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16 Books That Will Make You Cry
Casey Nugent
Is there anything better than a good cry? The emotional release I get from crying is so deeply satisfying that it can power me for days. There are so many books out there that move me to tears — because they're particularly sad, or because they're incredibly joyful, or because they just cut to the depth of the human experience in a way that moves me. Whatever the reason, after I wipe my tears and my snot away, I always feel better about myself and the world. If you're searching for a good, cathartic cry I've rounded up a list of books that get me every time.
1. Barely Missing Everything by Matt Mendez
In the tradition of Jason Reynolds and Matt de la Peña, this heartbreaking, no-holds-barred debut novel told from three points of view explores how difficult it is to make it in life when you—your life, brown lives—don't matter.
2. Five Feet Apart by Rachael Lippincott
Soon to be a major motion picture starring Cole Sprouse and Haley Lu Richardson in March 2019!
In this moving story that's perfect for fans of John Green's The Fault in Our Stars, two teens fall in love with just one minor complication—they can't get within a few feet of each other without risking their lives.
3. This Might Hurt a Bit by Doogie Horner
Kirby Burns is still grieving the death of his sister, which happened exactly one year ago. Ever since then he hasn't stopped running: from his family, his memories, and the horse-sized farm dogs that chase him to the bus stop every morning.
But he can't run forever, and as This Might Hurt a Bit begins, Kirby and his friends PJ and Jake sneak out of his house to play a prank whose consequences follow them to school the next day, causing a chain reaction of mayhem and disaster. It's a story that's touching and funny, an authentic meditation on the pain of loss, and the challenge of getting paint to stick to cows.
4. Summer Bird Blue by Akemi Dawn Bowman
After Rumi's sister dies in a car accident, Rumi is sent to live in Hawaii with her aunt. With the help of a teenage surfer named Kai, who smiles too much and doesn't take anything seriously, and an eighty-year-old named George Watanabe, who succumbed to his own grief years ago—Rumi attempts to find her way back to her music, to write the song she and her sister never had the chance to finish.
5. Teach Me to Forget by Erica M. Chapman
After the painful death of her younger sister, Ellery doesn't want to live anymore. She can't bare to face her family and she blames herself for the accident that killed her sister. Now she's bought a gun and is ready to take her life. She has a plan.
Then, on the day she intends to take her own life, she meets Colter, a boy who recognizes her desperation and becomes determined to stop her.
6. See All The Stars by Kit Frick
Then: They were four—Bex, Jenni, Ellory, Ret. (Venus. Earth. Moon. Sun.) Electric, headstrong young women; Ellory's whole solar system.
Now: Ellory is alone, her once inseparable group of friends torn apart by secrets, deception, and a shocking incident that changed their lives forever.
7. The Last to Let Go by Amber Smith
In a year of firsts—the first year without parents, first love, first heartbreak, and her first taste of freedom—Brooke must confront the shadow of her family's violence and dysfunction, as she struggles to embrace her identity, finds her true place in the world, and learns how to let go.
8. The Place Between Breaths by An Na
Sixteen-year-old Grace is smart and responsible. She's going to help her father find a cure for schizophrenia, the mental illness that her mother had before she left them, disappearing. They're going to find a breakthrough. But something inside Grace has started to unravel. A stark and fascinating look at mental illness, as well as an interesting and provocative read.
9. You'll Miss Me When I'm Gone by Rachel Lynn Solomon
Twins Adina and Tovah have little in common except for their carefully planned futures. But those futures could be wrecked by the illness that might be hiding in their genes — Huntington's, a degenerative disease that turned their mother into a stranger. When the girls get tested for Huntington's the results are devastating. One twin is negative. The other is positive. Opposite outcomes push them even farther apart, and change everything. I have an extremely soft spot for books about complicated sibling dynamics, and this one really resonated. Heartbreaking and brilliantly written, it's a can't miss debut.
10. The Way I Used to Be by Amber Smith
I'll start with a big trigger warning for this one, as it follows the aftermath of a sexual assault — but it's a book about healing, trauma, and finding inner strength that carries a lot of meaning and is guaranteed to get you in tears. Eden was looking forward to high school, but now everything is different. Nothing makes sense anymore, so instead of telling anyone what's happened she buries it — and she buries her old self, too. Told in four parts across the four years of high school, this book is a phenomenal, heartbreaking tale of strength and survival.
11. Aristotle and Dante Discover the Secrets of the Universe by Benjamin Alire Saenz
A lot of books on this list made me sad-cry, so here's one that made me happy-cry instead. Aristotle is angry. His brother's in prison, and no one seems to talk about it. When he meets know-it-all Dante, who has an unusual way of looking at the world, they seem to have nothing in common. But as these two loners come together, they start to discover a special bond that will change both of them for a lifetime.
12. Second Chance Summer by Morgan Matson
And we're back to sad crying! Taylor Edward's family isn't the closest-knit, as overscheduled and busy as they are, but they get along fine. And Taylor herself is doing fine, even if she does have a slight tendency to run away from her problems. Then Taylor's dad is diagnosed with cancer, and the prognosis is bad — only a few months left to live bad. The Edwards' decide to spend one last summer altogether at their lake house, and Taylor discovers that there are some problems you can't run away from.
13. Starfish by Akemi Dawn Bowman
If you've ever been crushed by rejection or struggled through self-doubt, you need to read Starfish. Kiko Himura has a hard time saying what she's thinking. It doesn't help that she lives with her white mother, who's dismissive of Kiko at every turn. But it doesn't matter, because Kiko has a dream — she's going to go to Prism, a prestigious art college, and then everything will change. But when she doesn't get accepted to Prism, Kiko's devastated. And things are made worse when her mother invites her abusive uncle to live with them. When a childhood best friend reappears in her life with the offer to move out west and look at art schools, Kiko jumps at the chance to leave. Now, away from her mother for the first time in her life, she has to figure out who she really is, and what she really wants.
14. The Summer I Turned Pretty by Jenny Han
Belly measures her life in summers. Everything good, everything magical happens between the months of June and August. Winters are simply a time to count the weeks until the next summer, a place away from the beach house, away from Susannah, and most importantly, away from Jeremiah and Conrad. They are the boys that Belly has known since her very first summer — they have been her brother figures, her crushes, and everything in between. But one summer, one wonderful and terrible summer, the more everything changes, the more it all ends up just the way it should have been all along.
15. The Last True Love Story by Brendan Kiely
The point of living is learning how to love. That's what Gpa says. To Hendrix and Corrina, both seventeen but otherwise alike only in their loneliness, that sounds like another line from a pop song that tries to promise kids that life doesn't actually suck. Okay, so: love. Sure. One hot July night, Hendrix and Corrina decide to risk everything. They steal a car, spring Gpa from his assisted living facility, stuff Old Humper the dog into the back seat, and take off on a cross-country odyssey from LA to NY. With their parents, Gpa's doctors, and the police all hot on their heels, Hendrix and Corrina set off to discover for themselves if what Gpa says is true—that the only stories that last are love stories.
16. The Last Boy and Girl in the World by Siobhan Vivian
What if your town was sliding underwater and everyone was ordered to pack up and leave? How would you and your friends spend your last days together? While the adults' plan for the future, box up their possessions and find new places to live, Keeley Hewitt and her friends decide to go out with a bang. There are parties in abandoned houses. Canoe races down Main Street. The goal is to make the most of every minute they still have together.
Aristotle and Dante Discover the Secrets of the Universe Barely Missing Everything five feet apart Second chance summer See All the Stars Starfish Summer Bird Blue The Last Boy and Girl in the World The Last to Let Go The Last True Love Story The Place Between Breaths The Summer I Turned Pretty The Way I Used to Be this might hurt a bit You'll Miss Me When I'm Gone
13 Books That Will Make You Laugh
7 Books That Will Make You Hungry
5 Moms in YA That Will Make You Want to Hug Yours
14 Adorable Romances that Will Make You Believe in Love


