Diagnostic radiology examinations are generally very efficient processes optimized for high throughput and for serving the needs of physicians. On the downside, streamlined examinations disrupt the personal relationship between diagnosticians and patients. The radiology associations RSNA and ACR consider low visibility of radiologists a threat to the profession. Therefore, they launched counter-acting initiatives that aim at increasing patient satisfaction by providing more personal attention and care, and by raising knowledge about the discipline. However, they did not formulate concrete instructions on how to integrate care by radiologists into the examination process while inhibiting the flow minimally. From an internal patient satisfaction survey, we have seen that patients rated satisfaction with care and attention by physicians relatively low, indicating that patients would welcome a possibility to communicate with radiologists. In a controlled experimental setting, we have then changed our process to include a short medical history interview. Thereby we could corroborate that lack of educated communication is the primary cause of diminished satisfaction and could establish that the duration of the encounter is not critical to achieving improvement. Importantly, the interview also helped to improve the quality of the examination. Thus, short medical history interviews are a very efficient way to increase value by maximizing patient satisfaction and examination quality. Our approach is easy to implement in other radiology clinics that are interested in becoming more patient-centered and in raising patient satisfaction. Radiology examinations constitute an essential and indispensable part of modern medicine and accordingly cause a considerable fraction of health care costs ,2. HenceIt is well established that communication between patients and physicians influences the quality of medical care . PatientGiven the importance of patient involvement in the medical care process, the lack of possibilities for patients to talk to the radiologists seems to be detrimental. The radiological associations ACR and RSNA consider this shortcoming a potential threat to the profession and therefore promote a more patient-centered radiology , 12. HenFor internal purposes, we conducted a patient satisfaction survey and became aware that patients rated attention and care by physicians low when they had no contact with radiologists. We tried to address that problem in a controlled experimental setting by imposing a patient-doctor interaction that was minimally interruptive for radiologists. This change in the diagnostic radiology process raised patient satisfaction to a level that was comparable to much longer interactions and incidentally improved the quality of radiologic examinations. Thus, we describe an approach to reconcile the need of patients to communicate with the need of process optimization in diagnostic radiology and provide a blueprint for a patient-centered and efficient radiology.We performed the study in accordance with the policy of the Institutional Review Board  of the Kanton of Bern (Switzerland). As we documented neither the patients’ names, birth dates, nor their sex or other parameters that could identify the individual patient, an informed signed consent was waived by KEK-Bern (Reg-2016-00729).For internal organizational purposes, we wanted to conduct a patient survey in order to get objective data on what is going well and where there is room for improvement in our radiologic examination processes, putting emphasis on magnetic resonance imaging. The composition of the survey was based on the prime consideration that patients want to be treated competently, quickly, friendly, and caringly , 12, 16.In order to be all-embracing and meaningful, the survey was intended to cover all steps of the examination that are visible to patients. On the other hand, being considerate of the target group we also put emphasis on a clear design according to the corporate design guidelines of our hospital, good readability, and big font size, thus limiting the amount of questions . TherebyOverall, we formulated two questions about general satisfaction and fifteen questions about relevant steps of the radiologic examination process , accountAn accompanying message of greeting asked the patients to answer the questionnaire truthfully and informed that the answers would not have any influence on the medical treatment whatsoever . After tThe questionnaire was validated in 2013 when a big internal survey was conducted within 5 weeks comprising about 600 patients, who had been examined by 6 different modalities . The colAn apparent correlation of satisfaction with care by physicians and the visibility of radiologists led us to hypothesize that satisfaction of patients with their attending radiologists is not only based on a basic trust in the medical expertise, but also on the possibility to communicate about their medical state. However, it was not clear to what extent a radiologist would have to engage in patient care in order to reach levels that are associated with a 30-minutes (ultrasound-) exam. We also were undecided whether it would be better to communicate a provisional diagnosis after the exam or discuss the medical history prior to the exam. Organizational constraints led to the plan to introduce a medical history interview for MRI-patients prior to the exam. One year later in 2014, we implemented this process change. The survey was conducted concomitantly with the implementation of interviews for about one month and was performed as a prospective, observational, and mono-center study.In 2015, we repeated the survey again and questioned both MRI- and ultrasound-patients throughout the year Since when does the ailment exist?[Place for] Description of the ailment/sketchBesides, a check box about the need to change the original MRI protocol was introduced. The percentage of such adaptations due to insights from the interviews was taken as a quality measure .The study was conducted at the Institute of Diagnostic Radiology at the Inselspital Bern, the largest radiology practice in Switzerland. Inclusion criteria were non-restrictive: the patients had to be adult, to be willing to participate, and to be able to read and to understand the questionnaire. Participants were both in- and out-patients and examined by either MRI, CT, ultrasound, conventional X-ray, angiography, or fluoroscopy. The present study summarizes results from three rounds/years of interrogations conducted between 2013 and 2015 Tables .left blank or answered. Potential differences in the distribution of those classes were tested by chi-square statistics and expressed as derived P-values. Statistical significance was set at P values <0.01. The calculations were performed with the statistics program STATA2, version 12.1 .Survey data are expressed as percentages of answers with positive grading, i.e. as the relative occurrence of grades 6, 5, and 4. A 95% Wilson confidence interval was determined for those values. For each question, grades were then categorized into positive  and negative  classes. Besides, we classified responses as either We designed an anonymous patient survey that depicted the most relevant steps of the radiological exam process from the patient’s perspective , proper information (three questions), care and empathy (two questions), and waiting times (three questions) see . Besidesphysicians (rather than radiologists) and about the quality of care that they have received by physicians.As we did not have empirical data about how informed our patients are about the occupational profile of technologists and radiologists and about their knowledge of radiologists being physicians, we were especially interested in questions 9 and 13. There we asked whether they have had contact with Additionally, we queried three general subjects by multiple choice to record the modality, the type of stay, and the perceived absolute waiting time (questions 1 to 3).We asked patients to grade akin to the Swiss school grading system on a sexpartite scale from maximally 6 points to minimally 1 point; they were also free not to answer a question. In the Swiss school system, grades equal or greater than 4 are positive and grades smaller than 4 are negative.In the first year, 93% of the questionnaires handed out were returned, in the second year 91%, and in the third year 94% .As we conducted the survey anonymously, we could not link the obtained results to age groups, sex, or diseases.The total study population comprised of 761 out- and 215 in-patients and the status was unknown in 27 participants. Most patients underwent MRI-scans (n = 438), followed by conventional X-ray scans (n = 195), and ultrasound examinations (n = 183) Tables , derivedOverall, patients graded very approvingly such that survey results were highly skewed to grade 6 or 5 , Table 121.3% of the participants rated uniformly with the highest grade “6”, one-third of them answering all questions .Usually, patient satisfaction is highly dependent on the waiting time . To testLikewise, it is conceivable that satisfaction with the hospital in general would have an impact on the satisfaction with radiology. E.g., it has been shown that the objective physical environment affects satisfaction levels in in-patients and outpatients divergently . We therA closer analysis of our first-year survey results revealed in part significant differences in the average satisfaction between ultrasound and MRI patients .This result was to be expected for two questions: 1) question 5 relating to an MRI-safety questionnaire handed out to MRI patients only and 2) question 11 concerning the pleasantness of the exam, which is perceived inconvenient by many MRI patients. Moreover, ultrasound patients significantly rated contact with and care by physicians (questions 9 and 13) better than patients who underwent MRI . At our We therefore hypothesized that satisfaction with physicians was dependent on their presence and visibility to patients.very much to none at all) for esthetical reasons. We scrutinized that statement and additionally interrogated in a structured manner 38 ultrasound patients (who had continuous contact with radiologists) and asked the 22 patients rating lower than 6 about their motivation , we were wondering about the apparent negative rating of question 9 enquiring contact with physicians , Fig 1. tivation . Each 10We noticed that