Gut microbiota of adults with asthma is broadly similar to non-asthmatics in a large population with varied ethnic origins.

Bacterial gut communities might predispose children to develop asthma. Yet, little is known about the role of these micro-organisms in adult asthmatics. We aimed to profile the relationship between fecal microbiota and asthma in a large-scale, ethnically diverse, observational cohort of adults. Fecal microbiota composition of 1632 adults (172 asthmatics and 1460 non-asthmatics) was analyzed using 16S ribosomal RNA gene sequencing. Using extremely randomized trees machine learning models, we assessed the discriminatory ability of gut bacterial features to identify asthmatics from non-asthmatics. Asthma contributed 0.019% to interindividual dissimilarities in intestinal microbiota composition, which was not significant (P = .97). Asthmatics could not be distinguished from non-asthmatics based on individual microbiota composition by an extremely randomized trees classifier model (area under the receiver operating characteristic curve = 0.54). In conclusion, there were no prominent differences in fecal microbiota composition in adult asthmatics when compared to non-asthmatics in an urban, large-sized and ethnically diverse cohort.

Infant Feeding and Ethnic Differences in Body Mass Index during Childhood: A Prospective Study.

This study investigated ethnic differences in childhood body mass index (BMI) in children from Dutch and Turkish descent and the role of infant feeding factors (breastfeeding duration, milk feeding frequency, as well as the timing, frequency and variety of complementary feeding (CF)). We used data from 244 children (116 Dutch and 128 Turkish) participating in a prospective study in the Netherlands. BMI was measured at 2, 3 and 5 years and standard deviation scores (sds) were derived using WHO references. Using linear mixed regression analyses, we examined ethnic differences in BMI-sds between 2 and 5 years, and the role of infant feeding in separate models including milk or CF factors, or both (full model). Relative to Dutch children, Turkish children had higher BMI-sds at age 3 (mean difference: 0.26; 95%CI: 0.04, 0.48) and 5 (0.63; 0.39, 0.88), but not at 2 years (0.08; -0.16, 0.31). Ethnic differences in BMI-sds were somewhat attenuated by CF factors at age 3 (0.16; -0.07, 0.40) and 5 years (0.50; 0.24, 0.77), whereas milk feeding had a minor impact. Of all factors, only CF variety was associated with BMI-sds in the full model. CF factors, particularly CF variety, explain a small fraction of the BMI-sds differences between Dutch and Turkish children. The role of CF variety on childhood BMI requires further investigation.

Cultural Identity Conflict and Psychological Well-Being in Bicultural Young Adults: Do Self-Concept Clarity and Self-Esteem Matter?

ABSTRACT: The present study examined the relationship between cultural identity conflict and psychological well-being, as well as the role of self-concept clarity and self-esteem in mediating this linkage. Elevated cultural identity conflict was hypothesized to be associated with lower psychological well-being via both (lower) self-concept clarity and (lower) self-esteem, with self-concept clarity preceding self-esteem. In a cross-sectional design, 473 bicultural young adults (age range, 18-35) completed an online questionnaire assessing cultural identity conflict, self-concept clarity, self-esteem, emotional distress, psychopathological symptoms, and satisfaction with life. Correlation analyses revealed that elevated cultural identity conflict was positively associated with emotional distress and psychopathological symptoms, and negatively associated with satisfaction with life. Mediation analyses indicated that these associations were mediated by lower self-concept clarity and lower self-esteem. The results support the importance of interventions that foster the development of skills in bicultural young adults to obtain more self-concept clarity and promote self-esteem and psychological well-being.

Parents' Concepts of the Successful School Child in Seven Western Cultures.

Although children's school success is a parental goal in most cultures, there is wide cultural variation in the qualities that parents most wish their children to develop for that purpose. A questionnaire contained forty-one child qualities was administered to 757 parents in seven cultural communities in Australia, Italy, the Netherlands, Poland, Spain, Sweden, and the United States. Exploratory factor analysis was conducted separately within each sample and results revealed both similarities and differences across the seven samples. The factor structures showed considerable similarity: four domains of characteristics (Cognitive Qualities, Social Qualities, Negative temperament, and Good Characters) were identified in each sample as strongly influencing children's success in school. However, parents differed across the seven cultural communities in the importance they attributed to these factors. The results also reveal some culturally unique patterns in parents' concepts of the successful schoolchild; the seven samples were differentiated by distinctive associations of individual qualities around the four common domains. These results offer new insights for incorporating perspectives from other cultures into our own concepts of what qualities are most important for children's success in school, and how educators can be cognizant of differing cultural perspectives represented by the families whose children are their students.