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Women react outside of Al Noor Mosque in Christchurch, New Zealand March 21, 2019.
Mourners proceed with the coffin of a shooting victim, slain by an Australian white supremacist gunman who went on a killing spree at two mosques, at the Memorial Park cemetery in Christchurch on March 20, 2019.
A policewoman is seen as people attend the burial ceremony of a victim of the mosque attacks, at the Memorial Park Cemetery in Christchurch, New Zealand March 21, 2019.
50 people were killed, and dozens were injured in Christchurch on Friday, March 15 when a gunman opened fire at the Al Noor and Linwood mosques.
Messages of support are placed at the vigil to remember the victims of last week's terrorist attack on Christchurch's Al Noor mosque and Linwood Islamic Centre, in Adelaide, Australia, March 21 2019.
EPA-EFE
A tribute listing the victims of the mosque attacks is placed at a memorial site in Christchurch on March 20, 2019.
Locals look on during the vigil held at Forsyth Barr Stadium on March 21, 2019 in Dunedin, New Zealand.
People place flowers at memorial sites as a tribute to victims.
Candles are lit around pictures and messages at a tribute to 25-year old Masters student Ansi Alibava.
Royal Malaysian Navy Brass Band, Able Rate Abdul Iskandar, who said he was supposed to be at Masjid Al Noor mosque on Friday, is comforted by a bystander.
Floral tributes to those who were gunned down at the two mosques are seen against a wall bordering the Botanical Garden in Christchurch.
Mourners lay flowers on a wall at the Botanical Gardens in Christchurch.
A couple lights a candle at a memorial site at the Botanic Gardens.
ZUMAPRESS.com
Fifty pairs of painted white shoes are laid out at All Souls Church in memory of the victims.
A girl is comforted by her friend after paying their respects to the victims in Christchurch.
People pay their respects at a memorial site at the Botanical garden in Christchurch on March 18, 2019, three days after a shooting at two mosques in the city claimed the lives of 50 Muslim worshipers.
A New Zealand flag is placed next to flowers and tributes near Al Noor mosque.
High school students pray at the Deans Ave vigil near the Masjid Al Noor Mosque.
A police officer writes a message on a banner during a students vigil.
People pay their respects at a memorial site at the Botanical garden.
A picture left among flowers and tributes near Al Noor mosque.
Pakistani people light candles in remembrance of the victims of the Christchurch mosques.
Youngsters take part in a students vigil.
High school students mourn the loss of two students.
A 'love' ornament and candles are seen at a memorial site.
NYC becomes an emerald city for St. Patrick's Day parade
The New York City St. Patrick's Day parade, dating back...
New Zealand mourns the victims of mosque shootings

redpajama_set_name: RedPajamaCommonCrawl


Q What version of Lightroom is required?
Q What metadata does Syncomatic copy?
Q Does Syncomatic copy Develop settings?
Q What's the problem with cropping?
Because it uses undocumented code which I've had to figure out, cropping may not be synced correctly in every circumstance, and portrait orientation photos present particular difficulties. I'll continue to work on this area but I may not be able to help you if it doesn't sync crops correctly for every photo. Still, the worst that can happen is that it may apply an incorrect crop, or none – which seems preferable to never syncing any crop!
Q What does Syncomatic not copy? And why?
Q I have items stacked in collections. Why doesn't Syncomatic sync their metadata?


Click on "Books" or "Browse the Bookstore" and then type the book title in the "search" window.
Preachers and seminarians who dare to sit at the feet and learn from these preaching giants of the past will hopefully find their own preaching power lifted onto a new plain to the benefit of all who hear them.
Dr. Robert T. Henry answers the question "what fundamental changes to my entire approach to preaching must I make in order to elevate my effectiveness in the pulpit?"


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Law firm Heuking Kühn Lüer Wojtek
Law on living will is urgently required
After an accident or sudden illness, most Germans would prefer a quick and humane death to a long and lingering illness in a sickbed. Some people set out whether they want measures taken to extend their lives or not at an early stage in what is known as "living wills". These are intended to ensure that everything takes place in accordance with their wishes, even if they are no longer in a position to articulate such wishes. But even such statements of will are no guarantee, either.
"There is no legal basis. There is enormous legal uncertainty that must finally be ended", Claus-Henrik Horn, lawyer at law office Heuking Kühn Lüer Wojtek, says. This opinion is also gaining an increasing number of political advocates. In a first reading on June 26, the Bundestag therefore will discuss a draft introduced by SPD politician and law expert Joachim Stünker for a so-called "Patient's Living Will Act."
While the Federal Court of Justice in a fundamental decision on March 17, 2003 had recognized the wishes fixed in a living will as generally binding, it remains unclear, however, whether or not the treating doctor must adhere to the treatment instructions. In addition, the requirements for an effective living will are controversial.
"Despite the fact that the legal situation is still problematic, I consider a living will as extremely important even today", Horn clarifies. After all, this way the basic decision is taken as to whether or not life-extending measures are desired if the case arises. In addition, the future patient gives treating doctors precise treatment instructions.
Special precautionary powers of attorney are necessary for entrepreneurs. "Otherwise, the company in question will also be at risk of being unable to act", Horn warns. Should the entrepreneur have failed to take any precautions, the guardianship court will set up a guardianship. "In doing so, the court may appoint both a guardian close to the affected entrepreneur or a third party whose qualifications are uncertain", the expert of Heuking Kühn Lüer Wojtek says.
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Bundled up actress Maggie Gyllenhaal, who is in her 3rd trimester and her daughter Ramona, 5, head to class in Brooklyn yesterday, January 23. Gyllenhaal and her actor husband actor Peter Sarsgaard are expecting their second child soon. No word on the gender.


@agppl_tweets @iHrithik Eagerly waiting for the 1st look teaser trailers songs n finally the epic movie #MOHENJODARO #Aug12th #OSCAR!
@Dan Godbold: When will trailers get their own Oscar? #RogueOne now, and #TheForceAwakens before, sent me from 'meh' to 'give me now' in two minutes.


One of the things that I teach in my Bootcamp for Artists seminar is guerrilla tactics for reducing framing costs up to 80-90% from custom framing costs.
One valuable asset here are A.C. Moore stores, with their significant set of ready made frames at generally affordable prices, often coupled with weekly sales.
Moore's is also a prodigious coupon-generating factory, and quite often you get a coupon that proudly announces "55% off any regular priced item."
To me, being a pedantic Virgo, "any" means that all items in the store which are not on sale are discounted 55%.
The small print on the coupon notes several exceptions to "any."
Prior to the "any" coupon, I had received an email blast from A.C. Moore's proudly announcing "Today Only: 20% Off Everything." And so I rush to the store, thinking that "everything" means.... ahh... everything!
"Everything" is understood by the most casual observer to mean everything in the store... and thus I was surprised when I went and made a large purchase that there were many things at the store where it didn't apply -- that is dishonest advertising to say "everything" and then you get to the store and Essential Frames, clearance items, etc. are NOT part of "Everything."
This, of course, bugged me and thus I contacted A.C. Moore to explain to them that by using the word "everything", the implication was that any item on the store was eligible for the discount.
Thank you for contacting A. C. Moore Customer Care. We apologize for the misunderstanding about the 20% off coupon from our email subject line. The details of this coupon are printed on the actual coupon, where it explains that the 20% off is on your regular and sale price items, and lists excluded items. Your detailed feedback is greatly appreciated as it allows us the opportunity to address this type of situation for future visits.
I have added 500 points to your rewards account (the equivalent of making a $50.00 purchase) for the inconvenience.
We understand your position and we appreciate your feedback about this. We will forward your feedback to our marketing team to take this into consideration for future email coupons.
And I am grateful, and it is an inconvenience to load a cart with 30 Home Essential frames on two separate occasions, only to find out that they are not eligible under the "any" descriptor in the 55% "any" coupon, or under the "everything" descriptor in the 20% coupon.
What's the solution? Can Moore's get out of this borderline deceptive coupon by simply using an asterisk after the word "any" and "everything"? At least an asterisk raises an alarm that there are limitations.
Five gets you ten that the winner is Amy Sherald (also the most recent winner of the 2016 Smithsonian Outwin Boochever Portrait competition). In fact, the very talented Ms. Sherald is having a great year!
Amy Sherald earned a Bachelor of Arts from Clark- Atlanta University where she became an apprentice to Dr. Arturo Lindsay. Sherald received her Master of Fine Arts in painting from the Maryland Institute College of Art. After graduating, she secured a prestigious private study residency with well-known Norwegian painter Odd Nerdrum .
In 2008, she attained an artist residency assistantship at the Tong Xion Art Center in Beijing, China. Her work has been exhibited extensively including solo exhibitions at Richard Demato Gallery in New York, University of North Carolina at Chapel Hill, and the Reginald F. Lewis Museum in Baltimore, MD.
Sherald's work is also featured in the permanent collections of the National Museum of Women in the Arts, The Smithsonian Museum of African American History and Culture, the US Embassy in Dakar, Senegal, and the D.C. Commission of Fine Arts. Sherald is also the winner of the 2016 Smithsonian Outwin Boochever Portrait competition. She is currently living and working as an artist in resident at the Creative Alliance.