patients left some questions unanswered , Table 5We, therefore, stratified our sample and classified responses as being answered or being void. Potential deviations in the distributions were assessed by chi-square statistics . Especially, we were interested in whether response rates correspond to peculiarities of the radiology exam process. For example, question 5 was specifically created for MRI patients and was answered by more than 96% of the MRI patients, but by less than 75% of the ultrasound patients who did not get the enquired MRI safety questionnaire. There was also a significant difference in the response rate for questions about contact with and care by physicians: e.g., MRI patients without contact had lower response rates than ultrasound patients . We hypoFace of Radiology and 5 Patients per Day campaigns [The survey data suggested to us that patients would appreciate a personal contact with a radiologist. Based on experience and processual needs we decided that a patient-to-radiologist contact should be best in the context of a short interview prior to the exam. A medical interview would create more patient value than a mere “meet and greet” introduction of the examiner as suggested by the ampaigns , 15. TheConcomitant to the introduction of interviews by radiologists we surveyed our MRI-patients using the same questionnaire . In the first round, 86% of 182 surveyed MRI-patients had short medical interviews prior to the scan. In the consecutive year, we surveyed a group of 47 MRI patients who had an interview and an even group without interview , S1 Fig.Patients rated care by physicians significantly better when they had an interview and the increase in grading was even more accentuated in question 9 about contact with physicians as discussed before . StrikinIf the appearance of a radiologist leaves such an impression on the patients, one might argue that a simple “meet and greet” would have a similar effect on patient satisfaction and thereby would be even more effective. In order to scrutinize that possibility, we conducted an analysis of 2700 medical history protocols of MRI-patients authored from introduction of interviews upon the end of surveying.Overall, we found 27 (1%) cases where the originally specified MRI examination protocol  had to be changed due to information from the medical interview. The reasons for the alterations have been extracted from the respective patient records and are listed in Presumably, protocol changes related to choosing another body region would not have remained undetected by our radiology technologists, but most of the other adaptations required medical competence.Radiology Cares, Patient-Centered Radiology, Face of Radiology, Five Patients a Day, or Imaging 3.0 [Radiology Cares initiative stresses patient experience and advocates a “meet and greet” prior to the exam and a discussion of results after the exam. It is conceivable that the campaign has not been rigorously implemented, because exact instructions on how to introduce such drastic changes in the examination process and outcome measurements about the respective impact and usefulness of such measures were not given.Possibly, radiology is the medical discipline most affected by technological advances . Technolging 3.0 –15. E.g.To the best of our knowledge, this is the first systematic study to confirm the importance of a medical interview prior to diagnostic radiology exams for both patient satisfaction and examination quality. Others have addressed the interesting questions whether radiologists should communicate the findings of the examination and their impressions directly to patients and thereby communicate with their patients after the exam –23 or haWhen we started with an ordinary patient satisfaction survey in our diagnostic radiology department, we first noticed that patients rated contact with and care by physicians relatively low when compared to calibrator questions that allowed us to establish base levels in grading:Interrogation about the subjectively perceived examination comfort or about waiting time defined the baseline of patient satisfaction, even though there was a very positive prevailing mood in the replies with 21% of the responders giving only maximal scores. It was therefore unexpected that the question about contact to physicians was skewed towards seemingly negative values. A sample testing then revealed that patients were in part confused about the apparently ambiguously phrased question and gave a quantitative assessment rather than a grade.We further noticed that a majority of patients answered a question addressing a MRI-safety questionnaire, even when they were examined by another modality and did not receive a questionnaire. A closer analysis revealed that although a majority of our patients responded to every question, the response rate about the MRI-questionnaire was only high for MRI-patients and significantly lower amongst other patients Tables  and 7. SIn summary, we concluded that both the rating and the withheld answers indicate that patients would welcome an opportunity to discuss and share their history with a radiologist.After an internal discussion involving all stakeholders, covering all aspects of the examination process, and respecting spatial conditions, we decided to introduce a short medical history interview for MRI patients prior to the exam. We chose the modality because of a convenient proximity of the diagnostic workstations and the tomographs and because of a manageable number of patients.Approximately one year after the first round of surveying the mandatory implementation of a medical history interview with our MRI-patients was established. The radiologists received a “medical history questionnaire”, which provided structure for the interview and included a check box about the need to change the originally scripted MRI protocol. The fraction of protocols that were adapted due to information from the interview was taken as a medical quality indicator. Independently, we repeated the survey amongst some MRI-patients. In the following year, we conducted the survey again amongst ultrasound-patients and one group of MRI-patients receiving a medical interview and another group of MRI-patients who had no interview.Strikingly, over the years there was a remarkably constant appraisal of our services. Satisfaction with the friendliness and competence of our staff, waiting times, as well as potential recommendation and general satisfaction did not vary throughout the survey period and were independent of the examination modality. Likewise, modality-specific deviations or the marred attitude of patients with long waiting times prevailed over the years.Only when the process changed, patients gave the respective feedback. As expected from the scrutinized first-year survey results, patients appreciated the attention by radiologists. What was surprising, however, was the extent of patient value achieved by a medical history interview lasting for approximately 3 minutes. Approval rating achieved levels typical of examinations requiring constant, ca. 30-minute care by a radiologist.We interpret this result to mean that it is the mere existence and the resulting quality of radiologist-to-patient contact that increases patient satisfaction to a quantitatively maximal level. In other words, 3 minutes patient care are as effective in achieving patient satisfaction as a 30-minute close encounter during an ultrasound examination.Our work may be seen in the context of ample of literature on the importance of patient satisfaction in radiology and its economic value , therebyThere are many possibilities where radiologists could interact and communicate with their patients and create trust. We have chosen a way that fits into the constraints imposed by a high-throughput hospital and believe it is generally applicable. Our fundamental hypothesis is that the mere possibility to get sympathetic personal attention of a physician increases patient satisfaction. This would imply that interactions ranging from low-threshold handshakes to communication of diagnoses would have similar impacts. However, there are more dimensions beyond the scope of this study to the abstract value of “satisfaction” and the reduction to a sexpartite scale may not be an adequate tool to cover the whole spectrum. In this context, it would be interesting to validate the quality of the radiologist-patient communication, e.g. by differentiating between verbal, non-verbal communication, and clinical empathy.We only evaluated patient feedback in a single institution and hence we cannot completely exclude that variable local practice patterns and traditions could influence the impression of medical interviews on patients. However, the Bernese might be a little bit slower, but they are not fundamentally different. In this respect, we would encourage other clinics to conduct similar initiatives in order to understand patient experiences better in their own setting.In addition, our evaluation of the patient experience largely related to experiences occurring during the patient’s time in the radiology department. The total patient experience may be considered more widely to encompass a broader spectrum of contexts, ranging from the time when the examination is first ordered, to the referring physician receiving the results and taking the appropriate action for the patient.Further limitations are the missing information of age/sex of the included patients and that though we explored associations between various themes and patient satisfaction, these were not associated with downstream health outcomes.Based on our findings we suggest implementing medical history interviews as a better alternative to “meet and greet” style “Radiology Cares” encounters, because interviews have a specific, additional, and beneficial effect on the conformity of the examination protocol. Thus, a medical interview increases patient value by affecting both patient satisfaction and the planning quality of radiologic examinations.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S7 TableSatisfaction with radiologists was significantly higher amongst patients who had a personal contact.(DOCX)Click here for additional data file.S8 TableSatisfaction with radiologists was significantly higher amongst patients who had a personal contact.(DOCX)Click here for additional data file.S1 Fig(PDF)Click here for additional data file.S2 Fig(PDF)Click here for additional data file.