Contribution of Alcohol and Nicotine Dependence to the Prevalence of Depressed Mood in Different Ethnic Groups in The Netherlands: The HELIUS Study.

Objective: Ethnic minorities report different levels of drinking and smoking and higher rates of depression compared to native populations. In this study we aimed to investigate in six ethnic groups whether tobacco and alcohol use were associated with depressive symptoms, which are more prevalent in ethnic minorities.Methods: Cross-sectional data from the multi-ethnic Healthy Life in an Urban Setting (HELIUS) study sample (N = 22,471) was used, comprising 4,580 native Dutch participants which were compared with participants from five ethnic minority groups (3,259 South Asian Surinamese, 4,292 African Surinamese, 2,262 Ghanaian, 3,891 Turkish, and 4,187 Moroccan).Results: Alcohol misuse was positively associated with depressed mood in all ethnic groups except for the Dutch and the Ghanaians. Nicotine dependence was positively associated with depressed mood in all ethnic groups except for the Ghanaian group.Conclusions: Alcohol misuse and nicotine dependence were significantly associated with depressed mood in most but not all ethnic groups and especially in men. However, across all groups the contribution of alcohol misuse and nicotine dependence to depressed mood was small. Prospective multi-ethnic studies should confirm whether the relations are causal and elucidate their direction.

Reshaping Parental Ethnotheories of Dutch-Moroccan Immigrant Parents in the Netherlands: Networking in Multiple Worlds.

Ethnotheories of immigrant parents residing in the Netherlands are reshaped in response to the multiple and diverse educational practices they come in contact with after migration. Network analyses of "parenting relationships" of first generation Dutch-Moroccan parents living in the Netherlands show that they borrow from diverse resources including professionals and nonprofessionals in their construction of new ethnotheories. Through media as well as through interacting with family in their country of origin, with same-generation peers in the Netherlands, and with Dutch professionals and neighbors, these mothers develop "modern" notions of parenting such as stimulating child independence, while also using building blocks from traditional practices such as respect for the elderly. Individual variability is evident in parents' processes of adaptation, with some parents seeming stuck between these alternative and seemingly contradictory practices and ideas while others learn to use them to position themselves optimally in their multi-ethnic environment. The paper argues that recognizing these parents as creative producers of their own solutions, and becoming conscious of their self-made support networks and the resources they provide, can offer professionals and policy makers a new paradigm for the design of social services and support for immigrant parents.

Getting the Baby on a Schedule: Dutch and American Mothers' Ethnotheories and the Establishment of Diurnal Rhythms in Early Infancy.

One of the earliest challenges for infants and their parents is developing a diurnal sleep-wake cycle. Although the human biological rhythm is circadian by nature, its development varies across cultures, based in part on "zeitgebers" (German: literally "time-givers") or environmental cues. This study uses the developmental niche framework by Super and Harkness to address two different approaches to getting the baby on a schedule. 33 Dutch and 41 U.S. mothers were interviewed when their babies were 2 and 6 months old. A mixed-methods analysis including counts of themes and practices as well as the examination of actual quotes shows that Dutch mothers emphasized the importance of regularity in the baby's daily life and mentioned practices to establish regular schedules for the baby's sleeping, eating, and time outside more than American mothers did. The U.S. mothers, in contrast, discussed regularity less often and when they did, they emphasized that their baby should develop his or her own schedule. Furthermore, actual daily schedules, based on time allocation diaries kept by the mothers, revealed greater regularity among the Dutch babies. Discussion focuses on how culture shapes the development of diurnal rhythms, with implications for "best practices" for infant care.

"Me", "We", and Materialism: Associations between Contingent Self-Worth and Materialistic Values across Cultures.

