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As medical students undergo their clinical years, they exhibit a well-documented loss of idealism, increasingly negative attitudes towards poor and underserved patients, and less interest in working with these patients. Here we describe the pilot year of a longitudinal service-learning requirement implemented as a part of the medical student pre-clinical curriculum. We hypothesized that increased non-clinical contact would decrease the formation of negative attitudes towards underserved patients. Students completed service hours at assigned community sites each semester along with written reflections. Surveys were administered to track attitudes towards the underserved. Written reflections were analyzed qualitatively for thematic content as well as feedback on the experience. The requirement was largely acceptable to medical students, and many found value and enjoyment in the experience. The most common critique was that the required hours were insufficient to develop continuity, and that students desired more thorough briefing beforehand to increase their effectiveness. Students reported practicing clinical skills and communication skills. They identified social determinants of health and learned about their patients. They reflected on their professional identity, motivations for entering medicine, and specialty choices. Students experienced moments of connection and belonging, as well as feelings of guilt, otherness, and awareness of privilege. We continue to explore how working collaboratively and learning reciprocally with community members outside of the hospital and clinic may teach students cultural humility and help insulate students from cynicism and negative views of poor and medically underserved patients. / Urban Bioethics

[EN] Interaction is defined as the realization of a reciprocal action between two or more people or things. Particularly in computer science, the term interaction refers to the discipline that studies the exchange of information between people and computers, and is generally known by the term Human-Computer Interaction (HCI). Good design decisions and an adequate development of the software is required for efficient HCI to facilitate the acceptability of computer-based applications by the users. In clinical settings it is essential to eliminate any barrier and facilitate the interaction between patients and the system. A smooth communication between the user and the computer-based application is fundamental to maximise the advantages and functionalities offered by the system. The design of these applications must consider the personal and current needs of the user by applying a User-Centered Design methodology. The main purpose of this research work is to contribute in the improvement of HCI-based applications addressed to the clinical context, particularly to enhance computer-based interactive sessions to support people suffering from a mental disorder such as Major Depression (MD). Thanks to the advances in Artificial Intelligence techniques, it is now possible to partially automate complex tasks such as the continuous provision of Cognitive-Behavioural Therapies (CBTs) to patients. These CBTs require good levels of adaptability and variability during the interaction with the patient that facilitates the acceptability in the user, an optimal usability and good level of engagement for a successful mid/long term use of the application and treatment adherence. The modelling of complex deliberative and affective processes in artificial systems can be applied to support the prevention and treatment of mental health related issues, enhancing the continuous and remote assistance of patients, saving some economical and clinical resources and reducing the waiting lists in the health services. In this regard, the efforts of this Thesis have been concentrated on the research of two main lines: (1) the generation and planning of adequate contents in an interactive system to support the prevention and treatment of MD based on characteristics of the user; and (2) the modelling of relevant affective processes able to communicate the contents in an emotional effective way taking into account the importance of the affective conditions associated with the MD in the users. Rule Based Systems and the appraisal theory of emotions have been the roots used to develop the main two modules of the computational Framework presented: the Contents Management and the Emotional Modules. Finally, the obtained Framework was integrated into two interactive systems to evaluate the achievement of the research objectives. The first system has been developed in the context of the Help4Mood European research project and its main aim was to support the remote treatment of patients with MD. The second scenario was a system developed to prevent MD and suicidal thoughts in the University community, which was developed in the context of the local PrevenDep research project. These evaluations have indicated that the proposed Framework has reached good levels of usability and acceptability in the target users thanks to the personalizations and adaptation capabilities of the contents and in the way how these contents are communicated to the user. The research work and the obtained results in this Thesis has contributed to the state of the art in HCI-based systems used as support in therapeutic interventions for the prevention and treatment of MD. This was obtained by the combination of a personalized content management to the patient, and the management of the affective processes associated to these pathologies. The developed work also identifies some research lines that need to be addressed in future works to get better HCI systems used for therapeutic purposes. / [ES] Interactuar se define como la realización de una acción recíproca entre dos o más personas o cosas. Particularmente en informática, el término interacción se refiere a la