Engaging in effortful self-control can sometimes impair people’s ability to resist subsequent temptations. Existing research has shown that when chronic dieters’ self-regulatory capacity is challenged by prior exertion of effort, they demonstrate disinhibited eating and altered patterns of brain activity when exposed to food cues. However, the relationship between brain activity during self-control exertion and subsequent food cue exposure remains unclear. In the present study, we investigated whether individual differences in recruitment of cognitive control regions during a difficult response inhibition task are associated with a failure to regulate neural responses to rewarding food cues in a subsequent task in a cohort of 27 female dieters. During self-control exertion, participants recruited regions commonly associated with inhibitory control, including dorsolateral prefrontal cortex (DLPFC). Those dieters with higher DLPFC activity during the initial self-control task showed an altered balance of food cue elicited activity in regions associated with reward and self-control, namely: greater reward-related activity and less recruitment of the frontoparietal control network. These findings suggest that some dieters may be more susceptible to the effects of self-control exertion than others and, whether due to limited capacity or changes in motivation, these dieters subsequently fail to engage control regions that may otherwise modulate activity associated with craving and reward. Broadly defined, self-regulation refers to the human capacity to flexibly regulate thoughts, emotions, and behaviors. Self-control, in particular, describes those situations in which self-regulatory processes are engaged to inhibit prepotent or automatic impulses, especially when these impulses conflict with other goals . In situMost recently, the consensus appears to be that the available evidence, in favor of and/or against self-regulatory depletion effects, is inconclusive . Howeversome dieters may be more prone to self-control failure than others. For example, prior work in our lab has shown that those dieters who experience weaker food cravings and more positive mood in daily life are also most successful in controlling impulses to eat  as they frequently demonstrate weight fluctuations, weight gain, and self-control lapses , includis to eat . Anothers to eat . HoweverTo address these questions, we used functional neuroimaging in the present study to examine individual differences in the neural correlates of effortful self-control among chronic dieters and related activation in prefrontal regions associated with response inhibition to subsequent recruitment of control and reward-related brain areas during exposure to appetitive food commercials. In addition to their constant deployment of self-control, the dieting population is characterized by a motivation to regulate food intake, allowing for cleaner operationalization of self-control success and failure. In a recent brain imaging study, dieters randomly assigned to first complete an effortful self-control task showed, on average, significantly higher activity in orbitofrontal cortex (OFC), a key region in the brain’s reward system;  during sWork in cognitive neuroscience has identified lateral prefrontal cortex as a robust neural correlate of self-control, indexing one’s capacity to engage in response inhibition see . Additioa priori regions/systems of interest, namely the frontoparietal control network, which enables flexible exertion of self-control  altered brain responses during subsequent exposure to food commercials, and (2) ad libitum eating patterns following a later diet breaking episode. To test these hypotheses, we first measured brain activity as dieters performed an effortful self-control task in which they were required to actively inhibit reading a series of words that appeared on the screen over the course of seven minutes. Following this, participants engaged in a food-cue reactivity task involving food commercials that has previously been shown to reliably recruit the brain’s reward system . This du-control , and key-control .more recruitment of prefrontal cortex during effortful self-control, indexing task difficulty and/or the experience of effort, would subsequently show less recruitment of the frontoparietal control network and therefore more reward-related activity in OFC and VS when viewing food commercials—thus serving as evidence of a failure to appropriately engage self-control systems when confronted with appetitive food stimuli. Finally, we also hypothesized that higher PFC activity during effortful self-control, and/or lower frontoparietal (vs. reward) balance scores, would be associated with more disinhibited eating following a diet breaking episode—as measured in separate experimental session with the same participants.To constrain our hypotheses about potential relationships between PFC activity during effortful self-control and subsequent recruitment of control (vs. reward) regions during food cue exposure, we based our hypotheses on prior neuroimaging studies  that sugage = 19.48, SDage = 1.11) were recruited from the Dartmouth community to participate in a two-part neuroimaging study for course credit. Dieting status was assessed by the Restrained Eating Scale  commercials that were matched for duration and level of engagement and interest . At the conclusion of the scanning session, we asked participants to report on their experiences of the effortful self-control control task. Specifically, they provided ratings on a 1–7 scale in response to questions that asked: “How difficult did you find this task?” and “How much did this task ‘tire you out’ or make you feel mentally exhausted/fatigued afterwards?”Approximately one week after the scanning session, participants returned to the lab for a follow-up behavioral session, consisting of a commonly used milkshake preload manipulation  followedhttp://github.com/ddwagner/SPM8w). First, we carried out standard preprocessing procedures for both inhibitory control and cue reactivity tasks, to account for motion related artifact (by including six motion regressors in first-level GLM model specifications) and increase images’ signal-to-noise ratio via spatial smoothing (8-mm FWHM kernel). Between the two tasks, five participants’ data were excluded due to excessive motion, defined as ≥ 2 instances of ≥ 2 millimeters of movement in the x, y, or z plane . In the case of the main analysis (relating DLPFC activity to subsequent food cue reactivity), there were 26 participants who had complete data across those two measures. So, for those reported analyses, N = 26.All analyses of neuroimaging data were conducted using SPM8 , along with tools for batch preprocessing and analysis  and using spatial autocorrelation function parameters (via 3dClustSim’s “acf” option)—as per recent recommendations .Brain data for the two tasks were separately modeled and analyzed. First, for the effortful self-control task, we ran a whole-brain univariate GLM analysis at the first (subject) level, with two regressors specifying when words appeared on the screen and when words were absent . The main contrast of interest (words present vs. absent) identified period of the task when participants were actively engaging in self-control. Group-level T-maps were then generated using random effects analysis of all subjects’ word present-versus-word absent contrast images. To correct for multiple comparisons, we performed cluster-based correction via the AFNI tool ndations . These sX = 30, Y = 42, Z = 24) using a spherical ROI with a 6-millimeter radius. Additionally, given the role the frontoparietal network plays in cognitive control generally, and self-regulation of eating more specifically  and control (product) events. Next, contrast images were calculated to compare activity when food events occurred relative to that when control events occurred. Other commercial content  were modeled as baseline. We extracted food cue related activity from these contrast images using independently defined, -control ; and two-control . We sele-control . HoweverN = 828;  to re-coZ-scored), averaged activity in the frontoparietal control network and activity in reward regions . Higher balance scores represent relatively greater recruitment of the frontoparietal control network, whereas lower balance scores represent relatively greater recruitment of reward regions; this procedure and operationalization of a brain-based balance measure followed that of Lopez and colleagues’  during food cue exposure in the second fMRI task. This relative recruitment was captured by regulation–reward balance scores, which were calculated on a subject by subject basis by taking the difference of standardized , SD = 1.21, t(26) = 3.99, p < .001, Cohen’s d = 0.77; this value was significantly greater than dieters in a control condition from a similar study, t(26) = 3.09, Cohen’s d = 0.60, p = .005. The self-reported measures of difficulty and tiredness were not correlated with one another, r(25) = 0.004, t = 0.02, p = .985, so they were entered in as separate covariates in multiple regressions models described below. Next, we observed that across all 8 nodes of the FP network, there was significant activity in the first fMRI task during effortful self-control , mean parameter estimate = 0.159 (95% CI [0.092–0.226]), SD = 0.169, t(26) = 4.89, Cohen’s d = 0.941, p < .001.First, as a manipulation check, we examined participants’ ratings of their experience of the first (effortful self-control) task they completed in the scanning session. On average, participants found the task to be difficult, as inferred from a one-sample r(24) =  − 0.574 , b =  − 2.30, p = .002 , t(19) =  − 3.445, p = .003. In this multiple regression model, neither task difficulty  =  − 0.261, p = .797) nor tiredness  = 0.630, p = .536) was associated with balance scores. Additionally, upon examining zero-order correlations, self-reported difficulty was not associated with DLPFC activity during the effortful self-control task  or balance scores during food cue reactivity . This was also true for self-reported tiredness, which did not correlate with DLPFC activity  or balance scores .To relate brain activity during effortful self-control to subsequent food cue reactivity, we first calculated the correlation between brain activity in this region and the relative balance of activity in frontoparietal (vs. reward) regions during exposure to food commercials. There was a significant negative association, such that those participants who more readily recruited the DLPFC during the effortful self-control task had lower balance scores when viewing food commercials, .002 see . Importar(24) =  − 0.403 , b =  − 0.302, p = .041, and this relationship remained after controlling for self-reported difficulty and tiredness and BMI, b =  − 0.339 , t(19) =  − 2.168, p = .043. Critically, the association between frontoparietal network recruitment during effortful self-control was only observed with balance scores during food cue-exposure. Specifically, there was no relationship between FP network activity during self-control and subsequent FP network activity during cue-reactivity, r(24) =  − 0.206, t =  − 1.03, p = .313, nor was initial FP network recruitment associated with reward system activity during cue reactivity, r(24) =  − 0.081, t = 0.40, p = .693. To rule out influences of nuisance variables  we extracted parameter estimates based on an anatomical mask of the hippocampus (a region not engaged by either task) and found no relationship during the first self-control task and balance scores in the cue reactivity task, r(24) =  − 0.09, t =  − 0.444, p = .661.Next, consistent with the negative association between DLPFC activity during effortful self-control and balance scores during subsequent exposure to food cues, there was also a significant negative relationship between average recruitment of the frontoparietal network activation during effortful self-control and balance scores in the cue reactivity task, SD = 40.8, range: 9–158 grams), and there was a positive  correlation between recruitment of DLPFC during effortful self-control and grams of ice-cream consumed, r(24) = 0.319, t = 1.647, p = .112. There was also a negative, non-significant relationship between balance scores and grams of ice-cream consumed, r(24) =  − 0.309, t =  − 1.594, p = .124.Finally, we examined links between activity in the effortful self-control/cue reactivity tasks and ad libitum ice-cream eating from the behavioral session. On average, participants consumed 71.1 grams of ice-cream  while performing an effortful self-control task was subsequently associated with the balance of activity between brain regions implicated in self-control and reward during exposure to food commercials. Consistent with our hypothesis, greater recruitment of DLPFC—as well as the frontoparietal network as a whole—during effortful self-control was associated with less recruitment of the frontoparietal network and more reward related activity whenever food items appeared on the screen in the cue reactivity task. This suggests that more (or less) brain activity during an initial task requiring self-control exertion may serve to characterize the different response profiles that dieters may show when exposed to appetitive food cues.Notably, we only observed a significant, negative relationship between FP recruitment during effortful self-control and subsequent balance scores during exposure to food commercials. There was no such relationship between control-related FP recruitment in the first task and activity in either FP or reward systems, respectively, during food cue reactivity (second task). This is consistent with theorizing that suggests taking both impulsive and inhibitory processes into account to characterize self-control outcomes , as wellreduced brain activity in lateral prefrontal cortex when performing cognitive tasks  ve tasks .Without In addition, we examined the relationship between these neural measures and ad libitum eating of ice cream following a diet breaking episode in a separate experiment. Although the relationships were in the expected direction , the overall correlations with neural measures were not significant. Whether this reflects a true null effect, or instead that the mechanisms underlying individual differences in neural activity we observed following self-control exertion do not translate to disinhibited eating following a diet breaking episode, remains an open question.also calls for spontaneous regulation of prepotent responses—is arguably more ecologically valid than previous studies that have examined effortful self-control. Although speculative, we would argue that the sequence and nature of the two self-control tasks used here  instances that also require self-control) may mimic dieters’ experiences in daily life. For example, a dieter might exert self-control to block out distraction during an intense time of study or work. And, the extent to which they find this sustained inhibition taxing, they may have little self-control capacity to call upon when they are suddenly faced with a dessert tray at a restaurant later that day.There are several strengths to our study design and approach. First, our overall analysis approach—linking brain activity from an effortful self-control task to activity in a subsequent task that Second, the current study’s design may reliably identify those individuals who experience more (or less) success adhering to their dieting goals. For example, a dieter who more readily recruits certain cognitive control regions  during an effortful self-control task may be actively maintaining the task set , but such task engagement may be more cognitively demanding and render the frontoparietal network less able to exert control over the reward system during future exposure to food cues cf. . Indeed,Additionally, if it is true that greater recruitment of brain regions during an effortful self-control task can undermine future self-control attempts, then it means that more control-related activity  is not necessarily conducive to dieters’ self-regulatory goals. Indeed, and consistent with prior behavioral work on limited self-regulatory capacity e.g., , controlDespite the implications discussed thus far, the current study has some limitations that are worth mentioning. First, the self-control task we administered was somewhat short in length , so it is not clear how long effects of effortful self-control on cue reactivity might persist. Second, even though our participants gave ratings of difficulty and fatigue during the effortful self-control task, we did not have an independent measure of participants’ objective performance on the task . A future study would benefit from incorporating eye-tracking or another validation measure to calculate, on a subject-by-subject basis, successful inhibition of the impulse to read the words. And even though we used a validated diet-breaking procedure for the behavioral session, using a self-control exertion task would have led to more construct validity and may help explain why we did not find a relationship between the brain data and overeating after the milkshake preload.We should also note that, in comparison to behavioral work, the sample size was relatively small and thus was not powered for the detection of moderate correlations. This may place a limit on our ability to detect small to moderate effects of self-control exertion . Although to remain consistent with prior work, with recruitment necessarily constrained to female dieters, future work would benefit from either expanding beyond this population in order to increase sample sizes and test generalizability to other populations.SD = 40.8 grams) compared to previous studies that also measured disinhibited ice-cream eating in dieters , as well as a more restricted range (123.8 in . Also, iTo conclude, we probed the neural mechanisms of repeated self-control exertion among dieters, using a reasonably naturalistic dual-task paradigm that coupled an initial, effortful self-control task with subsequent exposure to appetitive food cues as presented in real-world food commercials. We extended past work, which took a brain-as-predictor approach  using th10.7717/peerj.6550/supp-1Supplemental Information 1Click here for additional data file.


