Eight Questions About Physician-Rating Websites: A Systematic Review

Background: Physician-rating websites are currently gaining in popularity because they increase transparency in the health care system. However, research on the characteristics and content of these portals remains limited. Objective: To identify and synthesize published evidence in peer-reviewed journals regarding frequently discussed issues about physician-rating websites. Methods: Peer-reviewed English and German language literature was searched in seven databases (Medline (via PubMed), the Cochrane Library, Business Source Complete, ABI/Inform Complete, PsycInfo, Scopus, and ISI web of knowledge) without any time constraints. Additionally, reference lists of included studies were screened to assure completeness. The following eight previously defined questions were addressed: 1) What percentage of physicians has been rated? 2) What is the average number of ratings on physician-rating websites? 3) Are there any differences among rated physicians related to socioeconomic status? 4) Are ratings more likely to be positive or negative? 5) What significance do patient narratives have? 6) How should physicians deal with physician-rating websites? 7) What major shortcomings do physician-rating websites have? 8) What recommendations can be made for further improvement of physician-rating websites? Results: Twenty-four articles published in peer-reviewed journals met our inclusion criteria. Most studies were published by US (n=13) and German (n=8) researchers; however, the focus differed considerably. The current usage of physician-rating websites is still low but is increasing. International data show that 1 out of 6 physicians has been rated, and approximately 90% of all ratings on physician-rating websites were positive. Although often a concern, we could not find any evidence of "doctor-bashing". Physicians should not ignore these websites, but rather, monitor the information available and use it for internal and ex-ternal purpose. Several shortcomings limit the significance of the results published on physician-rating websites; some recommendations to address these limitations are presented. Conclusions: Although the number of publications is still low, physician-rating websites are gaining more attention in research. But the current condition of physician-rating websites is lacking. This is the case both in the United States and in Germany. Further research is necessary to increase the quality of the websites, especially from the patients’ perspective.

Conditions for Teaching and Learning in Religious Education (RE) : Perspectives of Teachers and Pupils at the Beginning of the 6th Grade in Sweden

In this article empirical findings from interviews with teachers of three classes of 12-year-old pupils are presented, together with questionnaire-responses from these 54 pupils. The interviews focus on teaching aims for Religious Education (RE), a subject that in Sweden, besides dealing with religion, also explores other kinds of beliefs, ethics and life questions. In the questionnaire the pupils are asked to solve four RE tasks with content that is central from a Swedish curriculum perspective. The research involves pupils at the beginning of the sixth grade and the purpose of this article is to look at the teachers’ aims and the pupils’ responses, and consider what these may indicate about conditions for teaching and learning RE in these classes. The findings show that the perspectives of the pupils at the beginning of the sixth grade seem to be rather far from the expectations of the RE syllabus. The pupils’ statements are rather vague with regard to religion as a phenomenon and there are few examples of pupils interpreting religious symbols in a way that is useful in further analysis. While existential and ethical plots, messages and point of views are comparatively easy to describe, it is harder to express multiple perspectives, reasons, comparisons and questions. A problem for the teachers in developing the perspectives of their pupils is that they find it hard to say what kind of general difficulties pupils have in RE, a fact that makes it hard to direct the teaching. Another challenge is that the teachers’ RE-aims are rather overarching and primarily related to fostering fundamental values. What improves the conditions for teaching and learning is the teachers’ concern for the pupils and their relationships with the teacher and with each other, a factor which is of vital importance for learning and which can also be used as a specific teaching method in subject matter education.

