This study introduces a pioneering framework for modeling students\' cognitive processes in mathematics education through Fuzzy Cognitive Maps (FCMs). By integrating key educational theories-Duval\'s Semiotic Representation Theory, Niss\'s Mathematical Competencies, Marton\'s Variation Theory, and the broad Engagement, Motivation, and Participation framework- the model offers a comprehensive and holistic understanding of students\' cognitive landscapes. This research underscores the necessity of a multidimensional approach to capturing the intricate interplay of cognitive, affective, and behavioral factors in students\' mathematical learning experiences. The novelty lies in its methodological innovation, employing FCMs to transcend traditional qualitative analyzes and facilitate quantitative insights into students\' cognitive processes. This approach is particularly relevant in the current era dominated by digital learning environments and artificial intelligence, where real-time, automated analysis of student interactions is increasingly vital. The proposed FCM has been developed over the years with a data-driven approach; the concepts and relationships in it have been derived from the literature and refined by the author\'s experience in the field. Illustrated through case studies, the framework\'s utility is demonstrated in diverse contexts, highlighting how the quantitative data obtained are confirmed by qualitative approach: analyzing the impact of remote learning during the Covid-19 pandemic on student engagement and exploring Augmented Reality\'s role in enhancing mathematical conceptualization. These applications show the framework\'s adaptability and its potential to integrate new technologies in educational practices. However, the transition from qualitative to quantitative methodologies poses a challenge, given the prevalent use of qualitative approaches in mathematics education research. Additionally, the technological implementation of the FCM model in educational software presents practical hurdles, necessitating further development to ensure ease of integration and use in real-time educational settings. Future work will focus on bridging these methodological gaps and overcoming technological challenges to broaden the FCM model\'s applicability and enhance its contribution to advancing mathematics education.

OBJECTIVE: To identify the evidence of gender disparities in frailty and explore the factors contributing to male-female differences.
METHODS: A longitudinal study.
METHODS: A total of 24,429 older adults (60+) were enrolled. Frailty was assessed by frailty index and frailty risk based on Rockwood\'s cumulative deficit frailty index. OLS and logistic regression models were conducted, with Oaxaca-Blinder and Fairlie decomposition methods to further analyse the factors contributing to gender disparities in frailty.
METHODS: The paper used four waves of the China Health and Retirement Longitudinal Study from 2011 to 2018, a nationwide survey organised by the National Development Institute of Peking University.
RESULTS: Women had higher frailty status than men, with more pronounced increases. Among the factors, education has the most significant association with frailty gender disparities. The contribution of individual characteristics, particularly education, to gender disparities in frailty appeared to diminish over time, while the contribution of family and regional factors remained relatively stable, and the contribution of institutions was deemed inadequate.
CONCLUSIONS: The frailty in Chinese older adults is generally on the rise with continuously expanded gender disparities. It is crucial to consider the contributing factors to frailty in older adults for effective prevention and intervention strategies. Additional gender-specific geriatric care policies are needed in order to address gender inequality in health.
CONCLUSIONS: The findings of this study highlight the prevalence of increasing gender disparities in frailty and identify that the level of education, per capita annual household income as well as marital status are the most significant factors contributing to the gender gap. Those findings provide policy implications for healthcare nursing service from a gender-specific perspective in order to achieve health equity.
UNASSIGNED: This study has adhered to the STROBE guideline.
UNASSIGNED: No Patient or Public Contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY: This study provided implications on gender-specific geriatric care nursing services. The study highlighted the importance of focusing on frailty and its gender disparities in geriatric clinical nursing.