This study investigated nutritional, physicochemical, and sensory characteristics of coffee brewed with conventional and high-oleic peanut extracts. Compared to normal coffee, peanut coffee exhibited more diverse amino acids compositions. In constituent amino acids composition, peanut coffee exhibited increased proportions of glutamic and aspartic acids but decreased phenylalanine. Peanut coffee had higher thiamin, niacin, and sugar contents, improved antioxidant capacity, and lower caffeine contents. In electronic tongue analysis, peanut coffee showed an increased intensity of sweetness and umami taste but decreased bitterness, corresponding to the result of amino acids compositions and caffeine and sugar contents. In volatile compounds analysis using gas chromatography-mass spectrometry (GC/MS) with the sniffing test, peanut coffee had high concentrations of 2-ethyl-3,6-dimethylpyrazine, 2,2′-methylenebis-furan, and furfuryl propionate, which were perceived as peanut and roasted odors in the sniffing test. This study will provide informative data in extending the application of peanut to coffee and developing novel coffee, with added peanut, that is nutritionally beneficial. In recent years, consumers have raised their interest to gourmet coffee such as owntrend ,2.Peanut is a legume rich in lipids (50%), proteins (25%), carbohydrates 13%), and vitamins and minerals. Physiologically, peanut is effective in decreasing body weight %, and vi. For theVolatile compounds are of paramount importance in developing coffee flavor. Coffee includes over 1000 volatile compounds, among which 300 homo- and hetero- cyclic compounds are responsible for the unique coffee flavor. Volatile compound profiles vary upon roasting intensity, variety, and origin of coffee beans ,5. Commoth taste, recently identified [Taste is another critical sensory characteristic in coffee. Basic tastes consist of saltiness, sweetness, bitterness, sourness, and umami taste, with fat taste, which is known as the 6entified . Electroentified . Electroentified .Many studies have investigated different aspects of coffee: antioxidant capacities of coffee bean and coffee residues , enhanciWhereas many studies investigated volatile compounds, antioxidant capacities, physicochemical properties, and hazard substances with variations in coffee bean types and extraction methods, only few studies demonstrated changes in nutritional and physicochemical properties and tastes/flavors by adding other food sources  to coffee. As aforementioned, peanut is a nutritionally and physiologically exceptional food source, but its utilization is somewhat limited to mostly snacks. Therefore, in this study, coffee was prepared with peanut extracts using conventional peanut and high-oleic peanut, and comparisons were made in terms of amino acids compositions, water-soluble vitamins contents, physicochemical characteristics, tastes by electronic tongue, and volatile compounds with the sniffing test. This study will be an exemplary attempt at extending the utilization of peanut to coffee and developing novel coffee with peanut added.Daekwang) and high-oleic peanut variety (K-ol) were provided from National Institute of Crop Science .Coffee bean used in this study (Columbia) was produced by Bean Market  and purchased in a local grocery store in Jinju, Republic of Korea (Item number: 2012036853615). Conventional peanut variety . Coffee bean was ground using a coffee grinder  into medium size (600 μm). Peanut extract (5 g/100 mL) was prepared with water using a coffee maker . Coffee (3.75 g/100 mL) was extracted with the prepared peanut extract using the same coffee maker for 20 min. Three kinds of samples  were prepared upon extraction of solvent .Constituent amino acids were analyzed via a acid hydrolysis method using hydrochloric acid (HCl). One hundred milligrams of sample was added to 3 mL of 6 N HCl in a test tube. Acid hydrolysis was carried out at the following conditions: 110 °C for 24 h while stirring (150 rpm). The mixture (10 μL) was then diluted with sodium dilution buffer (990 μL) and filtered using a 0.2 μm membrane filter. An amino acid analyzer  was utilized to analyze the constituent amino acid profiles . Free am2PO4 at pH 5.5 and methanol , and the analysis was flowed at a rate of 0.8 mL/min in an isocratic elution condition [Agilent 1100 infinity HPLC with a diode array detector  was utilized to determine the contents of water-soluble vitamins with a column, YMC-Pack octadecylsilyl silica gel (ODS) AM   at 40 °C. The detector was set at 270 nm. The mobile phase solvents were prepared as follows: solvent A was prepared with 7.5 mL acetic acid, 0.2 mL triethylamine, and 5 mM sodium 1-hexanesulfonate, and solvent B was methanol. A linear gradient elution was taken for this analysis. The mobile phase was flowed at 0.8 mL/min and then subsequently flowed at the following conditions: 0 min: 100% solvent A, 8 min: 100% solvent A, 20 min: 75% solvent A and 25% solvent B, 30 min: 55% solvent A, 31 min: 100% solvent A, 45 min: 100% solvent A. The same instrument with an identical column to that used in water-soluble vitamins analysis was used to analyze riboflavin.. The wavelengths of the detector were set to 445 nm for excitation and 530 nm for emission. The mobile phase was prepared with 10 mM NaHondition .Glucose and sucrose contents were determined using the Agilent 1260 high-performance liquid chromatography (HPLC) system  with a ZORBAX Carbohydrate  column. Tertiary distilled water was used as mobile phase at 0.5 mL/min. The column was set at 50 °C and an refractive index (RI)  detector was used. Caffeine contained in coffee was determined using high performance liquid chromatography (HPLC) . Samples required no pretreatment for HPLC analysis. The column used was a ZORBAX Eclipse XDB-C18 , which was used at 40 °C. The detector was set at 270 nm. Sixty percent acetonitrile was used as mobile phase at 0.5 mL/min.Antioxidant capacity was measured by 2,2 diphenyl-1-picrylhydrazyl (DPPH) radical scavenging activity and total phenolic contents. DPPH radical scavenging activity was measured by a method outlined by Blois . The sam50  was calculated.Based on the radical scavenging activity (%), SC2CO3 and 160 μL of distilled water were then added to the solution and incubated at room temperature for 2 h. Total phenolic content was determined at 750 nm. As a standard, gallic acid (0–500 μg/mL) was utilized. Total phenolic content was calculated based on the calibration curve.The Folin–Ciocalteu’s method was employed to determine total phenolic content . After dFor pH measurement, 5 mL of sample was added to 45 mL of distilled water and 10 mL of the mixture was used to measure pH using a pH meter .x is RI of the unknown compound, tRx is retention time of the unknown compound, tRn is retention time of the n-alkane, and tRn+1 is retention time of the next n -alkane. tRx is between tRn and tRn+1 (n = number of carbon atoms).Volatile compounds in coffee samples were collected by solid phase microextraction (SPME) fiber coated with 100 μL polydimethylsiloxane (PDMS) . Pentadecane (10 μg in 1 mL of ethyl ether) was used as an internal standard. A total of 115 g of coffee sample was heated in a 60 °C heating block for 20 min and the volatile compounds were collected for 30 min in the SPME fiber. The collected compounds were introduced to desorption for 12 min, and then analyzed by gas chromatography-mass spectrometry (GC-MS) (Agilent 7890A and 5975C) with HP-5MS column (30 m × 0.25 mm i.d. × 0.25 μm film thickness). Oven temperature was maintained at 40 °C for 5 min and then increased to 200 °C at a rate of 5 °C/min, with the inlet temperature at 220 °C. Helium carrier gas was flowed at 1.0 mL/min with the split ratio of 1:10. The mass spectrum library (NIST 12), ion fragmentation pattern, and a reference were utilized to identify the volatile compounds separated from the total ionization chromatogram (TIC) . RelativGC/MS using GC-olfactometry (olfactory detection port (ODP) 3, Gerstel Co., Linthicum, MD, USA) mounted to the spectrometer was used for the sniffing test of the volatile compounds present in the coffee samples. The sniffing test was performed under the same GC/MS conditions as those of volatile compound analysis, and the test was conducted simultaneously with GC/MS analysis. Due to the solvent elution time (5 min) and possible olfactory tiredness of the panelists, the sniffing test was performed between 5 and 25 min only. Three panelists participated in the sniffing test and recorded the levels of olfactory intensity and subjectively described the characteristics of the odors. Olfactory