European student mobility and intercultural learning at a portuguese university

The purpose of this study is to understand, impact and evaluate the development of intercultural communicative competencies among European credit-seeking exchange students and other sojourners through purposeful intercultural pedagogy. This pedagogy encompasses intentional intercultural- educational approaches which aim to support and enhance sojourners’ intercultural learning throughout the study abroad cycle (pre-departure, in-country and reentry phases). To test and validate these pedagogies a 20-hour intervention was designed and implemented among two cohorts of 31 sojourners during the in-country phase of their sojourn in Portugal. The process to develop and validate the intercultural intervention was driven by a mixed-methods methodology which combined quantitative and qualitative data to triangulate, complement and expand research results from a pragmatic stance. The mixed methods research design adopted is multi-phased and encompasses a multi-case study and an evaluative component. The multi-case component is embodied by sojourner cohorts: (1) the primary case study involves 19 incoming students at the University of Aveiro (Portugal) as participants in the European exchange program Campus Europae; (2) the second case study comprises three incoming Erasmus students and nine highly skilled immigrants at the same university. All 31 sojourners attended two intermediate Portuguese as Foreign Language classrooms where the intervention was employed. Data collection was extensive and involved collecting, analyzing and mixing quantitative and qualitative strands across four research phases. These phases refer to the: (1) development, (2) implementation and (3) evaluation of the intervention, as well as to (4) a stakeholder analysis of the external value of the intervention and of the Campus Europae program. Data collection instruments included pre and posttest questionnaires and semi-structured interviews. Results confirm the intercultural effectiveness of the intervention and the positive impact upon research participants’ intercultural gains. This impact was, however, greater in case study 2. Among explanatory variables, three stand out: (1) participant meaning-making abilities, (2) host language proficiency and related variables, and (3) type of sojourn or exchange programs. Implications for further research highlight the need to systematize purposeful intercultural pedagogy in sojourner populations in general, and in European credit student mobility in particular. In the latter case, these pedagogies should be part of the design and delivery of credit-bearing exchange programs in pre- departure, in-country and re-entry phases. Implications for practice point to the urge to improve intercultural practices in: macro (higher education institutions), mezzo (exchange programs) and micro (sojourner language classrooms) contexts where this research took place, and wider social scenarios they represent.

Extracurricular language activities in higher education: Perspectives of teachers and students

This Master’s thesis researches the topic “Extracurricular language activities in higher education: Perspectives of teachers and students”. In the light of several learning theories, namely, Self-Determination Theory, Social Learning Theory and Incidental Learning Theory, extracurricular participation in language related activities is studied. The main aims of the research are as follows: to study how extracurricular language activities can be organized and supported by the education institution; to investigate how such activities can promote the participants’ learning; and, to research how these activities can be developed and improved in the future. Due to the qualitative character of this research, the empirical data collected through interviews and their thematic analysis allow to study the participants’ perceptions on the above-mentioned issues. Among other results of the research, it can be noted that the organizers of extracurricular language activities and the participants of the activities may have different perspectives on the aims of the activities, as well as their advantages. Additionally, it has been found that the participants of activities would often speak on certain categories that imply the connection to some learning theories, which allows to hypothesize that some learning could be observed in those participants, following participation in extracurricular activities. This is an implication for further research in the area, which can focus on correlations between participation in extracurricular language activities and learning outcomes of the participants.

BET on Top Hat: challenges to improve language proficiency

Within the business context, communication and interaction tends to be considerably rooted in the use of English (as lingua franca), as well as in ICT use. Thus, professionals have to be able to speak the English language, resorting to specific, internationally recognised terminology and be proficient in the use of manifold ICT tools. In fact, the tendency is for the great majority of higher education (HE) students to own mobile devices (laptops, smartphones and/or tablets) and use them to access information and communicate/interact with content and other people. Bearing this in mind, a teaching and learning strategy was designed, in which m-learning (i.e. learning in which the delivery platform is a mobile device) was used to approach Business English Terminology (BET). The strategy was labelled as ‘BET on Top Hat’, once the selected application was Top Hat (https://tophat.com/) and the idea was for students to face it as if it were a game/challenge. In this scenario, the main goals of this exploratory study were to find evidence as to: i) the utility of m-learning activities for learning BET and ii) if and how m-learning activities can generate intrinsic motivation in students to learn BET. Participants (n=23) were enrolled in English II, a curricular unit of the 1st cycle degree in Retail Management offered at Águeda School of Technology and Management – University of Aveiro (2014/15 edition). The data gathered included the students’ results in quizzes and their answers to a short final evaluation questionnaire regarding their experience with BET on Top Hat. Consequently, data were treated and analysed resorting to descriptive statistical analysis, and, when considered pertinent, the teacher’s observation notes were also considered. The results unveil that, on the one hand, the strategy had a clear positive impact on the students’ intrinsic motivation and, on the other hand, the students’ performance as to BET use tended to improve over time.