BACKGROUND: Designing effective health interventions and evaluating their impact is crucial to improving the health of the population. To ensure interventions are of high quality and effective, evidence-based research is essential, particularly studies that use randomised controlled trials (RCTs) or systematic reviews. However, RCTs may not be feasible or ethical in certain situations, such as in intensive care units. Cluster or stepped-wedge RCTs are alternative ways to assess interventions that also address these ethical concerns.
OBJECTIVE: To explain the stepped-wedge design and its main features as well as how to use it to evaluate nursing interventions.
CONCLUSIONS: Understanding stepped-wedge designs empowers nurses to implement evidence-based interventions and improve patient outcomes. The use of stepped-wedge designs has increased in nursing research over the past two decades, indicating growing recognition of its advantages: efficient evaluation of healthcare interventions, ensuring all clusters receive treatment over time; smaller sample sizes; ethical considerations; and time control. However, challenges remain: ensuring nurse researchers\' understanding and application of it is consistent, extended duration and logistical complexities. Methodological rigour, collaboration and understanding of secular trends are crucial, and nurses\' involvement in RCTs enhances cluster selection, data collection and dissemination.
CONCLUSIONS: The stepped-wedge design offers an ethical and adaptable method for studying interventions, considering healthcare complexities and allocating resources. Its versatility assists the advancement of nursing care delivery and in promoting evidence-based practice.
CONCLUSIONS: Understanding stepped-wedge designs in nursing practice enhances evidence-based care, decision-making, collaboration and professional development, benefiting patient outcomes.

BACKGROUND: SMS texting systems have been considered a potential solution to reduce missed appointments in primary care. Existing research in this area focuses on qualitative studies investigating the attitudes of SMS text users and receivers.
OBJECTIVE: This study aimed to examine appointment data from an independent general practitioner (GP) surgery in Wrexham, United Kingdom, with approximately 15,000 patients, to determine the impact of text messaging systems on reducing missed appointments. The objective of this study was to investigate whether the use of text messages can effectively reduce missed appointments.
METHODS: To collect data for the study, SQL reports were run on EMIS Web, the United Kingdom\'s most widely used clinical system. The data spanned 10 years, from September 1, 2010, to March 31, 2020. Data accuracy was verified by cross-referencing with appointment diary records. Mann-Whitney and Kruskal-Wallis tests, chosen for their suitability in comparing groups in nonparametric settings, were conducted in Microsoft Excel due to its accessibility.
RESULTS: Statistical analyses were conducted to compare data before and after implementation of the text messaging system. The results revealed a significant 42.8% reduction in missed appointments (before: 5848; after: 3343; P<.001). Further analysis of demographic characteristics revealed interesting trends, with no significant difference in missed appointments between genders, and variations observed across different age groups. The median number of missed appointments was not significantly different between genders (women: 1.55, IQR 1.11-2.16; men: 1.61, IQR 1.08-2.12; P=.73). Despite the prevalence of mobile phone use among young adults aged 20-25 years, the highest rates of missed appointments (848/7256, 11.7%) were noted in this group, whereas the lowest rates were noted in the 75-80 years age group (377/7256; 5.2%; P<.001). Analysis by age and gender indicated inconsistencies: women aged 20-25 years (571/4216) and men aged 35-40 years (306/3040) had the highest rates of missed appointments, whereas women aged 70-75 years (177/4216) and men aged 75-80 years (129/3040) had the lowest rates (P<.001 for both).
CONCLUSIONS: This study demonstrates that SMS text messaging in primary care can significantly reduce missed appointments. Implementing technology such as SMS text messaging systems enables patients to cancel appointments on time, leading to improved efficiency in primary care settings.

