Taking Advantages of Socrative in English as Foreign Language Teaching Classes

The advantages of technology cannot be overstated, and new technology advances at a breakneck pace. Every day, a new innovation is made. In this way, education may use the fast advancement of technology instruments for the purpose of facilitating effective teaching and learning, including language assessment. The assessment could be done real-time although the learning process is online. This study examines EFL students' opinions regarding utilizing Socrative in the classroom as a real-time response system, as well as their accomplishment after being treated with Socrative. Socrative is a sophisticated student response system (SRS) that enables teachers to discover and analyze in real time what students have learnt during lectures. The study was done at the fifth semester students of the English department in Teaching English as Foreign Language course. The survey was conducted following the semester- long practice of the Socrative. The students’ perception was derived from survey technique to ascertain students' perceptions regarding Socrative. The findings of this study show that Socrative is an appropriate tool for increasing users' participation in the classroom and assessment. Additionally, the students' success indicates an improvement after multiple uses of Socrative. The usage of Socrative is then highly recommended for classroom use in assessing students language knowledge.

INTRODUCTION
The use of digital technologies has spread to every single field of life. Recently, information and communication technologies are also increasingly used to support education, especially in teaching and learning process (Afrianto, 2018) as well as assessment. A school or teacher who uses up to date technologies is seen as having an indicator of high-quality education (Çakır, & Yıldırım, 2009). Educators use technologies in or out side classroom have one common purpose, they try to grab their students' engagement in learning in order to reach the objective of learning effectively because educational technology has been considered as part of the educational reform (Fullan, 2007). Additionally, several websites and a variety of tools have been included into the learning and teaching processes, which enables instructors to focus students' attention on the material being taught in the classroom.
A learner could learn much when they are engaged during learning process, so active learning is vital for students (Brown, 2004). In this scenario, the use of appropriate technology helps to motivate students to learn. Classrooms today have enough technology to keep students engaged, including smart boards, tablets, cellphones, laptops, and projectors. Using software, all of these devices may be integrated into a single lesson plan, allowing teachers to use a broad variety of teaching methods to keep students interested in the material (Dervan, 2014). Students' ability to participate more actively in class discussions and individual and group learning outcomes improves when cellphones are used in conjunction with other classroom technology (Duncan et al., 2012).
Moreover, the topic of language assessment has never gone unnoticed by scholars. The impact of assessment on teaching and learning has received much attention in the literature (Furaidah et al., 2015;Galikyan et al., 2019;Johnson & Shaw, 2019;Xu & Liu, 2018). Language evaluation has gained traction in online learning as the development of increasingly sophisticated learning technologies. Additionally, when its execution has to be online, the effect of online assessment for EFL learning has become increasingly important research content. The topic of effect of assessment is still relevant in this rapidly changing, as many experts argue that the mechanism of language teaching and learning has a causal connection with the evaluation. Recently, the implementation of online learning along with assessment resources also find their momentum (Ali, 2015;Cai, 2012;Daniels et al., 2019;Doculan, 2016). And thus, the effect may occur differently between online assessment and non-online assessment.
Information and communication technology has well beneficial for education practice. Socrative, an information and communication technology built on the foundation of a student response system (SRS), has a plethora of advantages. It has established itself as an advantageous technology in the field of education. For example, Liu and Taylor (2013) found that using Socrative in introductory biology and molecular biology service courses increased students' engagement with the material and aided in-class learning. Additionally, Awedh, Mueen, Zafar, and Manzoor (2015) demonstrated that Socrative can help students improve their collaborative learning performance by examining the effect of using Socrative and Smartphones on the collaborative learning of students enrolled in a community college's computer architecture course.
For example, Spivey & McMillan (2014) claim that online assessment can offer various advantages that paper and pencil testing cannot. In the first place, an online examination provides for a variety of testing cycles. For multiple-choice and matching questions, it is feasible to create online tools to randomize the sequence of questions and to randomize the answers. The third option is to provide varied levels of input, such as a test score, a test score with right answers, or a test score with detailed solutions. When it comes to giving feedback, teachers have entire control over the timing of it (e.g. immediately, set to a particular date and time after all questions are completed). As a final point, it is conceivable for preferred online testing systems to add hints or suggestions as to where the text or course notes will be used to answer questions posed in the tests. Spivey & McMillan (2014) also assert that neither study efforts nor course performance was influenced by the testing procedure. However, the authors found a strong positive relationship between students' effort and their performance in the course. In the same fashion, a study by Mohamadi (2018) implies that using engaging technology and techniques along with appropriate assessment strategies is a powerful way of making learning efficient. More specific, Johnson & Shaw (2019) assert that there is an implicit relationship between the development and implementation phases of a computer based test (CBT) initiative with washback framework playing a central role in bringing these elements together.
It is possible to employ a variety of tools in the classroom. Clickers were popular a short time ago, but have since fallen out of favor due to the rapid advancements in educational software, cellphones, and other mobile devices. Students are increasingly using Socrative as a student response mechanism. Socrative is a student-response system that allows teachers to keep their students engaged. Instructors who struggle to keep their students interested in what they're teaching might greatly benefit from this tool. It aids teachers in enticing their pupils to engage with the topic. It allows students to immediately observe the impact of the lessons they've been taught. Learning and receiving feedback are made easier with this tool, which can be utilized anywhere, at any time (Socrative home page).
Although IAIN Kediri has provided good internet connection for the user, the use of Socrative is still very limited in one or two instructors in this university. From those explanations, Socrative offers a lot good news for teachers to have more active, interactive and live class. Thus, this study tries to investigate whether Socrative can also supply good impacts for EFL learners in IAIN Kediri.
Several studies have been conducted in studying the use of Socrative in the classroom, whether it was tested as teaching or assessment technique or it was asked to the perception of the teachers. First study from Dervan (2014) noted that the students have positive attitude toward the use of Socrative in the classroom. Specifically, 65% of students strongly agreed (and 35% agreed) that the use of Socrative increased interaction during lectures.  conducted a study on the use of Socrative for ESL students in United State. Her qualitative study revealed some reasons why Socrative can emerge student's activeness, among others; SRS (e.g., Socrative) might be used to get students more involved in their learning. It is critical that every student in the class be able to express their thoughts on the material being covered. Shy and less engaged pupils (such as certain Asian students) would benefit from the adoption of Socrative in the classroom. Two of the most crucial 21st century abilities emphasized by the Common Core State Standards are critical thinking and teamwork. These two abilities might be enhanced by the proper application of SRS in the classroom. In the last several years, Socrative has gotten easier and more convenient to use. With Socrative, teachers may assess their students' knowledge of a subject topic and deliver immediate feedback to their students. In order to protect their students' identities, language instructors might employ SRS (for example, Socrative). It would inspire even more apprehensive kids to react without the risk of being humiliated if their responses were incorrect. It is possible to utilize Socrative as an assessment tool both in and out of the classroom. With the right use of SRS, a new generation of tech-savvy students may be met and the boredom of traditional classrooms shattered (Johnson, 2005).
A number similar studies (Cerqueiro and Harrison, 2019;Tirlea, Muir, Huynh and Elphinstone, 2018;Kayan and Balta, 2016) represent the use of Socrative increase the engagement of students during class and promote collaborative skill among students. This study is inspired by the recommendation of Dervan's study. He focused on the students' perception about Socrative in English language teaching and suggested the next study on measuring students, meanwhile this study also analyses the students score after being taught by using Socrative.
The different between previous studies and present study are in the form of approach of the methods and certainly the subject being analyzed. This study employs mixed method as recommended by some earlier researches. The previous studies are mostly conducted in the developed country where the use of such up to date devices has been common among community. Differ from Indonesia, where people, though they have cellphone everywhere, they use it only as a medium of pleasure such as social media or browsing unimportant information.
The aim of this study is to find out the attitudes of English language learners of IAIN Kediri towards using Socrative in their academic performance. 1). What are the attitudes of English language learners' towards Socrative?, 2). Do the students have better score in the course after being taught by using Socrative? The findings of this study are expected to give meaningful contribution for teachers, school stake holders, and further researcher. For teachers, the result of this study can be reflective practice for them in conducting classroom action research to increase their professional rank. They can be more aware on their perception, practice, problem and solution in conducting classroom action research. Then they can increase their professional rank through classroom action research. For the school stake holders, they can use the findings of this study as consideration in making decision especially in developing teachers' professionalism. They can make more appropriate program that is more beneficial for teachers. Then for further researchers, the findings and limitation of this study can be resources for them in conducting further research in similar or different area with the present study.