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Q: Convergence of $\sum_{n=1}^{\infty}(-1)^n\frac{x^n+1}{n}$ I have trouble with the following sum: $$S=\sum_{n=1}^{\infty}(-1)^n\frac{x^n+1}{n}$$
Since $a_n=\frac{2}{n}$ decreases monotonically and tends to $0$, it converges by Liebniz criterion.
Then, by Abel's theorem we have that $S$ converges uniformly for $|x| < 1$.

*

*Question 1. Is this correct?

*Question 2. How can I show that it diverges for $|x| > 1$? I've been unable to prove it with the usual tests.

*Question 3. How can I show that it doesn't converge absolutely in $(-1,1)$?

Any help would be appreciated, thanks in advance!

A: First you can just focus on the series $\sum\frac{(-1)^n}{n}x^n$ since the series $\sum\frac{(-1)^n}{n}$ is convergent. Now this first series is an entire series and it's convergent on the interval $(-1,1]$.

redpajama_set_name: RedPajamaStackExchange


text:
Q: How to use promise to cause function to wait before filling variable with returned data? I have an API which returns stock quote data, my problem is that the model variable is first returned undefined before the return_array has data.
I'm not sure how to use promises or some other method to wait for data correctly before filling the variable (besides using a terrible $timeout hack).

My problem as you can see here in the chrome inspector (ticker_chart = undefined):

I need ticker_chart to wait, before getting a value.

The first function that calls out to a service to return the ticker quote data:
function renderChart(ticker, limit) {
    ticker_chart = TickerChartFactory.returnTickerChartData(ticker, limit);
    console.log('ticker_chart = ',ticker_chart);
}

The full service function:
function returnTickerChartData(ticker, limit) {

    var q = $q.defer();

    var get_data = '';
    if (limit > 0) {
        get_data = '?limit=' + limit;
    }

    ApiFactory.getTickerQuotes(ticker.ticker).success(
        function(data, status, headers, config) {
            if (data.status == 'Success') {
                console.log('REST GET Ticker Chart', 'success');
                var data_array = [];

                for (var i=0; i<data.quotes.length; i++) {
                    data_array.push([data.quotes[i].start_epoch, data.quotes[i].price]);
                }

                var return_array = [{
                    "area": true,
                    "key": "Price",
                    "color": '#BFBFBF',
                    "values": data_array
                }];

                console.log('return_array = ',return_array);
                console.log('q =',q);
                q.resolve(return_array);
                return ticker_chart = return_array;

            } else {
                console.log('failed to REST GET Ticker Chart');
                q.reject('failed to REST GET Ticker Chart');
                return ticker_chart = 'failed to REST GET Ticker Chart';
            }
        }).error(function(data, status) {
            console.log('error in getting REST GET Ticker Chart');
            q.reject('error in getting REST GET Ticker Chart');
            return ticker_chart = 'error in getting REST GET Ticker Chart';
        });
}

The getTickerQuotes function in the ApiFactory:
function getTickerQuotes(ticker) {
    return $http.get('https://www.ourapi.../api/tickers/quotes/'+ticker, {cache: false});
}

How should I be using the promise here? The only other thing I can think of is using a $scope.watch function to wait till the value of ticker_chart changes before trying to render something.

A: Your are creating a promise in returnTickerChartData but I don't see you ever returning it. You need to change it to be
function returnTickerChartData(ticker, limit) {
    var q = $q.defer();
    // API call

    return q.promise;
}

In getTickerQuotes.success you just need to resolve the promise with the data. You don't need the line return ticker_chart = return_array;.
And then,
function renderChart(ticker, limit) {
    TickerChartFactory.returnTickerChartData(ticker, limit)
        .then(function (result) {
            ticker_chart = result;
            console.log('ticker_chart = ', ticker_chart);
        });
}

EDIT: @Bergi raises a valid point in the comments. If ApiFactory.getTickerQuotes already returns a promise, you should return that instead of creating a new promise with deferred. Also change to using ApiFactory.getTickerQuotes.then() instead of .success().


text:
Simple Pleasures Salon and Spa
Face and Body Waxing
Monthly Specials...
SPSAS LOYALTY DISCOUNT
Owners Biography
Nanette White Owner/Aesthetician
"You will love the new you!"
Nanette White is the proud owner of "Simple Pleasures Salon and Spa." Her love of people, skincare and make-up artistry started in 1986.
Nanette trained at "Showorks Studio" and "Central Coast Model and Talent" in Southern California, where she studied runway modeling and make-up artistry, including artistry for photography and television.
She started her freelance career in Orange County, California and worked with a vast number of *skincare lines in the beautiful "South Coast Plaza" and "Newport Beach Fashion Island" centers.
*Ultima II, Estee' Lauder, Elizabeth Arden, Orlane, Biotherm, I.S. Cosmetics, Borghese, Bodyography, La Prarie, Clarins, Sebastian, Cinema Secrets, Dermalogica, Decleor, Yonka, Sothy's, Laura Mercier, Jan Marini, Peter Thomas Roth, and Murad, and others.
In 1999 Nanette started to work for "Skin Deep Salon" in Santa Barbara, California. She planned structured study courses for aestheticians and sale associates for various skincare lines, recruited staff, organized and managed the sales floor, along with salon and spa departments. The result was a cohesive business environment that delivered service effectively.
In 2003 Nanette and her family moved to the Oregon area, where she started a job working for Paula Dorf, in "Washington Square", Nordstrom. After a year and a half, she transitioned back into freelance artistry/skincare, and began working with Osmotics Skincare in 2004.
In October of 2009, this professional, self-motivated lady, opened her own "Simple Pleasures Salon and Spa" in
Tigard Oregon. Eight years, after creating a successful business in the Northwest, she decided to transition her Aesthetic business to Solvang, California in May of 2016, where she now lives and continues to express her passion for aesthetics to her "forever growing" clientele and looks forward to meeting you!
Visit Simple Pleasures Salon and Spa and you will truly love the new you!
Content copyright . Simple Pleasures Salon and Spa LLC. All rights reserved.


