influence of the temperature gradient can be neglected when

The boundary conditions on the upper deformable surface of layer z = 1 are

where Uz is the vertical displacement of the upper boundary of the layer, i.e. the deviation of the boundary surface from the plane z = 1. Equations (36) and (37) follow from the condition of equilibrium of the forces acting on a unit area of the disturbed surface of the layer, and equation (38) follows from the condition of vanishing of the temperature disturbance on this surface. Equations (36) and (38) include the displacement of the boundary Uz due to the fact that in the state of equilibrium there is vertical gradients of pressure and temperature in the layer. Condition (38) assumes that the boundary motion is determined by the motion of material points located on this boundary. In equations (36) and (37), dimensionless parameters are introduced:

which characterize the deformable surface. For sufficiently small k, the influence of a thin elastic plate modeling the upper crust is negligible.

Using the parameter φ, the Rayleigh number can be written as  The parameter φ describes the mobility of the boundary and is the ratio of the additional hydrostatic pressure caused by the boundary displacement to the characteristic viscous stress in the layer. The smaller the parameter φ, the more mobile the boundary. For a very large value of φ, the upper surface of the layer behaves like a fixed boundary.

Under each lithospheric plate, there is an isothermal core of large-scale mantle convection, and there is movement with a constant horizontal velocity at the lithosphere-mantle boundary [16]. Therefore, in the coordinate system that moves together with the lithospheric plate, the following conditions must be imposed at the lower boundary of the plate

Thus, the lower boundary of the lithosphere, considered as a boundary layer of large-scale convection, is isothermal (the temperature perturbation is zero at this boundary) and “solid” (zero velocity components at this boundary).

The general solution of the ordinary differential equation (34) is written as

where   q1 , q2 , q3 are the roots of the equation

Investigating surface waves, for which disturbances do not penetrate into the deepest layers of the lithosphere, we consider only sufficiently large values of the wave number (k > 3), for which  eq1 z , eq2 z and eq3 z are close to zero at the lower boundary (z = -1). In this case, to satisfy the boundary conditions at the lower boundary of the lithosphere, it is sufficient to set C4 = C5 = C6 = 0 Substituting (40) into the boundary conditions (36) – (38) on the upper surface, we arrive at a system of three homogeneous equations for three unknowns C1 , C2 and C3. In order for this system to have a solution, it is necessary to equate its determinant to zero

As a result, we obtain the characteristic equation relating the decrement λ to the wave number k. For large wave numbers (k > 5), the imaginary parts of the complex decrements are very small. This means that the temperature gradient present in the lithosphere has a very weak effect and the Rayleigh number in equations (34) and (41) can be neglected. For k = 3, the decrement takes the value . Such a convective wave propagates with the dimensionless velocity . The dimensional velocity of this wave is extremely small: m/year. Values of k < 3 cannot be considered since equation (42) was obtained for surface waves. However, the study of thermoconvective waves [8,9,10,11] allows us to assume that for k < 3 the imaginary part of the decrement and the propagation velocity increase, while the real part of the decrement (attenuation) tends to zero.

The characteristic equation (42) is obtained for sufficiently small values of k and λ, for which the elasticity and inertia of the medium can be neglected. For large values of the wave number k and the decrement λ, the viscosity of the medium and temperature effects can be neglected but the elasticity and inertia of the medium must be taken into account. In this case, it is more convenient, while maintaining the length scale d=2∗ 105 m, to move to the velocity scale  and the time scale Then λ=iw (the decrement becomes purely imaginary), and the characteristic equation takes the form

This equation has solutions w(k) = Vk, where V ≈ 0.95529 is the dimensionless velocity of the surface wave. Its dimensional velocity is slightly lower than the velocity of the bulk transverse wave. Taking into account the effect of gravity (non-zero parameter φ) slightly increases the frequencies ω(k) ≈ 0.95531k. Equation (43) describes the Rayleigh wave in an incompressible medium. Taking into account compressibility, equation (43) becomes

where  This parameter can be considered small, since it has little effect on the result. The frequencies ω found from equation (43) and from equation (44) differ by approximately 3%.

When k and λ are small enough to neglect elasticity and inertia, but not small enough to take into account thermal effects, the complex decrement λ turns out to be a real number (lmλ = 0). In this case, which will be discussed in the next section, there is no wave motion at a fixed k but we can speak of a diffusion – type wave in the presence of a whole spectrum of values of k.

Laplace Transform. Diffusion-type Wave

Solving the problem of excitation of surface waves by the initial disturbance of the Earth’s surface, we will use the Laplace transform with respect to time t and the Fourier transform with respect to the spatial horizontal coordinate x. Representation (32) introduces the Fourier transform but not the Laplace transform, which allows us to find not only solutions of the form exp (λt).

The Laplace transform is a convenient mathematical apparatus for solving differential equations with initial conditions. The Laplace transform f∗(s), denoted by an asterisk, is related to the original f(t) by the equation

The Laplace variable s is a complex number, unlike the Fourier variable k, which is a real wave number.

Using the Laplace transform, we can write the rheological equation (3) as

where G∗A  is the Laplace analogue of the shear modulus for the Andrade medium, Γ(1/3) ≈ 3 is the gamma function. Equation (7) corresponds to the Laplace image

where G∗ is the Laplace analogue of the shear modulus for an elastic-creeping medium.

As follows from (46), the elasticity of the medium can be neglected if the condition

is satisfied, under which the Laplace analogue of the shear modulus for the Andrade medium G∗A is significantly less than the elastic shear modulus μ. According to the property of the Laplace transform, it follows from (47)

The compressibility of the medium can be neglected if the Laplace analogue of the shear modulus for the Andrade medium G*A is significantly less than the elastic bulk modulus K. Since the elastic shear modulus μ is less than the bulk modulus (K ≈ 3μ), condition (48) allows us to neglect not only the elasticity but also the compressibility of the medium. Since μ ≈ 6. 1010 Pa and A ≈ 1012 Pa ∗ s1/3 , it follows from (48) that the lithosphere beneath the elastic upper crust behaves as a creeping Andrade medium, not exhibiting elasticity or compressibility at times exceeding 104 s.