Technology-based learning
As a characteristic of Industrial Revolution 4.0, which is synonymous with the internet of things, the internet of people, icloud, big data, connectivity, and digitalization, it is critical for teachers to integrate cuttingedge information technology developments into their learning and teaching activities. They, for example, must integrate offline and online learning modes (blended/hybrid learning). They can increase students' learning by utilizing a variety of online learning programs, such as Nearpod, Google Classroom, ruangguru, Quizezz, Quipper, and Zenius, among others. Additionally, they can intend to use social media sites such as Youtube, Instagram, and Line as a type of learning material. Additionally, instructors must optimize the use of sophisticated gadgets such as cellphones in the classroom for educational purposes. In short, the integration of learning with the internet and/or a network will have a significant impact on the efficacy and speed with which learning outcomes are achieved in this digital era. (Afrianto, 2018).

Blended Learning
In the education system, there has been a shift from traditional systems to all-digital ones. Until recently, the teaching and learning process was restricted to the classroom; however, this is no longer the case. Blended Learning and e-Learning are two of the most common forms of digital education today (Graham, C. R et al, 2014). Indonesian students have shown a preference for e-learning and blended learning methods.
Teaching and learning may be made more efficient and effective via the use of electronic media and the internet as an intermediary. A method of teaching and learning known as "Blended Learning" blends and integrates traditional educational methods with cutting-edge digital technologies (Harmer, 2009).
There is a connection between E-Learning and Blended Learning in that they both make use of computers and the internet as middlemen. Elearning and blended learning, on the other hand, are two distinct approaches to education. When teaching and learning via E-Learning, there is no reciprocal interaction. Blended Learning is a teaching and learning strategy that incorporates direct engagement in the form of direct conversation. Blended learning occurs when instructors use cutting-edge tools like Socrative while still engaging students in one-on-one conversations.

Socrative for education
Online SRSs are becoming increasingly popular (Jordan & Mitchell, 2009). Socrative, a web-based SRS platform that is interactive and real-time (https://socrative.com), is one such platform. Students and instructors alike can benefit from Socrative's ability to construct quizzes and other educational exercises that can assist steer a lesson's focus as well as spark conversation. By providing instructors with quick feedback, the program allows them to keep tabs on their students' reactions and progress in real time, allowing them to modify the pace or focus of a session and discover areas that students are having difficulty with. You may use Socrative on a wide range of devices including PCs, laptops, tablets and smartphones since it is simple to use and can be viewed on any device. Teachers must first register for free on the Socrative website in order to utilize Socrative. Teachers use their e-mail address and password to check in to their account. The 'virtual classroom' is then made available to teachers who have been granted a special identification number. Then, for forthcoming lessons, teachers may prepare questions and construct tests.
Free accounts come with one classroom, which may be modified or simplified before being given to students. Socrative has a broad variety of task-creation options: It is possible to use a variety of instructional strategies, including teacher-paced or student-paced activities, predetermined or random question sequence, true/false, multiple choice, and short answer questions, in addition to adding an image for each question. Activities and quizzes can include as many questions as desired. We can also use it to store and distribute tests with other teachers, which comes in handy when doing many sessions in different locations at the same time.
Teachers utilize a variety of technology, including Student Response Systems (SRSs), to increase student engagement through active learning (Fies & Marshall, 2006). SRSs are electronic gadgets (e.g., Clickers) that let educators to pose questions to large groups of students during a lecture or tutorial. It was discovered that including such technologies into classroom instruction might assist pupils focus and become more engaged with the learning material. Additionally, research indicates that college students are responsive to approaches that include technology resources (Trees & Jackson, 2007).

METHODS
This research employs quantitative method; it is an approach to inquiry involving collecting quantitative data (Creswell, 2013:4). The study covered two designs; survey research and time series or one-shot case study as one of kinds of experimental design. A quantitative design employs strategies of inquiry such as experiments and surveys, and collects data on predetermined instruments that produce statistical data (Cresswell, 2013: 18). Survey is a research strategy in collecting information from large groups, where standardization is crucial. It consists of two components, questions and responses. Therefore, the present study uses survey method to investigate students' response and attitude on the use of Socrative in the classroom.
Meanwhile, a time series design is used to assess the effect of therapy many times during the procedure (Creswell, 2013: 326). Students' scores after treatment are also taken into account to determine whether the use of Socrative has a genuine effect on their learning. The second set of data is derived by computing the results of tests as a proxy for experimental study. As one of the pre-experimental designs, the experimental investigation employed a one-shot case study. It is examined at a single moment in time following some type of therapy that is assumed to have effected change. No control or comparison group is used in pre-experimental designs (Nunan, 1992). The carefully observed single incident is contrasted to general predictions of how the situation would have unfolded in the absence of the treatment and to other unobserved instances. There is no control or comparison group used. It is an illustration of a longitudinal design in which researchers gather language samples on a regular basis throughout a specified time period (Kirk, 2009;Mellow, Reeder, & Forster, 1996). By collecting data at multiple points in time, time series designs can provide insight into the time course of language development, including changes that are immediate, gradual, delayed, incubated, or residual (Mellow et al., 1996;Mellow, 2012), as well as the persistence of any treatment effects. Multiple observations are made both before and after the therapy in a time-series design. The number of observations made before and after treatment might vary, and there is no requirement to have the same number of observations made before and after treatment (Kirk, 2009).

Population and Sample
The target population of the present research is all fifth semester English department students in IAIN Kediri. They were in the TEFL course, 3 (three) classes were taught by the researcher and 2 (two) classes were taught by another lecturer. All of the classes will use Socrative as real-time response and tool of evaluating the comprehension. The researcher has utilized Socrative a semester earlier for only one class. Then, this is one of reason to count the effect of Socrative to larger number of students. The questionnaire was filled up by 117 students. The form was shared through Google form, the internet connection is one of reason that all of students cannot fill up the form.

Research Instrument
To conduct this research, a survey and a test are the tools of choice. The questionnaire is an open-ended form of a survey. The survey questions were adapted Dervan's (2014) study, which he performed at the Institute of Technology in Blancharstown, Dublin, Ireland. Dervan used a focus group of students to test the validity of the survey questions.  did a reliability check using data from the sample of his study. Stability and consistency are two ways to describe reliability. Reliability was measured as.77 in his study, which indicates how consistent each item is.
Socrative's use by English language learners is the subject of the survey. There were eight questions in all, the first two of which inquired about respondents' racial and gender identities. To learn more about Socrative, answer the following four questions. In the first and fourth questions, the answer is "yes" or "no." If the last item is answered affirmatively, participants are prompted to elaborate on the perceived drawbacks. As part of the second question, there were six sub-items on a balanced Likert scale of four points. The response language is strongly agree/ agree / disagree / strongly disagreed. In the third question, a balanced Likert scale of five points is used. You should use a lot more, use a lot more, use less, use a lot less, and OK now. Socrative is used for the last two problems, which encourage students to collaborate in groups to answer them. Earlier, it was said that the survey questions were taken from another project (Dervan, 2014). However, it has been altered to fit the contemporary context.

Data Collection
The survey was conducted to learn about students' experience with Socrative after using Socrative for four months. In collecting date, there are some steps. The first step is problem identification. In the problem identification, the researcher observes that the students never get a blended learning in a classroom, once they get, they have good comment on it. The next step is administering the treatment in the classroom for one semester. Distributing the questionnaire to the respondents is the following step. The survey will be conducted in classes through Socrative, and printouts are also used for those who do not have a smartphone to answer.
After the data are collected, the next step is analyzing the data. In analyzing the data, descriptive statistics analysis is used in this study. The data collected from the respondents are tabulated and grouped based on the characteristics of the data gathered. Then the data are displayed in the form of table and categorized based on the questions to be easier in reading and understanding the data. The last step is drawing conclusion based on the data display and discussion.

Result
The findings of the study are written based on the research questions of the study. a. What are the attitudes of English language learners toward Socrative?
In the first, second, third and fourth questions of the survey, the attitudes of students were measured. The results are described separately for each survey issue. First question: Do you think the use of an in-class student response system such as Socrative was helpful to your learning?

Figure 1: Students' perception toward Socrative
The answers of 117 respondents were complete and their information was used to disclose the thoughts of students about the first question. Just 8,5% of the 117 students answered NO, while 90,6% replied YES to the first question. It can be stated, according to these results, that students have more optimistic thoughts about using Socratic in the classroom, and it is useful for their learning. Second question: Please provide your answer to the EACH statement below (the statements are given on the graph shown in Figure 1) by thinking about HOW Socratic supported your learning. User responses to each sub-item of Question 2 are shown in Figure 2. A Likert scale was used to score each of the second question's sub-items. Each column's height displays the sum of the participants' ratings for that particular object. Counts of respondents who chose subitem alternatives for the second problem are shown in Figure 2. According to Figure 2, 57 students strongly agreed and 58 students agreed with the sixth item (Socrative is extremely easy to use) in the second question. In addition, more pupils (74 students) agreed than disagreed with the fifth item (Using Socrative assisted my understanding of course material). More than 3.4 percent of respondents decided to strongly disagree with all sub-items. Socrative questioning has been shown to boost students' involvement during lectures, with a total score of 103, which students agree with the most. Third sub-item (Socrative enhances lecture participation) has the biggest number of students disagreeing, which lowers its overall score. It's also a popular choice for students because they may obtain immediate response from their professors. A high strongly agree rating is given to item four, which states: "Feedback from Socrative helped the Lecturer determine where students were having trouble" (48 students). Overall, this fact shows that Socrative views are positive.  The third question was on a five-point balanced Likert scale, responded by 117 students. According to Figure 3, the options use a lot less was selected the least, while participants mainly preferred to use more and ok now. 52 students or 44,8% wanted to use Socrative more and 47 students (40,5%) like to use Socrative now. This question also gains positive respond from the students. The fourth question: Do you think the use of a feedback method like Socrative has disadvantages?