EXAMINING THE IMPACT OF TEACHER PRACTICE ON STUDENT LEARNING IN INTERACTIVE RADIO INSTRUCTION (IRI) CLASSROOMS: LESSONS FROM NEW DELHI AND RAJASTHAN (INDIA)

This quantitative study examines the impact of teacher practices on student achievement in classrooms where the English is Fun Interactive Radio Instruction (IRI) programs were being used. A contemporary IRI design using a dual-audience approach, the English is Fun IRI programs delivered daily English language instruction to students in grades 1 and 2 in Delhi and Rajasthan through 120 30-minute programs via broadcast radio (the first audience) while modeling pedagogical techniques and behaviors for their teachers (the second audience). Few studies have examined how the dual-audience approach influences student learning. Using existing data from 32 teachers and 696 students, this study utilizes a multivariate multilevel model to examine the role of the primary expectations for teachers (e.g., setting up the IRI classroom, following instructions from the radio characters and ensuring students are participating) and the role of secondary expectations for teachers (e.g., modeling pedagogies and facilitating learning beyond the instructions) in promoting students’ learning in English listening skills, knowledge of vocabulary and use of sentences. The study finds that teacher practice on both sets of expectations mattered, but that practice in the secondary expectations mattered more. As expected, students made the smallest gains in the most difficult linguistic task (sentence use). The extent to which teachers satisfied the primary and secondary expectations was associated with gains in all three skills – confirming the relationship between students’ English proficiency and teacher practice in a dual-audience program. When it came to gains in students’ scores in sentence use, a teacher whose focus was greater on primary expectations had a negative effect on student performance in both states. In all, teacher practice clearly mattered but not in the same way for all three skills. An optimal scenario for teacher practice is presented in which gains in all three skills are maximized. These findings have important implications for the way the classroom teacher is cast in IRI programs that utilize a dual-audience approach and in the way IRI programs are contracted insofar as the role of the teacher in instruction is minimized and access is limited to instructional support from the IRI lessons alone.

Biliteracy effects on phonological awareness, oral language proficiency and reading skills in Taiwanese Mandarin-English bilingual children

The present study examined the effect of learning to read a heritage language on Taiwanese Mandarin-English bilingual children’s Chinese and English phonological awareness, Chinese and English oral language proficiency, and English reading skills. Participants were 40 Taiwanese Mandarin-English bilingual children and 20 English monolingual children in the U.S. Based on their performance on a Chinese character reading test, the bilingual participants were divided into two groups: the Chinese Beginning Reader and Chinese Nonreader groups. A single child categorized as a Chinese Advanced Reader also participated. Children received phonological awareness tasks, produced oral narrative samples from a wordless picture book, and took standardized English reading subtests. The bilingual participants received measures in both English and Chinese, whereas English monolingual children received only English measures. Additional demographic information was collected from a language background survey filled out by parents. Results of two MANOVAs indicated that the Chinese Beginning Reader group outperformed the Chinese Nonreader and English Monolingual groups on some phonological awareness measures and the English nonword reading test. In an oral narrative production task in English, the English Monolingual group produced a greater total number of words (TNW) and more different words (NDW) than the Chinese Nonreader group. Multiple regression analyses were conducted to determine whether bilingual children’s Chinese character reading ability would still account for a unique amount of variance in certain outcome variables, independent of nonverbal IQ and other potential demographic or performance variables and to clarify the direction of causality for bilingual children’s performance in the three domains. These results suggested that learning to read in a heritage language directly or indirectly enhances bilingual children’s ability in phonological awareness and certain English reading skills. It also appears that greater oral language proficiency in Chinese promotes early reading in the heritage language. Advanced heritage reading may produce even larger gains. Practical implications of learning a heritage language in the U.S. are discussed.

SES-RELATED DIFFERENCES IN WORD LEARNING: EFFECTS OF COGNITIVE INHIBITION AND WORD LEARNING

Socioeconomic status (SES) influences language and cognitive development, with discrepancies particularly noticeable in vocabulary development. This study examines how SES-related differences impact the development of syntactic processing, cognitive inhibition, and word learning. 38 4-5-year-olds from higher- and lower-SES backgrounds completed a word-learning task, in which novel words were embedded in active and passive sentences. Critically, unlike the active sentences, all passive sentences required a syntactic revision. Measures of cognitive inhibition were obtained through a modified Stroop task. Results indicate that lower-SES participants had more difficulty using inhibitory functions to resolve conflict compared to their higher-SES counterparts. However, SES did not impact language processing, as the language outcomes were similar across SES background. Additionally, stronger inhibitory processes were related to better language outcomes in the passive sentence condition. These results suggest that cognitive inhibition impact language processing, but this function may vary across children from different SES backgrounds

