Symptoms and clinical signs of bacterial vaginosis, candidiasis, and trichomoniasis (adapted from) [85].
\r\n\t2) Human sexual disorders in males and females.
\r\n\t3) Psychological aspects of the human sexual response cycle and its disorders.
\r\n\t4) The therapeutic aspects.
\r\n\tThe human sexual response cycle and human sexual behavior are interrelated. How this inter-relationship and its association to normal sexual health need to be delineated. In a world torn between sex and sexually transmitted disease, clear-cut scientific information in the form of a monograph is required to educate.
\r\n\r\n\tHuman sexuality, gender identity, and sexuo-erotic orientation play great roles in human health and disease. Sex education is the need of the hour and a reflection will be timely.
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Both STDs and non-STDs are a major concern for public health system worldwide [1].
Sexually transmitted diseases (STDs) are the most frequently “unrelieved” diseases in the United States [2]; its prevalence is high all over the world, especially in the United States where about 12 million new cases occur each year [2].
Surprisingly, STDs represent a public health problem also in the developing countries, being the second cause of health loss in childbearing women [2].
STDs have a lot of health-related consequences between women, adolescent, and children, particularly in ethnic/racial minority group: In U.S. a lot of women (more than a million) experienced an episode of pelvic inflammatory disease (PID) per year: considering that PID represents an important health consequences of STDs and that 15% of the infertile U.S. women experienced a tubal inflammation related to PID, it seems obvious to ascribe to STDs as playing a leading role in women health [2].
Also, the relationship between untreated STDs and pregnancy are well known: neonatal pneumonia, neonatal ophthalmia, mental and physical developmental disabilities, and fetal death related to syphilis are the more impacting consequences of untreated STDs [2].
Unprotected sexual encounters and having multiple sexual partners, together with higher biologic aptness, are the leading causes of STDs in adolescents between 10 and 19 years, which seems to be the higher risk category among all age groups [2].
Bacterial vaginosis (BV) is a clinical syndrome resulting from the replacement of normal hydrogen peroxide-producing lactobacillus species in the vagina with high concentration of anaerobic bacteria such as
BV is the most prevalent form of vaginal infection among women of reproductive age, affecting 8–23%, and is the most common etiology of vaginal symptoms prompting women to seek medical care [4].
It does not appear to be a sexually transmitted disease, although it has been associated with having multiple sex partners [3].
It is the most common cause of vaginal discharge or malodor and is commonly encountered in the context of STDs [3].
Since the relationship between BV and STDs is not well established, the aim of this chapter will be to describe the role of BV in determining STDs and to point out how BV management could improve STDs’ epidemiology and prevalence.
There are approximately 10 times as many microbes associated with a human as there are human cells in the body [4]: despite recognition of the importance of the interactions between the host human body and the bacteria it supports, there remain many unanswered questions regarding how the microbial environment varies with and among individuals in healthy and diseased states [5, 6].
Historically, bacteria have been identified using Gram stain or culture-based techniques but, unfortunately, as few as 20% of bacteria closely associated with the human body can be cultivated via culture-based techniques [6].
Culture-based methods may therefore underestimate the diversity of microbiome [5, 6].
During the past decade there has been an explosion of interest in molecular-based, culture-independent techniques to study the microbiome [7–14].
Molecular-based techniques involve analysis of 16S ribosomal RNA (rRNA), DNA hybridization, or fingerprinting and next-generation sequencing [7–14].
The National Institute of Health, recognizing the potential of molecular techniques to further understand human bacterial communities, initiated the Human Microbiome Project (HMP) in 2007 [15].
The HMP targeted the genitourinary system because it has been well established for more than a century that bacteria are present within the vagina and that an imbalance within this microbial environment may be associated with disease [16–19].
Research has demonstrated that alterations in the vaginal microbiome affect susceptibility to gynecologic infections, including cervicovaginitis, postoperative infections, and human immunodeficiency virus (HIV) infection, but also that many of the differences in the vaginal microbiome may represent normal variation and may not necessarily indicate disease [20–24].
However, despite evidence from both culture-dependent and independent methods supporting the dynamic nature of the vaginal microbiome, both methods suggest that the microbiome is relatively stable through periods of hormonal fluctuation, such as puberty or the menstrual cycle [20–24].
It can be partially confirmed by the old statement of Albert Doderlein (1892): by using culture method he found that vaginal microbiome of healthy women possess a predominance of Gram-positive rods named “Doderlein lactobacillus” from his name [25].
More than 120 years later, it is universally accepted that lactobacilli are the predominant species of the human microbioma and that they have a key role in maintaining an acidic environment able to protect women against virus and bacteria responsible for opportunistic infections and STDs [26].
It was remarkable to observe that humans species are the only one with this relative abundance of lactobacilli in vagina (more than 70%), while other mammals present not more than 1% of lactobacilli in the vaginal microbiota [26] (Figure 1).
Mean vaginal relative abundance of
To date, most comparative studies in mammals find that hosts with similar lifestyles and evolutionary histories harbor similar microbiomes at a given body site, both in the bacteria taxa they contain and the functions they provide to hosts [27, 28].
One important exception to this pattern is the vaginal microbiome, where humans exhibit striking differences in community composition compared to other mammals; specifically, the human vaginal microbiome is dominated by
These lactobacilli process glycogen and it breaks down products to produce lactic acid, leading to an exceptional low vaginal pH of < 4.5 [26].
Lactobacilli dominance and low pH of the human vaginal microbiome are hypothesized to benefit women by reducing disease risk [31].
Furthermore, the loss of lactobacilli dominance is linked to bacterial vaginosis (BV), which is associated with an overgrowth of anaerobic bacteria, relatively high vaginal pH (>4.5) infertility, preterm birth, maternal infections, and increased risk of STDs [21, 30–33].
To date, four hypotheses have been proposed to explain the uniqueness of the human vaginal microbiome relative to other mammals: two mechanistic explanation and two evolutionary explanation: the first “mechanistic hypothesis” considers that the differences in vaginal microbioma between human and nonhuman mammals are related to the differences in reproductive physiology: a typical 28 days ovarian cycle of the humans is quite different from other mammals [34].
This 28 days ovarian cycle in reproductive women is orchestrated by steroids and lactobacilli abundance is strictly linked to estrogen levels [35].
The second “mechanistic hypothesis,” the common function hypothesis, proposes that in nonhuman mammals, other bacteria may protect hosts via mechanisms other than lactic acid and low vaginal pH so that the presence of lactobacilli may not be a requirement for a healthy vaginal environment [34, 35].
In addition to these mechanistic hypothesis, two evolutionary explanation have been proposed, the first, referred to as the “disease risk hypothesis,” proposes that humans have higher STDs risk than nonhuman mammals because species with promiscuous mating strategies are predicted to have higher STD risk than those with only single, brief reproductive episode per breeding season [36, 37].
The last evolutionary explanation, the “obstetric protection hypothesis” suggests that selection for lactobacilli in the human vagina is due to the high risk of microbial complications associated with pregnancy and childbirth, thus lactobacilli and low vaginal pH may serve as a protective function during human birth, and these traits are unnecessary in mammals with less pregnancies and birth risks [38, 39].
An understanding of the diversity of the vaginal microbial environment during states of health and disease is essential for the identification of risk factors for disease and the development of appropriate treatment [26].
Nowadays, it is well established that the normal vaginal microbiome is dominated by lactobacilli species [16, 40, 41].
Years of research have clearly demonstrated that the vaginal microbiota represents the first barrier against obligatory or facultative pathogens in the female reproductive tract [43].
It is well known that women with low lactobacillus species in vaginal microbioma are at high risk for urogenital infective diseases and adverse pregnancy outcomes [42].
Lactobacilli help to prevent vaginal infection by producing lactic acid, hydrogen peroxide, bacteriocins, or through competitive exclusion of other bacteria [43–46].
Studies utilizing 16S rRNA PCR have demonstrated that the vaginal microbial environment is usually dominated by one or two lactobacilli species, most frequently
Of the 73% of women with lactobacilli-dominant environment, the most frequently detected organism was
The second most common Lactobacilli-dominant environment was
The identification of an
It seems that the species of lactobacilli that dominate the vaginal environment may have implications for gynecologic health: different species may differentially predispose to dysbiosis [50, 51].
For example, it has been suggested that an
Culture-dependent and microscopy methods demonstrated that the composition of normal vaginal flora may also fluctuate within an individual woman: this “fluctuation” is related to the menstrual cycle or as result of sexual activities [54, 55].
During menses there is a decrease in lactobacilli and a relative increase in the proportion of bacteria associated with higher Nugent Scores [54, 55].
Recent sexual activity may also affects the microbial composition of the vagina by decreasing the proportion of the lactobacilli species present, which may predispose to dysbiosis with the loss of the protective effects of lactobacilli [53, 56].
Decreased of lactobacilli have also been observed in postmenopausal women, specifically those with vaginal dryness or atrophy [57–59].
The observed fluctuation throughout the menstrual cycle may be explained by evidence that high levels of E2 may favor a lactobacilli-dominant environment [53, 60, 61].
Evidence from culture-dependent and independent methods supported the dynamic nature of the vaginal microbiome [62–64].
A lot of studies have evaluated the vaginal microbiota in tandem by both culture-based and molecular techniques: the results demonstrate a moderate level of concordance providing similar but not identical vaginal microbiome profiles [62–64].
Also interesting is the fact that the quantity and proportion of specific microorganisms in the vagina may vary between women of different ethnic origins: African-American women may have an increased
This distinction is important because
Molecular studies have also demonstrated that African-American and Hispanic women are more likely to harbor a vaginal microbiome dominated by bacteria other than lactobacilli species compared with Caucasian women [9, 66, 67].
These studies suggest that African-American women may have higher levels of
Taken together, these data suggest that the differences in the microbiome between women of various races may alter woman’s predisposition to infection and may at least in part explain the racial disparities in the incidence of BV and STDs [67, 68].
Concluding, vaginal microbiome in healthy women is a lactobacilli-dominated environment in which pH (under 4.5), lactic acid, hydrogen peroxide, bacteriocins, biosurfactants and co-aggregant activities counteract the growth of Gram-negative anaerobes bacteria such as
From the beginning of 1900, the medical community accepted that a shift in the microbial environment of the vagina, specifically a decrease in “Doderlein’s rods” (later identified as lactobacilli) can lead to symptomatic vaginitis with vaginal discharge [16, 40].
Subsequent studies by Gardner and Dukes demonstrated that nonspecific vaginitis (the old name of BV) was associated with a relative increase in rod-shaped bacteria on Gram stain, later identified as
These studies also described the “clue-cells” as characteristic of BV, resulting from vaginal epithelial cells with grainy cell borders [17, 69].
In order to implement standardized diagnostic criteria, researchers pointed out diagnostic clinical criteria (Amsel’s criteria) and Gram stain criteria (Nugent scores): Amsel’s criteria requires almost three of four “clinical conditions” to be present: (1) thin, white, vaginal discharge; (2) vaginal pH > 4.5; (3) “clue cells” on microscopy evaluation; (4) positive “whiff test” (10% KOH addition to sample produces fishy odor) [19, 71].
Are Amsel’s criteria “Clinical Criteria”? Are we sure that pH values or clue cells or whiff test evaluation are “Clinical Criteria”?
The only “real” clinical criteria for women is “vaginal discharge” but, only taking into account TV and media campaigns for the use of panty-liners in women, it is easy to understand “the reason why” BV is underdiagnosed by gynecologists; on one side, the women feel their “vaginal discharge” like “physiological,” and on the other side, vaginal symptoms are not “so urgent” for gynecological consultation.
This is the reason why BV is “a very dangerous pathology”: the time from the beginning of the BV and the diagnosis is too much and, during this time, the local defense of the vagina disappeared leading, in the meanwhile, to more susceptibility to STDs and the bacteria facultative pathogen of vagina such as
The Nugent score is evaluated by calculating the proportion of large, Gram-positive rods (
The sensitivity and specificity of Amsel’s criteria was estimated to be around 70% and 94%, respectively, and of the Nugent score were 89 and 83%, respectively [72].
Culture-dependent studies of BV demonstrate increased diversity of vaginal bacteria (including an increase in facultative anaerobes as
With an increasing use of molecular-based techniques to study the vaginal microbiome, bacteria that seemingly evaded detection using culture-based methods have now been associated with BV, including
It seems universally accepted that increased bacterial diversity, as in BV, with the well-known vaginal ecosystem modifications, could be associated with gynecological infections, such as
It is unclear whether it is the altered levels of bacteria themselves that predispose to infection or whether the altered vaginal microbiome leads to BV, which predispose to these pathologies owing, for example, to altered pH (leading to less efficient neutralization of pathogen, decreased of immune response, loss of hydrogen peroxide activity).
Numerous studies have demonstrated the association between BV and an increased risk of HIV acquisition: hydrogen peroxide produced by lactobacilli is known to have viricidal activities and, consequently, the relative decrease in lactobacilli in BV women may increase susceptibility to HIV infection [23, 24, 39, 79].
A prospective cohort study evaluating the relationship between the vaginal microbial environment and infection risk, the absence of lactobacilli on culture, and the presence of abnormal vaginal flora on Gram stain were associated with an increased risk of HIV acquisition, even after controlling for risk factors [22].