Figure 4: Socrative disadvantages
There were no respondents did not give a response to this issue. 64 (55,2%) respondents picked NO, while 54 (46,6%) respondents picked YES for the same question. If their answer was YES, participants were asked to elaborate on their responses. 20 out of 54 demonstrated the Socratic drawbacks. Owing to ambivalence, three were excluded. The other drawbacks were technological difficulties, such as mobile memory ability, the challenges inherent in mobile use, and the fact that not everyone has good internet connection, etc. It is surprising since the positive attitudes mentioned in the three previous questions. The fourth question revealed that the use of Socrative does not give many advantages to the students regarding some drawbacks occur.

b. Students' score in the course after being taught by using Socrative
The second finding related to the students' score after using Socrative for several times (5 times) in one semester. The finding shows that students score tend to increase gradually from first time using Socrative to the last use of Socrative. The table reveals that the students' scores increase gradually. The first test conducted in two classes had a similar score with an average of 32,98% and 30,11%. Most of the students were relatively new to Socrative. It made them a bit nervous doing the test. The students show less anxiety at the second test since they were familiar enough with Socrative, and they learn from the mistakes from the previous session. The percentage between three classes shows a similar result, 47,3%, 42,9%, and 44,9%. The average score is not significantly different. The next test, given in multiple-choice, make the students more confident. It indicated by the average score of the students, 71,9 % and 80,7%. Socrative is easily used in the class or outside class since everyone committed to doing the task well. The zero scores showing in the table point out that the internet connection is the shortcomings of using Socrative.

Discussion
This study aims at investigating students' attitude toward the use of Socrative in English language teaching classroom and how Socrative effect to their understanding. The findings show that students present a positive attitude on Socrative. It is revealed from the result of each question, most of the students (more than 90%) said that Socrative is useful for their learning, accessible, Socrative improves their engagement in activities, students gain feedback from the lecturer, and Socrative makes the lectures more interactive. Moreover, almost fifty percent of students out of 117 students mention that they are eager to use Socrative more in the future. On the other finding, related to the second research question, students' scores were calculated after using Socrative for several times. The score indicates a gradual improvement from one test to another test. Although the score does not significantly improve, Socrative can be used gradually to make students' achievement improve little by little.
The finding is in line with , Dervan 2014, According to the findings of the research, Socrative is an effective tool for increasing student involvement in the classroom. There are several benefits to implementing the Student Response System (SRS) in the classroom, according to Johnson (2005). Students who are actively engaged in their studies are more likely to succeed academically. Involvement among students might be improved with the help of Socrative. In order for students to have a voice in the classroom, they need to be able to express their thoughts on the course material. Shy and less engaged pupils (such as certain Asian students) would benefit from the adoption of Socrative in the classroom. The Common Core State Standards highlight critical thinking and teamwork as two of the most crucial 21st century abilities. These two abilities might be enhanced by the proper application of SRS in the classroom. As a result, Socrative has become easier and faster to use. It's a great opportunity for language teachers. For ESL students, Socrative is a powerful tool that may give immediate feedback and assist teachers in assessing their students' comprehension of material. Language teachers can make their students' replies anonymous by using Socrative. It would inspire even more apprehensive kids to react without the risk of being humiliated if their responses were incorrect. 7. Socrative may be utilized both within and outside of the classroom as an assessment tool. Using SRS correctly and efficiently may make traditional educational settings more interesting and engaging for today's tech-savvy students.

CONCLUSION
Our fundamental objective in this study was to expose the attitudes of students towards the use of the Socratic and their score improvement after being taught by using socrative. For a teacher, it is very important to adopt developing technology and taking advantage of suitable software to incorporate into their classrooms. Only then can they be the kind of mentor who reacts to the time limits creatively and ensures a better education for students. Our research shows that Socrative is a suitable tool that in their English teaching courses, teachers can comfortably use them to obtain better instruction. Socrative, a student response method, promotes collaborative teaching in English language classes and can be imitated and implemented in other institutions, as evidenced by the fruitful use of Socrative at our University and the optimistic attitudes of students. The positive attitudes of students indicate that for the participants of this study, the argument that Socrative produces an active learning atmosphere in the classroom and helps to strengthen the learning process is at least right. In addition, the statistically insignificant findings between students' score also show that Socrative can safely be used in schools. However, this study was taken exactly before the outbreak of Covid-19. The next researcher is suggested to do study concerning the use of Socrative in remote class with larger sample than this current study.


Cosmetics: What Do Bruneian Female Adults Believe?

Objectives: The study aimed to measure the level of attitudes and the current practices of the female community in Brunei Darussalam regarding the usage of cosmetics. Methods: An online survey was conducted using a non-probabilistic snowball sampling approach via the social media channels WhatsApp and Instagram. The inclusion criteria were female Bruneian citizens or permanent residents, aged between 18 and 65 years old, who can understand English or Malay, and use cosmetic products at least once a day. Results: A total of 445 participants responded to the online survey. Most of the participants agreed that the use of cosmetic products improves one’s physical appearance to the public (391, 87.8%) and also improves self-confidence (405, 91.1%). There were significant differences in monthly cosmetic product expenses and participants’ attitudes about safe cosmetic use (p = 0.001). No significant changes in the individuals’ attitudes based on their age or educational level were observed. Overall, the participants had a good level of cosmetic safety practice. Almost half of the participants use social media to obtain information regarding what cosmetics to use or purchase. Conclusion: There is a medium to high level of attitude and a high level of practice regarding the safe use of cosmetics among Bruneian female adults. Social media was the main source of information for the respondents, followed by friend circle and family members.

Introduction
According to the FDA, a cosmetic is defined as "a product (excluding pure soap) intended to be applied to the human body for cleansing, beautifying, promoting attractiveness, or altering the appearance". Shampoos, hair dyes, toothpaste, and deodorants are all considered personal care goods, in addition to lipsticks, and eye and facial makeup [1]. An online survey of 1039 adult female and male participants in the United States showed that 82% of female respondents used skincare products at least once a week, while 64% of male respondents said the same [2]. Moreover, there was an increase in the worldwide cosmetics markets growth rate from 4.9% in 2018 to 5.5% in 2019 [3]. According to a study conducted in Saudi Arabia, where 50.6% of the 425 participants reported having at least one adverse event with a cosmetic product in the previous two years, the number of cosmetic products used per day has a statistically significant relationship with the occurrence of cosmetics-related adverse events; using more cosmetic products each day increases the likelihood of having adverse events [4].
In some countries, cosmetovigilance is practiced, with the goal of monitoring adverse reactions to cosmetic products [5]. Cosmetovigilance, according to Vigan and Castelain (2014) [5], is a type of public health monitoring that collects information on the safety of cosmetics and their ingredients. Furthermore, the level of attitudes and practices of the community in some countries regarding the safe use of cosmetic products are also low [6][7][8]. There are some examples of adulterated ingredients in cosmetic products that were illegally marketed in Brunei Darussalam and have been banned by the government, such as hydroquinone and steroids [9]. The reported adulterated cosmetics were banned from being imported and sold in Brunei Darussalam [10]. Due to a rise in cosmetics manufacture and importation, Brunei formalised the regulation of cosmetic products through the implementation of the Medicine (Cosmetic Products) Regulation in 2007, in line with the ASEAN (Association of Southeast Asian Nations) Cosmetic Directive (ACD). Prior to importing cosmetic products into Brunei Darussalam, manufacturers or importers must notify the Ministry of Health [9]. Those involved in the retail of these products, including online retail, are reminded that importing and marketing cosmetic products in the local market without a Cosmetic Product Notification Acknowledgement Letter issued by the health authority is illegal under the Medicines (Cosmetic Products) Regulation, 2007. A conviction for violating these restrictions carries a fine of up to BND 5000 (equivalent to USD 3595), a sentence of up to two years in prison, or both [11].
To our knowledge, there is currently no information available about the community's attitudes and practices around cosmetics in Brunei Darussalam. Hence, we conducted an online survey to determine the attitudes and identify the current practices towards the safe use of cosmetics among female adults in the country. Findings from this study may increase community awareness of the side effects of using cosmetic products. The findings can serve as a baseline of the knowledge level on the safety of cosmetics.