The effect of inertia is negligibly small (inertial forces are small compared to the forces arising during deformations of the Andrade medium), if

The right-hand side of (49) is estimated as 20 s for the lithosphere. Consequently, neglecting elasticity, inertia can be neglected even more so. Isostatic recovery processes with characteristic times not exceeding 10,000 years are slow enough to neglect elasticity, compressibility, and inertia, but are not slow enough to take into account the buoyant Archimedean force, the presence of which is due to the vertical temperature gradient in the lithosphere. The physical variables in equations (12) – (14) depend on the horizontal coordinate x, the vertical coordinate z, and time t. Applying the Fourier transform in the coordinate x and the Laplace transform in time t to these equations and excluding all physical variables except the vertical displacement, we arrive at the relations

where the differential operator D = d/dz is introduced, and U0=U0(x, z) is the initial (t = 0) distribution of vertical displacements. In the equations (50) – (53), the Fourier transforms of the physical variables are denoted by corresponding capital letters, the Laplace images are marked with the asterisk, k is the wave number (the Fourier variable), s is the Laplace variable. Then we obtain the ordinary differential equation for the vertical displacement

The solution of equation (54), which satisfies the boundary condition for z⟶ – ∞, is written as

where C1 and C2 are arbitrary integration constants that depend on the Laplace variable, and the wave number k can take negative values. Substitution of the solution (55) into the boundary conditions (19) – (20) allows us to eliminate arbitrary constants and represent the vertical displacement of the upper surface (z = 0) in the form

where G*A = As1/3 is the analog of the shear modulus for the Andrade medium. It should be noted that the substitution of (50) and (53) into the boundary condition (19) leads to the relation C2 = – C1 /k, at which horizontal displacements and tangential stresses are absent on the upper surface. Thus, when searching for a solution to equation (54), one can replace the boundary condition (19) with the condition U*x= 0 at z = 0 or with the condition Σ*xz= 0 at z=0.

In order to find the asymptotic (small times) dependence of the Laplace origin on time, it is sufficient to expand the Laplace image in a series in powers of s in a neighborhood of s = ∞ and invert by Laplace each term of the series [17]. The right-hand side of (24) for s⟶ ∞, is representable in the form of a series

Inverting the terms of the series (57), we obtain the asymptotic dependence of the vertical displacement on time

where the gamma-function at the point 4/3 is estimated as

The asymptotic dependence (59) is valid when

As follows from (60), the asymptotic dependence (59) can be represented in the form

The function Φ(k) has a sharp minimum, which is found from the condition

If we switch to the length scale introduced above d=2∗105 m, this wave number takes the value Km= 3.6

At large times, the displacements of the surface are described by another asymptotic formula. In the neighborhood of the point s = 0, the right-hand side of equality (56) can be represented as a series  

According to the theorem on the asymptotic behavior of the original [17], the Laplace original at large times can be represented as a series whose terms are obtained as a result of the inverse Laplace transform of each term of the series (64). Keeping only the first term of the expansion, we find

Asymptotic dependence (65) is valid at large times, when

As follows from (65), at large times, harmonics with different wave numbers k decay according to the same law t-1/3 and the effect of propagation of surface displacements, which occurs at small times, disappears. Since the minimum value of Φ(k) is achieved at k=km , inequality (66) is satisfied for any wave numbers if

If the medium underlying the elastic upper crust had the rheology of a Newtonian fluid with viscosity η, the analogue of the shear modulus G*A(s) should be replaced by ηs, and equation (56) would be written as

Inversion of the Laplace image (68) yields

where τ is the recovery time, depending on the wave number k. Relation (69) is valid for any times t, in contrast to relation (61), which characterizes the Andrade medium and is valid only for not too large times, limited by condition (60).

Let at the initial instant t = 0 the displacement of the upper surface (z = 0) be given as

The Fourier transform of the function (70) is

and the inverse Fourier transform gives

Inversing the Fourier image (61), we find

In the case when u0=x is an even function, (73) can be written as

Let the initial displacement have the form of a “step”

If x<-1/2 or x > 1/2 

The Fourier transform for such a “step” has the form

For a sufficiently large width l of the initial perturbation, the values of the function (76) are very small when k > 2π /l, i.e., the wider the perturbation region, the narrower the range of wave numbers k, in which the Fourier image is different from zero. Thus, the integration on the right-hand side of (74) is carried out over the region k<2π/l in the neighborhood of the point k = 0. According to the solution (55), for a fixed wave number k, the isostatic flow causes displacements in the lithosphere, depending on the depth as exp (- kz). Since k < 2π /l, we can say that this flow penetrates into the lithosphere to a depth of the order of l/π. Therefore, the flows arising after the removal of small-scale glaciations or other surface loads (for example, drying salt lakes), for which l does not exceed 200 km, are concentrated in the lithosphere. Caused by large-scale glacial loads (l ≈ 1000 ÷ 3000 km) flows that penetrate into the low mantle and recover isostasy over a period of time of about 10,000 years, are not considered in this paper.

As follows from (76), when the width of the initial perturbation is small (lk << 1), the Fourier transform does not depend on k

The image (77) corresponds to a point initial perturbation

where δ (x) is the delta function

In the case of a point initial perturbation (perturbation of any initial width l can be regarded as a point perturbation when we consider displacements at a sufficient distance from the initial perturbation, that is, for x >> l) , it is possible to obtain an analytic solution of the problem of vertical surface motions. For the point initial perturbation, the dependence of the vertical displacements of the surface on the horizontal coordinate and time is determined by the integral

As follows from (62), the expansion of the function Φ(k) in a power series in the neighborhood of has the form k=km

where

The power series (80), which represents the function Φ(k) given by (58), converges when |k-km|≤km, i.e., the radius of convergence of this series is R=km

After changing the variable

the integral (79) takes the form

Equation (83) can be rewritten as

where

The integral on the right-hand side of equality (84) is calculated using the saddle point method used in the theory of functions of a complex variable [18]). The stationary point vo is found from condition

The function of the complex variable f(v), which is given by (85), has a stationary point

As follows from (87), in a neighborhood of the stationary point vo, the function f (v) can be represented in the form

Substituting (88) into (84), we obtain

By choosing such a path of integration in the complex plane, which is determined by the saddle-point method, we find the relation

where erf(x) is the error function, and R=km is the radius of convergence of the power series (80). At times significantly exceeding 1010s ≈ 300 years, the condition

It is known that erf(x)=1 for x>>1, and the value erf(x) is close to 1 for x > 1.

Thus, as follows from (79), (89) and (90), the required distribution of the vertical displacements of the surface takes the form

The found solution (92) is valid for sufficiently long times (from several hundreds to several thousand years). The upper bound on time is imposed by condition (60), in which k=km.

The graphs in Figure 1 are constructed by the relation (92) and show the dependence of the vertical displacements on the horizontal coordinate at different instants of time.

Figure 1: The dependence of the vertical displacements of the Earth’s surface on the horizontal coordinate at different times for the case when the width of the region of the initial displacement l is 10 km. Curve 1 corresponds to 30 years, curve 2 to 300 years, curve 3 to 1000 years.

By differentiating the right-hand side of (92) with respect to t for a fixed value of x, it is not difficult to find the velocity of the vertical motion of the Earth’s surface at points sufficiently far from the region of the initial disturbance of the relief. For example, when uo= 100 m, l = 10 km, x = 100 km, the velocity  reaches its maximum value (about 1 mm/year) during the time t ≈ 600 years. The generalization of the considered case of the initial point vertical displacement to the 3D problem formulation implies not too much new to understanding of the process under consideration: it is sufficient to replace the coordinate x by the polar coordinate r in Figure 1 (the solution does not depend on the polar angle for the point perturbation of vertical displacement). The initial disturbance of the Earth’s surface leads not only to diffusion-type waves, but also to seismic waves and convective waves. Diffusion-type waves cannot be considered without the initial disturbance, which produces a spectrum of harmonics. Each of these harmonics is not a traveling wave. The wave effect appears only when the entire spectrum is considered.