Nevertheless, molecular-based techniques and culture methods confirmed that vaginal microbiome in STDs is usually modified and different from women in healthy status and that the absence of lactobacilli on culture and the presence of abnormal vaginal flora on Gram stain were associated with an increased risk of STDs.
The vaginal microbiome modifications affect vaginal health, and pathology may also predispose to upper genital tract infection, such as pelvic inflammatory disease (PID) [79].
Subclinical PID (histological evidence of endometritis) was detected in 15% of women with BV diagnosed by clinical and Gram stain criteria [79].
Women with vaginal samples (Gram stain and culture) positive for “BV-associated bacteria (BVAB)” (
Since isolation of BV-associated bacteria in the vagina has been demonstrated to increase the risk of sexually transmitted infection acquisition, the correlation of BV with PID may be related to altered vaginal flora that predisposes to STIs and subsequent ascending infection [76, 77].
Available data from upper genital tract structures confirm that BV-associated bacteria can be isolated from upper genital tract.
In a study on 89 women affected by acute salpingitis (45 with pathology and 44 as control group) 16SrDNA detected bacteria in the fallopian tubes of 24% of cases and none of controls [81].
There was a statistically significant difference in the proportion of upper genital tract microbiome based on race: African-American and Hispanic women were more likely to harbor an upper genital tract microbiome dominated by a nonlactobacilli species compared with Caucasian, and this is in contrast with those of vaginal microbiome.
The reasons of this “discrepancy” are not clear and, probably, future acquisitions on molecular-based techniques may facilitate to better understand these differences.
Bacterial vaginosis is a polymicrobial clinical syndrome resulting from replacement of the normal hydrogen peroxide producing Lactobacillus spp in the vagina with high concentration of anaerobic bacteria (e.g.,
BV is a common vaginal condition among U.S. women and also worldwide, especially in childbearing age women [79].
A recent analysis of the National and Nutrition Examinations Surveys demonstrated that almost one-third of women were positive for BV [80].
BV is almost three times more common among black than white women [12], and it has been correlated with particular sexual behavior such as young age at coitarche, life time number of sex partners, a recent history of multiple sex partners, and a recent history of new sex partner [80–83].
The reason for the higher prevalence of BV among black women is unknown but the relationship between BV and race is remarked also from the number of the percentage of black infants born preterm in U.S. (17.5%) vs 10.2% of white infants [82].
BV could account for as much as 30% of the racial difference in premature birth and infant mortality [82].
Other risk factors for BV seem to be “vaginal douching” and use of intrauterine device (IUD) for birth control so that these practices must be limited in women of childbearing age [83].
BV seems not to be a self-limiting pathology since it has been consider a predisponent factor for PID, infertility, PPROM, preterm delivery, and neonatal small for gestational age [82, 83].
Since a lot of cross-sectional and prospective cohort studies have found that BV is associated with acquisition of both HIV and sexually transmitted infections, it seems to be almost interesting to fully understand this vaginal pathology to better clarify its role in determining STDs.
One of the most important “practical problems” of BV is that it is a “silent vaginitis” from a symptomatic point of view.
Comparing BV with specific vaginitis (e.g., vaginal infections clearly referred to vaginal obligatory pathogen such as
Symptoms | Approx. 50% asymptomatic | 10–20% asymptomatic | 10–50% asymptomatic |
Offensive fishy smelling discharge | Vulval itching | Offensive vaginal discharge | |
Vulval soreness | Vulval itching/irritation | ||
Vaginal discharge (nonoffensive) | Dysuria | ||
Superficial dyspareunia | Rarely low abdominal discomfort | ||
Clinical signs | Thin white homogenous discharge, coating walls of vagina, and vestibule | Vulval erythema | Vulval erythema |
Absence of vaginitis | Vulval fissuring | Vaginitis | |
Vaginal discharge may be curdy (nonoffensive) | Vaginal dsicharge in up to 70% frothy and yellow in 10–30% | ||
Satellite skin lesions | Approx. 2% “strawberry” cervix visible to naked eye | ||
Vulval oedema | 5–15% no abnormal signs |
Symptoms and clinical signs of bacterial vaginosis, candidiasis, and trichomoniasis (adapted from) [85].
Approximately 50% of the women affected by BV are asymptomatic [82, 83].
In addition, also considering the standard clinical criteria for the diagnosis of BV (Amsel’s criteria): almost three of four “clinical conditions” are to be present: (1) thin, white, vaginal discharge; (2) vaginal pH > 4.5; (3) “clue cells” on microscopy evaluation; and (4) positive “whiff test” (10% KOH addition to sample produces fishy odor) [19]. It seems to be obvious that the only real clinical condition is the vaginal discharge that can often be perceived by women like “a kind of physiologic condition.”
This means that the rupture of vaginal microbiome equilibrium determining BV could frequently happened without a real alarm in women and, consequently, this long-lasting vaginal imbalance in “apparently healthy women” could bring to invalidate ascending pathologies such as PID or STDs.
Why the presence of BV could lead to such as improving urogenital pathologies?
Why the “natural vaginal microbiome” of healthy people could protect against vaginal infections?
Why the presence of lactobacilli seems to be pivotal in women health?
These Gram-positive bacteria possess a lot of activities that could be useful to counteract vaginal facultative and obligatory pathogen.
It is well known that the term lactobacilli means bacteria that are able to hydrolyze sugars (especially glycogen in the vagina) producing lactic acid and other acids (e.g., pyroglutamic acid): this happened because they try to conserve the optimal vaginal pH for their survival.
Vaginal pH < 4.5 is the optimal condition for their life but it is detrimental for other bacteria such as a lot of anaerobes Gram-facultative bacteria that are commonly present in vagina, also in the healthy women, but with low vaginal concentration: once that lactobacilli decrease, we assist to an increase in vaginal pH with a consequent increase in anaerobes facultative bacteria [82–84].
Low vaginal pH seems to possess also direct antiviral and antimicotic activities related to unfavorable vaginal condition for these infective agents [82–84].
Lactic acid is a potent broad-spectrum bactericide and virucide [83].
During the process of glycogen metabolism in the vagina, hydrogen peroxynitrite is produced: this molecule possesses antiviral, antibacterial, and antimicotic properties [82–84].
In addition, lactobacilli produced a lot of bacteriocins, substances that locally possess antibacterial activities [82–84].
Lactobacilli have demonstrated to possess some cosurfactant and antiaggregant activities that could be useful in controlling vaginal anaerobes growing-up [82–87].
Last but not the least, the ability of a lactobacilli predominants spp. to modulate local immunosystem [86, 87].
Genital epithelial cells and human microbiota seems to regulate the innate immune response: so that genital tract immune response plays a key role in the etiopathogenesis and pathophysiology of BV [87].
It has been demonstrated that the derangement of vaginal microbiota modifies pathogen’s susceptibility encouraging HIV shedding/replication in women genital tract and consequently leading to an increase in the transmission of HIV from female to male [86–88].
It seems that activation of Toll-like receptors (TLRs) could lead to BV-associated inflammation [87].
Recurrence of BV in HIV-infected people seems to be associated with agenetic variation in TLR4, TLR9, and TLR2 in African-American adolescents [89].
BV has also been associated with a polymorphism in TLR2 suggesting that different BV-associated bacteria (BVAB) were able to control cytokines secretion and that activation of immunity in differentiate vaginal epithelial cells was related to different bacteria: an increase in proinflammatory cytokines and in epithelial cells has been associated with the presence of
BVAB infections could result in a proinflammatory immune response that disrupts barrier functions where other microbes could elicit different responses [90].
Recently, the pivotal role of Gamma Delta (GD) cells in the innate and adaptive immune system has been demonstrated: these cells are well represented in the female reproductive tract and seems to play a key role in the vaginal epithelial barrier against pathogens [91].
The decrease in cervical GD1 cells and increase in GD2 cells among women with abnormal vaginal flora predisposes women with BV to HIV acquisition [91].
Considering the high rate of correlation between these parameters, the authors proposed to use GDT cells as markers of female genital tract vulnerability to HIV [91].
GD1 cells and GD2 cells substantially differentiates in vaginal localization and functioning: GD1 cells are well represented in mucosal tissue and play a leading role in maintaining mucosal structure, while GD2 cells are well represented in peripheral blood and are important in maintaining humoral immunity and in the development of the immune response to pathogens [91].
Increased cervical vaginal lavages seem to increase sialic acid residues leading to an increase in sialidase levels that are associated with BV [92].
BVBlue System method has been used to measure sialidase levels and to make diagnosis of BV [93].
Mucinases, sialidases, and biofilm production seem to be related with sialidase secretion by
The relationship between sialidases and HIV infection has recently been evaluated [95–98], as gp 120 and CD4 seem to carry sialic acid residues: sialidases administration to HIV cells has demonstrated to enhance HIV infection [9, 97] suggesting that sialic acid disruption could help virus-binding and enhanced virus transmission.
In addition, the negatively charged sialic acid molecules at the terminal ends of the O-linked sugar chains determine changes in mucosal viscosity [98, 99].
Concluding, there are a lot of activities related to lactobacilli presence in the vagina that seems to be helpful in counteracting BV and preventing BV-associated pathologies.
Treatment of BV is recommended in order to relieve vaginal symptoms and signs of infection and to reduce the risk of acquiring
Obviously, the treatment is necessary also to avoid risk of PID, infertility, and pregnancy/newborn’s complication.
Center for Disease Control’s (CDC) recommended regimen for B.V. is [83]:
Metronidazole 500 mg orally twice a day for 7 days
OR
Metronidazole gel 0–75% one full application (5 g) intravaginally, once a day for 5 days
OR
Clindamycin cream 2% one full application (5 g) intravaginally at bedtime for 7 days
Women treated with nitroimidazoles must remember that alcohol consumption should be avoided during treatment [83].
To reduce the possibility of disulfiram-like reaction, abstinence from alcohol use should continue for almost 24 hours after completion of metronidazole [83].
We also have to remember that clindamycin cream is oil-based and consequently might weaken latex condoms and diaphragms for almost 5 days after use; women should be advised to refrain from sexual activities or use condoms consistently and correctly during the treatment regimen [83].
Since no clinical data support the use of vaginal douching for symptoms relief or treatment of BV, and since vaginal douching increases recurrence of BV, this procedure must be avoided by gynecologists [83].
CDC’s alternative regimens to treat BV are:
Clindamycin 300 mg orally bid for 7 days or
Clindamycin vaginal ovules 100 mg once a day (bedtime) for 3 days or
Tinidazole 1 g oral route once a day for 7 days or
Tinidazole 2 g oral route for 5 days
Also, in this case we have to remember the same disulfiram-like reaction for nitroimidazoles so that alcohol consumption should be avoided during treatment and almost 72 hours after the completion of the tinidazole regimen [83].
For Clindamycin ovules, since an oleaginous base that might weaken latex or rubber products is present (condom and diaphragma), we have to remember to avoid condoms and diaphragms use during treatment and within 72 hours following treatment [83].
Treatment of vaginal infections requires different drugs although the recurrence rate posttreatment remains high due to adverse effects on the beneficial microbiota [86].
Metronidazole and clindamycin treatment do not prevent recurrent BV infections as the lactobacilli population is rarely reconstituted [86].
Thus, there could be clear clinical advantages for the use of biotherapeutic agents (prebiotics and/or probiotics) for treating these infections [84].
Biotherapeutic agents have been defined by McFarland and Elmer in 1995 as living microorganisms that are used to prevent or treat human disease by interacting with natural microbial ecology of the host [84].
Probiotics could though be highly beneficial in modulating the mucosal flora, maintaining the integrity of the epithelial barrier and regulating the immune response [84].
Hydrogen peroxide–producing lactobacilli have been shown to be protective against a number of bacterial infections [84].
Reid et al. observed that a vaginal application of Lactobacillus casei sub-rhamnosus was able to survive in vagina after 7 weeks of exogenous application concluding that “it was surprising and it was the first and unique observation referring to exogenously-applied Lactobacilli vaginal application” [100].
Consistently with this information, a lot of clinical trials have recently been performed by using vaginal commercial probiotics containing selected Lactobacillus rhamnosus spp [100–109].
Since the recurrence rate of BV is higher also after treatment with CDC-recommended protocols, the “probiotic vaginal approach” with
A review on its long-term use after CDC regimen administration seems to point out on a big sample size of women that its chronic use (almost 6 months) after CDC treatment administration in women affected by BV could significantly decrease the BV recurrence rates when confronted with the simple CDC regimen [104].
While this “vaginal approach” with selected Lactobacilli spp seems to be encouraging, to lower the recurrence rates of BV, the oral approach with probiotics seems to be ineffective for BV treatment [110].
Considering the relationship between BV and STDs, it could be useful to consider this biotherapeutics approach to prevent and control STDs.
The term sexually transmitted diseases (STDs) refers to many diseases and the number keeps expanding with the discovery of new pathogens (e.g., HIV) or a new route of acquisition of a known pathogen (e.g., hepatitis C) [3].
Historically, all the diseases known to be transmitted only by sexual intercourse have been classified as “venereal diseases”; Other terms, such as “sexually transmitted infections” (STIs), “sexually transmitted diseases and infections” and “reproductive tract infections” have been used [3].