Study Design
This online survey was conducted using a non-probabilistic snowball sampling approach, whereby the survey link was shared to known contacts on social media platforms such as WhatsApp and Instagram, who in turn were encouraged to share the link with their friends and relatives meeting the inclusion criteria. The inclusion criteria were female Bruneian citizens or permanent residents, aged between 18 and 65 years old, able to understand English or Malay, and using cosmetic products at least once a day. The definition of a cosmetic applied in this study was based on the aforementioned definition by the FDA in the United States [1].

Study Instrument
The questionnaire for the survey was adopted and modified from a published study [6]. It was distributed in both English and Malay, the latter being the official language of Brunei, though the majority of the population have a good command of English too. Pre-testing was conducted with 25 female participants to ensure that the questions were comprehensible to the target audience and relevant to the setting, and to assess the questions' reliability using Cronbach's alpha test.
The finalised questionnaire consisted of a total of 36 questions comprising 4 sections: (1) General socio-demographic characteristics; (2) Attitudes towards cosmetic products; (3) Practices towards cosmetic products; and (4) Sources of information. For the first section, participants' ages were collected as categorical variables (18-35 and 36-65 years old). Participants' education levels were also collected as categorical variables. Secondary education level comprises those with O-level, A-level, or International Baccalaureate qualifications; post-secondary non-tertiary education level includes those with Foundation, Certificate, or Diploma qualifications; and tertiary education level includes those with Bachelor's, Master's, or PhD qualifications. Responses for attitudes were collected using a 5-point Likert scale (strongly disagree = 1, disagree = 2, neutral = 3, agree = 4, and strongly agree = 5), while responses for practices (no, unsure, and yes) and sources of information were collected in a descriptive manner. The attitude and practice sections had Cronbach's alpha values of 0.84 and 0.69, respectively, indicating an acceptable internal consistency [12].

Data Analysis
All questionnaire responses were collected using Google Forms and uploaded for analysis as a Microsoft Excel spreadsheet. Descriptive statistics (percentages, mean, and standard deviation) were performed. The total attitude score (40 points) was then divided into 3 categories: low (total attitude score of ≤15), medium (total attitude score from 20 to 30), and high (total attitude score from 31 to 40). Associations between demographic characteristics and total attitude scores were investigated using the Chi-square test. A p-value of <0.05 was considered as statistically significant. All analyses were conducted using Microsoft Excel and R (ver. 4.1) [13].

Ethical Approval
The Joint Research Ethics Committee of the PAPRSB Institute of Health Sciences provided full approval of the study, which was given the reference number UBD/PAPRSBIHSREC/2021/74.

Results
A total of 445 participants were included in this study (Table 1), with the majority of them between 18 and 35 years old (328, 73.7%). A significant proportion of the participants were working (277, 62.2%), had a monthly income of less than BND 1000 (229, 51.5%), and spent more than BND 100 per month on cosmetic products (354, 79.6%).

Attitudes of the Community towards the Safe Use of Cosmetics
Attitudes towards safe use of cosmetics were generally high among our study participants, with a mean of overall total attitude scores ranging between 2.9 and 4.5 (Table 2). A high percentage of them agreed or strongly agreed that the use of cosmetics can cause allergies (231, 51.9%), can improve one's physical appearance (391, 87.8%), and can improve self-confidence (405, 91.1%). More than half of the participants (289, 54.9%) agreed or strongly agreed that before the cosmetics are sold on the market they must be well tested in laboratories. Only 19.3% (n = 86) agreed that using cosmetics can cause reproductive health problems. Overall, the study participants had medium to high attitudes towards the safe use of cosmetics (Table 3). Age groups, education levels, and monthly expenses for cosmetic products were the three chosen variables for the study, as each group had a balanced number of people. None were classified with a low attitude score. Notably, 62.8% of participants aged from 18 to 35 years old had medium attitude scores towards the safe use of cosmetics. No statistically significant differences were observed between total attitude scores and age group (p = 0.291), or between total attitude scores and education level (p = 696). Those who spent less than BND 100 per month on cosmetic products were more likely to have medium to high total attitude scores when compared with those spending more than BND 100 (p = 0.001).  Table 4 shows the responses of the participants regarding practices for the safe use of cosmetics. Most participants wash their hands before applying cosmetic products to their face or body (404, 90.8%), read the labels of the cosmetic products (353, 79.3%), and share information about the hazards of using cosmetics (300, 67.4%). Less than half (42.7%) reported buying skin or lip products with Vitamin A.

Participants' Source Information Regarding What Cosmetics to Buy or Use
Study participants tend to rely on a variety of sources for information about which cosmetics to buy or use, such as family members (22.1%), friends (25.7%), social media (43.3%), television (7.4%), and others (1.3%, Figure 1). Nearly half of the participants reported that social networking sites provided them with knowledge about what cosmetics to buy and use. Other sources reported include counselling from a beautician or aesthetician, shop posters, pharmacy store posters, and magazine advertisements.

Discussion
This is the first study of its kind in Brunei Darussalam to examine the general public's attitudes and practices regarding the safe use of cosmetics. Brunei Darussalam began regulating cosmetic products in 2007 under the Medicine (Cosmetic Products) Regula-

Discussion
This is the first study of its kind in Brunei Darussalam to examine the general public's attitudes and practices regarding the safe use of cosmetics. Brunei Darussalam began regulating cosmetic products in 2007 under the Medicine (Cosmetic Products) Regulation, in line with the ASEAN Cosmetic Directive (ACD). There were significant number of participants who stated that the use of cosmetics can improve one's physical appearance (391 participants) and self-confidence (405 participants). The findings of the study are similar to a study performed in Malaysia during the COVID-19 pandemic [14], which found that the application of cosmetics was aimed to further the appeal of one's appearance, especially during a time when online conferencing was widely used. This is the primary motive for consumers to purchase cosmetic items: because they want to improve their existing appearance and correct features that they dislike [15]. Moreover, applying cosmetics stimulates the senses of touch, smell, and sight, which boosts one's physiological pleasure and confidence level [16]. This is also in line with the findings of Handriana et al. (2020), who found that some women were unaware of their unsatisfactory face traits until they came across cosmetic products designed to correct them. They also noted that there is presently a product for every aspect of the face, and that as innovation and technology advance, the products will become increasingly invasive as they transition from temporary to permanent characteristics [17].
Based on the findings, there was a significant difference between monthly expenses on cosmetic products and the attitude of the participants (p = 0.001). This is also supported by Mohammed et al. (2021), who found a significant relationship between monthly cosmetic product expenditures and participants' attitudes in Malaysia [14]. The monthly expenses for cosmetic products served as a surrogate value of the consumers' particular interest in terms of quantum of time and money invested on cosmetics, as indicated by its statistical significance. The results show that the Bruneian community has a medium to high level of attitude towards the safe use of cosmetics. These include notions such as augmenting physical appearance to boost the users' self-confidence. Similarly, a study performed among the women at Najran University in Saudi Arabia revealed that there was an adequate attitude level in the area of cosmetics [18]. As shown in Table 2, more than half of the participants believe that using cosmetics could cause cancer. There are numerous controversies surrounding cosmetic products and increased cancer risk, though there is still a lack of scientific evidence to prove the relationship [19,20]. Similarly, a study on the everyday use of cosmetics and increased risk of breast cancer shows that there is no sufficient epidemiological data to support the relationship [21].
Furthermore, it was found that a large number of participants use sunscreen with SPF 50 and above. This is consistent with a study carried out in Yazd City, Iran, in which a high number of participants agreed that sunscreen should be used at an early age [8]. The usage of sunscreen has been shown to reduce the detrimental effects of UV radiation on the skin [22]. However, this contradicts a study conducted in Saudi Arabia, which indicated that there was an equal proportion of people who used and did not use sunscreen [7].
Additionally, a large proportion of participants purchase skin or lip products containing Vitamin A. One study showed that after 12 weeks of use, the retinol formulation significantly reduced fine wrinkles [23]. This also aligns with a study conducted among journalists in the Philippines in 2015, which showed that the respondents bought cosmetic products containing Vitamin A, such as retinol, retinyl palmitate, and retinyl acetate [6].
The safety of cosmetics has emerged as an important concern for every cosmetics user. Based on our results, participants are particularly concerned about moisturisers that contain petroleum jelly, want skin care products containing Vitamin A and, most importantly, paraben-free products. The knowledge on "paraben-free" was built on the tagline of cosmetic advertisement whereby the outer product label would clearly specify that. This is because the use of paraben-containing products could lead to adverse health outcomes such as estrogenic effects, disrupting hormones in the body, causing anguish and damage to fertility and the reproductive organs, as well as affecting birth outcomes [24].
While the use of petroleum-containing cosmetics is generally safe, provided it is properly refined, incompletely refined petrolatum could potentially be contaminated with polycyclic aromatic hydrocarbons, which cause cancer [25].
The use of Vitamin A-containing cosmetics has proven to reduce the appearance of wrinkles and improve skin elasticity [26]. Furthermore, some respondents chose to select products with a sun protection factor (SPF) 50 and above. Simplistically, most of the public believes that applying sunscreen with SFP 50 and above is best, but scientifically, SPF 50 gives only 1% more protection against UV rays (98%) than SPF 30 (97%) [19].
According to the findings, there is a high level of safe practice around cosmetics use, particularly when it comes to whether or not participants wash their hands before applying cosmetic products to their face or body. For example, 90.8% of the respondents agreed that this affects the safety of using cosmetics. This is consistent with the findings of Najran University in Saudi Arabia, which indicates that there are satisfactory practices in this regard [18].
Information regarding cosmetics can now be easily accessed via social media in this modern era of globalisation. This was shown by the findings of this research, which revealed that nearly half of the people surveyed obtain their knowledge about what cosmetics to buy or use from internet sites such as TikTok, Google, YouTube, and Instagram. They also obtain their knowledge from relatives and friends. This was different from the findings of Serrano (2015), who indicated that the participants received their information regarding cosmetics from mass media such as newspapers and magazines. As there are numerous sources to acquire information on cosmetic products, the public should be educated on the reliable sources. In addition to the FDA website, all countries have their own governmental agencies which control and regulate the safe use of cosmetic products, such as Control of Cosmetic Products in Malaysia, and the Korea Cosmetics Association. Consumers can also search for the information related to their cosmetic products on these authentic websites [27,28].
The goal of this study was to explore the public's attitudes and practices regarding the safe use of cosmetics. We can examine and understand the public's viewpoints on the definition and the safe use of cosmetics as a result of the study's findings. In addition, this study encourages the continuation of cosmetovigilance, which is useful for the safe monitoring of cosmetics usage. Through this, any adverse reaction from the use of cosmetics can be detected and prevented. Therefore, consideration should be given to further strengthening the idea of cosmetovigilance among consumers, vendors, and other stakeholders.