In the previous section, traveling harmonic waves, both convective and elastic, were considered. The solutions obtained can be represented as

where uo is the initial vertical displacement of the surface, ω=Imλ, Λ=Reλ, and λ is the found value of the complex decrement (Reλ<0). The use of the Laplace transform allows us to find an arbitrary constant C. To do this, we transform the original equations using the Laplace transform, and substitute the resulting general solution, containing arbitrary constants, into the boundary conditions Laplace transformed. As a result, we find the function F(s, k) and obtain a solution to the problem in the form of a Laplace image

To invert the Laplace image (94), we can use the well-known theorem on the asymptotic behavior of the original [17]. According to this theorem, in order to find an asymptotic solution at large times (t → ∞), it is sufficient to know the Laplace image in the neighborhood of the singular point . In our case, this singular point is a first-order pole, in the neighborhood of which

and the Laplace original has the form

The pole so is equal to the complex decrement λ found in the previous section.

Expression (96) is the Fourier image. To pass to the Fourier original, it is necessary to specify the function Uo(k) determined by the initial disturbance. As a result, we can obtain a solution in the form of a running wave packet.

Conclusion

The paper considers disturbances of the Earth’s surface relief caused by an initial small-scale disturbance that disrupts isostasy. The solutions of the equations of continuum mechanics are obtained using the Fourier transform with respect to the spatial horizontal coordinate and the Laplace transform with respect to time [19]. The propagation of vertical displacements along the Earth’s surface from the region of the initial perturbation is carried out by surface waves. At short times, the presence of vertical temperature gradient in the lithosphere can be neglected and a solution in the form of a decaying seismic wave can be obtained. In this case, the creep of the medium, leading to attenuation, is described by the rheological Lomnitz’s law. At very short times, creep can also be neglected, obtaining a solution in the form of an elastic Rayleigh wave. At very long times, the elasticity and inertia of the lithosphere can be neglected but, taking into account the vertical temperature gradient, a solution in the form of a thermoconvective wave can be obtained. At not too large and not too small times, one can neglect not only elasticity and inertia, as in the description of a thermoconvective wave, but also thermal effects, as in the description of Rayleigh waves, obtaining a wave of the diffusion type that occurs in the process of isostasy recovery.

The initial disturbance determines the spectrum of wave numbers k. Elastic Rayleigh waves are characterized by large values of k and propagate very quickly, determining the relief of the Earth’s surface only in the first seconds after the disturbance occurs. Thermoconvective waves are characterized by small values of k (large wavelengths) and propagate very Diffusion-type waves correspond to values of k lying between the wave numbers characteristic of thermoconvective waves and the wave numbers characteristic of Rayleigh waves. The wave character of the solution at short times is due to inertia, and at long times – to the vertical temperature gradient. In the case of Rayleigh and thermoconvective waves, each harmonic moves according to the law , where ω is the frequency and Λ(k) is the decrement. In a diffusion-type wave, each harmonic is motionless, and the harmonic with the wave number (wavelength decays most slowly. Wave motion appears after the inverse Fourier transform due to the dependence of attenuation on k.

Conflict of Interest

The author declares no conflicts of interest in this paper.

References

  1. Goetze C (1971) High temperature rheology of Westerly J Geophys Res 76: 1223-1230.
  2. Goetze C, Brace WF (1972) Laboratory observations of high-temperature rheology of rocks. Tectonophysics 13: 583-600.
  3. Murrell SAF, Chakravarty S (1973) Some new rheological experiments on igneous rock at temperatures up to 1120°C. Geophys J Roy Astron Soc 34: 211-250.
  4. Murrell SAF (1976) Rheology of the lithosphere – experimental Tectonophysics 36: 5-24.
  5. Berckhemer H, Auer F, Drisler J (1979) High-temperature anelasticity and elasticity of mantle peridotite. Phys Earth planet Inter 20: 48-59.
  6. Weertman J (1978) Creep laws for the mantle of the Phil Trans Roy Soc London A 288: 9-26.
  7. Karato S (2008) Deformation of Earth An Introduction to the Rheology of Solid Earth. Cambridge university press.
  8. Birger BI (1998) Rheology of the Earth and thermoconvective mechanism for sedimentary basins formation. Geophys J Inter 134: 1-12.
  9. Birger BI (2000) Excitation of thermoconvective waves in the continental Geophys J Inter 140: 24-36.
  10. Birger BI (2012) Transient creep and convective instability of the Geophys J Inter 191: 909 – 922.
  11. Birger BI (2013) Temperature-dependent transient creep and dynamics of cratonic Geophys J Inter 195: 695-705.
  12. Birger BI (2018) Andrade Creep at the Isostasy Recovering Flows in the Izv Phys Solid Earth 54: 849-858.
  13. Birger BI (2007) Attenuation of seismic waves and universal rheological model of the Earth’s Izv Phys Solid Earth 43: 635-641.
  14. Birger BI Internal friction in the Earth’ crust and transverse seismic waves. AIMS Geosciences 8: 84 – 97.
  15. Cathles LM (1975) The viscosity of the Earth’s mantle. Princeton university press.
  16. Turcotte and Schubert G (1982) Geodynamics: Application of Continuum Physics to Geological Problems. New York: John Wiley.
  17. von Doetsch G (1974) Introduction to the Theory and Application of the Laplace Transformation.
  18. Copson ET (2004) Asymptotic Cambridge University Press.
  19. Birger I. (2024) Instability of the Earth’s lithosphere. Cambridge Scholars Publishing.

Draft on Hygiene and Infection Prevention in Outpatient Care for the Second Quarter of the 21st Century – An Europe- and German-centred Perception

DOI: 10.31038/IDT.2025624

Abstract

Professional care and nursing for people in need of care in Germany faces a number of serious challenges. Due to the demographic development and the recruitment of nursing personnel and aides of different educational and professional background, an increasing number of people in need of diverse forms of care encounter a diversity of nursing personel with a variety of language and professional skills.

A basic pillar of healthcare and nursing, hygiene and infection prevention, stands under high pressure. On the one hand, the concept of hygiene in a home environment is heavily person-bound and may widely diverge between person in need of care and nursing personnel. On the other hand, practice and interpretation of the recommendations for infection prevention of the leading healthcare institutes, as well as the basic learning contents, are highly variable, at times deficient or not present at all.

The perceptions of when hands or gloves are contaminated differ considerably. The touching of different surfaces and objects in the working environment during a workflow often does not agree with strategies to minimize the spreading of pathogenic germs. Also, wearing a protection mask is handled at will, at times covering mouth and nose, at times only the mouth, at times sitting under the chin.

This way of nursing practice meets a world of pathogens, in which the bacteria during the last 50 years underwent a genuine evolutionary change. Antibiotic-resistant bacteria now pose an over-size challenge for the current practice of home nursing and care for elderly. An adjustment in education, quality validation, and appreciation of hygienic competent work is of need.

