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Introduction Health systems strengthening is becoming a key component of development agendas for low-income countries worldwide. As a means to achieve this, systems thinking provides perspectives on how health systems can be assessed [1], recognizing non-linearity, complexity, heterogeneity, uncertainty, and ambiguity of real-world settings [1][2][3][4]. The 2009 Flagship Report from the Alliance for Health Policy and Systems Research proposes "Ten Steps to Systems Thinking", emphasizing the roles of diverse stakeholders in designing solutions to system problems, including sustainability [1]. Studying information flow mechanisms between actors and within networks can help us to understand decision-making processes, as well as the social processes which influence the resilience of socio-ecological systems (including health systems). Asch [5] showed that individuals' decisions in an unpredictable world are often based on peers' opinions and actions. Interactions and collaboration between stakeholders depend on various social factors, such as trust, conflict resolution, and knowledge integration [6], and also on circulation of information within social networks [7,8]. The structure of social networks influence individual actors' capacity to respond to the needs of the system as a whole [9,10]. It follows that understanding system stakeholder networks may be important when analysing how information on system sustainability can be used by the actors of the system to make informed decisions [11,12]. However, the structure of social networks may only be one amongst other factors contributing to the use of data in decisions. Understanding the dynamics of systems therefore requires combining several methodologies to capture the complexity of health programmes, the embeddedness of systems within other systems, and the multi-layered governance of health systems [13][14][15]. In this paper, we build on previous work to introduce systems thinking among local stakeholders of the physical rehabilitation system in Nepal and Somaliland [16]. Although sustainability has been at the heart of recent international health programmes and policies, the meaning of sustainability remains unclear and confusing to most public health professionals [17,18]. The current challenges for policy-makers and researchers are to translate the concept of sustainability into concrete indicators [19], which will help policy makers and health service managers make public health and management decisions [20]. However, in order to be successful, such a process should also attend to the political tensions involved in "knowledge production" and "norm creation" inherent to sustainability planning in any system. We used the Sustainability Analysis Process (SAP), a system-oriented tool, which encourages participants to arrive at consensus about system boundaries, define sustainability, and identify measurable indicators for a sustainable system [21]. During this process, the concept of sustainability is upheld as normative [22]. The process also avoids decisions taken by a limited number of "experts". This implies that those participating in the consensus building process are not only acting in their technical expert capacity, but also as "political actors" taking normative decisions on what aspects to uphold [23][24][25][26]. Involving a wide range of diverse actors of the health system, including users, of course raises practical problems. For example, the imbalance of power existing between different groups of stakeholders [27,28] means that some topics can be neglected during this process because people who defend them do not receive enough consideration within the group [29][30][31]. The final "step" of the process additionally includes piloting and re-visiting the measurement of sustainability indicators to judge their fit outside of a workshop setting. The consensus building process needs to capture the tensions between "knowledge production" and "norm creation" in a particular context. Along with convening and observing sustainability analysis workshops in each setting, we sought to analyse the contextual factors and the characteristics of the social networks to identify the influences affecting actors' decisions about using sustainability data or not [32,33]. The objective of this paper is to compare the definition and use of sustainability indicators developed through the SAP in two rehabilitation sectors, one in Nepal and one in Somaliland, and analyse the contextual factors (including the characteristics of system stakeholder networks) influencing the use of sustainability data. --- Methodology In order to capture social phenomena such as management decisions and interactions between individuals, an in-depth qualitative research approach was adopted. According to Fitzpatrick and Boulton ([34] p. 107), qualitative research "is used where it is important to understand the meaning and interpretation of human social arrangements such as hospitals, clinics, forms of management or decision making". In real-life contexts, multiple case study designs are known to be appropriate for understanding and interpreting complex causal links in natural setting interventions [35,36]. We combined three different methods; we used stakeholder network analysis, and the SAP at baseline (2010) and at a 2-year follow-up (2012). Interviews with key informants lent depth to the observations, the analysis and helped understand the relationship between the structure of the network, the contextual factors, and the use (or not) of sustainability indicators. Each of these three methods is described below. --- Stakeholder network analysis Stakeholder network analysis was used to map key stakeholders in the physical rehabilitation system and identify network characteristics. The analysis was conducted in both Nepal and Somaliland in 2010 and again in 2012, and is detailed elsewhere [37,38]. In summary, stakeholder network analysis consists of three stages: (i) describing the set of stakeholders in the network/system (using interviews with stakeholders and document review), (ii) characterising the relationships between stakeholders (interviews), and (iii) analysing the structure of the network/system (using software, see below) [38]. Stakeholders were defined as persons, informal groups of people, or formal organisations who may influence the sustainability of the system through their interactions and individual or collective actions [39][40][41]. Relationships between actors can be of different kinds and depend on various social factors such as trust, conflict, or knowledge sharing [42]. However, all these social factors are interdependent with one key process: the circulation of information between and within social networks [43,44]. The second stage of stakeholder network analysis consisted of identifying the existence of flows of information