Strengths and Limitations of the Study
The study comprised a large sample size, with a balanced representation of people of each age and educational category level. However, the study was only open to female participants, as colloquially, cosmetics are directly translated to makeup products catering only for females. Future studies should cater specifically to males by introducing the term cosmetics as skin cleansing and hygiene products, to change the myth that cosmetics are only for women. Another limitation of this study was that the questionnaire was only distributed via Instagram and WhatsApp. Only followers and contacts were contacted for the survey. People who do not use these social media platforms, such as those who primarily use TikTok or Facebook in their daily lives, were not reached.

Conclusions
The female communities in Brunei Darussalam generally have a medium to a high degree of attitude and a high level of practice when it comes to the safe use of cosmetics. It is noteworthy that there was a significant difference between monthly expenses on cosmetic products and the attitude of the participants, which denotes that females that are willing to invest more money towards their appearance tend to portray better self-confidence. Raising public knowledge on the safe use of cosmetics is necessary to reduce the number of reports of cosmetic side effects. Aside from this, more in-depth research into community attitudes and practices regarding the safe use of cosmetics in Brunei Darussalam should be conducted; more questions could be added, because there is still insufficient research on the topic, particularly on public knowledge.


Psychometric properties of the Barthel Index for evaluating physical function among Chinese oldest‐old

The Barthel Index (BI) is among the most widely used instruments for evaluating physical function, yet its applicability has not been well studied in the oldest‐old population.

Introduction
The ability to perform activities of daily living (ADL) is an essential component of healthy aging. 1 With the global population ageing, the oldest-old have been the fastest-growing segment and more susceptible to ADL decline and functional dependence. 2 According to China's General Program for Sustainable Development, China was projected to becoming a super-aged society by 2033 and having the largest population of the oldest-olds across the globe. 3 Conveniently and accurately evaluating ADL impairments for the vulnerable oldest-old using appropriate tools requires considerable attention. The Barthel Index (BI), originally developed for stroke rehabilitation, has been widely used for evaluating ADL in healthcare and community settings. 4,5 The BI can be used for a variety of clinical purposes, such as determining the degree of disability, evaluating treatment effects and identifying home care needs. 6,7 In clinical practice, subjects with a total BI score of less than 90 or 95 are considered to be function dependent. Although substantial literature describing the BI's applicability in general population is available, questions remain regarding certain properties among oldest-old population, especially in those from low-and middle-income countries (LMICs).
The BI measures a person's physical function through 10 basic daily tasks (grooming, bathing, feeding, toileting, stair climbing, dressing, bowel control, bladder control, transferring and ambulation) regarding the ability of performing ADL. Identifying the latent categories of functional dependence according to the BI's factor structure is beneficial for targeting long-term care and clinical intervention. However, whether the BI is a single measurement or a multiple-dimensional instrument among oldest-old is still unclear. A number of validity researches demonstrated the unidimensionality of the 10-item BI, 8,9 whereas a few studies from Asian countries including China obtained a two-factor structure. 10,11 Notably, specific self-report ADL tasks (bathing, toileting and stair climbing) are closely related to the living environment and facility, which have been confirmed to be associated with functional disability among older adults in the United Kingdom and China. 12,13 The interaction between living environments and specific ADL task reinforces the need for in-depth analyses of item quality in function assessment tools. Item response theory (IRT) analyses, which have many advantages over the classical test theory (CTT), are applicable for evaluating individual item's contribution to a scale through parameter estimation. 14 In the last two decades, this psychometric methodology has been increasingly applied in comprehensive geriatric assessment. 15,16 The BI has been validated by previous studies among hospitalized and community population. Shahram et al. confirmed the BI to be a reliable and valid questionnaire stroke clinical trials. 17 In another study, the BI showed acceptable fit of a unidimensional structure among geriatric rehabilitation patients. 18 However, the majority of previous validity studies of the BI generally focused on middle-aged or older populations from Western countries, 18,19 with only one study focused on the oldest-old yet with small sample size. 20 As many cultural-related diversity exist regarding residential environments and culture gaps of older people between LMICs and Western world, whether previous results derived from developed countries could apply well to oldest-old adults in LMICs such as China remains unclear. To address these gaps, we comprehensively evaluated the reliability, validity and factorial invariance of the BI in a large sample of the oldest-old and centenarian Chinese population. We also employed the IRT framework to evaluate the quality of each item.

Study populations
The data used in this study was collected from two-stage investigations in the China Hainan Centenarian Cohort Study (CHCCS) from June 2014 to December 2017. The goal of CHCCS is to assess the physical function, mental health, and social status of longevous adults and establish ageing indicators for healthy longevity. Details of sampling strategies, inclusion criteria, and age verification were described in our previously published profile. 21 In total, 1794 old persons aged 80 or above by household register of the Department of Civil Affairs in Hainan were invited to participate, and 794 oldestold participants (aged 80-99 years) and 956 centenarians were involved in the final study. For the centenarian participants, strict three-step age verification methods (Supplementary Figure 1) were adopted to ensure the age authenticity, and 58 subjects who failed to meet the validation were excluded. First round: housed register, identification card, census-derived list; Second round: claimed birthday and Chinese zodiac sign, claimed age when they experienced the specific social upheaval; Third round: milestone assessments such as marriage date, date of first born, subsequent birthdates of children, mother's death. In the current study, 124 subjects who were unable to cooperate due to dementia or paralysis were excluded before the survey, and participants who failed to complete any question in the BI were also excluded. The flow chart of participant recruitment in this study was described in Figure 1.
The ethics committee of the Hainan Hospital of the Chinese People's Liberation Army General Hospital approved the study protocol (serial no. 301hn11201601). All subjects (or guardians) provided written informed consent before participating in the survey. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.

Procedures
For the survey data used in this study, participants were interviewed at their residences or nearby health service centres by a well-trained interdisciplinary medical group. 21 The face-to-face interview was performed by native nurses who were trained in interviewing older adults and able to speak the local dialect. For the ADL measurement, investigators checked the participants' self-report function performance according to their performance during the clinical examinations. There were 3-21 missing values for the 10 items in the BI. Considering the subjects' age and poor health condi- Psychometric properties of the Barthel Index tions, missing data of individual BI questions were coded as incapacity with a score of '0' (dependence). Participants' response and the corresponding missing values are described in Supplementary Table 1. Demographic characteristics including age, gender, ethnicity, education, residence, marital and birth status were collected. To test the criterion-related validity of the BI, related health outcomes (depressive symptoms, subjective well-being and self-report health status [SRH]) were also obtained. Subjects with good literacy and cognitive function completed the survey independently, whereas subjects who were illiterate answered questions with the cooperation of the investigator and their legal representative.