Keywords

Pathogens, Antibiotic resistance, Home nursing, Asepsis, Infection prevention

Introduction

Over the past 150 years, life expectancy in our country has more than doubled [1], maternal and infant mortality have fallen to a fraction of what they were in 1872 [2], and the importance of infectious diseases as a cause of death has been almost entirely replaced by heart and circulatory diseases or malignant neoplasms [3].

In the mid-19th century, tuberculosis was the number one death angel in Germany, apart from times of war and years of severe cholera epidemics; today, the “tubercle bacillus” Mycobacterium tuberculosis plays hardly any role in Germany [4].

Due to an adaptation process of various bacterial strains to the rapidly increasing use of antibiotics following the enormous success of Penicillin G in field hospitals during World War II, the golden age in the fight against bacterial infections is at stake [5]. Strains of different bacterial species are establishing antibiotic resistances combined with high virulence, and are developing into pandemic threats [6,7]. They are responsible for a large share of deaths worldwide related to bacterial infections. National leading institutions point to an expected resurgence of deaths from infectious diseases and call for general attention [8].

These infections have been closely monitored in hospitals, while outpatient settings and the general population are only gradually becoming aware of the situation. The permeability of the interface between inpatient care, nursing homes, and home care highlights a critical problem in this context [9]. It is questionable whether the hygiene standards found in current outpatient care at home or in shared living arrangements are sufficient to deal with this threat.

The Threat

In a comprehensive study, an inventory of deaths from antibiotic-resistant infections and their distribution across the continents was carried out for the year 2019 [6]. Modeling for the expected development up to the year 2050 shows an increase [7], which, even in the Western world, places death from infectious disease on an equal footing with death from cardiovascular diseases or malignant neoplasms. The seriousness of this situation is expressed, for those not directly affected, in the call for attention from national leading institutions and ministries [8].

Now, the grim reapers in the Western World are no longer Mycobacterium tuberculosis, but Escherichia coli, followed by Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa [6] (Table 1). The organism described by the physician Friedrich Escherich in 1885, isolated from the rectum of a girl, ranges in appearance from a beneficial gut commensal to a highly virulent pathogen. Various E. coli strains are equipped with genes for different pathways of antibiotic inactivation or toxin production [10-12], thereby offering a high diversity of virulence mechanisms.

Table 1: Pathogen spectrum and antibiotic resistance in community-acquired and nosocomial infections

A) Urinary tract infections, pathogen prevalence, antibiotic resistance.

Study objective

Pathogen spectrum

References

Pathogen spectrum uncomplicated cystitiscomplicated urinary tract infection E. coli (70–80%),Staphylococcus saprophyticus (5-15%), .IIn individual cases, other enterobacteria like Proteus mirabilis, Klebsiella spp. Enterococcus ssp.

E. coli and other enterobacteria, enterococci

Pseudomonas ssp.

[41] Wagenlehner et al.Urinary tract infections (UTI)Akt Urol 2014; 45: 135–146
Pathogens of catheter-associated urinary Tract infections E. coli (43,6%, ESBL-positive proportion 11,8%), Enterococcus spp. (23,0%), P. aeruginosa (10,7%), Klebsiella spp. (10,3%), Proteus spp. (9,6%),S. saprophyticus (2,2%),S. aureus (3,2%) [42] KRINKO at the RKI, Bundesgesundheitsbl 2015 · 58: 641–650 DOI 10.1007/s00103-015-2152-3
Nosocomial urinary tract infections and resistenciesUrosepsis pathogens global in urology70 countries

ca. 30.000 participants

(Prevalence Europe; Global)

E. coli (41%; 43%),P. aeruginosa (13%; 10%),Enterococcus (12%; 11%),

Klebsiella spp. (8%; 10%)

Enterobacter spp (6%; 6%),

Proteus spp. (4%; 4%)

Staphylococcus aureus (4;4)

Acinetobacter spp (1%; 2%)

45% of Enterobacteriaceae and 21% of P. aeruginosa multidrug-resistant.

[43] Tandoğdu Z, Bartoletti R, Cai T, et al. Wagenlehner R,Resistance patterns of nosocomial urnary tract infections in urology departments: 8-year results of global prevalence of infections in urology study. World J Urol 2013;
Pathogen spectrum and resistance rates in community-acquired uncomplicated urinary tract infectionsNationwide cross-sectional study in Germany 2019-212390 study participants E. coli (70,5%),Klebsiella pneumoniae (5,5%), Enterococcus ssp (5,2%), Proteus mirabilis (4,6%), Staphylococcus ssp (4,8%)Resistance rates in E. coli depending on previous infections, with a single infection being <15% [14] Klingeberg et al.,Dtsch Arztebl Int 2024; 121: 175-81; DOI: 10.3238/arztebl.m2023.0267

B) Pathogen spectrum in nosocomial infections in healthcare facilities.

Nosocomial infections in long-term care facilities in 2016German results of the HALT 3 study131 facilities

10,556 residents

Infectionsof the urinary tract (31.1%)of the respiratory tract (24.3%)

of the skin/soft tissue (23.7%)

21 microbiological diagnostics:

2 viruses, 1 fungus

6 E. coli, 3 Pseudomonas aeruginosa, 3 Streptococcus pneumoniae,

2 Staphylococcus aureus,

2 Clostridoides difficile

 

[13] Schmidt N. et al.,Bundesgesundheitsbl. 2022; 65: 863–871 https: //doi.org/10.1007/s00103-022-03566-3
Prevalence of nosocomial infections in German hospitals in 2016218 hospitals64,412 patients E. coli (16,6%),Clostridoides difficile (13,6%), Staphylococcus aureus (12%), Enterococcus faecalis (6,9%), Pseudomonas aeruginosa (5,8%) [44] Behnke M, Aghdassi SJ, Hansen S, Peña Diaz LA, Gastmeier P, Piening B: The prevalence of nosocomial infection and antibiotic use in German hospitals. Dtsch Arztebl Int 2017; 114: 851–7. DOI: 10.3238/arztebl.2017.0851

C) global impact and spectrum of pathogens of antibiotic-resistant bacteria.

Global burden of bacterial antibiotic resistance 2019for 23 pathogensin 204 countries the 6 leading pathogens associated with deaths related to antibiotic resistanceEscherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosaresponsible for approximately 929,000 deaths due to AMR and around 3.6 million deaths associated with AMR in 2019. [6] Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022 Feb 12;399(10325): 629-655. doi: 10.1016/S0140-6736(21)02724-0. Epub 2022 Jan 19.

Infections caused by Escherichia coli have long been clinically recognized, as they are responsible for a large proportion of urinary tract infections (UTIs) (Table 1). In the HALT-3 surveys on nosocomial infections in long-term care facilities, UTIs were recorded as the greatest burden in Germany on a reference day in 2016, with E. coli being the most frequently detected bacterium [13]. In a cross-sectional study from 2019-21 on resistance rates in community-acquired UTIs, E. coli was detected in 75.4% of cases, with a significant number of resistances against various antibiotics [14]. The second most frequently detected bacterium was Klebsiella pneumoniae.