text:
FDA panel backs 3 psychiatric drugs for kids
By MATTHEW PERRONE , AP Business Writer
(AP) -- Advisers to the Food and Drug Administration said Wednesday that three blockbuster psychiatric drugs appear safe and effective for children and adolescents, despite side effects that can increase the risk of diabetes.
The FDA's panel of psychiatric experts voted to approve the use of drugs from AstraZeneca, Eli Lilly and Pfizer for treating schizophrenia and bipolar disorder in patients ages 10 to 17.
The FDA is not required to accept the group's advice, though it usually does.
"We'll take all of this into consideration, but I can't make any promises about when we'll take action," said Dr. Thomas Laughren, FDA's director of psychiatric drugs.
All three drugs already are approved for adults with schizophrenia and bipolar disorder. Their side effects include weight gain, high blood sugar and sleepiness.
A positive FDA decision will expand the use of drugs that already make up the top-selling class of prescriptions in the U.S., with 2008 sales of $14.6 billion, according to health care analysis firm IMS Health.
The panel - mainly comprised of psychiatrists - largely brushed aside concerns from patient and consumer advocates that the companies should have been required to conduct longer studies of the drugs' side effects.
The panel voted 11-4, with four abstentions, that Lilly's drug Zyprexa is safe for treating bipolar, despite evidence the drug causes significantly more weight gain than other treatments. The Indianapolis-based company is only seeking approval for the drug as a second-choice, after other drugs have been tried.
"I had concerns about the metabolic side effects but if this is going to be used as the last treatment option then I think having other treatments available to physicians is worthwhile," said Dr. Frank Greenway, of Pennington Biomedical Research Center in Baton Rouge, La.
On the first day of the two-day meeting, more than a half-dozen nonprofit groups complained about the short length of the studies submitted to the FDA. The studies averaged between four and six weeks in length.
"Schizophrenia and bipolar disorder last for decades, often for life, and treatment is needed during all those years," said Dr. Diana Zuckerman of the Research Center for Women and Families in Washington. "These studies provide almost no useful information about long-term adverse reactions."
Schizophrenia affects about 2.4 million Americans and is characterized by hallucinations, delusions and social withdrawal, according to the National Institute of Mental Health. About 5.7 million Americans experience bipolar disorder, which causes rapid mood swings and shifts in energy.
Many doctors already prescribe the medications to children and adolescents. Doctors are free to prescribe drugs as they see fit, though companies can only market them for FDA-approved indications.
Prescriptions of anti-psychotic drugs for patients under 19 years old have more than doubled since 2001, according to pharmacy benefit manager Medco Health.
AstraZeneca and Lilly are seeking approval of their drugs - Seroquel and Zyprexa, respectively - for adolescents with schizophrenia and bipolar mania, also called manic depressive disorder. Pfizer is seeking approval to market its pill Geodon for bipolar patients ages 10 to 17.
The FDA panel voted 8-1 that Geodon is safe for children and adolescents with bipolar disorder, though nine panelists abstained, complaining of incomplete data from the company.
With only two anti-psychotic drugs currently approved for younger patients, a positive decision for the three drugs would significantly increase competition in the market for anti-psychotics.
Currently, only Bristol-Myers Squibb's Abilify and Johnson & Johnson's Risperdal are approved for those uses. Abilify was the second best-selling anti-psychotic drug in the U.S. last year with sales of $3 billion. Risperdal was fourth with $1.6 billion in sales, according to IMS Health.
Those drugs and the three under FDA consideration are known as atypical anti-psychotics, a class of treatments introduced in the 1990s that were designed to be safer and more effective than older drugs.
But recent studies have concluded the newer drugs are no more effective than those first developed in the 1950s. And while atypical anti-psychotics do not have the older drugs' risks of tremors and muscle spasms, they have their own side effects which can increase the risk of diabetes and heart problems.
Because the newer drugs are still under patent they generally sell for between $300 and $500 per month, compared with the $100 price on original anti-psychotics.
FDA weighs approval of psychiatric drugs for kids
Citation: FDA panel backs 3 psychiatric drugs for kids (2009, June 11) retrieved 17 January 2020 from https://medicalxpress.com/news/2009-06-fda-panel-psychiatric-drugs-kids.html
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Published on 2.3.2021 in Vol 23, No 3 (2021): March
Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/23362, first published August 10, 2020 .
Barriers to the Large-Scale Adoption of a COVID-19 Contact Tracing App in Germany: Survey Study
Authors of this article:
Annelies G Blom 1, 2 ; Alexander Wenz 1, 2 ; Carina Cornesse 2 ; Tobias Rettig 2 ; Marina Fikel 2 ; Sabine Friedel 2 ; Katja Möhring 1, 2 ; Elias Naumann 2 ; Maximiliane Reifenscheid 2 ; Ulrich Krieger 2
Article Authors Cited by (6) Tweetations (12) Metrics
Annelies G Blom1,2*, PhD ;
Alexander Wenz1,2*, PhD ;
Carina Cornesse1, PhD ;
Tobias Rettig1, MA ;
Marina Fikel1, MA ;
Sabine Friedel1, MA ;
Katja Möhring1,2, PhD ;
Elias Naumann1, PhD ;
Maximiliane Reifenscheid1, MA ;
Ulrich Krieger1, PhD
1Collaborative Research Center 884 "Political Economy of Reforms", University of Mannheim, Mannheim, Germany
2School of Social Sciences, University of Mannheim, Mannheim, Germany
*these authors contributed equally
Alexander Wenz, PhD
Phone: 49 621 181 2298
Email: a.wenz@uni-mannheim.de
Background: During the COVID-19 pandemic, one way to reduce further transmissions of SARS-CoV-2 is the widespread use of contact tracing apps. Such apps keep track of proximity contacts and warn contacts of persons who tested positive for an infection.
Objective: In this study, we analyzed potential barriers to the large-scale adoption of the official contact tracing app that was introduced in Germany on June 16, 2020.
Methods: Survey data were collected from 3276 adults during the week the app was introduced using an offline-recruited, probability-based online panel of the general adult population in Germany.
Results: We estimate that 81% of the population aged 18 to 77 years possess the devices and ability to install the official app and that 35% are also willing to install and use it. Potential spreaders show high access to devices required to install the app (92%) and high ability to install the app (91%) but low willingness (31%) to correctly adopt the app, whereas for vulnerable groups, the main barrier is access (62%).
Conclusions: The findings suggest a pessimistic view on the effectiveness of app-based contact tracing to contain the COVID-19 pandemic. We recommend targeting information campaigns at groups with a high potential to spread the virus but who are unwilling to install and correctly use the app, in particular men and those aged between 30 and 59 years. In addition, vulnerable groups, in particular older individuals and those in lower-income households, may be provided with equipment and support to overcome their barriers to app adoption.
J Med Internet Res 2021;23(3):e23362
doi:10.2196/23362
digital health; mobile health; smartphone; mobile phone; app; digital technology; contact tracing; coronavirus; COVID-19; survey
Since the outbreak of COVID-19, millions of people worldwide have been infected with SARS-CoV-2 [1]. In the absence of an effective vaccine or cure, societies across the globe are testing various combinations of measures to contain the spread of the virus [2]. Many countries have introduced lockdowns to reduce the number of new infections to a level that allows national health systems to treat all patients effectively despite the additional influx of seriously ill people [3].
While lockdowns have proven effective at reducing the spread of the virus, they have a major impact on the economy and social life [4,5]. A less economically damaging measure is contact tracing, where persons who have been in close proximity of someone known to be infected are quarantined until they can be confirmed not infected (ie, tested negative) or, if confirmed infected (ie, tested positive), until they are not contagious anymore. In Germany, this task has been performed by officials in local public health departments, who through personal conversations with infected persons, have been collecting proximity contacts to inform them of their potential infection and to implement quarantines [6].
To grant some relief to this labor-intensive system and to account for regionally strewn sudden new outbreaks, scientists have been discussing app-based contact tracing as a supplementary measure [7]. Once installed on a smartphone, a contact tracing app warns users when they have been in close contact with an infected person and may advise them to go into quarantine and get tested for infection. Thus, if adopted widely, apps may allow for a more efficient tracing of infection chains.
On June 16, 2020, 141 days after the first diagnosis of COVID-19 in Germany [8], the federal government and the Robert Koch Institute (RKI) (ie, the German center for disease control and prevention) launched their official COVID-19 contact tracing app [9,10]. Simulations estimate that for the app to contain the epidemic, at least 56% of a country's population needs to use the app and comply with the app's recommendations [11], although lower uptake rates are also effective in reducing the number of infections [12]. This paper examines to what extent this goal is likely to be achieved in Germany by providing answers to the following research question: What proportions of the general population aged 18 to 77 years in Germany (1) have access to the devices required to install the official contact tracing app, (2) are able to install it, and (3) are willing to install the app, use it, and act according to its recommendations?
Our predictions show that the adoption rate of 56% needed to contain the epidemic will be missed by a considerable margin. However, contact tracing apps may still be effective if specific subgroups adopted them at a higher rate. In particular, if a high proportion of persons who are frequently in contact with persons outside their household (ie, potential spreaders) adopted the app, its spread may be significantly curbed. In a similar vein, if a high proportion of persons who are likely to get severely ill from the disease (ie, vulnerable groups) adopted the app, health workers may be able to treat them early on and, thus, decrease the impact of COVID-19. Therefore, we investigate adoption rates among these two population subgroups by asking the following research questions:
What proportions of potential spreaders (1) have access to the devices required to install the official contact tracing app, (2) are able to install it, and (3) are willing to install the app, use it, and act according to its recommendations?
What proportions of persons with high vulnerability to a serious infection (1) have access to the devices required to install the official contact tracing app, (2) are able to install it, and (3) are willing to install the app, use it, and act according to its recommendations?
The official COVID-19 contact tracing app in Germany, the Corona-Warn-App, can be downloaded from the Apple App Store or Google Play free of charge and installed on iPhones, with iOS version 13.5 or higher, and Android smartphones, with Android version 6.0 or higher [9,10]. The app can be installed by the same person on multiple devices. Once installed, the app detects other app users in proximity by exchanging encrypted ID numbers between devices using Bluetooth Low Energy technology. The ID numbers change constantly and are stored locally on the device, relying on a decentralized approach for data storage. The user's geolocation is not tracked. The app automatically informs users when they have been in contact with someone confirmed infected with SARS-CoV-2 and provides behavioral recommendations, including domestic quarantine and tests for SARS-CoV-2. The identity of the person using the app remains anonymous. An app user with a positive test result can enter this result into the Corona-Warn-App. By doing so, all proximity contacts are automatically notified of their own potential infection. Users can deactivate and reactivate the COVID-19 exposure notifications at any time or can completely uninstall the app. Using the Corona-Warn-App is voluntary and meets the European Union General Data Protection Regulation [13,14].
There are several potential barriers that may prevent people from using an app [15,16]. An initial barrier is access to a smartphone capable of installing the desired app and access to the internet [17,18]. In the case of the Corona-Warn-App, persons additionally need a smartphone with an iOS or Android operating system [9,10]. Among smartphone users with compatible devices, a second barrier is their ability to carry out the tasks required to operate the app [19]. The Corona-Warn-App requires the user to have the ability to download and install the app and to handle Bluetooth [9,10]. A final potential barrier is a person's willingness to use the contact tracing app. A key correlate of this barrier in Germany seems to be privacy concerns regarding the sharing of personal data and distrust in unfamiliar technology and processes running in the background [20,21].
The effectiveness of contact tracing apps not only hinges on access, ability, and willingness to use such an app, but also on how individuals use the app. People need to carry their smartphone with them throughout the day, regularly recharge the smartphone batteries, keep their smartphone turned on, and keep the contact tracing feature activated so that the app can detect proximity contacts at all times. For some activities, however, people usually do not take their phone with them; for example, while exercising. As a result, the contacts during these periods are not being tracked. In addition, app-based contact tracing is subject to technical limitations, such as Bluetooth-based measurement errors, which may cause errors in the contacts detected [22].