All these diseases will be included in this chapter under the term “sexually transmitted diseases.”
STDs have complex political, social, and public health implications, in addition to their medical significance [3].
Syphilis continues to remain an important disease in spite of the introduction, more than 60 years ago, of effective treatment such as penicillin; its rate is on the rise in men who have sex with men (MSM) in some areas of U.S. [3].
STDs still remain the most common infectious diseases in developed and developing countries [3].
Considering the availability of effective therapies and that STDs could be prevented by changing one’s behavior, it is surprising that these pathologies have been on the rise in developed and developing countries: only the complex nature of these diseases and the complex relationship between public health and social community could explain this continuous rise [3].
In this chapter, we divided the STDs in two main categories: diseases characterized by genital ulcers and diseases characterized by genital discharge; HIV infection will not be discussed in this chapter.
Syphilis, herpes simplex virus (HSV), and chancroid are STDs with ulcer; each of these diseases has been associated with an increased risk of HIV infection [2, 3].
Genital ulcers diseases (GUD) facilitate enhanced HIV transmission among sexual partners. In the presence of genital ulcers, there is a fivefold increase in susceptibility to HIV, and HIV-infected individuals with genital ulcer disease may transmit HIV to their sexual partner more efficiently [2, 3].
A genital ulcer is defined as a breach in the skin or mucosa of the genitalia.
Genital ulcers may be single or multiple and may be associated with inguinal or femoral lymphadenopathy.
HSV is the most common cause of genital ulcers in U.S. among young, sexually active partners,
In developing countries, the most frequent genital ulcer disease is represented by “chancroid” [2, 3].
Travelers or native in the tropics could present
The relationship between GUD and pathogens are strictly related to patient population and geographic area [2].
There is a considerable overlap in the clinical presentation of herpes, primary syphilis, and chancroid [2].
Genital herpes typically presents with multiple, shallow ulcers and bilateral lymphadenopathy [2].
Primary syphilis can usually been differentiated from genital herpes by the presence of single deep, defined ulcer with induration [2, 3].
Also from chancroids and syphilis, a difference could be done according to the presence of a painful, undetermined ulcer with a purulent base that tender to lymphadenopathy [2, 3].
The cause of genital ulcers cannot be based on clinical findings alone because it possesses only 30–34% of sensitivity: this means that diagnostic testing should be performed [3].
Vaginal discharge is a frequent gynecologic complaint, accounting for more than 10 million office visits annually in U.S. [2, 3].
The three most common causes of vaginal discharge are BV (40–50% of cases), vulvovaginal candidiasis (20–25% of cases), and
Pelvic inflammatory diseases (PIDs), Gonococcal infections (
Human papilloma virus (HPV) infections are the most common viral STDs worldwide; 1% of the sexually active persons in U.S. between the ages of 15 and 49 years are estimated to have genital warts from HPV [3].
Most genital HPV infections are subclinical and are transmitted primarily through sexual contact. HPV is a double-stranded DNA virus that causes a spectrum of clinical diseases ranging from asymptomatic infection to frank malignancy. External genital warts have various morphological manifestations such as condyloma acuminata, smooth dome-shaped papular warts, keratotic warts, and flat warts [3].
Because of the well-known relationship between HPV and cervical cancer, in June 2006, U.S. Food and Drug Administration approved a quadrivalent vaccine for HPV [2, 3].
Several states have already recommended HPV prevention making HPV vaccination mandatory for middle school girls [2, 3].
Several prospective studies have reported an association between abnormal vaginal microbiota, in particular BV and depletion of lactobacillus species and increased risk of STIs’ acquisition [32, 111–121].
Human papilloma virus (HPV), human immunodeficiency virus (HIV), human herpes simplex virus (HSV), and PID infections/acquisition seem to be more frequent in women affected by BV [32, 111–121].
Also,
The vaginal microbiome has been well characterized although cultivation-based and molecular methods and data from epidemiological studies indicate that the vaginal microbiota influences and enhanced STI susceptibility [20, 32, 113, 115, 116].
Immunologic, enzymatic, and metabolic mechanisms could operate independently or in combination to enhance STI acquisition [20, 115].
An increasing number of evidences provide a strong foundation for a biologic relationship between BV and increased STIs susceptibility.
It is well known that vaginal Lactobacilli spp fermented local sugars (e.g., glycogen) producing an acidic vaginal pH that have been associated with decreased
This acidic environment seems to be unfavorable also for HPV, HIV, and HPS infections [32].
Hydrogen peroxynitrite produced in vagina by Lactobacilli spp through sugar fermentation seems to be a key point for reducing risk of STIs [32].
Hydrogen peroxynitrite possesses a well-known bactericidal and virucidal activity [32].
Cervical mucus has the ability to trap pathogens but, unfortunately, this mucus barrier may be compromised by mucin-degrading enzymes such as sialidase and mucinase, which are produced by BV-associated bacteria: loss of the protective mucus provides pathogens with unhindered access to target cells, increasing epithelial binding potential [32, 114].
Sialidase also cleaves terminal sialic acids from glycoproteins, exposing other sugar on their carbohydrate side chains, which can be used as energy for bacteria [32, 116].
Several BV-associated bacteria produced indole that is used by
The relationship between genital epithelial cells in the vagina and vaginal microbiota seems to strongly influence the innate immune response suggesting a pivotal role of the reproductive tract immune response in determining BV and its compliances: vaginal microbiota derangement could decrease local immunity with a consequent increase of STDs risks in the women urogenital tract [87].
Lactobacilli have historically been considered keystone species of vaginal communities in reproductive-age women [32, 87].
Lactobacilli produce bacteriocins (low molecular weight proteins) that can inhibit the growth of a variety of bacteria reinforcing the concept of reducing susceptibility to STDs [32, 87].
BV may predispose to acquisition of STDs upon exposure because local cytokine production associated with BV may facilitate the acquisition of STDs [32].
Finally, lactobacilli exhibit cosurfactant and coaggregant activities that could envelop STDs virus or bacteria so that in BV the absence of these “mechanical inhibition” could facilitate the acquisition of STDs [32] (Figure 2).
Differences in BV and non-BV in predisposing factors for STDs.
Concluding, BV, a worldwide common vaginal infection, which is mostly asymptomatic, could be a predisposing factor, also if asymptomatic, to STDs acquisition and then to eradicate this very frequent pathology in developed and developing countries could represent a gold standard for STDs’ primary prevention.
Since BV is one of the key risk factors for STDs’ acquisition, and since asymptomatic and symptomatic BV actually represents the most common vaginal infection worldwide (account for almost one-third of childbearing women), it seems obvious that BV treatment and definitive infection’s eradication could be one of the most important plan for STDs’ primary prevention.
Considering that BV increases susceptibility to STDs, two limiting factors are associated with BV treatment:
The fact that treatment for BV asymptomatic nonpregnant women is not currently recommended [118, 120–122];
The urgent need to develop more effective intervention for BV because the recurrence following current treatment is disappointingly high [42].
Women with an abnormal vaginal microbiota were at an increased risk of acquiring STDs compared to women with a normal vaginal microbiota; it seems that the risk of STD acquisition increased with higher Nugent score category [32].
Considering vaginal microbiome modifications as a predisposing factor for STDs acquisition, restoration of vaginal flora seems to be the crucial keystone for long-term BV treatment and, consequently, for STDs primary prevention.
Interventions that decrease the incidence and the recurrence rates of BV and promote a normal vaginal microbiota could potentially contribute to the reduction in STDs’ incidence.
Current available and recommended treatment for BV [83] as follows:
CDC’s (Center for Disease Control) recommended regimens are:
Metronidazole tablet 500 mg oral route bid for 7 days or
Metronidazole vaginal gel 0.75% (5 g intravaginally every day for 5 days) or
Clindamycin vaginal cream 2% (5 g intravaginally every day at bedtime for 7 days)
CDC’s alternative regimens to treat BV are:
Clindamycin 300 mg orally bid for 7 days or
Clindamycin vaginal ovules 100 mg once a day (bedtime) for 3 days or
Tinidazole 1 g oral route once a day for 7 days or
Tinidazole 2 g oral route for 5 days
Failure to produce sustained changes in the vaginal microbiota [113, 115, 120] clearly demonstrated that alternative regimens that improve cure rates and produce sustained changes in the vaginal microbiota are needed.
The CDC recommended therapies failed to control relapses of BV (almost 40% of recurrences rate at 3 months and 50% of relapses at 6 months), and this seems to be the most relevant problem in treating BV eradication in order to prevent STDs acquisition [104].
With >500 million new cases of STIs each year, the development of innovative strategies for STIs prevention is a global public health priority [32].
By using only Nugent score to classified and scoring BV, the relationship between BV and STDs seems to be clear: BV microbiota as gauged by Gram stain is associated with a significant elevated risk for acquisition of STDs [32].
Obviously, the Human Microbiome Project (http://nihroadmap.nih.gov/hmp/), providing also the genomic studies of the vagina, is expected to describe the structure of the complex microbial communities and how they contribute to disease susceptibility: when it will be available we will probably add more information to control BV recurrence.
Anyway, only by using Gram stain culture and Amsel’s clinical criteria, which is available worldwide today, it is possible to make a BV diagnosis and to have a picture of the women “more susceptible” for STIs acquisition.
From the other side we have to manage the problem related to treatment recommendations that differentiate between women who report symptoms and those who do not; to our knowledge there are no published studies on differences in sequelae between asymptomatic and symptomatic BV [114, 115, 118].
Adverse outcomes linked to BV are probably caused by alterations in the vaginal flora that are seen in both [117, 118].
Screening and treatment for asymptomatic BV women would prevent STDs by restoring optimal vaginal flora, thus reducing susceptibility to STDs as supported by studies demonstrating a clear association between BV and an increase prevalence and incidence of STDs and HIV infection [114–118].
So the first recommendation is:
to treat also asymptomatic BV women in order to reduce STDs acquisition susceptibility;
However, recent largest study to evaluate the impact of treatment of BV on STD outcomes demonstrated that treatment of women with oral metronidazole does not affect the incidence of gonorrhea and chlamydia concluding that we are waiting for more effective therapies for BV [113, 119].
Standard of care for BV treatment is effective in the short term, and it is not able to restore vaginal microbiota. So by using this regimen, we obtain a clearance of BV more than a real eradication and, consequently, the long-term effect is detrimental with a high percentage (more than 50%) of recurrence after 6 months.
Nowadays, we could describe BV recurrences as a “drug-free pathology” for which every effort has to be done in order to restore vaginal pH and, obviously, to reduce the acquisition susceptibility of STDs.
If STDs acquisition is related to asymptomatic and symptomatic BV, and if standard of care seems to be unable to modify, almost in long term, STIs’ epidemiology, the relationship between vaginal microflora modifications and STIs’ susceptibility seem to be a key point to prevent STDs.
So that BV management in terms of restoring vaginal microflora such as in healthy women seems to be pivotal in STDs’ primary prevention: taking into account that almost one-third of the women worldwide are affected by asymptomatic and symptomatic BV and that most of them are undiagnosed, untreated, or treated with the only available standard of care, BV management could represent a new/old cost-effective modality to primary prevent STDs.
Since sexual behaviors are changing year by year especially in young population, and since the percentage of sexually active girls/women that could have sexual intercourse with STDs people are increasing, we strongly believe that vaginal microbiota restoration could become the next milestone in STDs prevention.
So, the second recommendation is:
to restore vaginal microbiota in every sexually active women of childbearing age in order to reduce STDs acquisition susceptibility;
Since the standard of care (CDC recommended therapy) seems not to be able to restore vaginal microflora and possess a high rate of recurrences, alternative approaches are needed.
Biotherapeutic agents (living microorganism used to prevent or treat human disease by interacting with natural microbial ecology of the host) have been used to treat vaginal infections during the time [84].
Vaginal biotherapeutic agents can be divided in three classes:
Prebiotic (carbohydrates that topically stimulated the growth of the body’s indigenous lactobacilli) [84];
Probiotic (living microorganisms—usually
Synbiotic (a combination of the two concept) [84].
A lot of clinical trials have been done with vaginal probiotics; probiotics such as
Other strains such as
Vaginal probiotics have been compared with vaginal metronidazole in a randomized clinical trial and the results show the superiority in terms of effectiveness for two intravaginal capsules of probiotic containing Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 taken once a day for 5 day vs 0.75% metronidazole vaginal gel applied daily for 5 days; another randomized clinical trial showed that there was no difference in BV treatment of patients administered Lactobacillus acidophilus and 0.03 mg estriol with vaginal metronidazole at 3–7 days [84].
Probiotics can be used as complementary to traditional therapies to improve the treatment of vaginal infections and to reduce recurrences of such episodes [84].
Probiotics can also be prophylactic in healthy subjects with a history of recurrent BV [84].
Unfortunately, a review published on EFSA Journal points out the ineffectiveness of probiotics for oral use in restoring vaginal microbiome [111], and another review published on Cochrane showed that probiotics clinical trials were inconsistent to demonstrate clinical efficacy of this approach in BV women [122].
The reported data on a vaginal tablet synbiotic containing
The results obtained in controlled trials [101–109] substantiated the effectiveness of the combination therapy (metronidazole 500 mg twice daily for 1 week followed by a once weekly application of vaginal tablets containing Lactobacillus rhamnosus and lactose for 6 months in preventing BV relapses, not only during the treatment time (6 months) but also during the 6-month follow-up without any treatment) (Figure 3).