Individuals with high levels of externally contingent self-worth tend to base their self-esteem on factors such as appearance, competitive success, and others' approval. Such tendencies might also elevate people's focus on material possessions. However, cultural moderation of these associations has yet to be explored. A cross-cultural survey among Chinese and Dutch college students examined the link between externally-based contingent self-worth and materialistic values, as well as the mediating roles of need to belong and need for self-enhancement. An initial multi-group path analysis indicated a stronger link between externally contingent self-worth and materialism for Chinese students than for Dutch students. For both Chinese and Dutch students, externally contingent self-worth was positively related to materialistic values, need to belong, and need for self-enhancement. Need to belong and need for self-enhancement were positively linked with materialism, and need to belong and need for self-enhancement mediated the link between externally contingent self-worth and materialism. Though the indirect effect via self-enhancement was somewhat stronger among Chinese participants, this research demonstrates that people's externally contingent self-worth might be a factor predicting materialism across cultures, with need to belong and need for self-enhancement playing similar roles as underlying processes in different societies.

The prevalence and risk of Female Genital Mutilation/Cutting among migrant women and girls in the Netherlands: An extrapolation method.

OBJECTIVES: The aim of the study was (I) to estimate the prevalence of Female Genital Mutilation/Cutting (FGM/C) and distribution of types of FGM/C among migrant girls and women in the Netherlands, and (II) to estimate the number of migrant girls at risk of being cut in the immediate future. METHODS: National population-based survey data regarding FGM/C prevalence were applied to female migrants in the Netherlands who migrated from 29 countries with available nationally representative data on FGM/C. RESULTS: As of January 1st 2018, there were 95,588 female migrants residing in the Netherlands, originating from 29 countries with available nationally representative data on FGM/C. Our findings suggest that about 41,000 women had undergone FGM/C, of which 37% had Type III (infibulation). In total 4,190 girls are estimated to be at risk of FGM/C in the next 20 years, of whom 394 were first-generation girls. CONCLUSION: These findings show the urgency to develop appropriate strategies and policies to prevent FGM/C, to protect girls and women at risk of the practice, and to provide adequate services and support for those affected by FGM/C in the Netherlands.

A Closer Look at Loneliness: Why Do First-Generation Migrants Feel More Lonely Than Their Native Dutch Counterparts?

BACKGROUND AND OBJECTIVES: Along with the current aging demographics in the Netherlands, the number of older first-generation migrants is also increasing. Despite studies suggesting a higher quantity of social contacts of migrants, loneliness is more common among migrants as compared to native Dutch. We theorize that migrants experience more emotional and social loneliness due to a lower satisfaction with social relationships and lower participation in social activities, respectively, compared to their native counterparts. RESEARCH DESIGN AND METHODS: We use data from Statistics Netherlands (N = 7,920) with first-generation migrants aged 40 years and older and their Dutch counterparts. Contact frequency, household composition, satisfaction with social relationships, relationship quality with the partner, and social activities, are used as main predictors and separate regression models for social and emotional loneliness are analyzed. RESULTS: Compared to the native Dutch, first-generation migrants are both socially and emotionally more lonely. Migrants have a similar contact frequency as the native Dutch, but are less satisfied with their social relationships, which contributes to their higher emotional, social, and overall loneliness. Migrants engage less in social activities but this does not put them at additional risk of loneliness. DISCUSSION AND IMPLICATIONS: Migrants experience more social and emotional loneliness and are less satisfied with their social relationships compared to their native counterparts. Interventions should focus on reducing both social and emotional loneliness among older migrants. Specific attention should be paid to fostering satisfying social interactions. Additionally, encouraging migrants to broaden their social network may reduce social loneliness.

The Experience of Aging and Perceptions of "Aging Well" Among Older Migrants in the Netherlands.

BACKGROUND AND OBJECTIVES: In this study, we examine the experience of aging and subjective views of what it means to age well among older adults with a migrant background in the Netherlands. We embed the study within the successful aging debate and tackle two of its most persistent critiques: the failure to adequately include subjective views in the definition of aging well and the failure to recognize that the process of aging is culturally determined. RESEARCH DESIGN AND METHODS: The research draws on qualitative data collected through eight focus-group discussions with the six largest migrant groups in the Netherlands, namely Indo-Dutch and Moluccans, and migrants with Western, Surinamese, Antillean, Turkish, and Moroccan background. RESULTS: The study findings show that in general older migrants experience aging more positively than commonly assumed. Nevertheless, some negative aspects of aging were also mentioned. These together with fears about the future underpin participants' perceptions about aging well. Key aspects of successful aging include remaining healthy, independent, and engaged. Differences between and within groups exist in the meaning given to these concepts and the extent to which other specific aging-related wishes were mentioned. These differences are rooted in participants' experiences of the migration event, employment history, and their current socioeconomic conditions. DISCUSSION AND IMPLICATIONS: We conclude that the life course perspective is essential in understanding migrants' aging process and their views on successful aging, and suggest that policies and interventions which promote disease prevention and tackle social exclusion will be beneficial for older adults with a migration background.