Heritage Language Maintenance and Biliteracy Development for Immigrants' Children: A Study of Chinese Immigrants' Family Language Policy and Biliteracy Practices

This study reports on research that examines the family language policy (FLP) and biliteracy practices of middle-class Chinese immigrant families in a metropolitan area in the southwest of the U.S. by exploring language practices pattern among family members, language and literacy environment at home, parents’ language management, parents’ language attitudes and ideologies, and biliteracy practices. In this study, I employed mixed methods, including survey and interviews, to investigate Chinese immigrant parents’ FLP, biliteracy practices, their life stories, and their experience of raising and nurturing children in an English-dominant society. Survey questionnaires were distributed to 55 Chinese immigrant parents and interviews were conducted with five families, including mothers and children. One finding from this study is that the language practices pattern at home shows the trend of language shift among the Chinese immigrants’ children. Children prefer speaking English with parents, siblings, and peers, and home literacy environment for children manifests an English-dominant trend. Chinese immigrant parents’ language attitudes and ideologies are largely influenced by English-only ideology. The priority for learning English surpasses the importance of Chinese learning, which is demonstrated by the English-dominant home literacy practices and an English-dominant language policy. Parents invest more in English literacy activities and materials for children, and very few parents implement Chinese-only policy for their children. A second finding from this study is that a multitude of factors from different sources shape and influence Chinese immigrants’ FLP and biliteracy practices. The factors consist of family-related factors, social factors, linguistic factors, and individual factors. A third finding from this study is that a wide variety of strategies are adopted by Chinese immigrant families, which have raised quite balanced bilingual children, to help children maintain Chinese heritage language (HL) and develop both English and Chinese literacy. The close examination and comparison of different families with English monolingual children, with children who have limited knowledge of HL, and with quite balanced bilingual children, this study discovers that immigrant parents, especially mothers, play a fundamental and irreplaceable role in their children’s HL maintenance and biliteracy development and it recommends to immigrant parents in how to implement the findings of this study to nurture their children to become bilingual and biliterate. Due to the limited number and restricted area and group of participant sampling, the results of this study may not be generalized to other groups in different contexts.

Structured Approaches for Exploring Interpersonal Relationships in Natural Language Text

Human relationships have long been studied by scientists from domains like sociology, psychology, literature, etc. for understanding people's desires, goals, actions and expected behaviors. In this dissertation we study inter-personal relationships as expressed in natural language text. Modeling inter-personal relationships from text finds application in general natural language understanding, as well as real-world domains such as social networks, discussion forums, intelligent virtual agents, etc. We propose that the study of relationships should incorporate not only linguistic cues in text, but also the contexts in which these cues appear. Our investigations, backed by empirical evaluation, support this thesis, and demonstrate that the task benefits from using structured models that incorporate both types of information. We present such structured models to address the task of modeling the nature of relationships between any two given characters from a narrative. To begin with, we assume that relationships are of two types: cooperative and non-cooperative. We first describe an approach to jointly infer relationships between all characters in the narrative, and demonstrate how the task of characterizing the relationship between two characters can benefit from including information about their relationships with other characters in the narrative. We next formulate the relationship-modeling problem as a sequence prediction task to acknowledge the evolving nature of human relationships, and demonstrate the need to model the history of a relationship in predicting its evolution. Thereafter, we present a data-driven method to automatically discover various types of relationships such as familial, romantic, hostile, etc. Like before, we address the task of modeling evolving relationships but don't restrict ourselves to two types of relationships. We also demonstrate the need to incorporate not only local historical but also global context while solving this problem. Lastly, we demonstrate a practical application of modeling inter-personal relationships in the domain of online educational discussion forums. Such forums offer opportunities for its users to interact and form deeper relationships. With this view, we address the task of identifying initiation of such deeper relationships between a student and the instructor. Specifically, we analyze contents of the forums to automatically suggest threads to the instructors that require their intervention. By highlighting scenarios that need direct instructor-student interactions, we alleviate the need for the instructor to manually peruse all threads of the forum and also assist students who have limited avenues for communicating with instructors. We do this by incorporating the discourse structure of the thread through latent variables that abstractly represent contents of individual posts and model the flow of information in the thread. Such latent structured models that incorporate the linguistic cues without losing their context can be helpful in other related natural language understanding tasks as well. We demonstrate this by using the model for a very different task: identifying if a stated desire has been fulfilled by the end of a story.