Measurements
We used a Chinese BI version firstly translated by Leung and colleagues in 2007 using standard translation methods 10 to assess the ADL of the participants. The BI consists of 10 items: grooming, bathing, feeding, toileting, stair climbing, dressing, bowel control, bladder control, ambulation and chair-bed transferring. Due to the generally low educational level and potential sensory impairment of oldest-old adults living in Hainan, research team further simplified the linguistic expressions of the BI's questions and responses and tested the feasible and valid in a pilot survey in 2014. 13 The scoring of BI was provided in Supplementary Table 2. In brief, participants' physical performance was assessed on a 2-4 Likert classified response depending on the amount of assistance required for accomplishing the tasks in daily living. Items were scored on a scale of '0', indicating dependence, to '5, 10 or 15', indicating 'needs help' to 'independent'. A higher score indicates higher levels of function, and the maximum summed score of 100 indicates complete independence. When the total score is ≥95, the subject is considered to have good functional ability or independent; participants with a total score of less than 95 were considered dependent.
Depressive symptoms were measured using the Geriatric Depression Scale (GDS-15), which consists of 15 dichotomous items that assess the presence of depressive symptoms in the last week. A higher score indicates more depressive symptoms (a possible range of 0-15; the observation range is 0-15), and as previously described, Chinese oldest-old with a score of 7 points or higher were considered to have a depressive symptom. 22 The Satisfaction with Life Scale (SWLS) consisting of five 7-point Likert items was used to assess participants' subjective well-being aspect (a possible range of 0-35; the observation range is 0-35). SRH was measured using a Visual Analogue Scale (VAS). The VAS score records an individual's self-rated health on a 20-cm, vertical visual analogue scale ranging from 0 to 100, with notes at both ends labelling 'the worst health you can imagine' (at 0) and 'the best health you can imagine' (at 100).

Statistical analysis
Continuous variables with a normal distribution were described as the mean ± standard deviation (m ± SD), continuous variables with a skewed distribution were presented as median (interquartile range), and categorical variables were described as numbers with percentages [n (%)]. As for the skewed distribution of the summed BI score, the Wilcoxon or Kruskal-Wallis rank sum test was used to compare the differences of the BI scores across different groups. Spearman correlation coefficient was used to analyse the correlation between the BI score and other measured outcomes. Internal consistency of the BI was evaluated using Cronbach's α coefficient and item-total correlation. An α coefficient > 0.7 indicates good internal reliability. An exploratory factor analysis (EFA) using the principal component method was performed to explore the factor structure. The eigenvalue criterion (>1) of each factor was used to identify the number of meaningful factors. Confirmatory factor analyses (CFA) with robust weighted least squares estimation were conducted in Mplus (Version 7.4) in cases of violation of the multivariate normality assumption. The χ 2 /df, root mean square error of approximation (RMSEA), comparative fit index (CFI) and normed fit index (NFI) were used to evaluate fitness. The model is considered to have a good fit with a χ 2 /df of 5 or less, an RMSEA of 0.1 and a CFI and NFI greater than 0.90. 23 Factorial invariance of the BI across age, gender, education, ethnicity and residence was tested by a multi-group confirmatory factor analysis (MGCFA) approach, which consisted of a series of nested confirmatory steps. Configural invariance (free parameters), metric invariance (constraints of equivalent factor loadings), scalar invariance (further constraints of the intercepts) and strict invariance (further constraints of residual variances) models were tested across subgroups. A non-significant △ χ 2 (P > 0.05), a △ CFI value < 0.01 and a △ RMSEA value < 0.015 were used to compare the fit of nested models. 24 Since subjects in the current study would not rely guessing to answer questions about physical function, we estimated the discrimination (a) and difficulty (b) parameters of 10 items in the BI using the IRTPRO Version 4.2 software. As the previous research did, a two-parameter logistic (2PL) model was used for two binary items ('grooming' and 'bathing'), and a graded response model was used for the other eight multigraded items. 20,25 In clinical settings, the discrimination between [À2.80, +2.80] is suitable, and the difficulty is acceptable at [À3, +3]. 25 Primarily, we tested the assumptions of an item response analysis. The fit of each item under the particular models was tested using the S-χ 2 statistic suggested by Orlando and Thissen. 26 A non-significant S-χ 2 statistic (P > 0.05) indicates fitness to the model. The unidimensionality assumption was tested according to results from factor analyses. The local independence was confirmed using the χ 2 LD statistic recommended by Orlando. 26 A χ 2 LD statistic < 10 between any two items indicated an acceptable level of local independence, which means that subjects' item responses are independent after controlling for the underlying trait. 27 The item characteristic curve (ICC) was used to establish the relationship between subjects' potential trait and their responses, and the item information curve (IIC) was used to evaluate the measurement precision through the test information function (TIF). The measurement precision of a scale is sufficient when the total test information is above 25. 28

Reliability, validity and factor structure of the BI
The summed BI score was significantly correlated with GDS-15 (r = À0.36, P < 0.001), SWLS (r = 0.23, P < 0.001) and VAS (r = 0.22, P < 0.001). As Table 2 showed, the overall α coefficient of the BI was 0.903 and increased only when 'stair climbing' was deleted. The item-total correlation coefficients ranged from 0.508-0.789 (Ps<0.001). Two factors explaining 73.64% of the total variance were retained in the EFA, and all item loadings on the corresponding factor were greater than 0.6. Factor 1 consisting of eight items (grooming, bathing, toileting, dressing, feeding, stair climbing, transfer and ambulation) was defined as 'somatic function'; Factor 2 consisting of two items (bowel control and bladder control) was defined as 'physiological self-care'. Considering previous studies obtained a unidimensional structure of the BI and the item 'stair climbing' impaired the overall internal consistency in the current study, we involved four competition models to explore the optimal structure of the BI in CFAs. Model A: two factors with 10 items; Model B: delete 'stair climbing' from Model A; Model C: one factor with 10 items; Model D: delete 'stair climbing' from Model C. As described in Table 3, all the four CFA models showed acceptable RMSEA (<0.1), CFI(>0.9) and NFI (>0.9), whereas the Model A had a smaller χ 2 /df (5.538) and RMSEA (0.051). Next, we tested the factorial invariance of the two-factor BI model (Model A) across age, gender, education, residence, and ethnicity using MGCFA ( Table 4). The configural invariance model (free parameters) was used as a basic model, and three restrictive models (restrict loading, intercept and residual sequentially) were tested in a stepwise manner. The invariance of metric, scalar, and residual restricted models was confirmed (△CFI < 0.01, △NFI < 0.01, △RMSE<0.015) across residence and ethnicity subgroups. For gender and education subgroups, the invariance of metric and scalar restricted models was confirmed, but the residual restricted model was not (△CFI > 0.01, △NFI > 0.01). For age subgroups, the metric restricted model met the invariance criteria (△CFI = 0.010, △NFI = 0.009, △RMSE = 0.011).

Psychometric properties of the Barthel Index
Item characteristics of the BI As described in Supplementary Table 3, no statistically significant S-χ 2 was found for the 10 items (ranged from 10.05 to 41.41, Ps > 0.05), which indicated that the parametric models were fit to the data. In the EFA, the ratio of the first eigenvalue (6.014) to the second eigenvalue (1.351) was greater than 3 ( Table 2), and the one-factor Model C (CFI = 0.988, RMSEA = 0.057) showed acceptable fitness. Thus, the unidimensional hypothesis was supported by Hambleton's criteria. 29 As Supplementary Table 4 described, the χ 2 LD statistic between 'bowel control' and 'bladder control' was 63.7, which was the highest, and the χ 2 LD statistic between any other two items (0.1-8.4) were all less than the criterion of 10. The ICC and IIC of 10 items in the BI were summarized in Figure 2, and estimated parameter values were shown in Table 5. The discrimination parameter of 10 items ranged from 1.62 ('stair climbing') to 5.87 ('bathing'), and the difficulty parameter ranged from À2.65 to 1.11. The test information provided by 'stair climbing' (1.73), 'bowel control' (2.19) and 'bladder control' (2.56) was relatively low compared with others. As Figure 3 showed, the to-tal test information of the BI was 43.85, and the corresponding latent trait level (θ) located at À0.94. When 'stair climbing', 'bowel control' and 'bladder control' were deleted from the BI, there was no obvious loss of the total information function.