intensities perceived by the panelists were expressed in the numbers 1 to 4 and a higher number indicates stronger olfactory intensity. .Electronic tongue analysis of coffee samples was conducted using an electronic tongue module  with seven sensors attached. These include two reference sensors, SPS (spiciness) and GPS  sensors, as well as 5 basic taste sensors, SRS (sourness), STS , UMS (umami), SWS (sweetness) and BRS (bitterness). Each coffee sample, 50 mL, was diluted with 50 mL of distilled water and the analysis was performed in 7 repetitions. Multivariate analysis was conducted to analyze the taste patterns, and the outcomes from the sensors were expressed in relative taste scores .p < 0.05).The results of this study were presented as means and standard deviations. Differences among treatments were tested using one-way analysis of variance, Tukey’s post-hoc 194 test, by SAS version 9.0  package . This may be due to addition of high-oleic peanut extract that is thermally more stable than conventional peanut. A consistent result was observed by Kim et al. [p < 0.05), showing that peanut coffee possessed significantly higher niacin content than normal coffee (p < 0.05), albeit no significant difference between the peanut coffees was found (p > 0.05). Such higher niacin content in peanut coffee than normal coffee is attributed to niacin present in peanut, which was also confirmed by Kim et al. [Water-soluble vitamin contents in the coffee samples were determined and the results were described in m et al. , reportim et al. ,26. Ribom et al. . As showm et al. , riboflam et al. ,28. Niacm et al. . The niam et al.  in conveGlucose and sucrose content in the coffee samples were measured and the results were demonstrated in Caffeine content in the coffee samples were analyzed and the results are shown in 50 showed 61 ± 3.93, 55 ± 3.28, and 54 ± 0.67 mg/mL, in normal coffee, conventional peanut coffee, and high-oleic peanut coffee, respectively, indicating that antioxidant capacity is relatively higher in peanut coffee than normal coffee. Hydrogen atoms in peanuts provide reductones and decompose active oxygen chains, resulting in an increased antioxidant capacity [Cheonggukjang with peanu (Arachis hypogaea L.) powder added [Antioxidant capacity was measured by DPPH radical scavenging activity and total phenolic content and the results are shown in capacity . Such a er added . Total per added  that anaThe pH in the present study was higher in peanut coffee  compared to normal coffee (4.37 ± 0.07). pH is not influenced by extraction rate but by extraction conditions and roasting conditions . Such pHVolatile compound analysis and the sniffing test were performed by GC/MS, and the results are shown in Platycodon grandiflorum roots [As shown in um roots .Platycodon grandiflorum roots and peanut sprout extracts [Platycodon sample. The taste result by electronic tongue not only comes from major taste components of peanut but is an expression of a complex interaction of tastes from coffee and peanuts [Electronic tongue analysis was performed to investigate the chemical sensors-assisted taste differences among the coffee and the results are shown in extracts ,30. Peanextracts . Kato etextracts  suggesteextracts ,20,22. Pextracts  reported peanuts . Electro peanuts . HoweverIn order to broaden the utilization of peanut that possesses potential nutritional and health benefits, this study prepared coffee with conventional peanut and high-oleic peanut extracts by hot water extraction and investigated nutritional and physicochemical parameters, volatile compounds, taste, and flavor. Overall, peanut coffee was superior in type and content of amino acids, thiamin and niacin content, glucose and sucrose content, and antioxidant capacity in comparison to normal coffee. Furthermore, peanut coffee showed an increased sweetness and umami taste and possessed volatile compounds that induced roasted and peanut odors. To our knowledge, this is the first study that prepared coffee with peanut extracted water and determined various parameters from a nutrition and food chemistry perspective. Future studies need to optimize the extraction conditions to generate desirable sensory characteristics and confirm detailed mechanisms of volatile compound generation in developed coffee. More studies are also warranted, in the investigation of sensory attributes of the developed coffee, with sensory panels. This study will be useful for researchers who are interested in creating coffee flavors, understanding the nutritional quality of peanuts from breeding improvement, and broadening peanut utilization other than snacks.


Coffee is a widely consumed beverage, both in Europe, where its consumption is highest, and on other continents. It provides many compounds, including phenolic compounds. The aim of the study was to assess the effect of various brewing methods on the total phenolic content (TPC) in the infusion. Research material comprised commercially available coffees: Instant Arabica and Robusta, freshly ground Arabica and Robusta , ground Arabica and Robusta, decaffeinated Arabica, and green Arabica and Robusta. The following preparation methods were used: Pouring hot water over coffee grounds or instant coffee, preparing coffee in a percolator and using a coffee machine. Additional variables which were employed were water temperature (90 or 100 °C) and its type (filtered or unfiltered). In order to determine the impact of examined factors, 225 infusion were prepared. Total phenolic content was determined by the spectrophotometric method using the Folin-Ciocalteu reagent and the obtained results were expressed in mg gallic acid (GAE) per 100 g of brewed coffee. The highest value was obtained for 100% Arabica ground coffee prepared in a coffee percolator using unfiltered water at a temperature of 100 °C: 657.3 ± 23 mg GAE/100 g of infusion. High values were also observed for infusions prepared in a coffee machine, where the highest TPC value was 363.8 ± 28 mg GAE/100 g for ground Arabica. In turn, the lowest TPC was obtained for Arabica green coffee in opaque packaging, brewed with filtered water at a temperature of 100 °C: 19.5 ± 1 mg GAE/100 g of infusion. No significant effect of temperature and water type on the TPC within one type of coffee was observed. Due to its high content of phenolic compounds, Arabica coffee brewed in a coffee percolator should be the most popular choice for coffee drinkers. Coffee is a widely consumed beverage, drunk primarily for its stimulating effect and aroma. Due to its worldwide popularity, it occupies an important place in international trade. The 2018 data show that the total production of coffee beans exceeded 10 million tons, an increase of 4.6% compared to the previous year. The leading producer of coffee is Brazil, where 3.8 million tons of beans were produced in 2018   ,20,21.In order to estimate the daily consumption of phenolic compounds with coffee, the infusion with the highest TPC value was selected for each type of coffee. The value was multiplied by four cups (average coffee consumption per day) .The results of analyses of the total content of phenolic compounds depending on the method of brewing in various types of coffee were statistically analyzed using Statistica 13.3 and Excel.p < 0.05. Additionally, descriptive statistics were determined: arithmetic means, standard deviations, minimum and maximum values, medians as well as lower (Q1) and upper (Q3) quartiles and the range between them (IQR). Additionally, Principal Components Analysis (PCA) was performed to reduce data and identify main factors responsible for variability.The normality of the data distribution was verified by appropriate tests: Shapiro-Wilk, Kołmogorow-Smirnow and Lilliefors. The Wilcoxon sequence test was used to assess differences in TPC values between individual coffee brews. The level of significance in the analyses was Brewing methods—using a coffee machine, a coffee percolator and pouring water from a kettle—have a significant impact on the total phenolic content in a coffee brew, which was confirmed by the PCA analysis. The most recommended method for all ground and freshly ground coffee is a coffee percolator. TPC values for instant coffee infusions were higher in comparison to those for ground and freshly ground coffee brewed by pouring water over coffee grounds. The infusion prepared from green coffee was characterized by a lower TPC value than that from roasted coffee, while higher TPC values were observed for coffee in transparent packaging in comparison to opaque packaging. Water temperature and type of water used had no effect on TPC.