Guided portfolio writing as a scaffold for reflective learning in in-service contexts: a case study

Language is widely recognized as an inescapable mediating tool for professional learning, and with this text we want to contribute to a better understanding of the particular role that guided writing can play in in-service professional reflective learning. We analysed one pre-school teacher’s written portfolio, the construction of which was guided to scaffold deep thinking about (and the transference of theory into) practice during participation in an in-service program about language education. Our case study shows that the writing process sustained robust learning about professional knowing, doing and learning itself: The teacher elaborated an integrative ethical understanding of the discussed theory, fully experienced newly informed practices and assessed her own learning by using theory to confront her previous knowledge and practices. Throughout the portfolio, the learning stance revealed by her voice varied accordingly. The study illustrates the potential of guided writing to scaffold reflective learning in in-service contexts.

A case study of the English language teachers’ attitudes toward use of information and communication technology (ICT) in Finland

This qualitative study was aimed at investigating foreign language teachers’ attitudes toward use of information and communication technology (ICT) in their instruction. The insight was gained through the reported experience of ICT implementation by teachers, in what way and for which purpose they refer to use of technology, what kind of support and training they are provided with, and what beliefs they express about the influence of ICT implementation. This case study took place in one of the training schools in Finland. Five teachers participated in semi-structured interviews through a face-to-face approach. The findings demonstrated positive attitudes of teachers toward integration of ICT. The teachers shared their opinions about positive influence that ICT implementation has on both teaching and learning processes. However, they also pointed out the negative sides of ICT use: distraction of the students from usage of technology and technical problems causing frustration to the teachers. In addition, the responses revealed that the teachers are provided with adequate training aimed at enhancing their qualification which is provided with well-timed technology support and colleagues’ collaboration facilitating an efficient and smooth pace of the teaching process. According to the teachers’ opinions ICT integration in education appeared to have changed the role of the teacher. Due to different alterations in the field of ICT development teachers are required to upgrade their skills. The paper concludes with the limitations of the study and the recommendations for conducting further research.

"Knock, knock! Is it english or portuguese sign language?"

A presente investigação mostra a importância do contacto de crianças muito jovens com línguas estrangeiras. Este trabalho concentra-se na tentativa de investigar, numa abordagem plurilingue, com enfoque para a Língua Inglesa e a Língua Gestual Portuguesa, a sensibilização de um grupo de alunos do 1º Ciclo do Ensino Básico para uma língua diferente da sua língua materna. Nesta pesquisa, adotou-se uma postura de investigação-ação, apoiando-se com grande particularidade numa metodologia qualitativa e com menor relevância numa metodologia quantitativa, onde os alunos, através das várias atividades que desenvolveram foram adquirindo diferentes competências nas duas línguas. Isto permitiu aos alunos despertarem todas as suas potencialidades para a aprendizagem destas duas línguas (Língua Inglesa e Língua Gestual Portuguesa), tendo como ponto de partida a sua sensibilização e a aprendizagem de alguns vocábulos. Acreditamos que esta abordagem plurilíngue poderá auxiliar os alunos no desenvolvimento de habilidades linguísticas, cognitivas e pessoais tais como: a intercompreensão, o conhecimento de características específicas de diferentes línguas existentes em seu redor, a comparação linguística entre elas, a sua compreensão lexical, e por fim a competência em relacionar as línguas a culturas, e acima de tudo, o respeito e valorização da diversidade linguística e cultural. Foram utilizadas nas aulas atividades de nível de compreensão e produção oral, num processo de sensibilização e aprendizagem de alguns vocábulos destas línguas, sendo que os resultados foram posteriormente analisados, através de grelhas de observação das atividades, de dois inquéritos por questionário e fotos. Das observações e conclusões retiradas desta análise, confirmou-se que a sensibilização quanto à Língua Inglesa assim como quanto à Língua Gestual Portuguesa promove o desenvolvimento da criança, assim como a valorização da respetiva diversidade linguística e cultural.