Trend of “vaginosis-free” patients in each group during follow-up. *A
Another controlled clinical trial performed by using the same synbiotic for 12 weeks once weekly in pregnant women vs no-treatment control group supported its effectiveness in preventing the development of abnormal vaginal microflora and in control of cervical parameters that could represent risk factors for preterm delivery [108].
A very long-lasting clinical trial (24 months) showed that the same combination between lactose and Lactobacillus rhamnosus BMX 54 via vaginal tablets was able to control vaginal pH in BV during the long-lasting treatment [103].
This “synbiotic vaginal approach” seems to be useful especially if administered for long time course (from 6 months to 3 years) to restore vaginal microflora and to prevent BV recurrences and mutually supported the standard of care for BV.
This probably means that the right Lactobacillus together with the right prebiotic could add complementary effectiveness vs the only therapy with vaginal probiotics resulting in an interesting option to prevent STDs’ infections and acquisition.
A recent controlled clinical trial performed on 117 women affected by BV/vaginitis and associated HPV infection showed a significant decrease in HPV-related cytological anomalies (71.9 vs 36.6%:
Synbiotic vaginal tablets were administered after metronidazole or fluconazole treatment with a precise long-term schedule (once a day for 10 days, then every 3 days for a month, then once every 5 days till 2 months, and the last 6 months 1 vaginal tablet once a week) [109].
These results support the evidence from Mitra et al. [123] “there is emerging evidence which leads us to conclude that increased diversity of vaginal microbiota combined with reduced relative abundance of Lactobacillus species is involved in HPV acquisition and persistence and the development of cervical precancer and cancer.”
Concluding, considering the lack of short-long term efficacy of standard of care in decreasing BV prevalence and recurrences, it seems that every effort must be done during the next years to control “microbioma modifications related to BV”: selected biotherapeutic agents, using for long-term course, could be an interesting and cost-effective treatment to prevent STDs acquisition.
During 2020 and 2021, education worldwide underwent a seismic shift. Universities moved online at short notice [1, 2], school districts and local authorities shifted overnight to remote learning, teachers altered curricula and families had to adapt to the new way of working imposed as a result of COVID-19. In the United Kingdom, the terms ‘home-schooling’ and ‘remote learning’ were often used to refer to education delivery following lockdown in March 2020 [3]. However, it is important to consider the immediacy and temporality of this type of learning in contrast with education which is planned as remote/online. As noted in [4], ‘Emergency remote teaching is a temporary teaching solution to an emergent problem.’ This was the case with the first wave of lockdowns in England, where schools moved to ‘emergency remote teaching’ over one weekend in March 2020.
Time to consider pedagogy and delivery of learning was limited; changes were made in special educational needs (SEN) legislation to allow for this. The legal duty in England for schools to implement all provision for young people with an Education, Health and Care Plan (EHCP) was relaxed. Thus, where proscribed provision was not in place, local authorities had used ‘reasonable endeavors to discharge the duty,’ [3] to source provision, they were protected somewhat from adverse legal proceedings. Pragmatically, this meant that young people with EHCPs did not have full, statutory provision to support their curricular access. The effects of lockdowns and ‘emergency remote teaching’ on young people with ‘special educational needs and/or disability’ (SEND), without EHCP-defined provision remains poorly studied in an English context. While dyslexic young people’s experiences of ‘emergency remote teaching’ have been explored in higher education [1, 5] and amongst school children in Spain [6], Italian children’s progress in reading over lockdowns has been evaluated [7] and parental views of effects of remote learning have been explored in several national contexts [4, 5, 8, 9], little-to-no research exists in an English context. Parental conceptualization and navigation of systems to deliver ‘emergency remote teaching’ for children with dyslexia and/or other specific learning difficulties (SpLD) due to COVID-19 within the English context is lacking.
This study aims to fill that gap in knowledge and presents results of an ‘online social survey’ [10] in the form of a ‘web survey’ [10] administered between April and June 2020. Data analysis used a framework developed by Ross [11, 12], informed by Jenkins ‘orders of interaction’ [13], and underpinned by Bourdieu’s concepts of habitus, field and practice [14, 15]. Technology and infrastructure implicated in ‘emergency remote teaching’ is considered both in terms of effective use and access to appropriate devices. The survey aimed to explore the following areas of parental experience through both closed and open-ended questions:
parents’ internal conceptualization of ‘emergency remote teaching’ and their role in its implementation, drawing on their own experiences and sense-making.
How parents’ conceptualization of ‘emergency remote teaching’ informed and/or prompted their interactions with others, such as their children and their children’s educators.
Parents’ capacity to meaningfully navigate institutional expectations, barriers and roles related to ‘emergency remote teaching’ based on their internal sense-making, interactions with others and own agentic capacities.
In this section, practices to support young people with SpLD are briefly discussed, with reference to the changes that took place following COVID-19 school closures in England. The roles of parents within school-based support systems for young people with SpLD are outlined. An overview of shifts in these roles due to COVID-19 and ‘emergency remote learning’ is given, drawing on existent literature. Finally access to resources is discussed and the use of technology in supporting young people is outlined, drawing on pre- and post-COVID-19 experiences. Importantly, barriers to engagement with education and ‘emergency remote teaching’ are also discussed here.
Frameworks for supporting young people with SEN in England were updated in 2014 [16]. Formerly, the tiered system of support categorized young people’s needs by the amount/type of additional or specialized input they received in school [17]. The current framework does not differentiate between young people’s levels of need when considering non-statutory support/intervention. However, where statutory provision is in place, young people’s EHCPs detail their needs and the provision which must be in place. Dyslexia and other SpLD are the principal need for many young people: 14.85 of young people with non-statutory provision and 3.8% of those with EHCPs [18]. Few young people with SpLD have an EHCP, as it is expected within policy that their needs are met in mainstream settings, through high quality teaching and school-based intervention packages. The nature of the package or support program for young people largely depends on the school. There is a paucity of robust evidence detailing what works to support learners with SpLDs [19]. Policy stipulates that young people and their families should be meaningfully engaged in support processes. However, this is not always the case [20, 21], particularly for young people who do not have statutory protection for their provision.
COVID-19 and the swift change to ‘emergency remote teaching’ did not allow adequate space or time for consideration of the pedagogical needs of different groups of students whether in higher education [1, 2, 4] or in the school systems [7, 22, 23] of various countries. In England, the picture was much the same, to the extent that statutory provisions for young people were ‘relaxed’ [3] and young people without statutory provision were not supported in school at all. Places were only available for those with an EHCP or fulfilling other criteria (see [3]). As such, schools supporting young people with additional needs such as SpLDs were left to fend for themselves and to design their own curricular provision.
Despite legal frameworks and guidance necessitating ‘reasonable adjustments’ for young people with SEN, COVID-19 appeared to erase protections written into law and policy. ‘Best endeavors’ were sufficient even for those with statutory documentation [3]. There was little protection afforded for young people with SEND such as SpLD within COVID-19 legislation.
Within policy, according to Bourdieu, certain categories are defined and formally recognized within certain fields [14, 24]. In education in England, teachers are granted ‘Qualified Teacher Status’ following completion of formally accredited training [25]. The roles of teachers such as Special Educational Needs and Disability Coordinators (SENDCos) [26] or Specialist Dyslexia/SpLD teachers [27] are clearly defined within policy and practice through legislation or professional accreditation. Others working in schools may also have certain statuses dependent on their respective qualifications and professional pathways. However, the role of ‘parent’ is less clear both within policy and practice.
Largely parents advocate for their children within policy and proactively seek to secure appropriate support, through their relationships and interactions with professionals [28]. Policy frameworks [16, 26] expect parents to be meaningfully engaged in the organization of support provision for their children. However, the reality of this may be different. Steps taken to engage parents/carers in processes differ at local level but are largely controlled by Local Authorities in England. As such parents’/carers’ capacity to engage fully and effectively alongside their families through these sometimes-complex processes is limited [20, 21]. This has changed little since governmental evaluations of pilot studies, undertaken before the introduction of new policy frameworks [29], particularly for those without statutory provision, such as those with SpLD.
Despite little research on ‘emergency remote teaching’ experiences of young people with SpLDs and their families in an English context, there is substantial evidence that the roles of parents differ substantially from those they embody in a non-COVID world. Parents were largely in a supporting role that saw them oversee technical difficulties in online teaching [4]. At other times, whether engaging in remote learning online or through paper-based materials, parents/carers found themselves in the position of teachers and supporting their children to engage, access and undertake their learning. Young people’s ‘parents became their teachers, their tutors and advocates’ [28]. Parents reported in several studies that online learning was particularly burdensome for them because they did not have the technical knowledge to support their children (or themselves where applicable) to access the relevant websites, applications or conferencing software [4, 5]. The support processes in place provided asynchronous text-based support, as well as some video or live sessions with real-time instruction. However, there was little evidence of specific differentiation to support young people with SEN, even within Higher Educational settings, where students were overall more self-sufficient [2]. As such, it is likely that provision to support young people with SpLD in England, was patchy at best and somewhat inconsistent. The lack of research, however, makes it difficult to draw meaningful conclusions about support/adjustments for learners during COVID-19 lockdowns and parents’ related roles.
There is some work on the use of different assistive technologies to support young people with SpLD, in UK education settings. However, much of the research uses incomparable metrics, epistemologies and methodologies, making it impossible to draw robust conclusions on what technology is best-suited to different learners [19]. Young people may have access to different technologies according to their statutory EHCP support measures. However, a substantial barrier to the use of assistive technology in schools is the cost; even for technology, this cost factor has a high impact on both well-being and academic outcomes [30, 31, 32, 33, 34]. The same can be said of 1:1 or small-group instruction [35]. Thus, we can see that some effective support interventions are prohibitively costly and therefore, many young people do not have sufficient access to them.
Much of the work relating to COVID-19 shows that most instruction moved online [4, 5, 8], with some paper-based work delivered where digital infrastructure was lacking [8, 36]. However, moves were made to secure access to appropriate technology and internet access for families who did not have those resources in place. Literature shows that access to paper-based materials required parents to support their children’s learning; this was problematic for working parents. Access to printers or devices to submit work for marking/feedback was also noted as problematic for some families [4, 9]. The overall themes arising in studies undertaken in other national settings were that lack of access to appropriate devices and reliable internet connections made accessing ‘emergency remote learning’ very problematic for families. Cost of technologies and internet access were a barrier to families to access online learning. Many families in England did not have the resources in place at home and subsequently could not access online teaching [37].
Theories underpinning the Jenkins-Bourdieu analysis framework are discussed here, with reference to prior work undertaken by the author, addressing strengths in the framework. Visual representation of the connections is also given.
The unifying concept between Jenkins’ and Bourdieu’s social projects is the notion to which they both ascribe: the inseparability of social actors and the social context in which they operate. The connections made between Jenkins’ and Bourdieu’s frameworks are shown in Figure 1 [38].
Identity and interaction- a visualization.
Parents and young peoples’ sense-making in education has been explored through the knitting together of Jenkins’ ‘levels of interaction’ with Bourdieu’s concepts of ‘field’, ‘habitus’ and ‘practice’ into a single theoretical framework [11, 12]. This framework provides a robust and effective way of bridging the subjectivist-objectivist gap perceived by Jenkins in Bourdieu’s theoretical project [39], and allows for a thorough consideration of objective, external social structures as well as those (re)produced internally [40]. It also gives insight into how identity is constructed and how individuals make sense of the world around them. However, analysis of data for this project and other work undertaken in the COVID world have shown how challenging it is to apply this framework to static social settings without consideration of the wider social world outside a particular field. Here and in previous work [11, 12], education has been the field under consideration. While policy, schools and family settings have all been considered effectively, there has been little exploration of the effect on education of changes in other ‘fields.’
This research explores the experiences of parents/carers of young people with dyslexia arising from schools’ rapid switch to ‘emergency remote teaching.’ This was undertaken via an online survey, with closed, Likert scale and open-ended questions. This report focuses on responses to open-ended questions but occasionally draws upon closed questions to provide context for participants’ responses. The questionnaire explored use of technology and other strategies implemented during initial COVID-19 lockdowns. This chapter investigates parents’/carers’ experiences of ‘emergency remote teaching’ during 2020.
All work was undertaken in line with BERA ethical guidelines [41] and in full consideration of the Teachers’ Standards for England [42], due to the researcher’s part-time position in a mainstream secondary school. Data was constructed between April and June 2020 via an online survey. In line with Bryman [10], this small-scale survey took the form of a structured interview and a self-completion questionnaire. Some elements were ranked responses, some used a Likert Scale, and others were closed questions, which is similar to a self-completion questionnaire. In addition to these questions, there were items on this survey where participants could provide open-ended responses in a text box. This was done to gain understanding of frequencies of response as well as reasons for those responses.