COVID-19 exposure apps have been developed in many countries [23-25]. The MIT Technology Review's Covid Tracing Tracker currently lists 47 countries with available or soon-to-be available contact tracing apps [23], yet installation rates across countries are low. For example, there were only 22.4 million app downloads in Germany as of November 12, 2020, around 5 months after its introduction, compared to a population of 83.2 million [10], even though an early Oxford-led study suggested high support for contact tracing apps of 74.8% across five countries: France, Germany, Italy, the United Kingdom, and the United States [26]. However, the Oxford study comes with a major caveat: the predictions were based on nonprobability online samples, which are known to be self-selective and severely overrepresent technologically interested persons; thus, they do not accurately represent likely behaviors in those countries' populations [27]. The selective nature of the data may, therefore, explain the discrepancy between the high support for the apps in the Oxford study and observed installation rates.
To allow for timely and accurate population predictions of the adoption of the Corona-Warn-App, we based our analyses on data collected close to the launch of the app and on a probability sample of the general population aged 18 to 77 years. In this section, we describe key aspects of our data collection according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [28].
The data were collected in the Mannheim Corona Study (MCS) [29]. The MCS was implemented within the German Internet Panel (GIP), a long-standing, offline-recruited, probability-based online panel of the general adult population in Germany. GIP sample members were recruited in 2012, 2014, and 2018. The 2012 and 2014 recruitments were based on area probability samples with full address listings and face-to-face recruitment interviews [30]. Persons in households without internet and/or computer access were provided with user-friendly devices, internet connections, and/or information technology support to enable their participation in the panel [31]. The 2018 recruitment was based on a probability sample drawn from municipal population registers and initial postal invitations. Sample members were informed about the scope of the study, the investigator, as well as how their data would be stored, and they consented to their participation and data storage.
A subsample of the GIP was invited to participate in the MCS that was conducted for 16 weeks from March 20 to July 10, 2020. The MCS was fielded with a rotating daily panel design. Each week the same MCS sample members were invited via email to participate in the study on the same day of the week and were re-interviewed on a variety of social, psychological, and economic topics [29]. They were sent a personalized link to the survey or were able to log in to the study website using their username and password to access the survey. Upon survey completion, respondents received an incentive of €2 (US $2.40). Our study on the Corona-Warn-App, which was launched on June 16, 2020, was implemented within the MCS in week 13 (ie, June 12 to 19, 2020). The questionnaire from that week contained 44 pages, with one item per page. Respondents were able to change their answers using a back button on most pages. Prior to fielding the study, the usability and technical functionality of the questionnaire was tested. A total of 5427 persons, aged 18 to 77 years, were invited to participate in our study, of which 3276 responded (60.4%).
To correct for a potential overrepresentation of persons with higher digital affinity [32], all predictions were weighted with a two-stage weighting procedure. Our weighting accounted for potential coverage, sampling, and nonresponse biases of the online data collection [33,34]. At the first stage, we estimated a response propensity weight, which projected the characteristics of the MCS respondents to the GIP recruitment samples. The weighting characteristics for the 2012 and 2014 samples included computer and internet access within the household; weighting characteristics for the 2018 sample included frequency of internet use, intensity of internet use, computer use, smartphone use, tablet use, and importance of up-to-date technology. At the second stage, we estimated a raking weight, which extrapolated the characteristics of the MCS respondents to the general population according to the Mikrozensus, that is, official statistics provided by the German Federal Statistical Office [35]. The weighting characteristics included age, gender, marital status, highest level of education, household size, and federal state. Missing values on the weighting variables were imputed with a chained-equations algorithm [36]. The final weight was trimmed for values greater than 4 and values less than 0.25. Despite the weighting procedure, our analyses were still likely to overestimate the app adoption rate in the general population, which we further address in the Discussion section.
Access, Ability, and Willingness
We measured adoption rates and potential barriers to adoption in sequential sets of survey questions and estimated (1) the population's access to and use of compatible smartphones, (2) their ability to install and correctly use the app, and (3) their willingness to adopt the app and act according to its instructions.
Through three questions, we estimated people's access: "Do you personally use a smartphone?"; if yes, "Which of the following types best describes your smartphone?" and "How often do you carry your smartphone with you when you leave the house?" (see Multimedia Appendix 1). We defined persons as having access to the app if they own an iPhone or Android phone and carry it with them at least most of the time when they leave the house. We did not differentiate between operating system versions and were, thus, likely to overestimate access to the app. However, research about the distribution of operating system versions installed on smartphones in Germany suggests that the large majority of Android smartphones and iPhones have the version installed that is required for the Corona-Warn-App to work [37,38].
People's ability to use the app was measured through four questions: "Do you know how to install an app, i.e. an additional program, on your smartphone?"; if no or not sure, "Do you know anyone who could help you with installing the Corona-Warn-App on your smartphone, e.g. family, friends, or neighbors?"; "Do you know how to activate Bluetooth on your smartphone?"; and if no or not sure, "Do you know anyone who could help you with the activation of Bluetooth on your smartphone, e.g. family, friends, or neighbors?" (see Multimedia Appendix 1). A limitation of the two questions about the potential help of family, friends, or neighbors is that they do not differentiate between the usual situation before the COVID-19 lockdown measures came into effect and the present situation: while some individuals may generally know plenty of people who can assist them with technology-related issues, they may not be able to meet these people due to the lockdown measures. However, since infection rates fell in June 2020 and the lockdown measures were gradually lifted, this limitation likely ceased to affect adoption rates during the summer. We defined persons as able to use the app if they know how to install an app or have someone who can help them with it, and if they know how to activate Bluetooth on their smartphone or have someone who can help them with it. Since access is a necessary condition for being able to install the Corona-Warn-App on a smartphone, persons who were defined as not having access were also defined as not being able to use the app.
Finally, we measured people's willingness to correctly use the app through four questions: "Would you install the official Corona-Warn-App on your smartphone when it is available?"; if at least probably not install, "Would you follow the request of the Corona-Warn-App and go into domestic quarantine as a precaution?"; "Would you comply with the request of the Corona-Warn-App and get tested for the virus?"; and "Would you enter the test result into the Corona-Warn-App if you were tested positive for the virus?" (see Multimedia Appendix 1). We defined persons as willing to correctly use the app if they are probably or definitely willing to install the app, if they are probably or definitely willing to quarantine if requested, if they are probably or definitely willing to get tested if requested, and if they are probably or definitely willing to enter their own test result into the app if they were tested positive. Since access and ability are necessary conditions for being willing to install the Corona-Warn-App on their smartphone, persons who were defined as not having access or not being able to use the app were also defined as not being willing to correctly use the app.
Potential to Spread SARS-CoV-2 and Potential to Be at Risk of COVID-19
Two variables from the MCS and GIP data collection classified persons according to their potential for spreading the virus: number of social contacts within the past 7 days and employment situation, both collected from the MCS in week 13 (see Multimedia Appendix 1). The resulting variable has the following categories:
Met socially with other persons several times in the past 7 days and worked full time outside the home.
Met socially with other persons several times in the past 7 days but did not work full time or did not work outside the home.
Met socially with other persons once or less often in the past 7 days but worked full time outside the home.
Met socially with other persons once or less often in the past 7 days and did not work full time or did not work outside the home.
In addition, two variables from the MCS and GIP data collection classified persons according to their potential for being vulnerable to a serious infection: being aged 60 to 77 years, collected from the GIP, and having any health condition that, according to the RKI, may be correlated with an increased risk, collected from the MCS in week 13 (see Multimedia Appendix 1). The resulting variable has the following categories:
Aged 60 to 77 years and with at-risk health conditions.
Aged 60 to 77 years but without at-risk health conditions.
Aged 18 to 59 years but with at-risk health conditions.
Aged 18 to 59 years and without at-risk health conditions.
Although participants were not required to respond to all questions in the MCS survey, the amount of missing data was low for frequency of social contacts (8 missing values), work outside home (1 missing value), and health condition (5 missing values).
Analytical Strategy
First, we reported overall rates of Corona-Warn-App adoption, distinguishing the three levels of potential barriers: access, ability, and willingness. Subsequently, we estimated separate adoption rates by the potential to spread SARS-CoV-2 and the potential to be vulnerable to COVID-19. All estimations were weighted as described above to enable reliable population predictions. Adoption rates across subgroups were reported by means of the predicted probabilities of a logistic regression, not including any covariates. Using the margins command in Stata 16.0 (StataCorp LLC), predicted probabilities were computed to conduct chi-square tests of differences in adoption rates across subgroups. Finally, we examined whether the introduction of the Corona-Warn-App during our data collection period influenced people's willingness to install and use the app. For this purpose, we estimated a logistic regression for willingness on a dummy variable identifying whether our data were collected before or after the publication of the Corona-Warn-App, controlling for key sociodemographic characteristics (see Multimedia Appendix 1).
For the overall rate of adoption of the Corona-Warn-App, we estimated that 37.9% of the population in Germany aged 18 to 77 years have access to, are able to, and are willing to install the app (see Figure 1 and Multimedia Appendix 2). Asked whether they would be willing to go into domestic quarantine and get tested when requested to do so by the app, these rates reduce to 34.9% and 37.3%, respectively. If tested positive, 37.6% of the population aged 18 to 77 years would be willing to enter the test result into the app.
Whereas a lack of willingness is the foremost barrier to app adoption, access also plays a considerable role. Only 91.8% of the population aged 18 to 77 years uses a smartphone, 88.5% uses one with a compatible operating system, and 85.0% carries it with them most or all of the time when outside the house. An inability to install apps and handle Bluetooth further reduces potential adoption rates to 81.3% and 81.8%, respectively.
Next, we examined whether higher adoption rates were achieved among the relevant subgroups of potential spreaders (see Figure 2 and Multimedia Appendix 3) and the potentially vulnerable (see Figure 3 and Multimedia Appendix 4).
Figure 1. Predicted adoption rates by access, ability, and willingness (N=3276). Error bars represent 95% CI.
View this figure
Figure 2. Predicted adoption rates by potential to spread SARS-CoV-2 (access: N=3267; ability: N=3267; willingness: N=3266). Error bars represent 95% CI.
Persons with a high potential to spread the virus (ie, met socially several times last week and worked full time outside the home: 91.8%) are significantly more likely to have access than those with a medium potential to spread the virus (ie, met socially several times last week and did not work full time outside the home: 83.0%; and met socially once or less often last week and worked full time outside the home: 85.9%). Persons with a medium potential to spread the virus are, in turn, significantly more likely to have access than persons with a low potential to spread the virus (ie, met socially once or less often last week and did not work full time outside the home: 77.4%). The same pattern of significant group differences was found for ability (90.7% vs 81.9% and 84.4% vs 75.2%). However, in predicting the overall adoption rates (ie, access + ability + willingness), we did not find any significant group differences (ie, met socially several times last week and worked full time outside the home: 31.0%; met socially several times last week and did not work full time outside the home: 37.0%; met socially once or less last week and worked full time outside the home: 32.6%; and met socially once or less last week and did not work full time outside the home: 35.2%). In fact, the pattern does not deliver support for the hope that the contact tracing app may be more effective in the subgroup with a high potential to spread the virus, with similarly low overall adoption rates for those with a high potential to spread SARS-CoV-2 compared to those with a medium or low potential.