OBJECTIVE: The minimum sample size for multistakeholder Delphi surveys remains understudied. Drawing from three large international multistakeholder Delphi surveys, this study aimed to: 1) investigate the effect of increasing sample size on replicability of results; 2) assess whether the level of replicability of results differed with participant characteristics: for example, gender, age, and profession.
METHODS: We used data from Delphi surveys to develop guidance for improved reporting of health-care intervention trials: SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) and CONSORT (Consolidated Standards of Reporting Trials) extension for surrogate end points (n = 175, 22 items rated); CONSORT-SPI [CONSORT extension for Social and Psychological Interventions] (n = 333, 77 items rated); and core outcome set for burn care (n = 553, 88 items rated). Resampling with replacement was used to draw random subsamples from the participant data set in each of the three surveys. For each subsample, the median value of all rated survey items was calculated and compared to the medians from the full participant data set. The median number (and interquartile range) of medians replicated was used to calculate the percentage replicability (and variability). High replicability was defined as ≥80% and moderate as 60% and <80% RESULTS: The average median replicability (variability) as a percentage of total number of items rated from the three datasets was 81% (10%) at a sample size of 60. In one of the datasets (CONSORT-SPI), a ≥80% replicability was reached at a sample size of 80. On average, increasing the sample size from 80 to 160 increased the replicability of results by a further 3% and reduced variability by 1%. For subgroup analysis based on participant characteristics (eg, gender, age, professional role), using resampled samples of 20 to 100 showed that a sample size of 20 to 30 resulted to moderate replicability levels of 64% to 77%.
CONCLUSIONS: We found that a minimum sample size of 60-80 participants in multistakeholder Delphi surveys provides a high level of replicability (≥80%) in the results. For Delphi studies limited to individual stakeholder groups (such as researchers, clinicians, patients), a sample size of 20 to 30 per group may be sufficient.

The aim of this study was to examine the mediating effect of e-health literacy levels on the relationship between individuals\' awareness of COVID-19 and dispositional hope during the COVID-19 pandemic. The research was conducted with a mixed-methods design. Quantitative data were collected for the study online using Google Forms and qualitative data were collected online with an interview technique. In this framework, the qualitative data were obtained from a total of 15 people who had been diagnosed with COVID-19. These participants were selected using the snowball sampling method. A personal information form, e-Health Literacy Scale, Coronavirus Awareness Scale, Dispositional Hope Scale, and semistructured interview form were utilized in the course of the research. As a result of, it was determined that there were significant relationships between coronavirus awareness and both e-health literacy and dispositional hope, as well as between e-health literacy and dispositional hope. The measurement model was found to have good fit values. Testing the structural equation model, it was determined that e-health literacy had a full mediating role between coronavirus awareness and dispositional hope. In addition, this study showed that people who had COVID-19 had increased awareness of COVID-19 after contracting the disease.

OBJECTIVE: To evaluate the effect of the fear of violence of nurses working in Turkey on their intention to migrate and to examine the mediating role of psychological well-being on this effect.
BACKGROUND: Many countries are concerned about nurses\' fear of violence and their intention to migrate. The fear of violence at work may influence nurses\' intention to migrate. Additionally, psychological well-being may impact this process. However, the impact of the fear of violence at work on the intention to migrate, as well as the moderating effect of psychological well-being in a nursing context, is not well understood.
METHODS: We conducted this cross-sectional study on a sample of 221 nurses from two public hospitals. We collected survey data between November 2022 and January 2023 using three scales. We analyzed the data using SPSS, AMOS, and HAYES. We followed the STROBE statement guidelines for cross-sectional studies.
RESULTS: Nurses reported a moderate intention to migrate and a moderate to high level of fear of violence and psychological well-being. Fear of violence is positively associated with the intention to migrate. Mediation analyses indicated that the association between fear of violence and intention to migration was mediated by psychological well-being.
CONCLUSIONS: The fear among nurses of being exposed to violence increases their intention to migrate. However, high psychological well-being can reduce this intention.
CONCLUSIONS: Nursing managers, policymakers, and decision-makers need to take serious precautions against the fear of violence in the future and make necessary improvements for nurses who witness violence. To achieve this, it can begin by paying attention to the high psychological well-being of each nurse.