Discussion
This is the first study to evaluate the psychometric properties of the BI among oldest-old and centenarian populations with a considerable sample size. We observed significant variances of the participants' ADL score across age, gender, education and health status subgroups, which confirmed the known-group validity of the BI. Significant correlations between the BI score with measurements of GDS-15, SWLS, and VAS supported the BI's criterion-related validity with was reported in most previous validity studies. 30,31 The BI had a satisfactory internal consistency coefficient of 0.903, which was generally consistent with that reported in previous studies ranging from 0.69 32 to 0.96. 33 The dimensionality of The mean item-total correlation of the Barthel Index. the BI is not consistent across all the studies. EFA and CFA showed that the two-factor structure was an optimal solution in Chinese oldest-old population. Studies from Iran, 11 Sri Lanka 34 and China 10 obtained the same two-dimensional structure in older adults. However, a number of studies confirmed the unidimensionality of the BI in neurology rehabilitation patients. 8,35 Conceptually, somatic disability and incontinence are two latent categories of functional dependence in this population. Factor 1 ('somatic function') mainly reflected the performance of limb muscles, whereas factor 2 ('physiological self-care') represented the performance of the sphincter. The composition of items contained in the above two factors was consistent with Leung et al.'s study among stroke inpatients. 10 But grooming and two incontinence items were extracted into the same factor in Sakar et al.'s study among outpatients. 11 According to the World Health Organization's International Classification of Functioning, Disability and Health, incontinence was classified as impairment of physiological function rather than restricted mobility. 36 Among the 856 functional dependent oldest-old in our study, 163 had incontinence and they needed more targeted long-term care. Our results highlighted the definition and scoring approach of the measurement when using the BI among Chinese community oldest-old. We used the MGCFA to test the BI's factorial invariance that were not well reported by previous psychometric studies. The two-factor structure showed acceptable invariance across age, gender, education, residence, and ethnicity subgroups, which supported the comparability and robust property of the BI. For instance, despite concerns that demographic differences exist between the oldest-old and centenarians, the age invariance indicated that subjects across the two subgroups responded to the scale with the same underlying framework. In IRT analyses, the highest χ 2 LD statistic (63.7) between 'bowel control' and 'bladder control' indicated that they seriously destroyed the BI's local independence. Local independence of a valid scale means that the subject's latent trait is the only factor affecting their response. 26 In terms of physiological function of the human body, 'bowel control' and 'bladder control' were not only related to the ability to take care of oneself but also to factors including spinal injury or neurological function. In a Rasch analysis study among hospitalized older patients, these two continence items also appeared to Psychometric properties of the Barthel Index measure a different concept of the other items. 37 Hartingsveld et al. 38 also found that incontinence items impeded the BI's one-dimensional property. Although 'bowel control' and 'bladder control' provided less information than other somatic items ( Table 5), these two incontinence items are necessary to identify potential categories of disability when using the BI. All the 10 BI items showed sufficient discrimination parameters (>1). Another IRT study conducted by Liu and colleagues found that most items in the BI showed similar good discrimination, but two items ('stair climbing' and 'feeding') had very low discrimination parameters among older persons from long-term care facilities. 20 The common low difficulty parameter found in the current study (À2.65 to 1.11) was derived from the ceiling effect of the BI, which has been frequently reported in previous validation studies. 39,40 The BI had sufficient measurement precision with a total test information of 43.85. In Liu's study, 20 the BI's information function was as sufficient as ours (TIF > 40), and the corresponding location was also relatively low (θ < 0). Notably, the TIF of the 10 individual items ranged from 1.37 to 10.22, which meant that the contribution of individual items to the scale was quite different. Particularly, the TFI of 'stair climbing' was the lowest, and this item impaired the overall internal consistency. The majority of partic-  ipants in the current study lived in bungalows and did not need to climb stairs. Therefore, 'stair climbing' seemed to be a redundant task in population from current study. Although this findings might not be completely applicable to other older groups, we argued that living conditions were to precise measurement of ADL for a specific population. Similar viewpoints were reported in Tomoko et al.'s study, 41 which focused on individuals that lived in long-term healthcare facilities that had either an elevator or no stairs. In this study, we provided psychometric evidence and methodology suggestion for the development and modification of function assessment item banks. Comparability of ADL measurement should be linked to the diversity of living facilities for older people in different areas. For conveniently measurement purpose, researchers have suggested that the standard BI versions should be modified to accommodate different populations with varied living settings. 42 A recent systematic review found that six simplified versions of BI containing three to eight items were also used well in patients with stroke. 37 One strength of this study is the unique study population with a considerable sample size. Another strength is the combination of psychometrical methodologies of CTT and IRT. This study has some limitations. Firstly, the sample used in this study originated from one province in China, and generalizability to older people with varied background needs to be further verified. In any case, we have provided commonly practical methodological suggestions for assessing and optimizing ADL assessment tools. Secondly, due to the subjects' advanced age and cognitive impairment, information bias was inevitable. However, we have adopted strict quality assurance approaches to ensure the authenticity of subjects' ages and ADL measurements during the investigation. Thirdly, clinical factors such as chronic diseases, geriatric syndromes and polypharmacy were not included, which might influence the psychometric evaluation of the BI. Fourthly, we could not analyse the test-retest and inter-rater reliability of the BI due to the lack of repeated measurement data. Future studies are justified to investigate this issue.

Conclusion
The BI has appropriate reliability, validity and measurement precision for community-based Chinese oldest-old and centenarians. Somatic disability and incontinence are two latent categories of functional dependence in this population. Living environment needs to be taken into consideration for ADL instrument development and modification.

Online supplementary material
Additional supporting information may be found online in the Supporting Information section at the end of the article. Figure S1. Three-steps age validation process of centenarians in CHCCS. Table S1. 1750 participants' response ratio of 10 items in the Barthel Index Table S2. Rating scale of activities of daily living by the Barthel Index Table S3. S-χ 2 statistics diagnostic statistics of 10 items in the Barthel Index Table S4. The χ 2 LD statistic matrix of 10 items in the Barthel Index


The Impact of COVID-19 on The Teaching of Non-Medical Healthcare Professionals in Bangladesh: Observations and Implications From A Pilot Study

Objective: At the start of the Covid-19 pandemic, educational establishments, including universities, were closed. Educators in high-income countries quickly shifted all education online, building on available infrastructures and approaches. However, there were concerns in developing countries regarding the necessary skills among students and faculty as well as financial support for equipment and the internet. Consequently, a pilot was undertaken in Bangladesh to determine the impact of Covid-19 on the non-medical education system, building on similar research with healthcare professionals. Materials and Methods: A purposively designed questionnaire was disseminated among eight non-medical healthcare educators in private and public universities in Bangladesh. Results and Discussion: Private university educators reported their universities readily adopted e-learning systems and resumed classes more quickly than public universities. Both private and public university educators shared similar challenges, including a lack of training on e-learning initially, variable internet connections, affordability of internet bundles, concerns with available devices, as well as mental stress of faculty and students. Private universities reduced their tuition fees, extended submission deadlines, and shared class recordings to address challenges. Public universities arranged student loans, established Covid-19 testing centers, and the trained students in biosafety practices and molecular tests to volunteer in testing facilities. Conclusion: Lessons learned from the pandemic emphasize introducing hybrid education systems with full technological and financial support, alongside biosafety education in the curriculum.

Introduction
Covid-19 is a highly pathogenic contagious viral disease that has resulted in severe morbidity and mortality across countries 1,2 , resulting in over 516 million cases and over 6 million deaths by 13 May 2022 3 . In the absence of effective treatments for the prevention and management of patients with Covid-19 at the start of the pandemic, including effective vaccines, countries typically introduce a variety of lockdown and other measures to control its spread [4][5][6][7][8] . However, the rapidity of their implementation, coupled with the stringency of their enforcement, impact morbidity and mortality rates in practice across countries, certainly in the early phase of the pandemic 4,[9][10][11][12] . Bangladesh was no exception introducing several lockdowns and other measures at the start of the pandemic 13,14 . Initiatives included the closure of educational establishments, including universities [13][14][15][16] , with these measures subsequently having an appreciable impact on educational sectors 14,17 . Universities typically need to postpone or immediately cancel all campus-related activities. All face-to-face teaching-learning programs and other academic activities, such as conferences, workshops, and sports activities, were also typically halted in the initial days following the Covid-19 [16][17][18][19] . Subsequently, globally traditional face-toface teaching was replaced by online or e-learning programs across countries [19][20][21] .
Online education, or e-learning, is a subcategory of a distance learning system that denotes educational models utilizing information technologies to provide teaching-learning instruction to pupils in variable locations, which was necessary following the closure of universities 22,23 . However, this raised many issues, especially among low-and middle-income countries (LMICs), which included inadequate training of faculty members beforehand in e-learning techniques, affordability of internet bundles and computer equipment among students, and quiet locations for studying ( Figure 1) 19,21,24,25 . This was less of an issue among high-income countries with typically greater utilization of online teaching-learning instructional methods before the pandemic, better availability of necessary equipment, and affordability of internet bundles 20,21, 26-28 .
It has been reported that Bangladesh and many other LMICs had limited experience with online learning at the start of the Covid-19 pandemic among academic staff and students and poor internet access, and high prices for the internet 19,21,29 . Other studies have revealed that improved faculty training on e-learning among LMICs, students supported financially to purchase the necessary equipment and internet bundles, launching Covid-19 prevention protocols including providing protective equipment, video-recorded lectures, tutorials to make up for a lost time, and simulated methods to teach clinical aspects, have all helped address identified barriers, with hybrid approaches to learning likely to stay 19,21,[30][31][32] . Other identified issues include addressing stress and mental health issues 16,19,23 .
Consequently, this study aims to assess non-medical HCP academic staff perceptions regarding the current challenges of Covid-19 on online teaching systems. This builds on the earlier study regarding dental and medical education in Bangladesh following the closure of universities in Bangladesh and similar studies in other LMICs 16,19,21,31,43 .