The survey was built using MS Forms and was disseminated through the researchers’ personal network, as well as via social media, specifically through the researcher’s Facebook, Twitter and LinkedIn platforms throughout this time. The researcher’s own network was approached personally with an overview of the research purposes via WhatsApp. The survey form was also accessible via the researcher’s business website. The call for participants was presented alongside a small introduction on social media and was open to all. The initial page of the survey then gave full information on the project’s purpose and aims. This survey was part of a larger project where parents, teachers and other educators, and students were asked about their experiences of accessing education during the initial wave of COVID-19 lockdowns [43]. The survey garnered 123 responses. A total of 47 parents/carers responded to the survey, of which five responses were not usable: the parents/carers did not have children with SEN. This exclusion criterion was built into the survey design: parents were asked whether they had children with SEN and where they did not, they were thanked for their time and the survey ceased. The overall response rate for the survey was relatively low, given that there were 155,825 children with documented SpLD within English education in 2019–2020 [18]. However, there are various factors, which may account for this. It is unclear how many young people have formal diagnoses of SpLD; there may be other young people whose needs are not formally identified or are such that they are not on school SEN registers as noted by the British Dyslexia Association [44]. While there is substantial data available relating to young people in England such as the National Pupil Database [45], there is no capacity built into it; this allows researchers to contact students, their parents/carers or teachers individually. Subsequently, researchers are dependent on professional networks, personal contacts and paid-for survey promotion tools to connect with the target population. Even within targeted sampling, there are often high non-response rates [10]. As such, where parents/carers are in a time-poor, high-stress situation often with relatively poor access to the internet, it is unsurprising that the response rate was not as high as might be hoped. That said, this study does not attempt to capture large-scale, reproducible and generalizable data. Rather this survey aims to take a snapshot of people’s experiences of supporting their children through learning during COVID-19 lockdowns to gain understanding of what barriers and facilitators to learning they experienced.
Table 1 shows school-types attended by participants’ children. Participating parents, teachers/educators and students were assigned a participant number according to the timestamp on their response to the survey. As such, parents here are numbered in the order they participated in the wider survey rather than parents having a separate identification number system from other respondents.
School type | Number of parents |
---|---|
Mainstream secondary | 15 |
Mainstream primary | 13 |
Independent secondary | 3 |
Independent primary | 0 |
Other | 11 |
Participant overview.
All data was cleaned and identifying features removed for analysis. Files containing participants’ personal details are encrypted and password protected. Information is also stored on password protected hardware and is process/stored in line with the Data Protection Act 2018 [46]. The Researcher and their organization are also registered with the Information Commissioner’s Office [47].
Data was saved to MS Excel files on exportation from the survey in MS Forms, and was password protected. Categorical and ranked responses were explored using MS Excel and graphing functions in MS Forms to provide some context for findings. This aims to help improve transferability of conclusions by adding to the thick description sought in qualitative research [48]. Qualitative responses to open-ended questions were then manually exported from the Excel data files and pasted into word documents for each participant. These word documents were saved under each participant’s identifier number and later imported in to QDA Data Miner Lite [49] for analysis.
A framework for analysis based in Jenkins’ and Bourdieu’s work was in place for data analysis. However, very little research had been undertaken into COVID-19 and ‘emergency remote teaching’ at the start of this project. As such, initial open coding was undertaken using a grounded theory approach [50]. On initial reading of documentation, core categories were identified. These related to parents’ experiences of remote learning versus expectations, roles and technology. Following initial reading, a further reading of each parent’s responses was undertaken and the coding framework was refined further until data saturation was reached [50]. For data-triangulation, initial findings from analysis were shared, in the form of a report, with participants who had provided email addresses. They were offered the opportunity to comment on findings and address any inconsistencies. There was no feedback that suggested findings were erroneous; several participants did write positively in response to the report. The potential for further triangulation and deeper understanding of data was also built into the project design. The survey sought participants for further interviews as a further phase of the project where outcomes from the survey would inform real-time interviews with participants. These interviews were undertaken in Summer 2021 and analysis is ongoing at the time of writing.
The Jenkins-Bourdieu framework then underpinned data analysis using core-categories to address research questions. This was done through the exploration of coding intersections in QDA Data Miner Lite. The researcher explored code-intersections which related to each of the three levels of interaction separately by exporting them to MS Word files and reading them. Nine code-intersections were produced: 3 for each ‘levels of interaction’ [13]. The coding-intersection outputs were then read by the researcher and coded by hand with specific consideration of the research objectives. Each output was read at least 3 times and coding was undertaken until data saturation was reached. The grounded theory approach, followed by the Jenkins-Bourdieu coding process highlighted the need for a more sophisticated model, capable of addressing the complex dynamics of field–field interactions, and their effects on individual actors and inter-actor dialog. Fields’ interdependent natures also needed ‘space’ to be adequately addressed. Foundations for this model are laid in sections 5 and 6. The model is discussed in Section 7.
Here, findings from Jenkins-Bourdieu-based data analysis are presented. Data is drawn from open-ended responses to questions and contextualized with reference to participants’ responses to quantitative questions. First, parents’ individual sense-making of ‘emergency remote teaching’ is discussed. Parents’ conceptualization of it versus the reality, and how they are implicated is explored. Finally, institutional barriers and facilitators affecting parents during ‘emergency remote teaching’ are discussed. Where participants are quoted, square brackets indicate editing by the researcher; all spelling is as written in the survey.
Of all 42 respondents, only three families did not have work set online. Thus, for almost all parents, ‘emergency remote teaching’ meant online teaching, although 7 parents reported schools did also provide paper-based work-packs.
Parental conceptualization of remote teaching differed in some areas, but an area of agreement was that there should be an interactive element. One parent’s (55- mainstream secondary) role within a remote learning provider led them to state that, ‘Merely setting task and research to complete is not teaching. There also needs to be an interactive element … built into teaching material.’ Parent 107 (Mainstream secondary) also felt that ‘Face to face learning is essential especially in subjects like maths & sciences.’ A lack of interaction in real time appeared to cause concern that there would be gaps in learning, according to parent 12 (Mainstream secondary). While only three families did make reference explicitly to a connection between interactive teaching and lost learning, those that did appeared to feel strongly about its importance.
Some parents felt that because work was set online, schools were, ‘Not providing online learning just suggested links,’ (parent 42 – mainstream primary) and that their children, ‘didn’t feel that the teachers are communicating or supporting … learning’ (parent 73). However, being given links and choice over what was undertaken was positive for parent 52 (mainstream primary) who noted that, ‘They are providing many different ideas and allowing parents to set appropriate tasks and timings.’ This was echoed by the 10 parents who noted that there was no pressure on them to complete everything or for work to be handed in.
Parental experiences of remote learning were largely unified in that work was delivered online, with the exception of three families. A substantial proportion of parents reported that they could submit work on paper (nine families) or that there was no expectation to submit any work (10 families) upon completion. This was in addition to the 23 families who could submit work online. Most parents did not specify the platforms used but some did use MSTeams, Class DoJo or Google Classrooms at the start of lockdowns. The platform for dissemination was not cited as problematic by any parents; rather the practicalities of online learning were the barrier for some, with parents not having the capacity to support their children. In this survey, 35 children had access to their own devices. The switch to online instruction is within a context where two-thirds of parents reported that their children used no assistive technology in school. Thus, there has been a substantial culture and experience change for most families.
Twenty-four families reported that work took more time to complete at home than in school, which suggests that the volume of work set was substantial. As noted by parent 60 (mainstream secondary), schools had ‘given far too much work for the time available’ and were ‘determined to work their way through the curriculum with little account of how online learning is very different.’ Only five families found that time spent on remote-learning was in line with in-school working. One family (parent 91), whose independent secondary school routinely used iPads found ‘Remote working no different to that when in school.’ This differs substantially from others’ experiences of online learning, who felt that ‘reliance on technology has made it significantly more difficult,’ (parent 57 – mainstream secondary). Having said that, only 9 families reported that accessing technology was harder at home, versus 17 who found it easier and 18 who found it in line with school access. As such, we can see that remote/online working was not a straight ‘switch’ for parents/carers and their children, but there were variations in experiences.
Delivery of teaching materials relied heavily on technology and on parents. With parents working at home, time/availability to support children was a pressure point for families. As noted by parent 113 (mainstream primary), ‘I don’t have the time to encourage him or help him when he’s struggling.’ They felt that ‘work has clearly been set on the basis that the children will have access to computers to compete the work, or at least a printer with an unlimited ink supply!’
It is of note that 27 parents (64%) felt that work was pitched at the right level; with only 30% finding it too complex, they still felt work took longer at home. This suggests then, that there was too much work set and/or that the work needed substantial differentiation by parents. This echoes parental views of ‘normal’ lesson delivery, where two-thirds of parents were unaware of differentiation for their children or felt that teachers did not adapt their children’s work.
Differentiation was minimal and parents were key in addressing this: parent 57 (mainstream secondary) reported that they, ‘have had to adapt [work] for our daughter, which has taken a lot of time.’ Other parents reported that work was set but that they as parents were expected to ensure that work was done, either through choosing a daily program of study for their children and/or through adapting work set so that their children could access it. Differentiation of work and adjustments for young people with SpLD was a point of contention for many families. Parent 55 (mainstream secondary) noted that there was ‘a huge amount of ‘project work’ set which I expect is perceived as self-differentiating.’ They felt that the school was not adjusting work, as did parent 73 (mainstream secondary) who noted, ‘My son says that the school is not adapting work for him,’ and parent 101 (mainstream primary) who said that ‘nothing had been adapted for SEN’ until the week that the survey was taken in mid-May.
Some families believed that lack of interaction would lead to knowledge gaps irrespective of young people’s needs and capacity to engage with remote learning. Of respondents, 29 families were not confident or neutral in respect to teachers’ ability to deliver online learning, with most families reporting that learning was not interactive or real-time. This lack of confidence may underpin families’ concerns around gaps in learning.
However, this view was not universal. Some families felt that online/remote teaching was very successful for their children; 13 families reported high confidence in teachers’ ability to deliver remote learning. Parent 39 (mainstream secondary) noted that, ‘teachers have been emailing C and marking all his work online. Feedback has been excellent. As they are not dealing with bad behaviours, the focus is all on teaching and learning.’ Parent 91 (independent secondary) found remote learning effective and noted that, ‘Contact with subject staff and learning support staff is always available.’ Other parents experienced contact with staff differently. Parent 99 (other) found that, ‘not all tutors are chasing him for the work he is supposed to have done’ and that understanding what was expected work-wise was challenging.
Parent 119 (mainstream secondary) perceived a difference in delivery dependent on teachers noting that ‘some teachers have adapted better than others. Some subjects [are] being taught by the teams’ platform; other subjects there has just been work set by email.’
Where delivery of lessons was problematic, it was largely attributed to difficulties in accessing platforms or loss of routine for learners, as found elsewhere [51, 52]. Parent 109 (mainstream secondary) found that ‘work isn’t user friendly. Platforms used like ‘show my homework’ is inconsistent and not very user friendly.’ Parent 60 (mainstream secondary) found that their daughter, ‘misses the routine, and her friends, and her timetable.’ Despite some difficulties in sequencing and organizing work, some parents did appreciate flexibility and feedback from teachers. As parent 42 (mainstream primary) noted, ‘They are reassuring all parents not to stress about it. Explaining all children are different. Learn in different ways.’ This appeared to provide comfort emotionally and pragmatically, allowing for responsive management of children’s workloads.
Although some parents found communication from school efficient and accessible, and prompted by positive experiences, others disagreed. This theme arose from qualitative responses from some parents around communication and the forms it took; it was not a specifically structured question. However, communication between families and professionals was described in several extended answers. The issues raised were useful for consideration when addressing pragmatic outcomes from remote learning.
Lack of differentiation prompted parents to contact schools to request appropriate work. Some parental communication did result in adapted work for children. Parent 60 (mainstream secondary) noted that for her daughter, ‘Some of the teachers have thankfully responded to her need for ‘private’ questions and I would like to see that continued as it really helps with her social anxiety.’ Parent 110 (mainstream primary) found that following contact with her child’s schools, the ‘Teacher has emailed me more appropriate work.’ Other parents found contacting teachers was less fruitful.
Parent 12 (mainstream secondary) did not have clear communication with their child’s school stating, ‘I’m not clear how he is at school… he says he finds things popping up on the screen distracting.’ This suggests that delivery of learning was not adapted for their son. Parent 119 (mainstream secondary) found that individual contact with the school was less effective than collective action reporting. They felt the need to work alongside other parents to contact the school and request differentiated learning materials. Parent 119 (mainstream secondary) commented, ‘At the start of the situation there was no adjustments in place for my child… we had to make a complaint to get this changed… all the students of one subject have complained too.’ Parent 113 (mainstream primary) had ‘spoken with the SENCO Manager at the school 3 times now and each time I am told they are not putting on any additional resources or remote teaching for children with SEN.’ Despite contact, them school made no concessions during the first lockdown for her child and others with SEN. These themes were present in a large number of responses: schools did not differentiate work appropriaptely. However, given other work on SEN and the difficulties expected in relation to provision (see changes in policy highlighted in sections 2.1.2 and 2.2.2), the lack of differentiation was unsurprising.
Some parents have found their new roles as ‘teachers’ a positive experience, as noted by parent 35 (mainstream primary): ‘We can discuss on a one-to-one level, make connections across subjects easier because I don’t have to stick to lesson plans.’ Other parents had less positive experiences: ‘I don’t have the time to encourage him or help him when he’s struggling’ (parent 35 – mainstream primary). Others described an expectation for them to step in to teach (parent 123 – mainstream primary), ‘there is assumption and agreement that parents will intervene (and I do).’ The shift in roles was a theme in over half of extended answers. Parents experienced changes in how they supported their children. Parents were key in actors as facilitating young people’s ability to access their work through remote learning. This finding echoes outcomes in other studies undertaken during COVID-19 related remote learning.