In the HALT-2 study, methicillin-resistant Staphylococcus aureus was still in the foreground as the first notable antibiotic-resistant pathogen in the German healthcare system [15]. Antibiotic-resistant Staphylococcus aureus are known for causing wound infections and respiratory tract infections [16]. For the years 2021/22, a declining incidence of antibiotic-resistant Staphylococcus aureus was reported in Germany compared to other regions in Europe [17]. A problematic MRSA strain, which was able to spread in the USA and evolved from a skin and soft tissue infection pathogen to a sepsis-causing pathogen, has not established itself in Europe [18].

The report from the German national reference center for Gram-negative hospital pathogens can be regarded as a proxy for the burden of antibiotic-resistant bacterial infections [19]. The increase in submissions of bacterial isolates for the years 2022–2023 by more than 7%, mostly for the investigation of reduced carbapenem susceptibility or carbapenemase activity, reflects an actual rise in resistance to beta-lactam antibiotics as used in hospitals. In addition to the Enterobacterales E. coli and Klebsiella pneumoniae and others, Pseudomonas aeruginosa and Acinetobacter baumannii are also strongly represented.

The worldwide occurrence of highly problematic strains of the species Klebsiella pneumoniae [20], Acinetobacter baumanii [21], and Enterococcus faecium [22] highlights the issue at stake. Together with viral pathogens [23], they confront healthcare with changing challenges. In particular, elderly care and care provision in nursing homes seem to be on shaky ground [24].

The Challenge

Clean and Uncontaminated – Incorrect Teaching and Basic Assumptions

In the patient’s room, the geriatric nurse tells her student that “there are no bacteria in this clean room and no risk of contamination”. She then continues, saying she “does not need to disinfect the hands anymore since she already disinfected them in the hallway earlier”. After having changed her clothing, brushed her hair back with her hand, and touched two door handles after hand disinfection, 3 different ways of introducing germs, skin, hair, and cloths of care givers, but also surfaces in the patient surroundings, like door handles and bed control, since they are not freshly disinfected, are not recognized.

This kind of false communication in such a mixed teaching/nursing situation Is one reason for the establishment of entirely wrong beliefs in nursing students on pathogen sources (Ernsberger, 2024, not puplished). Indeed, a significant portion of the nursing staff in outpatient care share the belief that hand disinfection upon entering the care area ensures clean hands throughout the entire stay. Similarly, a surprisingly large number of nurses assume that they can assess the degree of contamination in a care area with the naked eye (Ernsberger, not published).

A striking example is the assurance by a senior managing caregiver that the urine in this drainage bag looks clear and clean. In fact, a few days earlier, laboratory tests had confirmed stable colonization with Pseudomonas aeruginosa in this urine at a density of >100,000 colony-forming units [25]. The colonizations that are reliably recognized as such by the outpatient care staff are in urine with clouds of bacteria aggregated in flakes. This corresponds to bacterial cultures in a senescent growth phase, which have gone hours or days beyond their exponential growth phase.

In these frequently observed cases in outpatient care, serious misjudgments by numerous caregivers become apparent. The knowledge that microscopy and time-intensive observation under suitable laboratory conditions were necessary to allow Robert Koch, for the first time 150 years ago, to make bacteria visible to the eye [4] is largely unknown. Equally unknown is the understanding of the historical development of concepts on the nature of infectious diseases and the germ theory of infection causation [26].

These case studies demonstrate how failures in teaching and evaluation may misguide nurses to decide for a non-appropriate safety level and disinfection regime for a planned workflow.

Hand Hygiene – A Surprisingly Demanding Matter

The “five moments of hand hygiene” defined by the WHO and specified in national guidelines [27,28] are considered the most effective single measure for preventing the spread of germs and the most useful means to reducing nosocomial infections. However, their full application to essential nursing routines, such as emptying a patient’s urine drainage bag and assisting with elimination, is not sufficiently followed by many outpatient care workers [24].

Deficient hygiene practice, inadequate training, and the lack of continuing education programs among outpatient care workers in a residential long term care facility, associated with the spread of MRGN4 Acinetobacter baumannii, highlights the scale of the problem [9]. Due to problems in hygiene competence, there is currently not sufficient protection against the spread of viral or bacterial pathogens in many home care settings.

In outpatient care, the WHO recommendations on hand hygiene, the section D [27], summary on the use of gloves, is most frequently violated. The section “D. When wearing gloves, change or remove gloves in the following situations: during patient care if moving from a contaminated body site to another body site” [27-30] is often not followed, and if followed, only efficient when the workflow is well structured. Especially when assisting with excretions, there are many opportunities for cross-contamination when both hands are involved [24]. Confusion of left and right hand will easily result in the spread of Enterobacteriales and Enterococci.

Focusing the work of one hand on tasks in contaminated areas, such as removing feces or operating the drainage port of the urine bag, and the other hand on tasks to be performed cleanly, such as supporting the patient, selecting hygiene papers, or operating the bed control, requires good preparation and high concentration (Table 2). Maintaining such a strait workflow for both hands, and not switching between sides, is not easily achievable for many caregivers. Errors at this time have the potential to transfer Enterobacteriaceae or Enterococcaceae from stool and, possibly, Pseudomonas aeruginosa from bacteriuria into the bed environment, the bathroom sanitary installations, hygiene paper storage areas, or even clothing via contaminated disposable gloves [31].

Table 2: Common misjudgments and hygiene violations and affected pathogens.

Hygiene violation or misjudgment

Affected activities or items

Affected or spread pathogens

Misjudgment of cleanliness Contaminated disposable gloves from assistance with excretions

assistance with urine from bacteriuria or urinary tract infection

surface not freshly disinfected for temporary storage

alle germs from previous activities

Escherichia coli, Enterococcus spp,
Klebsiella spp, Proteus mirabilis, u.a.

Escherichia coli, Pseudomonas aeruginosa,

Enterococcus spp. Klebsiella pneumoniae u.a.

poorly defined microbial mixture from the patient’s environment

Incomplete preparation Too little hygiene paper
Disinfection aid supplies forgotten
No suitable disposable gloves
During a hasty trip to the storage area, door handles, cabinet handles, and supply depot packages became contaminated with germs from the excretions (see above) due to wearing contaminated gloves
Inadequate hand hygiene Dirty hands perform tasks that need to be kept clean
when assisting with excretions
when emptying the urine bag
Fingernails and jewelry
With assistance with excretions; pathogens (see above) transferred to bed, control devices, surfaces, and in the storage area

urine drops and splashes pathogens (see above) transferred to bed, control devices

foreing pathogens

Inadequate training No employee notes With inaccurately remembered and shortened workflows, hygiene-relevant steps are forgotten from memory.