Recent educational changes at higher educational level in Pakistan: English language teachers' perceptions and practices

Higher Education Institutes (HEIs) of any country could be a source of providing professionals to the country in many fields. By doing so, HEIs could play a pivotal role in the economic growth of the country. In Pakistan, it seems that, in the wake of this realization, steps have been taken to reform Higher Education. Drawing on the Triple I model of educational change covering Initiation, Implementation and Institutionalization (Fullan, 2007) this study focuses on the planning and implementation of reforms in the Education system of Pakistan at higher education level that have been introduced by the Higher Education Commission (HEC) since its inception in 2002. Kennedy’s model of hierarchical subsystems affecting innovation and Chin and Benne’s (1985) description of strategies for implementing change also provided guidelines for analyzing the changes in education in the country to highlight the role that the authorities expect the language teacher to play in the process of implementing these changes. A qualitative method is followed in this study to gather data from English language teachers at three universities of the Khyber Pakhtunkhwa province of Pakistan. A questionnaire was developed to look into the perceptions of English language teachers regarding the impact of these reforms. This was followed up by interviews. Responses from 28 teachers were received through questionnaire out of which 9 teachers were interviewed for detailed analysis of their perceptions. Thematic Content analysis was used to analyze and interpret the data. Some of the most significant changes that the respondents reported knowledge of included the introduction of Semester System, extending the Bachelors degree to four years from two years, promotion of research culture, and increased teachers’ autonomy in classroom practices. Implications of these reforms for English teachers’ professional development were also explored. The data indicate that the teachers generally have a positive attitude towards the changes. However, the data also show concerns that teachers have about the practical effectiveness of these changes in improving English language teaching and learning in Pakistani Universities. Some of the areas of concern are worries regarding resources, the assessment system, the number of qualified teachers, and instability in the educational policy. They are concerned about the training facilities and quality of the professional training available to them. Moreover, they report that training opportunities for their professional development are not available to all the teachers equally. Despite the HEC claims of providing regular training opportunities, the majority of the teachers did not receive any formal training in the last three years, while some teachers were able to access these opportunities multiple times. Through the recent reforms HEC has empowered the teachers in conducting the learning/teacher processes but this extra power has reduced their accountability and they can exercise these powers without any check on them. This empowerment is limited to the classroom and there appears to be no or minimal involvement in decision making at the top level of policy making. Such lack of involvement in the policy decisions seems to be generating a lack of sense of ownership among the teachers (Fullan 2003a:6). Although Quality Enhancement Cells have been developed in the universities to assure the desired quality of education, they might need a more active role to contribute in achieving the level of enhancement in education expected from them. Based on the perceptions of the respondents of this study and the review of the relevant literature, it is argued that it is unlikely for the reforms to be institutionalized if teachers are not given the right kind of awareness at the initiation stage and are not prepared at the implementation stage to cope with the challenge of a complex process. The teachers participating in this study, in general, have positive and enthusiastic attitudes towards most of the changes, in spite of some reservations. It could also be interesting to see if the power centers of the Pakistani Higher Education appreciate this enthusiasm and channel it for a strong Higher Education system in the country.

A case study of the English language teachers’ attitudes toward use of information and communication technology (ICT) in Finland

This qualitative study was aimed at investigating foreign language teachers’ attitudes toward use of information and communication technology (ICT) in their instruction. The insight was gained through the reported experience of ICT implementation by teachers, in what way and for which purpose they refer to use of technology, what kind of support and training they are provided with, and what beliefs they express about the influence of ICT implementation. This case study took place in one of the training schools in Finland. Five teachers participated in semi-structured interviews through a face-to-face approach. The findings demonstrated positive attitudes of teachers toward integration of ICT. The teachers shared their opinions about positive influence that ICT implementation has on both teaching and learning processes. However, they also pointed out the negative sides of ICT use: distraction of the students from usage of technology and technical problems causing frustration to the teachers. In addition, the responses revealed that the teachers are provided with adequate training aimed at enhancing their qualification which is provided with well-timed technology support and colleagues’ collaboration facilitating an efficient and smooth pace of the teaching process. According to the teachers’ opinions ICT integration in education appeared to have changed the role of the teacher. Due to different alterations in the field of ICT development teachers are required to upgrade their skills. The paper concludes with the limitations of the study and the recommendations for conducting further research.