When examining the characteristics of those with a high potential to spread SARS-CoV-2 but unwilling to install and correctly use the Corona-Warn-App, we found that the large majority (68%) are between the ages of 30 and 59 years, with an additional 22% between 18 and 29 years and 10% between 60 and 77 years. Furthermore, most of these individuals are male (67%), with an intermediate (42%) or higher education (40%) as opposed to a lower education (18%). Only 10% feel personally threatened by COVID-19, while a majority (65%) think that the economic damage of the measures taken by governments to fight the pandemic is greater than their benefit for society. Interestingly, privacy concerns do not seem to be the driving factors that influence their decision to not adopt the app, since only 13% indicated they are very concerned about their privacy.
Regarding potential vulnerability, we observed an age effect on access and ability (see Figure 3 and Multimedia Appendix 4). The older age groups (ie, aged 60-77 years, with at-risk health conditions; and aged 60-77 years, without at-risk health conditions) are significantly less likely than younger age groups (ie, aged 18-59 years, with at-risk health conditions; and aged 18-59 years, without at-risk health conditions) to use a compatible smartphone (62.4% and 63.2% vs 87.1% and 91.8%) and to be able to install and use the app (60.6% and 59.7% vs 85.8% and 90.6%), with very large differences independent of at-risk health conditions. In predicting the overall adoption rates (ie, access + ability + willingness), we did not find any consistent significant differences across vulnerability groups (ie, aged 60-77 years, with at-risk health conditions: 35.9%; aged 60-77 years, without at-risk health conditions: 34.7%; aged 18-59 years, with at-risk health conditions: 41.3%; and aged 18-59 years, without at-risk health conditions: 30.6%).
Figure 3. Predicted adoption rates by potential vulnerability to COVID-19 (access: N=3270; ability: N=3270; willingness: N=3269). Error bars represent 95% CI.
When examining the characteristics of those with a high vulnerability to COVID-19 who do not have access and are unable to use the app, we found that the majority (43%) are older than 70 years, with an additional 28% between 60 and 64 years and 29% between 65 and 69 years. Most of these individuals are living in lower-income households, with a monthly net income between €0 (US $0) and €1999 (US $2414) (41%) or between €2000 (US $2415) and €2999 (US $3623) (39%), as opposed to those living in higher-income households (ie, between €3000 [US $3624] and €3999 [US $4830]: 11%; and €4000+ [US $4831+]: 10%).
Finally, when examining whether persons who were interviewed before the introduction of the Corona-Warn-App showed different adoption rates than persons interviewed after the app launch, we found no significant differences (see Multimedia Appendix 5).
The official contact tracing app by the German federal government and the center for disease control and prevention, RKI, was introduced on June 16, 2020. The Corona-Warn-App was heavily advertised by government officials and health representatives as an effective way to contain the spread of SARS-CoV-2. According to epidemiological models, however, 56% of the population needs to adopt the app for it to contain the epidemic [11].
Our study shows that the 56% target mark will likely be missed by a considerable margin. For the population aged 18 to 77 years, our estimations predict an overall adoption rate of 34.7%. The largest barrier is people's willingness to install and correctly use the app; however, access to a compatible smartphone and the ability to install the app also play roles. Given the age groups covered in our study, we consider this an optimistic estimate. For cohorts aged 78 years and over and children, the adoption rates are likely considerably lower.
Persons with the highest potential to spread the virus (ie, with frequent social and work contacts) are more likely to have access and the ability to use the app (90.7%) than the average in the population aged 18 to 77 years (81.0%). Overall, persons with a high potential to spread the virus are no more likely to adopt the app than persons with fewer social and work interactions.
Persons at risk to fall seriously ill or die from an infection (ie, those aged 60 to 77 years with at-risk health conditions) have significantly reduced access and ability to use the app (60.6%) compared to the average in the population aged 18 to 77 years (81.0%). Those who can use the app, however, are overwhelmingly willing to do so. As a consequence, persons with high vulnerability to COVID-19 are equally likely to adopt the app as are less vulnerable groups.
Overall, the findings imply a pessimistic view on the effectiveness of app-based contact tracing to contain the COVID-19 pandemic in Germany, with low adoption rates in the general population and issues of selectivity across subgroups as noted by Klingwort and Schnell [22]. In addition to low uptake in the general population, vulnerable groups who would benefit from an efficient contact tracing approach have limited smartphone coverage and limited ability to use the app. Furthermore, those with a high potential to spread SARS-CoV-2 who would have the necessary devices and abilities to install the app are predominantly unwilling to do so. Even though, as Hinch et al [11] pointed out, uptake rates of contact tracing apps lower than the 56% target may still contribute to a reduction in the number of infections, Germany will miss the 56% target by a huge margin and would do well investing in additional routes of tracing potentially infected individuals.
Our study was conducted during the week the Corona-Warn-App was introduced in Germany. This enabled us to implement a questionnaire that considers all technological and data privacy specifications of the actual app. The findings also allow us to formulate actionable policy recommendations. First, we recommend targeting information campaigns at groups with a high potential to spread the virus but who are unwilling to install and correctly use the Corona-Warn-App, in particular men and those aged between 30 and 59 years, to encourage them to adopt the app. Our second recommendation is to invest further resources to provide vulnerable groups of the population, in particular older individuals and those in lower-income households, with the necessary devices and assistance to overcome their specific barriers to app adoption.
This study is not free from limitations. First, the data were collected from an online panel. Although individuals without computer or internet access were provided with the necessary equipment and support, and weights were used in all analyses to correct for coverage and nonresponse biases, we cannot rule out that the data still overrepresent individuals with an interest in technology. When invited to the MCS, panel members had already completed online surveys over the course of at least 2 years. They are, thus, more likely to be interested in digital technologies, such as the Corona-Warn-App, than their counterparts who dropped out of the online panel.
Second, we can expect panel members who agreed to participate in the MCS and be interviewed every week on topics related to the COVID-19 pandemic to be more interested in contributing to a better understanding of the social impacts of the pandemic and possibly be more concerned than the average citizen. Such traits may also affect their willingness to install a contact tracing app.
Third, our analyses are limited to individuals aged between 18 and 77 years. We are, thus, missing sizable population groups: those aged 0 to 10 years make up 10% of the general population in Germany, those aged 11 to 17 years constitute 6%, and those aged 78 years or older make up 9% [39]. The youngest age group might be disregarded in an estimation of the effectiveness of the Corona-Warn-App since they predominantly move within small, defined social circles and are unlikely to carry smartphones with them at all times. The age group of 11 to 17 years is likely to have a high potential to spread SARS-CoV-2 but possibly low interest in adopting the Corona-Warn-App, whereas the oldest age group is highly vulnerable to COVID-19 and is also likely to have low app adoption rates because of limited smartphone access. As a result of all of these limitations, our predicted adoption rates are an optimistic view of the situation. True values in the general population are likely to paint an even more pessimistic reality.
Fourth, our study is based on reported hypothetical behavior rather than actual behavior. Although hypothetical measures of willingness to install an app are subjective and may be subject to various response errors, such as social desirability or recall errors [40], these measures were shown to be correlated with actual behavior in previous studies [15,16,20,41]. In weeks 14 to 16 of the MCS, fielded between June 19 and July 10, 2020, we also collected data about whether people installed the Corona-Warn-App on their smartphone. The results suggest that the actual installation rate is very similar to the app adoption rate estimated in this paper: by July 10, 2020, almost 1 month after the app was introduced, 36% (95% CI 34%-38%) of the population between 18 and 77 years had installed the app, 55% (95% CI 53%-58%) had not installed the app, 1% (95% CI 1%-2%) had installed the app but had uninstalled it since then, and 7% (95% CI 6%-8%) did not use a smartphone. We also compared the responses about hypothetical and actual willingness to install the app among 2877 survey respondents who completed the questions both in week 13 and week 16 of the MCS survey, combining the categories app not installed; app installed, but uninstalled since then; and don't use a smartphone. The results show a correlation of r=0.6 (P<.001), which gives us confidence that the hypothetical measures used in this paper are rather accurate.
A potential avenue of future research would be to study whether the use of such a contact tracing app changes people's behavior. After the installation, individuals' behavior may become riskier (eg, less compliant toward social distancing measures), since the app may give them a feeling of security. If such a behavior is prevalent in the population, this may further reduce the effectiveness of app-based contact tracing.
Regarding data availability, the GIP data used in the analyses of this article are freely available as part of the GIP Scientific Use Files. They can be requested from the GESIS Data Archive for the Social Sciences (GESIS-DAS) [42]. The MCS data are envisioned to be published as Scientific Use Files by the end of 2021 at the latest. Until then, these data can be accessed at the Onsite Data Access facilities of the GIP Secure Data Center located at the Collaborative Research Center Political Economy of Reforms (SFB 884), University of Mannheim, B6 30-32, Mannheim, Germany. Researchers wishing to make use of the Onsite Data Access facilities may contact secretary@reforms.uni-mannheim.de. Researchers wishing to get access to the analysis code may contact the corresponding author.
We thank Elena Madiai, Lisa Wellinghoff, Katja Sonntag, and Sabrina Seidl for excellent research assistance. The GIP and the MCS are funded by the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG) through the Collaborative Research Center Political Economy of Reforms (SFB 884; project ID: 139943784). The data collection for the MCS is also funded by the German Federal Ministry for Work and Social Affairs (BMAS; project ID: FIS.00.00185.20).
AB was responsible for the study conceptualization and methodology, funding acquisition, study investigation, supervision, obtaining resources, writing the original draft, and reviewing and editing subsequent drafts. AW was responsible for the study conceptualization and methodology, data analysis, study investigation, data visualization, writing the original draft, and reviewing and editing subsequent drafts. CC was responsible for the study investigation and methodology. TR was responsible for data curation, study investigation, and project administration. MF was responsible for study investigation and project administration. SF was responsible for data curation and study investigation. KM, EN, and MR were responsible for study investigation. UK was responsible for study investigation and methodology as well as supervision.
None declared.
Multimedia Appendix 1
Study questionnaire.
PDF File (Adobe PDF File), 182 KB
Predicted adoption rates of the COVID-19 contact tracing app in Germany by access, ability, and willingness.
PDF File (Adobe PDF File), 80 KB
Predicted adoption rates of the COVID-19 contact tracing app in Germany by potential to spread SARS-CoV-2.
Predicted adoption rates of the COVID-19 contact tracing app in Germany by potential vulnerability to COVID-19.
Results of a logistic regression of willingness to use the COVID-19 contact tracing app.
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CHERRIES: Checklist for Reporting Results of Internet E-Surveys
GESIS-DAS: GESIS Data Archive for the Social Sciences
GIP: German Internet Panel
MCS: Mannheim Corona Study
RKI: Robert Koch Institute
Edited by G Eysenbach, R Kukafka; submitted 10.08.20; peer-reviewed by U Kohler, M Revilla; comments to author 15.08.20; revised version received 09.09.20; accepted 18.01.21; published 02.03.21
©Annelies G Blom, Alexander Wenz, Carina Cornesse, Tobias Rettig, Marina Fikel, Sabine Friedel, Katja Möhring, Elias Naumann, Maximiliane Reifenscheid, Ulrich Krieger. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 02.03.2021.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
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Blom AG, Wenz A, Cornesse C, Rettig T, Fikel M, Friedel S, Möhring K, Naumann E, Reifenscheid M, Krieger U
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Wanderings of a Pilgrim – In search of the Picturesque, During Four-and-Twenty Years in the East with Revelations of Life in the Zenana.
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Picturesque Illustrations of Ancient Architecture in Hindostan.
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London: Day and Son, Lincoln's-Inn Fields, 1860.