disciplina que estudia el intercambio de información entre las personas y computadoras, y suele conocerse por el término anglosajón Human-Computer Interaction (HCI). Un buen diseño y un adecuado desarrollo del software es necesario para lograr una HCI eficiente que facilite la aceptabilidad del sistema por el usuario. En entornos clínicos es fundamental eliminar cualquier tipo de barrera y facilitar la interacción entre los pacientes y el computador. Es de vital importancia que haya una buena comunicación entre usuario y computador, por este motivo el sistema debe de estar diseñado pensando en las necesidades actuales, cambiantes y personales del usuario, basándose en la metodología de diseño centrado en el usuario. El propósito principal de esta investigación es la identificación de mejoras en HCI aplicada en entornos clínicos, en concreto para dar soporte a personas con trastornos mentales como la Depresión Mayor (DM) y que precisan de terapias psicológicas adecuadas y continuas. Gracias a técnicas de Inteligencia Artificial, es posible automatizar eficientemente ciertas acciones asociadas a los procesos de las terapias cognitivo-conductuales (CBTs, del inglés Cognitive-Behavioural Therapies). Los sistemas de ayuda a la CBT, requieren de una adaptabilidad y variabilidad en la interacción para favorecer la usabilidad del sistema y asegurar la continuidad de la motivación del paciente. Una buena gestión de esta automatización influiría en la aceptabilidad de los pacientes y podría mejorar su adherencia a los tratamientos y por consiguiente mejorar su estado de salud. Adicionalmente, la unión de procesos deliberativos dinámicos pueden liberar recursos clínicos, mejorando el control de los pacientes, y reduciendo los tiempos de espera y los costes económicos. En este sentido, los esfuerzos de esta Tesis se han centrado en la investigación de dos líneas diferentes: (1) la selección y planificación adecuada de los contenidos presentados durante la interacción a través de una planificación dinámica y personalizada, y (2) la adecuación de la comunicación de los contenidos hacia el paciente tomando en cuenta la importancia de los procesos afectivos asociados a estas patologías. Los Sistemas Basados en Reglas (SBR) han sido la herramienta utilizada para dar soporte a los dos módulos principales que componen el Framework presentado en esta Tesis: el módulo de gestión de los contenidos y el módulo emocional. Concluida la fase de diseño, desarrollo y testeo, el Framework fue adaptado e integrado en sistemas reales, para validar la viabilidad y la adecuación del marco de trabajo de esta Tesis. En primer lugar, el sistema se aplicó durante tres años en el tratamiento de la DM en varios centros clínicos europeos en el contexto del Proyecto Europeo de investigación Help4Mood. Finalmente, el sistema fue evaluado en la tarea de prevención de la DM y del suicidio en el Proyecto Local de investigación PrevenDep, de un año de duración. El feedback de estas evaluaciones demostraron que el HCI del Framework tiene unos niveles altos de usabilidad y aceptación, gracias a la personalización, variabilidad y adaptación de los contenidos y de la comunicación de los mismos. Los experimentos computacionales llevados a cabo en esta Tesis han permitido avanzar el estado del arte de sistemas computacionales emocionales aplicados en entornos terapéuticos para la prevención y tratamiento de la DM. Principalmente, gracias a la combinación de una gestión personalizada de los contenidos hacia el paciente tomando en cuenta la importancia de los procesos afectivos asociados a estas patologías. Este trabajo abre nuevas líneas de investigación, como la aplicación de este sistema en otras patologías de salud mental en las qu / [CA] Interactuar es defineix com la realització d'una acció recíproca entre dos o més persones o coses. Particularment en informàtica, el terme interacció es refereix a la disciplina que estudia l'intercanvi d'informació entre les persones i computadores, i es sol conèixer pel terme anglosaxó Human-Computer Interaction (HCI). Un bon disseny i un adequat desenvolupament del software és necessari per aconseguir una HCI eficient que faciliti l'acceptabilitat del sistema per l'usuari. En entorns clínics és fonamental eliminar qualsevol tipus de barrera i facilitar la interacció entre els pacients i el computador. És de vital importància que hi hagi una bona comunicació entre l'usuari (o pacient) i el computador, per aquest motiu el sistema ha d'estar dissenyat pensant en les necessitats actuals, cambiants i personals de l'usuari, basant-se en la metodologia de disseny centrat en l'usuari. El propòsit principal d'aquesta investigació és la identificació de millores en HCI aplicada en entorns clínics, en concret per donar suport a persones amb trastorns mentals com la Depressió Major (DM) i que precisen de teràpies psicològiques adequades i contínues. Gràcies a tècniques d'Intel·ligència Artificial, és possible automatitzar eficientment certes accions asociades al processos de les teràpies cognitiu-conductuals. Els sistemes computacionals de ajuda a la CBT, requereixen d'una adaptabilitat i variabilitat en la interacció per afavorir la usabilitat del sistema i assegurar la continuïtat de la motiviació del pacient. Una bona gestió d'aquesta automatització influiria en l'acceptabilitat dels pacients i podria millorar la seva adherència als tractaments i per tant millorar el seu estat de salut. Addicionalment, la unió de processos deliberatius dinàmics poden alliberar recursos clínics, millorant el control dels pacients, i reduint els temps d'espera i els costos econòmics. En aquest sentit, els esforços d'aquesta Tesi s'han centrat en la investigació de dues línies diferents: (1) la selecció i planificació adequada dels continguts presentats durant la interacció a través d'una planificació dinàmica i personalitzada, i (2) l'adequació de la comunicació dels continguts cap al pacient tenint en compte la