Prenatal Maternal Stress and Child IQ.

The evidence for negative influences of maternal stress during pregnancy on child cognition remains inconclusive. This study tested the association between maternal prenatal stress and child intelligence in 4,251 mother-child dyads from a multiethnic population-based cohort in the Netherlands. A latent factor of prenatal stress was constructed, and child IQ was tested at age 6 years. In Dutch and Caribbean participants, prenatal stress was not associated with child IQ after adjustment for maternal IQ and socioeconomic status. In other ethnicities no association was found; only in the Moroccan/Turkish group a small negative association between prenatal stress and child IQ was observed. These results suggest that prenatal stress does not predict child IQ, except in children from less acculturated minority groups.

Dementia Matters: User-Building Interactions Shaping Institutional Life in the Netherlands.

In this article, I examine building-user interactions on three dementia wards in the Netherlands. I coin the concept of "sociomaterial awareness" to articulate a collective situational sensitivity to the ways in which the built environment invites its users (professionals, but also people with dementia themselves) to act in specific ways, as well as to possibilities to adjust (elements of) the building. I argue that along with different enactments of dementia, different positions become available for residents when the built environment is acknowledged as actively shaping care interactions.

Psychological Resilience in the Context of Disability: A Study With Turkish and Moroccan Young-Old Immigrants Living in the Netherlands.

BACKGROUND AND OBJECTIVES: The disability paradox postulates that some individuals with severe functional limitations demonstrate psychological resilience, that is, good mental health and quality of life. Resilience to disabilities has been linked to psychological (e.g., mastery) and social factors (e.g., social provisions). It is, however, less clear whether cultural factors can provide additional resources for resilience building in older immigrants. We investigated the extent to which sociodemographic, psychosocial, and cultural factors contributed to psychological resilience to disabilities among immigrants of Turkish and Moroccan descent in the Netherlands. RESEARCH DESIGN AND METHOD: The sample included 478 older immigrants aged 55-65 years. Data were analyzed using latent profile analysis and multinomial logistic regressions. RESULTS: Five categories were identified: (a) High physical and emotional functioning; (b) High physical but poor emotional functioning; (c) Low physical but high emotional functioning (resilient); (d) Low physical and emotional functioning; and (e) Low physical and very low emotional functioning. Resilient functioning (reference category) was associated with poorer Dutch language proficiency, lower levels of loneliness, greater mastery, and more religious coping. DISCUSSION AND IMPLICATIONS: Findings provide support for the disability paradox and highlight social provisions, mastery, and religiosity/spirituality as important resources for psychological resilience in older labor migrants. Poor Dutch language proficiency is discussed as a potential factor contributing to severe functional limitations in the resilient category.

For debate: advanced bleeding control potentially saves lives in armed forces and should be considered.

INTRODUCTION: Advanced bleeding control options for truncal and junctional haemorrhage including resuscitative endovascular balloon occlusion of the aorta (REBOA) have been used in managing catastrophic bleeding. The primary aim is to report on potential indications for advanced bleeding control in combat casualties during the Dutch deployment in Uruzgan, Afghanistan, between August 2006 and August 2010. The secondary aim is to report on training methods for advanced bleeding control in (para)medical personnel. METHODS: The trauma registry from the Dutch role 2 enhanced medical treatment facility at Tarin Kowt, Uruzgan, Afghanistan, was used to analyse patients who sustained a battle injury with major haemorrhage. Furthermore, a comprehensive search was performed on training (para)medical personnel in advanced bleeding control. RESULTS: There were 212 possible indications for advanced bleeding control with mortality of 28.8% (61/212). These possible indications consisted of 1.9% (4/212) junctional lower extremity injuries with a 75% (3/4) mortality rate, 59% (125/212) visceral vascular injuries with a mortality rate of 12.5% (26/125). The junctional and visceral injuries (n=129) were all potential indications for advanced bleeding control options, such as REBOA. Further 39.2% (83/212) casualties with central thoracic or neck injuries had a mortality rate of 38.6% (32/83). Based on an Abbreviated Injury Scale chest or abdomen score ≥461 indications for advanced bleeding control were identified. A 24-hour average of 8.8 packets of red blood cells, 4.2 packets of plasma and 1.9 packets of platelets was used to prevent exsanguination. The total out-of-hospital survival rate was 64% (39/61). CONCLUSION: Retrospective analysis revealed 212 potential indications for advanced bleeding control with a mortality of 28.8% (61/212). Advanced bleeding control, such as REBOA, might have improved survival in approximately 61 of 212 casualties. Advanced bleeding control could be used as an adjunct to improve outcomes in major truncal or junctional haemorrhage in prehospital, remote settings and implementation should be considered. Vascular access training and REBOA placement for (para)medical military personnel should be explored in future research.