Tim Kopra is a NASA Astronaut and a retired U.S. Army Colonel and he will be sharing his experiences at a free community event on Friday, March 1st.
The Vision Foundation and Vance Thompson Vision are sponsoring this once in a lifetime event. The event will take place at the Washington Pavilion at 5:00 PM.
The event is free, but you will still need to register in advance to reserve your seats. Click here for more details.
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Tim Kopra's talk will focus on team development not only in space or in the military, but also how that relates to the workplace on a broader level. He will focus on team dynamics and leading with integrity.


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Ubisoft Shows Off Skull and Bones PC Specs, and Shares Details On The Many Customization Options
Christina Gonzalez Updated: Aug 25, 2022 6:17 PM Posted: Aug 25, 2022 6:16 PM
Since Ubisoft confirmed that Skull and Bones will be coming out this November, they've been making all sorts of announcements and now we know the PC specs via a new blog and a detailed trailer.
A full slate of options have been announced for the game and shown off in a new PC specs trailer demoing everything. Among the features will be a variety of settings like 4K HDR, uncapped FPS, which will give players flexibility for reducing lag and having better performance, and image upscaling. Image of scaling options will include ray tracing, Nvidia DLSS, and AMD FSR. Ubisoft is also emphasizing that there is complete customization on the input settings so that you'll be able to tailor your experience to your rig and get the most out of the game when it's out.
They have a variety of hardware configurations starting with lower system requirements to make the game playable by a wider audience, and offering so many options should mean you can find something that works for you.
Skull and Bones will also feature a balanced matchmaking system so that there's will get matched with others based on their own Infamy level and PVP preferences. There will be other features to enhance the experience, like fully remappable keys, controller support, which will also be customizable, from remapping buttons to swapping input from the sticks. Expect aim assist options, a FOV slider, and cross-play between pc and other platforms. They'll also include a series of community tools, including reporting and blocking for a better experience.
In a release discussing these features, Ubisoft mentioned that the game will run with physical servers as well as cloud servers, which is pretty typical for our bigger games to maintain stability, especially when there are login spikes. Dedicated servers will be in North America, Europe, South America, Asia, South Africa, and Oceania, pointing at a pretty big backed up global rollout for Skull and Bones. Ubisoft is going big.
Read the full announcement over at Skull and Bones.