UNASSIGNED: Our aim was to better understand and raise awareness of the diagnosis journey and quantify any barriers for timely diagnosis of haemophagocytic lymphohistiocytosis (HLH), to support patients\' struggle with diagnosis and reduce time to diagnosis.
UNASSIGNED: Patients diagnosed with, or caregivers for those diagnosed with primary or secondary HLH and physicians involved in the treatment of HLH were recruited. Quantitative interviews were undertaken with patients/caregivers to quantify key elements of the diagnosis journey, followed by qualitative interviews with participants. Interviews took place between March-May 2021.
UNASSIGNED: Thirty-three patients/caregivers and nine physicians took part in this mixed methods study. Lack of physician awareness of HLH was a common frustration for patients/caregivers, causing delayed diagnosis. All physicians indicated bone-marrow testing is a key step in the diagnosis process, and some patients/caregivers had frustrations around testing. Emergency care doctors, although not usually involved in the diagnosis process, were among the most-seen specialists by patients/caregivers. Patients/caregivers suggested potential improvements in available information, such as providing information on treatment options and condition management.
UNASSIGNED: Patients/caregivers and physicians agreed on the need to raise overall awareness of HLH signs/symptoms among priority groups of physicians to recognise how signs/symptoms can progress and develop. Improvements in the testing process and communication would directly impact the speed of diagnosis and support patients/caregivers during the diagnostic journey, respectively.
UNASSIGNED: Raising awareness of key issues, such as signs/symptoms, tests and diagnostic procedures, and improved communication and support for patients/caregivers, are key to speeding up HLH diagnosis and improving outcomes.

UNASSIGNED: Psychiatrists often encounter ethical dilemmas in their daily clinical practice. Clinical ethics consultations (CECs) have been recently increasing, especially in general hospitals. However, the current situation in the psychiatric field is unclear. This study clarifies clinical ethics problems in psychiatry and determines the need for CECs.
UNASSIGNED: We conducted an anonymous self-administered questionnaire survey in February 2022, which targeted directors and supervisors of psychiatric specialty training programs at 1224 psychiatry facilities.
UNASSIGNED: Responses were received from 311 facilities (response rate: 25.4%). CEC systems existed in 223 (72.2%) facilities, and medical safety committees were the most common. Clinical ethics problems occurred at 248 (80.3%) facilities; the most common method for managing the problems was discussions at case conferences without using CECs. The top four reasons for psychiatrists to solicit advice were conflicts with patients\' relatives, treating a patient with cognitive impairment, discontinuation of treatment, and suicide/attempted suicide. Most respondents (89.9%) considered CECs necessary.
UNASSIGNED: Although CECs exist in psychiatry, they may not meet the needs of clients. Future studies are needed to investigate client satisfaction and CEC evaluation methods in facilities where psychiatric CECs are provided.

OBJECTIVE: To examine the relative importance of social cognitive predictors (ie, performance accomplishment, vicarious learning, verbal persuasion, affective state) on health promotion self-efficacy among older adults during COVID-19.
METHODS: Cross-sectional.
METHODS: Data collected online from participants in British Columbia (BC), Canada.
METHODS: Seventy-five adults (n = 75) aged ≥65 years.
METHODS: Health promotion self-efficacy was measured using the Self-Rated Abilities for Health Practices Scale. Performance accomplishment was assessed using the health directed behavior subscale of the Health Education Impact Questionnaire; vicarious learning was measured using the positive social interaction subscale of the Medical Outcomes Survey - Social Support Scale (MOS-SSS); verbal persuasion was assessed using the informational support subscale from the MOS-SSS; and affective state was assessed using the depression subscale from the Depression Anxiety Stress Scale (DASS-21).
METHODS: Multiple linear regression was used to investigate the relative importance of each social cognitive predictor on self-efficacy, after controlling for age.
RESULTS: Our analyses revealed statistically significant associations between self-efficacy and performance accomplishment (health-directed behavior; β = .20), verbal persuasion (informational support; β = .41), and affective state (depressive symptoms; β = -.44) at P < .05. Vicarious learning (β = -.15) did not significantly predict self-efficacy. The model was statistically significant (P < .001) explaining 43% of the self-efficacy variance.
CONCLUSIONS: Performance accomplishment experiences, verbal persuasion strategies, and affective states may be the target of interventions to modify health promotion self-efficacy among older adults, in environments that require physical and social distancing.