Approach
This study used a pragmatic approach to ascertain and review challenges and difficulties regarding teaching non-medical HCPs at the start of the pandemic [44][45][46] . This is because pragmatism allows an adaptable and thoroughly instinctive research strategy, thereby logically holding deductive and inductive form judgments 47,48 . Consequently, we believed the current research methodology was the most relevant to address such critical research questions 49 .
Non-probability sampling was utilized for this pilot study based on the expert knowledge of the coauthors, who are themselves non-medical health professional educators. This improved the capacity to acquire a rich data source from a limited sample 50,51 .
To augment the study's credibility, transferability, and dependability, a data source triangulation method was used with participants from non-medical and other health professional disciplines [52][53][54] . The initial sample of eight participants included five educators from public and three from private universities to ensure complete coverage, similar to the previous pilot study in Bangladesh 16 . The participants covered various subjects, including microbiology, pharmacy, Biotechnology & Genetic Engineering. No students participated in this pilot study as we wanted to gain an understanding from the educators first.
A qualitative semi-structured questionnaire was adopted based on recent research conducted among African and Asian countries 16,19,43 . Respondents had enough time to construct and amend their answers before being sent back 14,55 . Participants were encouraged to remain in constant communication with the researchers to clarify any details regarding the research as needs arose.
The questionnaire consisted of four main open-ended questions coupled with prompt questions. The main questions focused on the challenges presented by the Covid-19 pandemic, the response and support the educators and their universities provided to address them, and lessons learned for future pandemics. These four questions included: I. What challenges has Covid-19 presented to HCP education in Bangladesh?
II. How did your university/institution respond immediately to the challenges presented by the Covid-19 pandemic?
III. What support was harnessed to help mitigate the challenges faced by your higher learning institution?
IV. What lessons can be learned to prepare HCP educators for non-medical HCPs in Bangladesh for future pandemics?

Analysis
A framework method of data analysis was applied, similar to previous studies 16,19,43 , which provides a detailed outline of individual observations and enables themes to develop deductively and emerge inductively from participants' experiences and views 56,57 .
The main themes from the responses were predetermined deductively by the research questions and stored using different sheets of Microsoft Excel. The further analysis relied on inductive reasoning in which sub-themes emerged through repeated evaluation of the questionnaire data. Initially, one research team member independently coded the responses (KC) from the same eight questionnaires and subsequently developed a set of codes to form the initial analytical framework. Some of the codes were later grouped into categories. Several codes were subsequently mapped using diagrams to explore the relationship between the subthemes. In addition, patterns among the different types of participants were identified.

Ethical Considerations
Ethical approval was not needed for the study, similar to other pilot studies and similar studies conducted by the co-authors in the absence of patients 9, 10,13,16,19,40,43,[58][59][60] . However, written informed consent was taken from the participants before starting the pilot project to ensure that they fully comprehended all aspects of the study and voluntarily agreed to participate. Participants were subsequently informed that their identities would be kept confidential, guaranteeing respect for autonomy and trust.

Results
We will first document the participants' demographic details ( Table 1) before discussing key and additional challenges faced by the non-medical HCPs at the start of the pandemic (Tables 2 and 3). Table 2 discusses the top six challenges reported by faculty members teaching non-medical HCPs at the pandemic based on their replies to the various questions. Table 3 discusses additional challenges that emerged from the study.  There were various immediate responses to the challenges of e-learning and taking safety measures among the educators and students. These included concerns among students with the potential financing of home computers/smartphones and internet bundles. In addition, addressing limited knowledge regarding e-learning approaches among faculty members at the start of the pandemic (Table 4). There were several responses among the universities to assist students and faculty members with e-learning approaches during the initial stages of the pandemic. These are summarized in Table 5. Examples of financial support mentioned by the participants included reduced accommodation fees, arrangements of loans to students to enable them to buy ICT devices, and reduced tuition fees (25%) to support the internet costs.
There were also several lessons learned about educating non-medical HCPs students during the early stages of the pandemic (Table 6). These developments facilitate hybrid learning approaches in the future, with such strategies likely to stay.

Discussion
Similar to other nations and continents, the pandemic severely disrupted traditional educational approaches in Bangladesh 9,16,17,61,62 . There were significant hurdles to be addressed to fully prepare non-medical HCPs in Bangladesh for their activities post qualification at the onset of the pandemic, which was similar to other LMICs 63-65 . The topmost challenges among private and public universities (Table 2) included a lack of prior training regarding e-learning approaches and tools before the pandemic. However, this was more prevalent among public versus private universities. Educators from other LMICs 19,43,61,65,66 also faced this challenge. There was also a scarcity of funding and the ability to undertake a research project at the start of the pandemic; however, again, this mainly occurred among public versus private universities.
Of concern was that most students, particularly among public universities, did not have access to a computer and other required equipment or could afford the various internet packages for e-learning at the start of the pandemic ( Table 3). Most of the nonmedical HCP educators in the public sector were also unfamiliar with online meeting platforms during the early stages of the pandemic (Table 2). Furthermore, when educators undertook classes from home, they encountered problems, including internet outages due to inadequate connections. This was also a major concern among education across Africa and other LMICs; 21 however, potentially less of an issue in India 16,19, 21,43,67, . This was less of an issue in Saudi Arabia and other high-income countries, which had already made significant investments in e-learning approaches before the pandemic, smoothing the transition from in-person to online learning at the pandemic 21,27,68 .
Other key issues that arose at the start of the pandemic included non-medical HCP educators concerned that students lacked adequate feedback for studies or projects, exacerbated by the inability to undertake complete supervision. There was also a need to ensure a calm and quiet environment at home for teaching and learning. This is recognized as more challenging in LMICs, especially when all family members, including children, are forced to stay at home in cramped conditions during successive lockdowns causing turmoil and distraction. Students also lost touch with their classmates and teachers, and faculty members have also lost touch with their students and colleagues 69 .
These issues had a significant psychological and emotional impact on both educators and students in Bangladesh and across countries ( Table 5), with the mental stress caused needing to be addressed going forward 6,19,63,67,[70][71][72][73] . This has been helped in Bangladesh by private universities providing full support to their students and faculty members through scheduling counseling sessions to inspire and build mental strength and minimize stress, which has proved beneficial 74,75 . Other activities ( Overall, educators in Bangladesh were quick to adapt to the online learning mode at the start of the pandemic. However, initial challenges included skill development and the necessary digital infrastructure 76 . The universities typically provide webinars and online workshops to exchange and update knowledge ( Tables 4 and 5). Public universities also established Covid-19 awareness programs and transmission prevention training by making hand sanitizers and distributing masks. One private and one public university also established Covid-19 sample collection booths and performed RT-PCR tests, a confirmatory test for Covid-19 77 . Moreover, nonmedical HCP educators, specifically microbiologists, trained their students for Covid-19 diagnosis, who later became volunteers at the RT-PCR testing facility all over Bangladesh. We also observed that the experiences and challenges posed by the Covid-19 pandemic on the non-medical healthcare professional are not unique but related to studies in other LMIC countries on medical healthcare professionals 16,24 .
Lessons learned from this pandemic will provide suggestions to deal with the future pandemic. Recommendations included ( Table 6) creating a specialized infection control unit for each institution and providing periodic infection control training. Participants also recommended expanding digital platform capabilities across universities and distributing ICT equipment to those in need. Improvements to the university website and training for both students and faculty members in e-learning and hybrid learning were also recommended to ensure unbroken academic sessions in future pandemics. This alongside providing adequate funding for internet bundles.
We are aware of several limitations of this study. These include that only a few universities with non-medical HCP educators were approached for this pilot project. Secondly, the sampling procedure was purposeful in achieving the study's goals and objectives. Thirdly, students were purposefully excluded from this discussion so that their perspectives could not be examined in full. Despite these constraints, we feel that our findings are sound and that they will contribute to a future pandemic response strategy.

Conclusion
Covid-19 and the shift from traditional classrooms to online environments had an appreciable impact on the education of non-medical HCPs at the start of the pandemic. Several concerns and obstacles need to be addressed with the shifting of education to an e-learning environment. Challenges included a lack of prior training in e-learning methodologies, lack of ICT equipment, and the cost of internet subscriptions. The pandemic also caused appreciable mental stress among both educators and students. These are starting to be addressed, indicating a path forward. The study's findings also emphasize the need for HCP educational institutions to pay close attention to teacher-student issues and the influence of lockdown on academic careers.
The next stage of this research will be a more comprehensive study among non-medical HCPs to offer a complete picture for future guidance.

Conflict of Interest
The authors have no relevant conflicts of interest to declare

Funding
There was no funding for this project. The research was self-funded by the authors.

Data Availability
Additional data is available on reasonable request to the corresponding authors.