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Eden Hazard would become one of the main axes of the attack if his arrival at Real Madrid was to become a reality. Accustomed to playing on the left flank, his signing could drag Vinicius, with whom Zidane is counting, to another position.
The days go by and Real Madrid's campaign to sign Hazard remains active. More active than ever, possibly. Appropriate steps are being taken for the Belgian national to switch from London to Madrid, although there is still no consensus between clubs. Zidane wants him for his new project and the midfielder, as he has said on countless occasions, would be delighted to work under the Frenchman's wing.
If the transfer goes through, there is no doubt Madrid would have a lot to gain with his signing. He is in one of the best moments of his career, and his goals have been rolling in. However, his position on the left hand side might clash with one of Madrid's most promising young stars: Vinicius. This would of course prove problematic, as despite adapting to any avant-garde position, Hazard performs better on the left.
Where Cristiano played, where Vinicius plays. The Brazilian settled in his first season in Madrid, although he still has much to improve. Regardless, his evolution has been remarkable and only an untimely injury against Ajax stopped it. He is about to return, and Zidane is clear on what his role is going to be: a protagonist in the first team.
Although Vinicius once played as a striker center and right, he has recently spent most of his time in the left hand side. It's where he feels most comfortable, as from there he faces and looks for solutions, either with his team-mates or finishing on goal; something that he has yet to be so lucky with.
The same goes for Hazard, although the Belgian player has appeared in many more games on the right flank or even as a 'false 9'. Sarri bet on him there, but the Chelsea player does not feel so comfortable with such few spaces.
When Hazard arrives, if it arrives, Zidane will have the difficult task of deciding who takes their preferred position in a team that has high expectations to come back from an average season at best.