People with dementia are not routinely offered rehabilitation services despite experiencing disability associated with the condition and accumulating evidence for therapies such as exercise, occupational therapy, and cognitive or physical rehabilitation. It is important to understand the needs and preferences of people with dementia regarding rehabilitation services. The aim of this study was to explore thoughts and beliefs about rehabilitation amongst people with dementia and their families.Interviews with people with dementia and family members regarding their experience of care following diagnosis and their attitudes and beliefs about rehabilitation for dementia. Surveys with older people with cognitive impairment and/or a diagnosis of dementia to determine preferences for services and understanding of rehabilitation programs.n = 6 people living with dementia with mean age 60 and n = 7 care partners) revealed gaps in care post diagnosis. People reported having to seek out services and frequently sought out services which were rehabilitative in nature. Survey data  showed that most people had heard of rehabilitation (92%) or had experience of rehabilitation (49%) at some point. There was a wide range of services identified as being beneficial. Rehabilitative interventions including case management, exercise and memory strategies were considered desirable.Interviews with 13 participants (People with dementia report having a wide variety of needs. There are gaps following diagnosis where people with dementia report having to seek out their own services. Some interview participants (who tended to be younger) clearly articulated the need for tailored interventions which maximised independence and quality of life. Survey participants, who were on average older, reported that they would participate in individually applicable rehabilitative therapies if they were available. The global prevalence of dementia is rising sharply and is expected to exceed 131 million by 2050 , 5, faciDespite these recommendations, multidisciplinary rehabilitation programs are not a part of the usual treatment pathway for dementia. This is unlike other chronic neurological conditions (like multiple sclerosis) and acquired brain injuries, for which rehabilitation is more accepted in the clinical pathway . People Health professionals have questioned the potential goals and benefits of rehabilitation in dementia care, citing concerns about the potential for meaningful outcomes for this population and the ability for people with dementia to master new learning . HoweverWhile there are increasing calls for rehabilitation to be available for people with dementia, there has been less exploration of how these services might be delivered or which elements are of highest priority. Dementia Alliance International, an advocacy body run by people living with dementia, have argued that access to rehabilitation is a human right under the Convention on the Rights of Persons with Disabilities . ResearcThe aim of this study was to examine understanding of rehabilitation among people with dementia and their families, assess whether this approach is desirable and/or consistent with their beliefs about best-practice care provision, and examine their perspectives about how, when, and why rehabilitation should be delivered.A interpretive descriptive approach  was applA convenience sample of 13 interview participants were recruited through social media, dementia advocacy organisation newsletters, email invitations through existing networks of the research team, and snowball sampling. Eligible participants had a diagnosis of dementia or provided informal (i.e. unpaid) care to a person with dementia, spoke fluent English, were living in the community  and were able to provide informed consent. Dementia diagnoses were self-reported and were not verified by the research team. One-off semi-structured qualitative interviews were conducted by MCa, who has many years of experience working with people with dementia in both clinical and research settings. She had only worked directly with one participant, who had contributed expertise to a previous research project. Interviews were private and confidential, conducted either in the participant’s home or over the phone. The interview asked the person with dementia to describe their experiences of care following diagnosis, attitudes towards rehabilitation in general, and beliefs about rehabilitation for people with dementia. Where participants had favourable attitudes toward rehabilitation for dementia, they were asked to consider how they would prefer these services be delivered. Questions were open to reduce the risk of imposing the interviewer’s assumptions and beliefs (which have been published ). IntervQuantitative survey participants were recruited via an aged care assessment service and from a Geriatric Evaluation and Management (GEM) ward in a large hospital in metropolitan Adelaide. Patients admitted to the GEM ward were eligible to complete the survey if they had a score of 19–24 (indicating dementia or mild cognitive impairment) on the Mini Mental State Examination , usuallyThe survey, which was specifically designed for this research project, .n = 6), frontotemporal dementia (n = 6) and Lewy Body disease (n = 1), diagnosed on average 6 years prior to the interview (range 1–9 years). Nine of the 13 people with dementia (interview participants or care recipients of interview participants) received a disability or aged care pension while the remaining four relied on private income. Eleven received funding for services under the aged care (n = 7) or disability systems (n = 4).Six people living with dementia and seven care partners of people living with dementia participated in a qualitative interview. Interview participants with dementia included four women and were aged 60 years on average (range 50 to 67 years). All the care partner participants were women. Six provided care to their male spouse with dementia and one provided care to her mother. The people with dementia they cared for were aged 65 years on average (range 60 to 79 years). Dementia diagnoses included Alzheimer’s disease  experiences with post-diagnostic care, referring to the existing context that shapes their views toward rehabilitation; (b) highly conceptual understanding of rehabilitation; (b) mixed views about rehabilitation for people with dementia in a general or theoretical sense, and; (c) engagement in rehabilitative services.“It was medical, very medical …. … I wasn’t referred to anybody … .apart from see you in six months …. There wasn’t a brochure from Alzheimer’s Australia in his office, nothing” (PWD1)“They gave me a piece of paper … it was basically the dementia nurses within the hospital system, as it were, and suggested that I ring one of those locally with no real indication of why I’d want to ring them” (PWD4).Most interview participants reported that they had been diagnosed with dementia by a specialist medical practitioner , but few participants were linked with dementia specific supports beyond the appointment.“The key worker actually rang me once or twice to see if there was anything. But it’s one of these catches of is there anything we can do, but you don’t know what they can do so there’s no real way of answering that, or asking those questions without that sort of knowledge” (PWD4).Some had been linked with services that, at the time, were available only for people with YOD to help identify suitable community supports. These services were highly valued by those who could access them and missed by those who could not. However, there were some limitations to the service even when it was available as some participants felt that more continuity of care was required. Other issues related to difficulty communicating needs with the key worker and turnover of staff.“I found my own merry way to the Alzheimer’s Association” (PWD2).“I’m pretty resourceful myself, so I started hunting down things on Google and started out hunting down various peak bodies and all of that sort of thing” (Carer8).Participants in the study were receiving a variety of services including community-based groups run through councils or carer organisations. Several people had utilised social and day respite programs. In most cases participants had initiated these services themselves through their own research.“It was only because I went through someone I knew. Otherwise I think I would still be struggling” (PWD1).“You are literally pushing at the system every step of the way. Why on earth does the government make it this difficult?” Carer8.This process of discovery was described as a “battle’ for an outsider to the health and aged care system. One participant reported that they turned to people they knew in health and aged care through their social networks to help understand the system.People with dementia who completed the quantitative survey reported similarly inconsistent experiences with care Table , with 36“Rehabilitation is, my understanding, is getting back to some sort of semblance of what might have been a normal lifestyle” Carer10.Interview participants overall had a comprehensive understanding of rehabilitation. They understood it to be focused on enhancing independence and quality of life, and that it was individualised and tailored to the needs and goals of the individual.A support team to assess difficulties and help you achieve goals”, “Helping people get back onto their feet, back into the world”), while others were more generic (e.g. “To help you get better”) or specifically referenced illness or injury (e.g. “Time to recover after being ill or injured”).However, a coherent understanding of rehabilitation was less common among the people with dementia who completed the quantitative survey as presented in Table “Doesn’t mean that I’ll get completely better. It means I can maintain independence in as many areas as possible for as long as possible” (PWD1).“I see it as providing people with coping mechanisms to keep their lives as positive and fulfilling for as long as they can” (PWD2).“Of course with dementia they can’t ever be the person that they were before, but, you know, I can see this even as rehabilitation because it’s getting him to be – keeping him the best that he can be” (Carer9).Most interview participants agreed with taking a rehabilitative approach to care for people with dementia. Indeed all agreed that it was important for dementia care to be individualised, to focus on the person’s strengths and what the person can do and maintaining that focus where possible and promoting quality of life from early dementia symptoms until the end.“I’m never going to be rehabilitated to back where I was prior to my diagnosis. However, there are certain skills and certain abilities that I have now post-diagnosis that I want to maintain, to keep intact. And though I’m not going to call it rehabilitation I like the word reablement.” (PWD3).“The term sounds a bit strange partly because it’s something that, I think maybe it’s one of those terms that needs a new word because realistically rehabilitation to regain skills that you’re losing is not going to happen” (PWD4).While some participants could relate this approach of maximising independence and quality of life with the term rehabilitation, others struggled with the terminology. Often, participants had perceptions of rehabilitation which involved recovery to pre-morbid function. People used examples such as recovering after a broken leg or recovering from substance addiction.“It gives a false hope … And that’s very dangerous. It can be very dangerous. Moreso, for the family …. Probably just calling it ‘therapy’ or just something – keeping it deliberately vague could probably be the most helpful (PWD5).One participant was cautious that offering rehabilitation services may offer false hope:“A major issue is that there isn’t any hope given. That is a major thing. If the people who diagnose can’t actually give particularly younger people who are usually in the mild stages still some hope that they can perhaps continue to work with support, they can continue to do their hobbies and still continue with their interests and whatever but they’re not given any …” (Carer7).Whereas others reported that a major problem with current services is that they didn’t offer any hope:“Everyone gives up on them when they go into residential care, and particularly when their mobility becomes impaired, they’re just left and they just go downhill like a rocket” (Carer6).There was also discussion about the timing of rehabilitation and when it might be most appropriate. One participant suggested that there was a role for rehabilitation for people in residential care.