Higher Plasma Sclerostin and Lower Wnt Signaling Gene Expression in White Adipose Tissue of Prediabetic South Asian Men Compared with White Caucasian Men.

BACKGROUND: South Asians generally have an unfavourable metabolic phenotype compared with white Caucasians, including central obesity and insulin resistance. The Wnt protein family interacts with insulin signaling, and impaired Wnt signaling is associated with adiposity and type 2 diabetes mellitus. We aimed to investigate Wnt signaling in relation to insulin signaling in South Asians compared with white Caucasians. METHODS: Ten Dutch South Asian men with prediabetes and overweight or obesity and 10 matched Dutch white Caucasians were included. Blood samples were assayed for the Wnt inhibitor sclerostin. Subcutaneous white adipose tissue (WAT) and skeletal muscle biopsies were assayed for Wnt and insulin signaling gene expression with quantitative reverse transcription polymerase chain reaction (Clinicaltrials.gov NCT02291458). RESULTS: Plasma sclerostin was markedly higher in South Asians compared with white Caucasians (+65%, P<0.01). Additionally, expression of multiple Wnt signaling genes and key insulin signaling genes were lower in WAT in South Asians compared with white Caucasians. Moreover, in WAT in both ethnicities, Wnt signaling gene expression strongly positively correlated with insulin signaling gene expression. In skeletal muscle, WNT10B expression in South Asians was lower, but expression of other Wnt signaling and insulin signaling genes was comparable between ethnicities. Wnt and insulin signaling gene expression also positively correlated in skeletal muscle, albeit less pronounced. CONCLUSION: South Asian men with overweight or obesity and prediabetes have higher plasma sclerostin and lower Wnt signaling gene expression in WAT compared with white Caucasians. We interpret that reduced Wnt signaling could contribute to impaired insulin signaling in South Asians.

'Our work was in the service of the suffering of mankind': a case study of the motives of the Easternfront Ambulance nurses, 1941-1944.

During World War Two, a group of Dutch nurses chose to join the Nederlandse Ambulance ('Easternfront Ambulance'), a controversial though currently relatively unknown field hospital for the eastern front. In doing so, they supported the German war effort. This case study elaborates on the motives of these women to make a choice that was ultimately determined as 'wrong', by emphasising their unique gender role of nurse in the public sphere. By providing an insight into a relatively small group of 'wrong' women, this article aims to act as a call for further research into the gender context of limitations and opportunities of Dutch women during the German occupation. These nurses appear to have had various intentional and unintentional motives for enlisting. Nearly all of them later claimed they had pursued a 'calling'. They had all been Nazi or Nationalist Socialist Movement in the Netherlands sympathisers and they had all enjoyed material benefits due to their position with the field hospital. In a few cases, it seems they had longed for interaction with soldiers, or men in general, and sometimes they had simply craved for an adventurous life far from home.

Cultural differences in positive psychotic experiences assessed with the Community Assessment of Psychic Experiences-42 (CAPE-42): a comparison of student populations in the Netherlands, Nigeria and Norway.