Parents had substantial expectations placed on their resourcing and capacity at home as a result of COVID-19 lockdowns. Most parents responding to this survey had appropriate technology and devices to access learning (37 families). However, five families did not have sufficient devices. Parents also had to manage competing demands of work and supporting their children at home.
Parent 113 (mainstream primary) reported that school was, ‘not adapting the work at all. Both my husband and I are working full time… I am working full time at home whilst home-schooling 2 children.’ Parent 52 (mainstream primary) also noted that at home ‘he has the attention of an adult to help and keep him on track.’ Parents reported that they intervened to support their children’s learning despite their work commitments. This echoes findings from elsewhere and demonstrates the structural barriers in place [4, 5]; what if parents are not available to work with their children, or what should parents do, where they are without access to appropriate technology to facilitate their children’s remote teaching?
Parent 57 (mainstream secondary) noted that, ‘The reliance on technology has made it significantly more difficult’ to access remote learning. Parents and children simultaneously working from home caused substantial difficulties for some families: they did not have sufficient access to devices. Parent 58 (mainstream primary) said, ‘We only have one tablet with a small screen.’ Other parents noted the importance of having access to a device: ‘He has he own device [which] enables access. Technology is very important’ (parent 26-other). Other families with limited devices had to prioritize which child could use it and when. This caused substantial difficulties for them.
Parents felt that ‘emergency remote teaching’ highlighted their children’s difficulties, particularly with literacy; 18 families (43%) reported that their children found learning harder at home than at school. Parent 55 (mainstream secondary) asserted that, ‘It has really highlighted my child’s struggle with reading and being independent.’ Parent 35 (mainstream primary) also found this, stating, ‘the reading required for online learning (it can be text heavy) emphasizes his difficulties with literacy and memory. However, multimedia like YouTube … make it easier for him.’ This shows that families could to some extent ‘bypass’ reading to access class learning by using other learning strategies. However, parent 35 (mainstream primary) ultimately settled on ‘purposefully decid[ing] not to follow the curriculum.’ No other parent in this study actively chose to go ‘off plan’ for their children, which although not high frequency, is highly important as an apparent outlier within survey respondents.
As discussed above, parents viewed access to ICT as essential for engagement with remote teaching. There was also the expectation within parents’ sense-making/conceptualization of remote learning that they would be ‘available’ to support their children at home with learning, despite their own professional demands/roles. Lack of resources has been noted as problematic by parents, both within the home-sphere and within school. Parent 109 (mainstream school) felt that their child would benefit from technology, ‘but I canning [can’t] afford it.’ Conversely, parent 108 (mainstream primary) noted that, ‘School can’t afford a device for every child.’ There was reference made to free/integrated software addons, accessible to schools. Other parents asserted the importance of read-aloud software, touch typing, and dictation/speech-to-text capacities to support their children’s learning.
Some parents found that remote learning was beneficial, as access to technology facilitated their children’s learning (parent 109 – mainstream secondary; parent 39 – mainstream secondary). The freedom to use different technologies such as readers, Google searches and touch-typing, facilitated access to learning for some learners, according to their parents. Other parents noted that use of ICT and the systems implemented for ‘emergency remote teaching’ exacerbated their children’s difficulties, with children’s social needs not being considered initially (parent 60- mainstream secondary). ‘Screen use exacerbates… issues with attention and concentration’ (parent 102- mainstream primary) and some young people may be ‘… vile if [they have] been on technology too long’ (parent 105- mainstream secondary). Difficulties interpreting pop-up information were also reported; it is likely that ‘chat’ functions were the reason for these difficulties, given that many software packages have that feature.
In this section, how parental conceptualization of ‘emergency remote teaching’ underpins home-school communication, and the resulting roles adopted by parents during remote teaching is discussed. Connections between parents’ understandings of ‘emergency remote teaching’ and their engagement with institutional processes are made. Reference is made to resourcing, structural expectations on them and their capacity to navigate them, and links are made with existent literature.
Parental sense-making of home-schooling tended to focus on what they hoped for – interaction in real time with specific and personalized instruction for their children – in contrast with the reality. The reality encountered tended to be remote digital delivery through written instruction and/or some video resources. Parents found themselves in the position of facilitator of learning, which took place online for the most part, which echoes other work undertaken in the COVID-19 climate [4, 5]. While some parents felt that their children could complete more work than in school (parent 39-mainstream secondary), others’ feelings are summarized clearly by parent 96 (other), who said of their son’s experiences, ‘He needs a teacher.’ Time to support their children and (lack of) access to devices/internet were recurring themes in parents’ sense-making of emergency remote teaching, which again chimes with other work on parents’ and learner’s experiences during COVID-19 [4, 5]. As noted elsewhere, personal sense-making (of parents in this case) underpins their interactions with other individuals [13, 14]. Parental views and experiences of ‘emergency remote teaching’ influenced interactions substantially due to the gap in expectations versus reality of their experiences.
Parental conceptualization of ‘emergency remote teaching’ showed that some parents felt that interaction – ideally in real time – was a crucial element of teaching. This chimes with work undertaken elsewhere that found many students had difficulties accessing asynchronous learning [2, 36]. Lack of consistency in provision was noted in other studies on COVID-19 instruction [37]. Parents in this study reported different levels of satisfaction and confidence in their children’s teachers’ ability to deliver lessons. There was also considerable variation in how work was delivered across and within institutions. Some teachers were better able to adapt than others, which had been noted by parents. This suggests that even within individual schools, variation in implementation of ‘emergency remote learning’ policy is substantial, leading to notable differences in what is on paper versus the reality of remote lesson delivery. This echoes work relating to both school [36] and higher education [1, 6], where provision was developed in the first instance by educators independently according to their strengths, with institutional policies following later.
While parental advocacy has been discussed elsewhere [28], here parental roles have been developed from advocacy for their children towards ‘parents-as-teachers.’ Where young people had SpLD, parental knowledge of technology was not always secure; they felt that schools were not providing sufficient support and training, which echoes work on higher-education by Gould [2]. However, parents’ own tacit knowledge of technology was implicitly relied on, due to structural expectations placed on them during COVID-19 related lockdowns. How work was set also impacted parental roles; remote work which needed printing; if access to specific websites/resources was necessary; work being too difficult for children and so on meant that parents often adjusted work in place of teachers. Other studies also highlight the demands placed on parents, and their construction as parents-as-teachers by both pragmatic, personal actions and through systemic expectations [4, 5, 8].
In this study, access to devices was unproblematic, with a substantial majority of families having sufficient devices for their children. This is in contrast with other work [5, 36]. Nevertheless, systemic processes and expectations had a substantial influence on parents’ sense-making of what ‘remote teaching’ should be. We can see that parents’ sense-making of teaching depends on systemic decisions on provision strategies (particularly for those with dyslexia and specific learning difficulties [22] who are without formalized, statutory provision [3]) as well as their own resources and tacit knowledge.
Families’ difficulties in accessing devices echo in the work by Misirli and Ergulec [4] and Kaiper-Marquez et al. [5], where access to technology was vital for accessing work, and the ‘expected’ know-how associated with that technology was not always realistic for families. Given that statutory provision implementation required only ‘best endeavors’ [3], it is unsurprising that work was often unsuitably differentiated for learners without statutory provision; a substantial proportion of those learners have SpLD [18] and find accessing learning problematic even when they are in school under ‘normal’ circumstances [28]. Parents felt the ‘reading burden’ of the curriculum was substantial, reporting that where their children had no access to multi-sensory learning and/or reader-technology, their ability to engage well with remote learning was limited. Structures that already disadvantaged those with SpLD have been replaced (through ‘emergency remote teaching’) by structural expectations, such that learners with SpLD are substantially disadvantaged and their curricular access is limited where those expectations are not met – either by parents or their schools.
As asserted by Bourdieu [14], education is a site of production and re-production of practices and social relations. Consciously or otherwise, all but one parent in this study acted to propagate systems in place. They all tried to follow the curriculum delivered by professionals and so doing, acted to propagate oppressive systems which impeded their children’s ability to access the curriculum. Only one parent felt able to act agentically and remove systemic, curricular burdens from themselves and their child. This shows the power of parental hopes for their children to ‘fit in’ with social systems (SEN provision), even when those systems act to oppress children due to their SpLD.
The findings from this study demonstrate an overlap and interdependence between the levels of interaction. While this is not new and has been shown elsewhere [12, 40], this analysis demonstrates the interdependence between levels both from individual towards institutional and vice versa. The levels are mutually constituting and self-(re)producing, which echoes Bourdieu’s view of the self-propagation of social worlds [15]. For example, parents’ sense-making of ‘emergency remote teaching’ was based in systemic decisions/practices by their children’s schools as to how it would be undertaken. Parents had little influence over initial decisions relating to provision designed. Rather they conceptualized ‘emergency remote teaching’ through their own experiences of it systemically, and via their interactions with their children and professionals. Interactions sometimes prompted changes in systemic practice (for example, private messaging or emailing of more appropriate work); at other times no change occurred. The power and capacity to engage with systems through interactions and effect change in those systems influenced parental sense-making. Constant, cyclic (re)conceptualization of parents’ experiences of remote teaching and their positions/roles within that took place. Consideration of this was not fully possible within the Jenkins-Bourdieu framework as cyclic reciprocity and interdependence between all levels was not fully addressed. As such, further theorization was necessary and prompted by findings in this study.
COVID-19 caused waves across entire legal and social frameworks. Education was a field hit particularly strongly in the process. Many of the embedded practices, expectations and roles were upended through changes in other social fields such as health, law and politics. A model that addressed the dynamism connected to such a seismic and rapid shift in a systemic social practices was necessary. The model had to allow for consideration of individuals’ sense-making and agency in a framework that connects those to interactions between social agents in a field. The structures and boundaries of that field must also be considered to address expectations, roles and practices which (re)construct the field, its habitus and associated practices. However, as demonstrated in national, local and individual responses to COVID-19, fields rarely (if ever) exist in isolation, and responses to external events occurring in one sector of society are likely to impact other areas. Within a Jenkins-Bourdieu-based theoretical model, as described above, there is not sufficient and explicit capacity to these inter-field effects. As such, consideration of ‘habitus clashes’ [53], derived from Ingram’s [54] interpretation and use of Bourdieu’s concept of ‘dialectical confrontation’ [55] are useful here.
‘Habitus clash’ is a simple phrase used to explain the time and space within which habituses, practices and values from different (and sometimes opposing) fields intersect [53]. The intersection is then a site where a social actor must process and make sense of the clash. They will then determine how (and if) the different systems are to be embodied into their own habitus, practice and values. Much as snooker balls respond to impact in demonstrations of Newton’s law of Conservation of Momentum – they are repelled instantly or may move together with a change of direction and speed – so also social actors upon experiencing a ‘habitus clash’ may change their direction, their views and the way that they interact with others implicated in the clash. As such, a dynamic, moving model where interactions between fields can be easily visualized is necessary.
In the early COVID-19 world, the clash of habitus connected to lockdowns and national responses to the crisis instigated shifts in practice and socially determined values across various sectors. These shifts then impacted education. Within education itself, different actors’ experiences, interactions and roles were upended with very little time to make sense of those changes. The ‘Circles of Interaction’ model has been developed as a framework, which actively considers the impacts of changes in one sector of the social world on, and in, other sectors. Figure 2 shows the ‘Circles of Interaction,’ which are explained and defined below.
Circles of Interaction.
The ‘Circles of Interaction’ comprise three interconnected but mobile rings, which are free to move within the ‘Global Social Bubble.’ The three circles represent different levels of the social world and are described below:
The ‘Boundary Circle’ represents and encapsulates institutional practices that create and define objective social structures. Its large size demonstrates its power-capacity (arising from institutional agency), relative to other elements of the social world.
The ‘Dialog Circle’ is the space where interactions between social actors are considered, and the changes made through those interactions are delineated. The relative-power held in those interactions, through the roles individuals embody, is explored and its connection to changes in the ‘Boundary’ and ‘Self’ Circles is addressed.
The ‘Self Circle’ is the internal space where social actors make sense of the world around them and enact agency within their own experiences. Their sense-making and agentic capacity is informed by structures and institutions in the ‘Boundary’ and ‘Dialog’ Circles and is considered within this space.
Many ‘Circles of Interaction,’ representing different sectors of the social world exist within the ‘Global Social Bubble.’ These sets of circles then move around and interact. As they interact and shift their balance, the balance of sense-making, interaction and social structures of those inhabiting the circles is upset and altered. This shift is represented by the changes in physical points of contact between the circles; where the contact points alter due to changes external to the circle or changes within the circle, so a ‘habitus clash’ occurs. New habitus emerges at the points of contact caused by those clashes. COVID-19 has instigated habitus change in the education ‘Circles of Interaction’ through changes in other sectors’ ‘Circles of Interaction.’ These changes have then impacted education. Parents’ sense-making of ‘emergency remote instruction’ is inextricably linked to its structural implementation by schools and educators. This conceptualization and sense-making underpin interactions with educators; parent-teacher interactions are connected to potential systemic changes to remove barriers to learning for children. Where systemic barriers are then removed (or not), sense-making of remote learning must be re-visited. Changes in other social sectors such as health, employment and the economy affect other sectors and those sectors’ ‘Circles of Interaction’ collide, move and instigate new habitus and practice. COVID-19 and this project have shown how the interdependence of social sectors can be modeled dynamically and robustly through the ‘Circles of Interaction.’