“I feel like if someone was early stage dementia, that it’s probably a lot more applicable because it may be in helping them pre-plan and adjust” (Carer8).Whereas another participant felt that rehabilitation would not be beneficial for people with more severe symptoms but was appropriate in the early stages.“We just want to be supported to live our lives, whatever our lives are and I think that’s a fairly basic human right to do that” (PWD1).“I was absolutely gobsmacked that there were no designated rehab type services for people with dementia, which is basically a neurological disability, that what it is, we know. And why it was viewed and treated differently to every other neurological disability I could not understand.” (Carer6).Participants described access to rehabilitation as being a human rights issue and felt that there were inequities between the care offered for people with dementia and the care offered for people with other conditions.“All she could suggest that was available would be a monthly morning coffee meeting which was only 80 kilometres away” (PWD4).Inequities in accessing services were also present for people living in regional areas. Travelling to access services was considered a great challenge.“When therapies start coming online of any kind, it’ll be so welcome” (PWD5).Two participants described how telehealth options could overcome this challenge.“I think what you have to remember is the carer. So, you could have the best rehabilitative, you know, things and programs, but without looking after the carer it’s not going to work, you know” (Carer9).Participants who were care partners spoke of the need for rehabilitation programs to incorporate carers. This could either be through participating in activities together or using the time and opportunity to connect carers and provide each other with peer support.“I’ve made up my own little – I guess you might call it program” (PWD5).“I’ve just recently signed up for  drawing classes … And I cannot tell you how much I love this group …. I could just feel my brain like really working hard to do that. And I’ve really loved it” (PWD2).Most qualitative interview participants described how they had sought out activities and services which they felt would enhance their independence and quality of life or that of the person with dementia they provided care for. Their choice of activities and services suggest that rehabilitative approaches focussing maintaining independence are sought after following a diagnosis of dementia.However, quantitative survey participants provided mixed responses when asked to indicate how likely they would be to use a range of rehabilitative services Table . While sThis multi-methods study draws together findings from interviews with people with dementia and family members of people with dementia and surveys with older people with cognitive impairment or dementia. Our aim was to understand the attitudes and beliefs of these cohorts towards rehabilitation and to explore preferences for different types of services. People who responded to our advertisements inviting people with dementia to talk about rehabilitation tended to be younger (with average age 60 years) and due to our method of recruitment were likely more familiar with dementia services and progressive in their views about dementia care. Most participants had a good understanding of rehabilitation as maximising independence and quality of life and felt that this was an important goal of care for people with dementia. However, not all participants agreed that rehabilitation was the most appropriate term given that it was often associated with recovery-oriented programs. In contrast, participants who completed the survey were approached via health services and offered a broader range of views on rehabilitation. Survey respondents were also considerably older (average age 82 years). Although this cohort were familiar with the concept of rehabilitation, they tended to consider rehabilitation programs as focussed on regaining lost function (such as after injuring oneself). Family members of people with dementia were also supportive of therapies to enhance quality of life and maintain function. Survey respondents identified a wide range of services that they may use, and these depended on their needs and goals. Despite the differences in sample selection, age, and beliefs about rehabilitation we found that people from both cohorts felt that gaps in care exist and there is a need for individualised services which promote independence and quality of life.The World Health Organisation describes rehabilitation as a holistic approach to optimise function and reduce the experience of disability. Furthermore, the Organisation describes rehabilitation as being necessary not just for those recovering from injury or illness but for those with detriments in function linked to ageing. This more contemporary description of rehabilitation would be unfamiliar to the general public and it would not have previously occurred to many of our survey participants that rehabilitation for disability associated with ageing or dementia could be beneficial. Providing survey participants with education around what can be offered and the associated benefits and then asking them about their needs may have resulted in different answers. Furthermore, without direct experience of a therapy or intervention it can be difficult to make a judgement about whether that therapy or intervention may be beneficial. Several of our interview participants described seeking out rehabilitative services or therapies and experiencing benefits.The findings of this study have some similarities to our earlier work in which we interviewed health professionals to understand their attitudes and beliefs about rehabilitation for people with dementia . Health There is increasing evidence that rehabilitative interventions are of benefit for people with dementia. Rehabilitation has been shown to help people with dementia achieve their nominated goals , can delOur use of multi methods with different sampling strategies and populations provided us with the opportunity to compare and contrast. However, use of social media to recruit interviewees introduce a sampling bias in favour of younger people with dementia, with lower levels of cognitive impairment, and higher digital literacy. People were included in the interviews if they had a self-reported diagnosis of dementia and we did not verify the diagnosis. These participants gave rich and detailed descriptions of their process of being diagnosed with dementia and we have no reason to doubt the accuracy of their diagnosis. These participants also opted into an interview about rehabilitation for people with dementia, and so were found to have a personal interest in the topic. It is also possible that the interviewer’s views about the potential value of rehabilitation for people with dementia  influencSurvey participants were approached via a health service and therefore offer a more representative sample of older people with cognitive impairment or dementia. However, a larger population including those not accessing health services and those with more severe cognitive impairments would have increased generalisability. Recruiting from one single health service also limits generalisability. Another limitation is that changes in the aged care environment have been made since we completed data collection, including the introduction of new quality standards and an upgraded platform for accessing services. We are unable to comment on whether these changes resulted in improved services for people with dementia and easier navigation of services.Our research shows that rehabilitative interventions and therapies are valued by a wide range of people with dementia and their families although the types and level of services desired varies. Research is now required to determine how rehabilitation can be offered in a way that reaches those in need, that leads to beneficial outcomes for the person and that is cost effective.Additional file 1.


Improving public knowledge and understanding about dementia has been identified as a priority area by people living with the condition, researchers, educators, and policymakers for several years. Societies that have a better understanding of the condition are more likely to enable people living with dementia to enjoy a better quality of life. The aim of this study was to explore current public perceptions of dementia along with the facilitators and barriers to living well from the perspective of people living with the condition in Northern Ireland.Four focus group interviews were conducted with a total of 20 people living with dementia across three Northern Irish Counties in June 2019. These interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. Ethical approval was obtained for this study prior to data collection.Following thematic analysis, three themes emerged in relation to barriers and facilitators to living well with dementia. These were: ‘Emphasis on Disability NOT Capability’, which highlighted societal misconceptions about the activities and modes of life which people with dementia could or could not do; ‘Normalise Dementia – We Don’t Want a Fool’s Pardon’, which focused on how the public could encourage people living with the condition to enjoy greater independence, and ‘Dementia isn’t a Death Sentence’, which considered how professionals, family members and friends treated the person after diagnosis.Public perceptions about dementia have the potential to act as both facilitators and barriers to living well with dementia. People with dementia stated that they are more likely sustain wellbeing when they are valued and can maintain independence. On the contrary, poor public and professional attitudes to dementia had the potential to disempower people living with dementia. More than 850,000 people live with dementia in the United Kingdom and this number is expected to surpass one million in the next 5 years . NortherThe challenges people with dementia may face can manifest in a variety of ways. Arguably the biggest misconception the public have about dementia is that the disease is a normal part of the ageing process . This miThere have been several international research studies which have sought to explore public perceptions of dementia and all have concluded that interventions to improve public knowledge about dementia are a priority –21. If pwww.dementiagame.comThe aim of this study was to explore current public perceptions of dementia along with the facilitators and barriers to living well from the perspective of people living with the condition in Northern Ireland. The reported study findings have been used to inform another project being led by the authors; the co-development of a digital game to improve public perception of dementia: An interpretive qualitative approach was used based on the belief that social reality is shaped by both human experience and social context . TherefoThis study received ethical approval by Queen’s University Belfast, School of Nursing and Midwifery Research Ethics Committee in April 2019 (Reference: CBrownWilson 03.19 M2.V1).https://www.dementiani.org/). Dementia NI have several local empowerment groups that are comprised solely of people living with dementia and their overall function is to contribute to improving services for people with dementia. Dementia NI shared information about the study with members during local empowerment group meetings. People with dementia who were interested in participating in this study attended a focus group meeting 2 weeks later. Immediately prior to the focus group, all participants met with the researcher (GM) who provided information about the study, the structure of the interview and what would happen with the data. The consent processes were guided by Dewing  when you go back into it, they’ve moved the stuff all around’FG4P7‘Just when you’re used to a thing, the next week it’s all moved around’FG1P5One local intervention, which participants thought was extremely useful, was the JAM card (https://jamcard.org/). The JAM acronym means ‘just a minute’ and the laminated card has been designed to support people with dementia in telling others that they need ‘Just a Minute’ in a discrete manner. People throughout the four focus-group interviews expressed how the JAM card made life easier, particularly when paying for items at a shop, using public transport or becoming lost in a familiar place.