BACKGROUND: Previous studies have suggested that culture impacts the experience of psychosis. The current study set out to extend these findings by examining cultural variation in subclinical positive psychotic experiences in students from The Netherlands, Nigeria, and Norway. Positive psychotic experiences were hypothesized to (i) be more frequently endorsed by, and (ii) cause less distress in Nigerian vs. Dutch and Norwegian students. METHODS: Psychology students, aged 18 to 30 years, from universities in the Netherlands (n = 245), Nigeria (n = 478), and Norway (n = 162) were assessed cross-sectionally with regard to the frequency of subclinical positive psychotic experiences and related distress, using the Community Assessment of Psychic Experiences (CAPE-42). Multi-group confirmatory factor analysis and multivariate analysis of covariance were performed to assess measurement invariance of the positive symptom dimension (CAPE-Pos) and compare mean frequency and associated distress of positive psychotic experiences across study samples. RESULTS: Only CAPE-Pos items pertaining to the dimensions 'strange experiences' and 'paranoia' met assumptions for (partial) measurement invariance. Frequencies of these experiences were higher in the Nigerian sample, compared to both the Dutch and Norwegian samples, which were similar. In addition, levels of experience-related distress were similar or higher in the Nigerian sample compared to respectively the Dutch and Norwegian samples. CONCLUSION: Although positive psychotic experiences may be more commonly endorsed in non-Western societies, our findings do not support the notion that they represent a more benign, and hence less distressing aspect of human experience. Rather, the experience of psychotic phenomena may be just as, if not more, distressing in African than in European culture. However, observed differences in CAPE-Pos frequency and distress between samples from different cultural settings may partly reflect differences in the measure rather than in the latent trait. Future studies may therefore consider further cross-cultural adaptation of CAPE-42, in addition to explicitly examining cultural acceptance of psychotic phenomena, and environmental and other known risk factors for psychosis, when comparing and interpreting subclinical psychotic phenomena across cultural groups.

Assessment of Visual Association Memory in Low-Educated, Non-Western Immigrants with the Modified Visual Association Test.

BACKGROUND: Neuropsychological tests are influenced by culture, language, level of education, and literacy, but there are few cognitive tests of which the applicability in ethnic minority populations has been studied. OBJECTIVES: The aim of this study was to assess the reliability and validity of the Visual Association Test (VAT), a test of visual association memory, in a non-Western, low-educated memory clinic population. Additionally, a modified version of the VAT using colored photographs instead of line drawings was studied (mVAT). METHOD: Both the original VAT and the mVAT were administered to non-Western immigrants (n = 73) from 2 multicultural memory clinics in Rotterdam, The Netherlands, and a control sample of non-demented Turkish elderly (n = 14) with low education levels (32 and 29% illiterate, respectively). RESULTS: Both the VAT and the mVAT were able to discriminate persons with and without dementia (area under the curve: VAT, 0.77-0.88; mVAT, 0.85-0.95). The mVAT had more homogeneous item difficulty levels than the VAT. Administration of parallel versions of the VAT and the mVAT within the same person revealed higher scores on the mVAT (Z = -3.35, p = 0.001). CONCLUSIONS: The mVAT is a reliable and valid measure of memory in non-Western immigrants. Clinicians and researchers should be aware that the memory performance of immigrants may be systematically underestimated when using tests with black-and-white line drawings, such as the original VAT.

Everyday life situations in which mothers experience difficulty stimulating healthy energy balance-related behavior in their school-age children: a focus group study.

BACKGROUND: Parental support is an important element in overweight prevention programs for children. The purpose of this study was to examine everyday life situations in which mothers encounter difficulties encouraging healthy energy balance-related behavior in their school-age children. METHODS: We formed four focus groups containing 6-9 participants each. The participants were mothers of Dutch, Turkish, or Moroccan descent with a child 8-13 years of age. All focus group sessions were recorded, transcribed, and coded. Content was analyzed conventionally using ATLAS.ti 6. RESULTS: Twenty-seven difficult everyday life situations were identified in 14 settings. The five most frequently reported situations were a daily struggle regarding eating vegetables, eating breakfast on time before going to school, eating candy and snacks between meals, and spending excessive time watching television and using the computer. A perceived loss of parental control, the inability to establish rules and the failure to consistently enforce those rules were the most commonly cited reasons for why the mothers experience these situations as being difficult. CONCLUSIONS: We identified five difficult everyday life situations related to healthy energy balance-related behavior. These five difficult situations were used as the input for developing a web-based parenting program designed to prevent children from becoming overweight. We reasoned that if we use these situations and the underlying reasons, many parents would recognize these situations and are willing to learn how to deal with them and complete the e-learning.