Pathogens, Their Nature, and Their Means of Transmission – An Underrated Subject in Care

Conversations about hygiene and causes of infection with nursing staff in outpatient care, unfortunately, often fizzle out very quickly. Language skills play a role, given the increasing number of nursing staff from countries with highly different language background. Personnel from countries with highly diverse language and cultural backgrounds shall be reached by educational and Informational texts on the nature, ways of transmission, and clinical pictures attributed to different pathogens [32].

Providing short and easy to read texts in the native language of nursing staff (arabic, amharic, english, german, serbo-croatian, vietnamese) has a 2-fold intention. On the one hand, they shall explain the reasoning behind certain hygiene protocols in light of the different transmission pathways of the different classes of pathogens. On the other hand, the hope is to spark interest by addressing caregivers in their mother’s language, and to sensibilise for the challenge set by the transmission pathways used by antibiotic-resistant bacteria.

A significant factor here is the commitment of the nursing management and the quality of training in the nursing service. However, it, unfortunately, is common practice that clients or patients of nursing services are not informed about continuing education activities, and they are also not announced on the nursing services’ websites.

Risk in Both Directions – The Correct Use of Personal Protection Equipment

The transmission of germs in outpatient care is not a one-way street. The spread of bacterial germs through contact and smear infection, coughing, or cuts and puncture injuries transmits pathogens both toward the care recipient and the caregiver. Similarly, the transmission route of viral pathogens through aerosols, coughing, or smear infection is initially open in both directions.

Personal protection equipment (PPE) [33], disposable gloves and mouth-nose masks provide tools that should protect the staff, i.e., caregivers, reliably. However, the effectiveness of these aids in protecting personnel depends on correct handling (Table 3). The proper handling of PPE also plays a central role when it comes to disposable gloves. Here, timely donning, as well as timely removal or changing, is of central importance (Table 2).

Table 3: Training and further education deficits in the face of highly virulent bacterial and viral pathogens.

Poor hygiene knowledge and awareness Too often a lack of interest in questions about the biology and clinical aspects of pathogenstoo often a lack of interest in clinical microbiologythe importance of hygiene for infection prevention remains unclear Knowledge of the nature and distribution of viral and bacterial pathogens is very limited
the design of aseptic work routines is too often inadequate [39]
hygiene is often considered a nuisance, and its central importance for personal and public health is not clear
Lack of awareness about the pathogen load of lifestyle accessories Jewelry, necklaces, braceletsFingernails and hair Transfer of germ profiles between/from patients, staff, and personal surroundings including pets, also directly into the patient’s bedGerm reservoir strongly dependent on prior activity, personal hygiene,in particular Staphylococci, Enterococci, and Enterobacteriales
Deficits in the use of personal protective equipment Putting on the mouth-nose protective mask too late and taking it off too early, removing it temporarilytaking off contaminated disposable gloves too late Transmission of bacterial and viral pathogens in droplets and aerosolsTransmission of all germs from the area of activity and work, including Enterobacteriaceae,Enterococci, Pseudomonas, Staphylococci
Insufficient knowledge of asepsis and lack of aseptic work routines The necessity to always disinfect surfaces in new care situations or after contamination is often not recognized.The point at which disposable gloves become contaminated is not recognized.The classification of work areas and procedures according to an ANTT [39] often seems unfamiliar. This way, germs from previous care procedures can be carried over into new workflows.Pathogens from assistance with excretions and emptying urine are spread in this process (see above).Often, unclean, open areas are chosen for temporary placement, and contaminations already present there are carried further.

The example of a caregiver (Ernsberger, unpublished), who attends to clients scattered throughout the neighborhood with one pair of gloves, is an example that hardly ever comes to public attention or legal scrutiny. This stands in reprehensible contradiction to the WHO recommendations ‘C. Remove gloves after caring for a patient – do not wear the same pair of gloves for the care of more than one patient.’ [27]. Such behaviour risks to deposit bacteria and other pathogen collection of unknown composition in the environment of a person in need of care and the caregiver himself.

This is an example to illustrate how important continued education Is for the knowledge of hygienic principles in outpatient care, not only in Germany, for the sake of Infection prevention and well-being of the people in need of care and the caregivers.

Final Considerations

Hygiene Violations – Poor Planning and Execution on Various Levels

For an observant person in need of care, it becomes apparent how many problems arise from incomplete work preparation (Table 2). A rushed walk of the caregiver in the middle of assistance with excretions to the supply rooms is often because not enough hygiene papers were prepared for assistance, or because the disinfectant spray was forgotten during urine disposal. Here, the careful, thoughtful preparation makes a decisive difference.

Of a different nature are two levels of hygiene violations: knowledge that should be present from recommendations and learning content Issued by leading institutes for healthcare.

For the classical task of emptying urine drainage bags, examples include the height of the urine bag to remain below bladder level, preventing drips at the drainage port, and disinfecting wiping of the same [34]. In assistance with fecal excretion, it is changing gloves before transitioning from wiping to putting on a new incontinence pant [35].

A new level seems to be emerging with the development of antibiotic-resistant bacteria. The is the impression that many caregivers are aware that such a problem exists, but not that it could occur in their outpatient work. It appears that education and training “providing information about the nature and occurrence of pathogenic germs” could form a foundation for care in the coming decades. This should be complemented by a detailed examination of the surfaces in the work environment and their potential germ colonization.

Asepsis and Antisepsis – A Puzzling Relationship for Many Home Caregivers

The aseptic non-touch technique (ANTT) [36], is not well established in outpatient care in Germany. The division of a work environment into areas that must strictly be kept clean and free of contamination, the distinction between areas with different levels of cleanliness or microbial load, and the planning of workflows to prevent contact with contaminated areas during steps that need to remain clean, is too often inadequate. The question of infection prevention and its monitoring in home care arises only late and has only become a subject of serious consideration after the COVID-19 pandemic [37].

Unfortunately, hygiene and discussions centered around this topic, pathogens, and the nature of infectious diseases are often perceived as unnecessary or disruptive in the usual care context. The legacy of Semmelweis, Pasteur, Lister, and Koch has not made the impact here that it did in general hospital care and particularly in surgery [38,39]. Looking at the massive damage caused by the SARS-CoV-2 pandemic in residential facilities [40], the question arises how a genuine interest in this health care pillar can be triggered, In particular to promote the development of evidence-based infection prevention in home care

Conclusions

Currently, too many working routines in outpatient care are not suitable for containing the spread of bacterial strains via contact infections, droplets, or aerosols.

One aim is a better education, verification and training, combined with appropriate reward and recognition. The establishment of antibiotic-resistant bacterial reservoirs in the environment of people in need of care, due to inadequate structuring of nursing routines, lack of knowledge about asepsis, or wearing hygienically inappropriate lifestyle accessories and jewelry, must be strictly avoided.

Demanding outpatient care services to document their level of training and certified continuing education in hygiene, aseptic work practices, the use of PPE for staff and clients, as well as knowledge in clinical hygiene on their websites provides a way to link an obligation for hygiene training and continuing education with an information duty towards clients

Conflict of Interest

The author, UE, states that there is no financial conflict of interest.