importància dels processos afectius associats a aquestes patologies. Els Sistemes Basats en Regles (SBR) han estat la eina utilitzada per donar suport als dos mòduls principals que componen el Framework presentat en aquesta Tesi: el mòdul de gestió dels continguts oferits a l'usuari; i el mòdul emocional. Conclosa la fase de disseny, desenvolupament i testeig, el Framework va ser adaptat als dominis corresponents i integrat en sistemes madurs per ser avaluat en dos escenaris reals, per validar la viabilitat i l'adequació del Framework d'aquesta tesi. Primerament, el sistema es va aplicar durant tres anys en el tractament de la DM major en diversos centres clínics europeus en el context del Projecte Europeu d'investigació Help4Mood. Finalment, el sistema va ser avaluat en la tasca de prevenció de la DM i del suïcidi al Projecte Local d'investigació PrevenDep, d'un any de durada. El feedback de les avaluacions han demostrat que el HCI del Framework obté uns nivells alts d'usabilitat i acceptació, gràcies a la personalització, variabilitat i adaptació dels continguts i de la comunicació. Els experiments computacionals duts a terme en aquesta Tesi han permès avançar l'estat de l'art de sistemes computacionals emocionals aplicats en entorns terapèutics per a la prevenció i tractament de la DM. Principalment, gracies a la combinació d'una gestió personalitzada dels continguts cap al pacient tenint en compte la importància dels processos afectius associats a aquestes patologies. Aquest treball obre noves línies d'investigació, com l'aplicació d'aquest sistema en altres patologies de salut mental en què sigui recomanable l'aplicació de sessions terapèutiques. / Bresó Guardado, A. (2016). A Computational Framework for Planning Therapeutical Sessions aimed to Support the Prevention and Treatment of Mental Health Disorders using Emotional Virtual Agents [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/64082

Eudaimonic media entertainment has been shown to promote mental health, however, our knowledge of the underlying mechanisms that drive the effects is still limited. This project focuses on self-disclosure, a relevant factor for reducing distress and improvingmental wellbeing. The aimwas to test whether empathizing with a fictional character and the personal relevance of a story can facilitate self-disclosure responses, as well as to examine the role of social cues and audio-visual formal features. In Study 1, 227 participants were randomly assigned to watch one of 8 videos of individuals sharing their experiences of burnout. Shot scale and social cues were manipulated in the videos. Empathy with the characters but not personal relevance predicted the desire for self-disclosure. In Study 2, participants were randomly assigned to either a control condition (N = 78) or one of six manipulated short films (N = 436). Movies were manipulated for shot scale and music. Participants’ reports on state empathy with the filmcharacter, perceived personal relevance of the story, andmeasures related to self-disclosure were collected. One week later, participants were invited to a second survey on self-disclosure behavior (n = 390). Both personal relevance and empathy with character showed strong links to self-disclosure responses. The findings of this project shed light on how self-disclosure is elicited by narratives. These insights are important to further understand the therapeutic effects of narratives.

As medical students progress through their training, they experience a decline in empathy, mental health struggles, and difficulties in learning. The prevalence of depression, anxiety and burnout among medical students, along with the decline of empathy in medical students can impact their professionalism and quality of patient care as future physicians. This literature review shows how the integration of graphic medicine in provider training can address these problems, giving a new perspective on what medical education should look like. Thirty-three articles were found and reviewed by searching through the databases Academic Search Premier, PubMed, and Google Scholar, along with the website graphicmedicine.org. The findings revealed that graphic medicine promotes empathy by highlighting the patients’ experience of their illnesses through personal stories. Graphic medicine can also aid learning by increasing engagement and offering alternative ways to learn. Additionally, multiple studies showed how creating graphic memoirs can be a form of therapy for medical students, allowing them to express their difficult experiences in medicine through a creative outlet.

The dissertation explores middle-school students' abilities to engage in historical thinking. I dispute the Hallam-Piaget model, which discourages analytical thinking through the assumption that children lack skills to think critically about history. My historical narrative inquiry model (1) teaches procedural knowledge (the process of "doing" history); (2) enhances interpretative skills; (3) cultivates historical perspectives based upon evidentiary history; and (4) encourages student authorship of historical narratives. In the fall semester of 2006, with a classroom of twenty-five seventh-graders, I initiated a research study designed to explore the impact of the historical narrative inquiry model through a sequence of thirty-two lessons. The lessons involved small- and large-group activities, including oral presentations, discussions about primary documents, and consideration of the relation between narratology and the creation of written history. Students generated their own historical narratives in order to articulate their perspectives. Eight students having varied reading-level proficiency served as primary participants in the study. Each of these students received pre- and post-intervention interviews. Outcomes reflected the enhancement of pedagogy intended to facilitate historical thinking and historical empathy in the classroom.