‘The JAM card would be used when you’re trying to count out your money out in a shop…and you just show them [the shop keeper] your pass and then they would say ‘oh hold on yes’ and they will give you a bit of time to get yourself organised’.FG3P1‘The JAM Card alone has helped me. It is a little comforter that I don’t always need, but if things are racing a bit, I just take the card out [and show this to the service-provider] and that helps put the brakes on’FG1P3The JAM card was a tangible example how local communities could enable people living with dementia to be independent through focusing on their capability, not their disability. People who participated in the focus-groups also stated that people’s attitude was a major facilitator in supporting independence.Another aspect discussed within these groups was the capability of performing the task of shopping and dealing with money. In terms of shopping, most people living with dementia stated that they often had to shop with a partner/family or friend due to their own concerns about confusion, anxiety or getting lost during busier times. One key challenge which led people with dementia to feel more dependent on family or friends related to the frequently changing location of items in shops.viewed as an illness, much like heart failure or cancer. These people living with dementia also wanted the public to be aware of the symptoms of dementia and use this knowledge to help make their life more manageable. One aspect which people with dementia found particularly distressing was the potential of being labelled as a ‘fool’ due to the symptoms of the disease.One significant barrier to ‘living well’ was the general public’s interpretation of what dementia is and how they believe it affects people living with the disease. Focus group participants wanted dementia to be normalised and ‘I thought it was fantastic! It was nice to see just how they [the public] were reacting, and I mean they [people with dementia] were just normal, you know?’ It was very positive…It’s not something you need to hide’.FG4P1People with dementia also discussed the positivity of recent local public health campaigns that had promoted awareness about the condition to the public. In Northern Ireland, the ‘Still Me’ campaign was a media campaign produced by the Public Health Agency to raise awareness of the signs of dementia and to reduce stigma about the condition. People living with dementia felt a sense of empowerment with the campaign as stated below:‘It [the campaign] was letting more people know, don’t be scared, if you’ve got dementia don’t be scared.’FG2P4While participants were keen to describe the positive contributions that the media could make to improving public awareness of dementia, many also highlighted the negative media portrayals. They felt this exacerbated stigma associated with dementia and disempowered participants. Participants consistently noted obstructive language used, in particular the use of labels such as ‘sufferer’, ‘demented’, ‘crazy’, ‘not-all-there’ and ‘child-like’ were extremely upsetting.While the task of normalising dementia often rested on key members of each person’s local community, like shop-keepers, law enforcement and health services, participants collectively asserted that the media had a huge part to play in positively influencing or informing the views of the wider public. Multiple participants spoke of the positive portrayal of dementia in a recent UK television documentary. The documentary, entitled ‘our dementia choir’ followed the journey of people living with dementia who formed a choir.‘Losing your job? That’s the biggest thing, that was a really REALLY hard thing to have happen to you…losing work was like losing a limb. You’ve now lost everything’.FG4P4Many participants felt that their formal diagnosis of dementia did not immediately change their level of function and often felt surprised when asked to give up work. They conveyed a sense of abandonment and confusion but strongly concluded that having the right to employment, or modification of one’s work role, was a pre-requisite for the normalisation of dementia. One person with dementia provided the following advice regarding employment:‘Learn about dementia to start with…that is what I would say and see what causes it and then make a decision as to why you should employ someone or not. Meet the person and actually see what stage of the dementia they are at’FG2P2Participants agreed that to normalise dementia the general public needed to see that people living with the condition can enjoy life through work and activity. The participants did acknowledge that the symptoms of dementia were often invisible earlier in the disease and independent living would become more difficult in time. While public support was always advantageous, participants unanimously agreed that never wanted to receive a ‘fool’s pardon’ because they lived with dementia.Focus-group participants also pointed to local employers as another key group that could do much more to normalise dementia. Several participants in the focus-group stated that the worst thing about being diagnosed with dementia was being forced by their employers to give-up their work.‘They [healthcare professionals] really ought to know better, right? I mean…my GP [General Practitioner] has been great, but the people I visit at the memory clinics…well, I am just a number. The information is all about future planning, worsening symptoms and what have you. What I really want to talk about is how I can live life to the fullest!’FG4P1These sentiments were echoed by several participants. Collectively, there appeared to be a professional focus on symptoms of dementia and a consistent reinforcement that dementia is a progressive incurable condition. One participant stated that she was advised by healthcare professionals that she should begin to put an advance care plan in place, a technique that is recommended by several clinical guidelines.‘I mean for God’s Sake…I had only just been diagnosed with dementia and they were talking about Power of Attorney this and write a Will that…I was so overwhelmed and I was just sat there thinking – how long have I got left [to live]? It took me a few months myself to realise, actually dementia isn’t a death sentence and there is plenty of fun still to be had!’FG1P3There were some positive accounts of healthcare professional interactions with participants, but portrayals of their input were often negative. Although the important role their family members and friends played in facilitating and enabling them to live well was widely acknowledged, at times many people with dementia perceived their family members to be, like healthcare professionals, looking too far ahead into the future. One example of this comes from a participant who, after being diagnosed, was taken by her family to a nursing home to have a look around.‘Visiting the home…kind of left me a bit stunned. I’m not there yet, my head was shouting at them, but I couldn’t say anything. I know they are trying to help me and wrap me in cotton wool to protect me because they are afraid…but I am ok. I can still go out to the pub and have a drink and a dance. I don’t particularly want to live in a place with people who I don’t know – I don’t need care yet!’FG3P2The role of the family member and healthcare professional was important to people living with dementia. These individuals could support people to overcome challenges in society or could behave in a way which inadvertently perpetuates societal stigma of dementia.The final theme that emerged from the focus-group data was around healthcare professional and family member treatment of people living with dementia post-diagnosis. The participants across all focus-groups expressed their surprise and dissatisfaction about how healthcare professionals’ treatment of people with dementia often lacked understanding or empathy. The participants collectively felt that healthcare professionals perceived dementia as a death sentence.The participants in this study have identified several facilitators and barriers to living well with dementia. This study demonstrates that people living with dementia often experience members of the public who believe they are no longer capable of managing their everyday lives. Whilst dementia does place limitations on their lives, there is still much people with dementia can do and have to offer, a fact that society may ignore. These findings are not unique when considering the global evidence-base. For example, most of the participants identified how they had to give up their job as soon as they received a diagnosis of dementia rather than being offered alternative opportunities within their place of employment –29. OtheThe participants in this study identified the role of the media in promoting the normalisation of dementia and considered how these positive messages might encourage positive changes in attitude. The Dementia Engagement and Empowerment Project (DEEP) is an organisation which have taken an active approach to this issue and have produced guidelines on language about dementia for journalists, organisations, and communication departments . Indeed,Healthcare professionals that people with dementia encounter during their journey play a key role in their experience. In the current study, people living with dementia were shocked and distressed by the focus of health care professionals and subsequently by their families on the end stages of the condition. As potential societal role-models, due to their medical knowledge of the condition, many participants expressed disappointment about how these professionals appeared to prioritise medical needs and focus on long-term planning. Participants articulated that they did not perceive that living with dementia was a death sentence because there was still much to be enjoyed. Medicalised and paternalistic approaches to people with dementia are commonly discussed in the literature. A recent Irish study found that many people living with dementia were excluded from care-planning and decision-making due to assumptions they lacked capacity or because of family member preference . Some paFacilitating people to live well with dementia in their local communities requires improvements in public perceptions and meaningful behavioural change. Participants in this study have spoken about the facilitators to living well in their community and the positive impact this had. It appears that participants who can continue to do what they are capable of are probably more likely to experience higher levels of wellbeing. This concept, known as the capabilities approach, developed by Nussbaum , assertsThe strength of this paper was that it engaged people living with dementia offering them a voice to describe facilitators and barriers to living well with the condition based on their own experience. Whilst this paper has illuminated public perceptions of dementia from people living with the condition across Northern Ireland, it might not be reflective of the views of people living with dementia in other parts of the UK. Whilst authors made every attempt to engage people with dementia as widely as possible across the region, the sample was only drawn from people attending Dementia NI empowerment groups. A consequence of this approach to recruitment is that this study represents the voices of people living with mild symptoms of dementia who can maintain a high-level of independence. While the views of these participants are valid, it is unlikely these views represent people living with advanced dementia. It was also apparent from the focus group interviews that some participants had been involved in local media campaigns to promote awareness about the condition.Public perception and knowledge about dementia are improving but people living with the condition still face significant challenges in their daily lives. There is substantial evidence to suggest that local communities can facilitate people with dementia to live well with their condition. On the contrary, the converse is also equally true. Improving how people think about dementia has been a priority for many years, however despite notable improvements there are still many people living with dementia that face significant barriers to living well in their local communities.