Acknowledgments

The author, UE, is grateful to Ute Wagner for extensive support and discussion on individual topics. The late specialist nurse Pedro Zieba contributed to initiating the project. Lorenz and Martin Sieber initiated the electronic working environment for preparing the manuscript (completely without AI and ChatGPT).

References

  1. https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Bevoelkerung/Sterbefaelle-Lebenserwartung/sterbetafel.html?templateQueryString=1+zu+10+rechner&templateQueryString=1+zu+10+rechner; Entwicklung der Lebenserwartung in Deutschland – Statistisches Bundesamt;
  2. https://www.bib.bund.de/DE/Fakten/Fakt/pdf/S10-Saeuglingssterblichkeit-ab-1872.pdf?__blob=publicationFile&v=4; S10-Saeuglingssterblichkeit-ab-1872.pdf;
  3. https://de.statista.com/statistik/daten/studie/1284105/umfrage/todesursachen-in-deutschland-historisch/;Todesursachen in Deutschland 1892-2010| Statista;
  4. Loddenkemper R (2007) Die Entdeckung des Tuberkelbacillus. Dtsch Ärztebl 104: A775.
  5. Jean SS, Harnod D, Hsueh PR (2022) Global threat of carbapenem resistant gram-negative bacteria. Front Cell Infect Microbiol 12: 823684. [crossref]
  6. Antimicrobial Resistance Collaborators (2022) Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 399: 629-655. [crossref]
  7. GBD 2021 (2024) Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance 1990-2021: a systematic analysis with forecasts to 2050. Lancet 404: 1199-1226. [crossref]
  8. Bundesgesundheitsministerium https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/G/G7/G7_AMR_de_2022.pdf; Antimikrobielle Resistenzen: Krankheitslast in G7-Staaten und weltweit;
  9. Schwerdtner N-L, Trommer S, Dietsch S, et al. (2020) Herausforderungen im Umgang mit MRE in außerklinischen IntensivpflegeWohngemeinschaften. Epid Bull 37: 3-11.
  10. Riley LW (2020) Distinguishing Pathovars from Nonpathovars: Escherichia coli. Microbiol Spectr 2020 8: 10. [crossref]
  11. Denamur E, Clermont O, Bonacorsi S, Gordon D (2021) The population genetics of pathogenic Escherichia coli. Nat Rev Microbiol 19: 37-54. [crossref]
  12. Nasrollahian S, Graham JP, Halaji M (2024) A review of the mechanisms that confer antibiotic resistance in pathotypes of E. coli. Front Cell Infect Microbiol 14: 1387497. [crossref]
  13. Schmidt N, Marujo V, Eckmanns T, Zacher B, Arvand M, et al. (2022) Healthcare-associated infections and antimicrobial use in long-term care facilities. German results of the third European point prevalence survey HALT-3]. Bundesgesundheitsbl 65: 863-871. [crossref]
  14. Klingeberg A, Willrich N, Schneider M, Schmiemann G, Gágyor I, et al. (2024) The percentage of antibiotic resistance in uncomplicated community-acquired urinary tract infections. Dtsch Ärztebl Int 121: 175-181. [crossref]
  15. Ruscher C, Schaumann R, Mielke M (2012) The challenge of infections and multiresistant bacteria among the elderly living in long-term care facilities. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 55: 1444-1452. [crossref]
  16. BfR, 2025, fragen-und-antworten-zu-methicillin-resistenten-staphylococcus-aureus-mrsa.pdf; https://www.bfr.bund.de/assets/01_Ver%C3%B6ffentlichungen/FAQ_deutsch/fragen-und-antworten-zu-methicillin-resistenten-staphylococcus-aureus-mrsa.pdf
  17. Layer-Nicolaou F, Strommenger B, Cuny C, Werner G (2023) Eigenschaften, Häufigkeit und Verbreitung von MRSA in Deutschland – Zur Situation 2021/2022. Epid Bull 44: 3-14.
  18. Planet PJ (2017) Life After USA300: The Rise and Fall of a Superbug. J Infect Dis 215: S71-S77. [crossref]
  19. Pfennigwerth N, Cremanns M, Eisfeld J, Hans J, Anders A, et al. (2025) Bericht des Nationalen Referenzzentrums für gramnegative Krankenhauserreger für das Jahr 2023. Epid Bull 2: 3-11.
  20. Jia X, Zhu Y, Jia P, Liu X, Yu W, et al. (2022) Emergence of a Superplasmid Coharboring Hypervirulence and Multidrug Resistance Genes in Klebsiella pneumoniae Poses New Challenges to Public Health. Microbiol Spectr 10: e0263422. [crossref]
  21. Ibrahim S, Al-Saryi N, Al-Kadmy IMS, Aziz SN (2021) Multidrug-resistant Acinetobacter baumannii as an emerging concern in hospitals. Mol Biol Rep 48: 6987-6998.
  22. Wei Y, Palacios Araya D, Palmer KL (2024) Enterococcus faecium: evolution, adaptation, pathogenesis and emerging therapeutics. Nat Rev Microbiol 22: 705-721. [crossref]
  23. Olano JP, Walker DH (2009) Agents of Emerging Infectious Diseases. Vaccines for Biodefense and Emerging and Neglected Diseases 30: 1-20. [crossref]
  24. Ernsberger U (2024) Pathogen-Verkehr am Patientenbett. HygMed 49: D43-D51.
  25. Ernsberger U (2025) Interrupting the spread of germs : The art of emptying urinary drainage bags. Urologie [crossref]
  26. Karamanou M, Panayiotakopoulos G, Tsoucalas G, Kousoulis AA, Androutsos G (2012) From miasmas to germs: a historical approach to theories of infectious disease transmission. Infez Med 20: 58-62. [crossref]
  27. WHO, 2009. Glove-use-information-leaf let.pdf (who.int) https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/infection-prevention-and-control/hand-hygiene/tools/glove-use-information-leaflet.pdf?sfvrsn=13670aa_10
  28. RKI, 2023. Medizinische Einmalhandschuhe und Schutzhandschuhe: Indikation und Desinfektion; https://www.rki.de/DE/Content/Infekt/Krankenhaushygiene/ThemenAZ/H/Handschuhe.html
  29. Gartmeier M, Baumgartner M, Burgkart R, Heiniger S, Berberat PO (2019) Why hand hygiene is not sufficient: modeling hygiene competence of clinical staff as a basis for its development and assessment. GMS J Med Educ 36: Doc39. [crossref]
  30. Imhof R, Chaberny IF, Schock B (2021) Gloves use and possible barriers—an observational study with concluding questionnaire. GMS Hyg Infect Control [crossref]
  31. Ernsberger U (2022) ESKAPE-Pathogene und -Infektionsketten – benutz te Einmalhandschuhe als Pathogen-Vektoren. Hyg Med 47: D44-D51.
  32. Ernsberger U (2023) Viren und Bakterien als Infektionsauslöser. Pflege Z 76: 34-35. [crossref]
  33. Hill B, Lamichhane G, Wamburu A (2024) Infection prevention and control: critical strategies for nursing practice. Br J Nurs 33: 804-811. [crossref]
  34. Ernsberger U (2021) Hygiene-Defizite bei der Versorgung suprapubischer Blasenkatheter und der Urinentleerung durch Pflegedienste in derhäuslichen Pflege. HygMed 46: D50-D57.
  35. Ernsberger U, Hilfe bei Ausscheidungen“in der häuslichen Versorgung bei bettlägerigen Pflegebedürftigen. HygMed 2023; 48: D36-D44.
  36. Clare S, Rowley S (2018) Implementing the Aseptic NonTouch Technique (ANTT®) clinical practice framework for aseptic technique: a pragmatic evaluation using a mixed methods approach in two London hospitals. J Infect Prev 19: 6-15. [crossref]
  37. Brockhaus L, Sass N, Labhardt ND (2024) Barriers and facilitators to infection prevention practices in home healthcare: a scoping review and proposed implementation framework. Infect Prev Pract 6: 100342. [crossref]
  38. Lepenos T, Sanoudou D, Protogerou A, Laios K, Androutsos G, et al. (2024) Louis Pasteur (1822-1895), Ignaz Semmelweis (1818-1865), Joseph Lister (1827-1912) and the Link Between Their Works Toward the Development of Antisepsis: A Narrative Review. Cureus 16: e62543. [crossref]
  39. Nakayama DK (2018) Antisepsis and Asepsis and How They Shaped Modern Surgery. Am Surg 84: 766-771. [crossref]
  40. Mbalayen F, Dutheillet-de-Lamothe V, Letty A, et al. (2022) The COVID-19 pandemic and responses in nursing homes: a cross-sectional study in four European countries. Int J Environ Res Public Health 19: 15290. [crossref]
  41. Wagenlehner FM, Pilatz A, Naber K, Weidner W (2014) Harnwegsinfektionen. Aktuelle Urol 45: 135-145.
  42. KRINKO beim RKI (2015) Prävention und Kontrolle Katheter-assoziierter Harnwegsinfektionen: Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 58: 641-650. [crossref]
  43. Tandoğdu Z, Bartoletti R, Cai T, Çek M, Grabe M, et al. (2016) Antimicrobial resistance in urosepsis: outcomes from the multinational, multicenter global prevalence of infections in urology (GPIU) study 2003-2013. World J Urol 34: 1193-200. [crossref]
  44. Behnke M, Aghdassi SJ, Hansen S, Peña Diaz LA, Gastmeier P, et al. (2017) The prevalence of nosocomial infection and antibiotic use in German hospitals. Dtsch Arztebl Int 114: 851-857. [crossref]