Although this is a small-scale study, the fact that it chimes with so much of the body of work relating to COVID-19 remote-teaching suggests that the findings are important. The voices of those who support young children with specific learning difficulties are missing from much discourse, and as a group, their needs often go unidentified and unmet. COVID-19 has highlighted and brought to the fore the difficulty families face when supporting their children with SpLD. Families are untrained, often lacking the material and time resources in a pre-COVID-19 world [11, 40]. COVID-19 has exacerbated these pre-existent difficulties and added to the burdens experienced by already-overstretched families. Parents lack training to support their children and often lack the physical devices needed to support children in remote learning. These devices and training would also be useful in regular schooling [19]. Investment in technology to support children and their families by central government is crucial to meeting their needs and would be beneficial in the event of future school-closures/remote teaching. Systemic expectations on parents must be grounded in families’ realities and resources. Flexibility is key and empowerment through constructive communication edifies all parties and improves practice.
Teachers need training and consistent expectations from their schools, local authorities and ultimately, the Department of Education in the implementation of remote teaching, with a particular focus on online learning. That way the needs of those with SpLD can be met through ‘friendly’ practices, which will ultimately benefit all learners [28].
This study has prompted the development of a new theoretical framework ‘Circles of Interaction,’ grounded in Bourdieusien principles and drawing on Jenkins’ sociology of identity. Further development through careful application of this framework is necessary to consolidate its principles and transposability to sectors other than education.
No funding has been granted for this project. Dr. Ross is a Trustee of the British Dyslexia Association and the Wiltshire Dyslexia Association.
My thanks are due to the following people:
Dr. Andrew Ross for pushing me and giving me the metaphorical kick that I needed to undertake this research, also for helping me argue with Paint 3D! The You and CO2 team for helping me to flex my creative muscles when I work with Bourdieusien Theory – it has been immensely liberating and exciting to build frameworks! FIRE-UK and the National Coalition for Independent Scholars for being the first place where I talked about my framework and for giving me such useful and constructive critique on its development; Women In Academia Support Network (#wiasn) for being a safe, collaborative forum where I could express exactly how I feel without judgment or condemnation.
The Internet has irrevocably changed the dynamics of scholarly communication and publishing. Consequently, we find it necessary to indicate, unambiguously, our definition of what we consider to be a published scientific work.
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\n\nIn cases where there is any overlap between the Author´s submitted manuscript and related internet postings, we will generally not consider it to be an instance of self-plagiarism. This also holds true for any co-Author as well.
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With a great deal to mankind with environmental friendly, these offer advanced technologies in addition to the enhanced business opportunities to several industrial sectors like automobile, construction, electronics and electrical, food packaging, and technology transfer.",book:{id:"10072",slug:"nanotechnology-and-the-environment",title:"Nanotechnology and the Environment",fullTitle:"Nanotechnology and the Environment"},signatures:"Mousumi Sen",authors:[{id:"310218",title:"Dr.",name:"Mousumi",middleName:null,surname:"Sen",slug:"mousumi-sen",fullName:"Mousumi Sen"}]},{id:"38951",title:"Carbon Nanotube Transparent Electrode",slug:"carbon-nanotube-transparent-electrode",totalDownloads:3985,totalCrossrefCites:3,totalDimensionsCites:5,abstract:null,book:{id:"3077",slug:"syntheses-and-applications-of-carbon-nanotubes-and-their-composites",title:"Syntheses and Applications of Carbon Nanotubes and Their Composites",fullTitle:"Syntheses and Applications of Carbon Nanotubes and Their Composites"},signatures:"Jing Sun and Ranran Wang",authors:[{id:"153508",title:"Prof.",name:"Jing",middleName:null,surname:"Sun",slug:"jing-sun",fullName:"Jing Sun"},{id:"153596",title:"Ms.",name:"Ranran",middleName:null,surname:"Wang",slug:"ranran-wang",fullName:"Ranran Wang"}]},{id:"49413",title:"Electrodeposition of Nanostructure Materials",slug:"electrodeposition-of-nanostructure-materials",totalDownloads:3732,totalCrossrefCites:1,totalDimensionsCites:7,abstract:"We are conducting a multi-disciplinary research work that involves development of nanostructured thin films of semiconductors for different applications. Nanotechnology is widely considered to constitute the basis of the next technological revolution, following on from the first Industrial Revolution, which began around 1750 with the introduction of the steam engine and steelmaking. Nanotechnology is defined as the design, characterization, production, and application of materials, devices and systems by controlling shape and size of the nanoscale. The nanoscale itself is at present considered to cover the range from 1 to 100 nm. All samples prepared in thin film forms and the characterization revealed their nanostructure. The major exploitation of thin films has been in microelectronics, there are numerous and growing applications in communications, optical electronics, coatings of all kinds, and in energy generation. A great many sophisticated analytical instruments and techniques, largely developed to characterize thin films, have already become indispensable in virtually every scientific endeavor irrespective of discipline. Among all these techniques, electrodeposition is the most suitable technique for nanostructured thin films from aqueous solution served as samples under investigation. The electrodeposition of metallic layers from aqueous solution is based on the discharge of metal ions present in the electrolyte at a cathodic surface (the substrate or component.) The metal ions accept an electron from the electrically conducting material at the solid- electrolyte interface and then deposit as metal atoms onto the surface. The electrons necessary for this to occur are either supplied from an externally applied potential source or are surrendered by a reducing agent present in solution (electroless reduction). The metal ions themselves derive either from metal salts added to solution, or by the anodic dissolution of the so-called sacrificial anodes, made of the same metal that is to be deposited at the cathode.",book:{id:"4718",slug:"electroplating-of-nanostructures",title:"Electroplating of Nanostructures",fullTitle:"Electroplating of Nanostructures"},signatures:"Souad A. M. Al-Bat’hi",authors:[{id:"174793",title:"Dr.",name:"Mohamad",middleName:null,surname:"Souad",slug:"mohamad-souad",fullName:"Mohamad Souad"}]},{id:"71346",title:"Application of Nanomaterials in Environmental Improvement",slug:"application-of-nanomaterials-in-environmental-improvement",totalDownloads:1691,totalCrossrefCites:0,totalDimensionsCites:13,abstract:"In recent years, researchers used many scientific studies to improve modern technologies in the field of reducing the phenomenon of pollution resulting from them. In this chapter, methods to prepare nanomaterials are described, and the main properties such as mechanical, electrical, and optical properties and their relations are determined. The investigation of nanomaterials needed high technologies that depend on a range of nanomaterials from 1 to 100 nm; these are scanning electron microscopy (SEM), transmission electron microscopy (TEM), and X-ray diffractions (XRD). The applications of nanomaterials in environmental improvement are different from one another depending on the type of devices used, for example, solar cells for producing clean energy, nanotechnologies in coatings for building exterior surfaces, and sonochemical decolorization of dyes by the effect of nanocomposite.",book:{id:"10072",slug:"nanotechnology-and-the-environment",title:"Nanotechnology and the Environment",fullTitle:"Nanotechnology and the Environment"},signatures:"Ali Salman Ali",authors:[{id:"313275",title:"Associate Prof.",name:"Ali",middleName:null,surname:"Salman",slug:"ali-salman",fullName:"Ali Salman"}]}],onlineFirstChaptersFilter:{topicId:"208",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"81438",title:"Research Progress of Ionic Thermoelectric Materials for Energy Harvesting",slug:"research-progress-of-ionic-thermoelectric-materials-for-energy-harvesting",totalDownloads:23,totalDimensionsCites:0,doi:"10.5772/intechopen.101771",abstract:"Thermoelectric material is a kind of functional material that can mutually convert heat energy and electric energy. It can convert low-grade heat energy (less than 130°C) into electric energy. Compared with traditional electronic thermoelectric materials, ionic thermoelectric materials have higher performance. The Seebeck coefficient can generate 2–3 orders of magnitude higher ionic thermoelectric potential than electronic thermoelectric materials, so it has good application prospects in small thermoelectric generators and solar power generation. According to the thermoelectric conversion mechanism, ionic thermoelectric materials can be divided into ionic thermoelectric materials based on the Soret effect and thermocouple effect. They are widely used in pyrogen batteries and ionic thermoelectric capacitors. The latest two types of ionic thermoelectric materials are in this article. The research progress is explained, and the problems and challenges of ionic thermoelectric materials and the future development direction are also put forward.",book:{id:"10037",title:"Thermoelectricity - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/10037.jpg"},signatures:"Jianwei Zhang, Ying Xiao, Bowei Lei, Gengyuan Liang and Wenshu Zhao"},{id:"77670",title:"Thermoelectric Elements with Negative Temperature Factor of Resistance",slug:"thermoelectric-elements-with-negative-temperature-factor-of-resistance",totalDownloads:71,totalDimensionsCites:0,doi:"10.5772/intechopen.98860",abstract:"The method of manufacturing of ceramic materials on the basis of ferrites of nickel and cobalt by synthesis and sintering in controllable regenerative atmosphere is presented. As the generator of regenerative atmosphere the method of conversion of carbonic gas is offered. Calculation of regenerative atmosphere for simultaneous sintering of ceramic ferrites of nickel and cobalt is carried out. It is offered, methods of the dilated nonequilibrium thermodynamics to view process of distribution of a charge and heat along a thermoelement branch. The model of a thermoelement taking into account various relaxation times of a charge and warmth is constructed.",book:{id:"10037",title:"Thermoelectricity - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/10037.jpg"},signatures:"Yuri Bokhan"},{id:"79236",title:"Processing Techniques with Heating Conditions for Multiferroic Systems of BiFeO3, BaTiO3, PbTiO3, CaTiO3 Thin Films",slug:"processing-techniques-with-heating-conditions-for-multiferroic-systems-of-bifeo3-batio3-pbtio3-catio",totalDownloads:96,totalDimensionsCites:0,doi:"10.5772/intechopen.101122",abstract:"In this chapter, we have report a list of synthesis methods (including both synthesis steps & heating conditions) used for thin film fabrication of perovskite ABO3 (BiFeO3, BaTiO3, PbTiO3 and CaTiO3) based multiferroics (in both single-phase and composite materials). The processing of high quality multiferroic thin film have some features like epitaxial strain, physical phenomenon at atomic-level, interfacial coupling parameters to enhance device performance. Since these multiferroic thin films have ME properties such as electrical (dielectric, magnetoelectric coefficient & MC) and magnetic (ferromagnetic, magnetic susceptibility etc.) are heat sensitive, i.e. ME response at low as well as higher temperature might to enhance the device performance respect with long range ordering. The magnetoelectric coupling between ferromagnetism and ferroelectricity in multiferroic becomes suitable in the application of spintronics, memory and logic devices, and microelectronic memory or piezoelectric devices. In comparison with bulk multiferroic, the fabrication of multiferroic thin film with different structural geometries on substrate has reducible clamping effect. A brief procedure for multiferroic thin film fabrication in terms of their thermal conditions (temperature for film processing and annealing for crystallization) are described. Each synthesis methods have its own characteristic phenomenon in terms of film thickness, defects formation, crack free film, density, chip size, easier steps and availability etc. been described. A brief study towards phase structure and ME coupling for each multiferroic system of BiFeO3, BaTiO3, PbTiO3 and CaTiO3 is shown.",book:{id:"10037",title:"Thermoelectricity - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/10037.jpg"},signatures:"Kuldeep Chand Verma and Manpreet Singh"},{id:"78034",title:"Quantum Physical Interpretation of Thermoelectric Properties of Ruthenate Pyrochlores",slug:"quantum-physical-interpretation-of-thermoelectric-properties-of-ruthenate-pyrochlores",totalDownloads:74,totalDimensionsCites:0,doi:"10.5772/intechopen.99260",abstract:"Lead- and lead-yttrium ruthenate pyrochlores were synthesized and investigated for Seebeck coefficients, electrical- and thermal conductivity. Compounds A2B2O6.5+z with 0 ≤ z < 0.5 were defect pyrochlores and p-type conductors. The thermoelectric data were analyzed using quantum physical models to identify scattering mechanisms underlying electrical (σ) and thermal conductivity (κ) and to understand the temperature dependence of the Seebeck effect (S). In the metal-like lead ruthenates with different Pb:Ru ratios, σ (T) and the electronic thermal conductivity κe (T) were governed by ‘electron impurity scattering’, the lattice thermal conductivity κL (T) by the 3-phonon resistive process (Umklapp scattering). In the lead-yttrium ruthenate solid solutions (Pb(2-x)YxRu2O(6.5±z)), a metal–insulator transition occurred at 0.2 moles of yttrium. On the metallic side (<0.2 moles Y) ‘electron impurity scattering’ prevailed. On the semiconductor/insulator side between x = 0.2 and x = 1.0 several mechanisms were equally likely. At x > 1.5 the Mott Variable Range Hopping mechanism was active. S (T) was discussed for Pb-Y-Ru pyrochlores in terms of the effect of minority carrier excitation at lower- and a broadening of the Fermi distribution at higher temperatures. The figures of merit of all of these pyrochlores were still small (≤7.3 × 10−3).",book:{id:"10037",title:"Thermoelectricity - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/10037.jpg"},signatures:"Sepideh Akhbarifar"},{id:"77635",title:"Optimization of Thermoelectric Properties Based on Rashba Spin Splitting",slug:"optimization-of-thermoelectric-properties-based-on-rashba-spin-splitting",totalDownloads:124,totalDimensionsCites:0,doi:"10.5772/intechopen.98788",abstract:"In recent years, the application of thermoelectricity has become more and more widespread. Thermoelectric materials provide a simple and environmentally friendly solution for the direct conversion of heat to electricity. The development of higher performance thermoelectric materials and their performance optimization have become more important. Generally, to improve the ZT value, electrical conductivity, Seebeck coefficient and thermal conductivity must be globally optimized as a whole object. However, due to the strong coupling among ZT parameters in many cases, it is very challenging to break the bottleneck of ZT optimization currently. Beyond the traditional optimization methods (such as inducing defects, varying temperature), the Rashba effect is expected to effectively increase the S2σ and decrease the κ, thus enhancing thermoelectric performance, which provides a new strategy to develop new-generation thermoelectric materials. Although the Rashba effect has great potential in enhancing thermoelectric performance, the underlying mechanism of Rashba-type thermoelectric materials needs further research. In addition, how to introduce Rashba spin splitting into current thermoelectric materials is also of great significance to the optimization of thermoelectricity.",book:{id:"10037",title:"Thermoelectricity - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/10037.jpg"},signatures:"Zhenzhen Qin"},{id:"75364",title:"Challenges in Improving Performance of Oxide Thermoelectrics Using Defect Engineering",slug:"challenges-in-improving-performance-of-oxide-thermoelectrics-using-defect-engineering",totalDownloads:214,totalDimensionsCites:0,doi:"10.5772/intechopen.96278",abstract:"Oxide thermoelectric materials are considered promising for high-temperature thermoelectric applications in terms of low cost, temperature stability, reversible reaction, and so on. Oxide materials have been intensively studied to suppress the defects and electronic charge carriers for many electronic device applications, but the studies with a high concentration of defects are limited. It desires to improve thermoelectric performance by enhancing its charge transport and lowering its lattice thermal conductivity. For this purpose, here, we modified the stoichiometry of cation and anion vacancies in two different systems to regulate the carrier concentration and explored their thermoelectric properties. Both cation and anion vacancies act as a donor of charge carriers and act as phonon scattering centers, decoupling the electrical conductivity and thermal conductivity.",book:{id:"10037",title:"Thermoelectricity - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/10037.jpg"},signatures:"Jamil Ur Rahman, Gul Rahman and Soonil Lee"}],onlineFirstChaptersTotal:6},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:87,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:98,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:27,numberOfPublishedChapters:287,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:139,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:0,numberOfUpcomingTopics:2,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!1},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:10,numberOfPublishedChapters:103,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:0,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!1},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:4,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}}]},series:{item:{id:"7",title:"Biomedical Engineering",doi:"10.5772/intechopen.71985",issn:"2631-5343",scope:"Biomedical Engineering is one of the fastest-growing interdisciplinary branches of science and industry. The combination of electronics and computer science with biology and medicine has improved patient diagnosis, reduced rehabilitation time, and helped to facilitate a better quality of life. Nowadays, all medical imaging devices, medical instruments, or new laboratory techniques result from the cooperation of specialists in various fields. The series of Biomedical Engineering books covers such areas of knowledge as chemistry, physics, electronics, medicine, and biology. This series is intended for doctors, engineers, and scientists involved in biomedical engineering or those wanting to start working in this field.",coverUrl:"https://cdn.intechopen.com/series/covers/7.jpg",latestPublicationDate:"May 13th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:12,editor:{id:"50150",title:"Prof.",name:"Robert",middleName:null,surname:"Koprowski",slug:"robert-koprowski",fullName:"Robert Koprowski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTYNQA4/Profile_Picture_1630478535317",biography:"Robert Koprowski, MD (1997), PhD (2003), Habilitation (2015), is an employee of the University of Silesia, Poland, Institute of Computer Science, Department of Biomedical Computer Systems. For 20 years, he has studied the analysis and processing of biomedical images, emphasizing the full automation of measurement for a large inter-individual variability of patients. Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. Since 2011, he has been a reviewer of grants and projects (including EU projects) in biomedical engineering.",institutionString:null,institution:{name:"University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:3,paginationItems:[{id:"7",title:"Bioinformatics and Medical Informatics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/7.jpg",isOpenForSubmission:!0,editor:{id:"351533",title:"Dr.",name:"Slawomir",middleName:null,surname:"Wilczynski",slug:"slawomir-wilczynski",fullName:"Slawomir Wilczynski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035U1loQAC/Profile_Picture_1630074514792",biography:"Professor Sławomir Wilczyński, Head of the Chair of Department of Basic Biomedical Sciences, Faculty of Pharmaceutical Sciences, Medical University of Silesia in Katowice, Poland. His research interests are focused on modern imaging methods used in medicine and pharmacy, including in particular hyperspectral imaging, dynamic thermovision analysis, high-resolution ultrasound, as well as other techniques such as EPR, NMR and hemispheric directional reflectance. Author of over 100 scientific works, patents and industrial designs. Expert of the Polish National Center for Research and Development, Member of the Investment Committee in the Bridge Alfa NCBiR program, expert of the Polish Ministry of Funds and Regional Policy, Polish Medical Research Agency. Editor-in-chief of the journal in the field of aesthetic medicine and dermatology - Aesthetica.",institutionString:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null},{id:"8",title:"Bioinspired Technology and Biomechanics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",isOpenForSubmission:!0,editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",slug:"adriano-andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",biography:"Dr. Adriano de Oliveira Andrade graduated in Electrical Engineering at the Federal University of Goiás (Brazil) in 1997. He received his MSc and PhD in Biomedical Engineering respectively from the Federal University of Uberlândia (UFU, Brazil) in 2000 and from the University of Reading (UK) in 2005. He completed a one-year Post-Doctoral Fellowship awarded by the DFAIT (Foreign Affairs and International Trade Canada) at the Institute of Biomedical Engineering of the University of New Brunswick (Canada) in 2010. Currently, he is Professor in the Faculty of Electrical Engineering (UFU). He has authored and co-authored more than 200 peer-reviewed publications in Biomedical Engineering. He has been a researcher of The National Council for Scientific and Technological Development (CNPq-Brazil) since 2009. He has served as an ad-hoc consultant for CNPq, CAPES (Coordination for the Improvement of Higher Education Personnel), FINEP (Brazilian Innovation Agency), and other funding bodies on several occasions. He was the Secretary of the Brazilian Society of Biomedical Engineering (SBEB) from 2015 to 2016, President of SBEB (2017-2018) and Vice-President of SBEB (2019-2020). He was the head of the undergraduate program in Biomedical Engineering of the Federal University of Uberlândia (2015 - June/2019) and the head of the Centre for Innovation and Technology Assessment in Health (NIATS/UFU) since 2010. He is the head of the Postgraduate Program in Biomedical Engineering (UFU, July/2019 - to date). He was the secretary of the Parkinson's Disease Association of Uberlândia (2018-2019). Dr. Andrade's primary area of research is focused towards getting information from the neuromuscular system to understand its strategies of organization, adaptation and controlling in the context of motor neuron diseases. His research interests include Biomedical Signal Processing and Modelling, Assistive Technology, Rehabilitation Engineering, Neuroengineering and Parkinson's Disease.",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",isOpenForSubmission:!0,editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",slug:"luis-villarreal-gomez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",biography:"Dr. Luis Villarreal is a research professor from the Facultad de Ciencias de la Ingeniería y Tecnología, Universidad Autónoma de Baja California, Tijuana, Baja California, México. Dr. Villarreal is the editor in chief and founder of the Revista de Ciencias Tecnológicas (RECIT) (https://recit.uabc.mx/) and is a member of several editorial and reviewer boards for numerous international journals. He has published more than thirty international papers and reviewed more than ninety-two manuscripts. His research interests include biomaterials, nanomaterials, bioengineering, biosensors, drug delivery systems, and tissue engineering.",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null}]},overviewPageOFChapters:{paginationCount:17,paginationItems:[{id:"81751",title:"NanoBioSensors: From Electrochemical Sensors Improvement to Theranostic Applications",doi:"10.5772/intechopen.102552",signatures:"Anielle C.A. Silva, Eliete A. Alvin, Lais S. de Jesus, Caio C.L. de França, Marílya P.G. da Silva, Samaysa L. Lins, Diógenes Meneses, Marcela R. Lemes, Rhanoica O. Guerra, Marcos V. da Silva, Carlo J.F. de Oliveira, Virmondes Rodrigues Junior, Renata M. Etchebehere, Fabiane C. de Abreu, Bruno G. Lucca, Sanívia A.L. Pereira, Rodrigo C. Rosa and Noelio O. Dantas",slug:"nanobiosensors-from-electrochemical-sensors-improvement-to-theranostic-applications",totalDownloads:4,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Biosignal Processing",coverURL:"https://cdn.intechopen.com/books/images_new/11153.jpg",subseries:{id:"7",title:"Bioinformatics and Medical Informatics"}}},{id:"81766",title:"Evolution of Organoids in Oncology",doi:"10.5772/intechopen.104251",signatures:"Allen Thayakumar Basanthakumar, Janitha Chandrasekhar Darlybai and Jyothsna Ganesh",slug:"evolution-of-organoids-in-oncology",totalDownloads:6,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Organoids",coverURL:"https://cdn.intechopen.com/books/images_new/11430.jpg",subseries:null}},{id:"81678",title:"Developmental Studies on Practical Enzymatic Phosphate Ion Biosensors and Microbial BOD Biosensors, and New Insights into the Future Perspectives of These Biosensor Fields",doi:"10.5772/intechopen.104377",signatures:"Hideaki Nakamura",slug:"developmental-studies-on-practical-enzymatic-phosphate-ion-biosensors-and-microbial-bod-biosensors-a",totalDownloads:4,totalCrossrefCites:0,totalDimensionsCites:0,authors:[{name:"Hideaki",surname:"Nakamura"}],book:{title:"Biosignal Processing",coverURL:"https://cdn.intechopen.com/books/images_new/11153.jpg",subseries:{id:"7",title:"Bioinformatics and Medical Informatics"}}},{id:"81547",title:"Organoids and Commercialization",doi:"10.5772/intechopen.104706",signatures:"Anubhab Mukherjee, Aprajita Sinha, Maheshree Maibam, Bharti Bisht and Manash K. Paul",slug:"organoids-and-commercialization",totalDownloads:31,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Organoids",coverURL:"https://cdn.intechopen.com/books/images_new/11430.jpg",subseries:null}}]},overviewPagePublishedBooks:{paginationCount:12,paginationItems:[{type:"book",id:"6692",title:"Medical and Biological Image Analysis",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/6692.jpg",slug:"medical-and-biological-image-analysis",publishedDate:"July 4th 2018",editedByType:"Edited by",bookSignature:"Robert Koprowski",hash:"e75f234a0fc1988d9816a94e4c724deb",volumeInSeries:1,fullTitle:"Medical and Biological Image Analysis",editors:[{id:"50150",title:"Prof.",name:"Robert",middleName:null,surname:"Koprowski",slug:"robert-koprowski",fullName:"Robert Koprowski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTYNQA4/Profile_Picture_1630478535317",biography:"Robert Koprowski, MD (1997), PhD (2003), Habilitation (2015), is an employee of the University of Silesia, Poland, Institute of Computer Science, Department of Biomedical Computer Systems. For 20 years, he has studied the analysis and processing of biomedical images, emphasizing the full automation of measurement for a large inter-individual variability of patients. Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. 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His fields of interest are anterior segment disease, keratoconus, glaucoma, corneal dystrophies, and cataracts. His research topics include\nintraocular lens power calculation, eye modification induced by refractive surgery, glaucoma progression, and validation of new diagnostic devices in ophthalmology. \nHe has published more than 100 papers in international and Italian scientific journals, more than 60 in journals with impact factors, and chapters in international and Italian books. 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We welcome chapters presenting research on the many applications of multi-agent studies including, but not limited to, the following key areas: machine learning for multi-agent systems; modeling swarms robots and flocks of UAVs with multi-agent systems; decision science and multi-agent systems; software engineering for and with multi-agent systems; tools and technologies of multi-agent systems.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/27.jpg",hasOnlineFirst:!1,hasPublishedBooks:!1,annualVolume:11423,editor:{id:"148497",title:"Dr.",name:"Mehmet",middleName:"Emin",surname:"Aydin",slug:"mehmet-aydin",fullName:"Mehmet Aydin",profilePictureURL:"https://mts.intechopen.com/storage/users/148497/images/system/148497.jpg",biography:"Dr. Mehmet Emin Aydin is a Senior Lecturer with the Department of Computer Science and Creative Technology, the University of the West of England, Bristol, UK. 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