Commentary: Rethinking Cultural Narratives of Infertility in Nigerian Cinema

DOI: 10.31038/AWHC.2025834

 
 

This study makes a noteworthy contribution to psychological research on reproductive health by revealing how cultural narratives shape personal experiences of infertility. Through a deconstruction of a hand‑picked array of Nollywood titles, the analysis draws a detailed picture of how entrenched convictions about motherhood, femininity, and marital expectations still map out the social and emotional landscape of infertility throughout Nigeria. The commentary then pulls apart the ramifications of these representations, pondering how media can either uphold or disrupt the prevailing norms.

Infertility stakes a claim in a sensitive, symbol‑laden corner of social life, where a woman’s sense of self is often judged by whether she can bear children. The movies surveyed reveal that infertility is far from a medical issue; it morphs into a public proving ground for character, virtue and societal worth. The women portrayed shoulder a load: unrelenting family pressure, biting social scrutiny and a deep‑rooted internalised shame.

The psychological strain that follows springs not from the inability to conceive but also from the cultural weight that childlessness carries. Jane, the protagonist of Wives and Infertility and Judith from 3 Nights and 3 Babies both lay bare how being stripped of agency can gnaw at a woman’s emotional core, seeping into every corner of her life. Their retreat, lingering grief, and the fear they keep locked inside echo the patterns repeatedly documented in research on infertility.

These movies illustrate how cultural myths that dump all responsibility onto women amplify the emotional weight they bear. By omitting any portrayal of infertility, the narratives reinforce gendered stereotypes that warp help‑seeking habits and postpone necessary medical care. This pattern mirrors real‑world trends where men tend to avoid fertility testing while women shoulder sanctioned blame. Such cinematic depictions matter because films function as mirrors, giving audiences the language to interpret infertility. When blame lands one‑sidedly and drags a stigma along, the mental repercussions are heavy. Self‑reproach, strife, and an ever‑growing sense of social isolation keep reappearing.

Even as the films delicately convey this heft, they simultaneously lay bare a deeper contest for self‑determination within the confines of patriarchal homes. Women navigate, endure and at times subtly push back against prescriptions, yet they often do so in muted tones, preserving both dignity and communal equilibrium. This understated bargaining mirrors the doctrines of nego feminism, which recognises that resistance, across African milieus, seldom erupts as overt confrontation. Instead, it emerges as calculated decision‑making that lets women persist within bounded environments. The psychological fallout of these coping tactics is, predictably, a tapestry. They may shield women from the social fallout, but in doing so, they leave them shouldering quiet, hidden emotional burdens that seldom get acknowledged.

The results also prompt questions about how the media either reinforces or challenges stigma. Nollywood’s reach spans millions, throughout Africa and its diaspora. When movies tie a woman’s identity closely to biological motherhood, they help shape a psychological climate that barely leaves room for alternative routes to building a family. The negative depiction of adoption and assisted reproduction in the films examined is especially worrisome, hinting that modern fertility solutions remain shadowed by suspicion and moral anxiety. These ramifications reach into health inform public‑health education and shape the broader societal openness to a range of reproductive choices.

At the time, the rich emotional texture of movies such as The Wait hints that Nollywood could indeed steer public opinion in a new direction. The support group shown in the film, for instance, carves out a space where shared vulnerability can surface and psychosocial healing can take root. If storytellers lean into arcs, they might spark healthier conversations about infertility by bringing male infertility into view, portraying reproductive technologies in a positive light and crafting narratives that affirm women regardless of their reproductive outcomes.

Ultimately, the paper invites psychologists, media scholars and public‑health practitioners to reflect on how cultural narratives intertwine with well‑being. It stresses that portrayals need to be more balanced while recognising infertility as a shared burden and encouraging empathy rather than judgment. As stigma keeps women and couples unheard, Nollywood still offers a powerful stage for rewriting the cultural scripts that shape attitudes and behaviour.

The study clears a trail for cross‑disciplinary ventures that knit together film, psychology, gender studies and public health. It urges a re‑imagining of reproductive narratives with one that honours infertility’s lived realities while refusing to amplify the surrounding cultural anxieties. By framing infertility as a shared challenge rather than a personal moral lapse, Nollywood can chip away at stigma and foster healthier psychological outcomes for the individuals and families navigating this intricate experience.