between actors or, in other words, the demand (receiving information) and supply (providing information) of information between individuals. This information was collected through interviews. Data collected through interviews were recorded in an information flow matrix: one matrix on the demand for information and a second one on the supply of information. Each respondent thus generated a row of "ones" and "zeros" for each of the two network relations (demand and supply of information): "one" symbolising the existence of demand/supply of information and "zero" signifying no information flow between the two actors. The final matrix was then analysed with the software UCINET to generate statistics about the network structure (Table 1) [39,45], to visually represent relationships within the network and to identify network brokers, who control the flow of information and/or resources within the network [46]. --- Sustainability analysis process (SAP) The SAP is a participatory method based on systems thinking, which combines the Process Analysis Method five-step approach [47,48] with a conceptual framework, the Sustainability Framework, which was applied and tested in international health [49,50]. The five components of the Sustainability Framework, which were used in our study, are: health outcomes, service delivery, organisational capacity and viability, community capacity and context [50]. The SAP also involves five steps, as follows: i) Establish a common understanding of the rehabilitation system in the local context; ii) Define system boundaries; iii) Develop a common vision of sustainability; iv) Select measurable sustainability indicators for the local system; v) Collect baseline indicator data [21,51]. In both Nepal and Somaliland, the SAP method was implemented during a three-day workshop sponsored by Handicap International in 2010 with key stakeholders involved in the physical rehabilitation system. Participants were purposively selected by Handicap International and Naspir, the national federation of rehabilitation providers in Nepal, and by the two national rehabilitation providers in Somaliland. The first list of participants was shared with and reviewed by the two investigators (KB and JP) in relation with the diversity within the rehabilitation sector. The participants included representatives from the Ministry of Health and/or Ministry of Social Affairs, regional health authorities, selected rehabilitation professional staff (physical therapists and orthopaedic technicians), rehabilitation centre managers, representatives of disabled people's organizations, and representatives of international donors and non-governmental organizations (NGOs) involved locally. Two-year follow-up workshops were held in both countries in 2012. All the organisations that were represented at the first workshop were represented at the follow-up workshop. After the SAP was reviewed, workshop participants discussed key events that influenced the sustainability of the rehabilitation sector during the intervening 2 years. Sustainability indicators were remeasured, where possible, and participants reflected on progress toward self-defined sustainability goals. --- In-depth interviews and observations Analytic narrative was used to provide explanations of unique events and outcomes, and can serve the interests of the social researchers who try to describe what events take place, why, as well as their significance to actors within a system [52]. Analytic narrative is considered "a useful tool for assessing causality in situations where temporal sequencing, particular events, and path dependence must be taken into account" ([53] p. 1,164). The analytic narrative approach consists of interviewing key actors and understanding their goals, and the main factors influencing their behaviour and decisions [52]. It also requires analysis of the interactions between actors and their impact on institutional settings: "The emphasis is on identifying the reasons for the shift from an institutional --- Table 1 Definitions of key network characteristics measured --- Characteristic Definition --- Betweenness Indicator of centrality of the network as a whole [39]. Corresponds to the number of direct ties a stakeholder has with any other actor compared to the total number of direct ties [39]. The higher the percentage of betweenness, the more centralised the network. --- Density Indicator of network cohesiveness [39]. Defined as the number of existing ties divided by the number of possible ties between stakeholders. Reported on a scale ranging from 0 (no ties at all) to 1 (all actors are connected to all others). equilibrium at one point in time to a different institutional equilibrium at a different point in time" ([54], p. 11). Information was collected from key informants on experiences with collecting and analysing sustainability information by individual actors/organisations. Interviews were conducted in private and participants were assured of confidentiality to encourage participants to share potentially sensitive issues and insights. Interviews were recorded. Transcripts and notes from each interview and group discussion were read in their entirety before coding line-by-line to identify and label ideas and meanings conveyed in each small section of text. These codes were then grouped and labelled to reflect broader themes within the data. Further additions and revisions to the coding framework were made on a continual basis as higher level constructs were generated, through reviewing emerging themes and interpreting them in relation to stakeholder network analysis findings. --- Results The 2010 (baseline) physical rehabilitation stakeholder networks in Nepal and Somaliland The structure and properties of the physical rehabilitation stakeholder networks in Nepal and Somaliland are described and compared elsewhere [16]. Key notions are summarised as follows. In 2010, the social network of rehabilitation actors in Nepal (56 actors) was over twice as large as the network in Somaliland (22 actors) and there were substantial differences in the types of actors involved in service delivery and system governance. Notably, in Nepal, three ministriesthe Ministry of Health and Population, the Ministry of Women, Children and Social Welfare, and the Ministry of Peace and Reconstructionwere directly involved in governance of physical rehabilitation services. In Somaliland, the Ministry of Public Health was solely in charge of rehabilitation services, although the Ministry of Labour and Social Affairs coordinated broader disability issues. Country differences in the involvement of local NGOs and disabled people's organisations were also marked. In Nepal, local organisations provided services and directly managed rehabilitation centres. These organisations included professional associations (Nepal Physical Therapy Association and Prosthetist and Orthotist Society of Nepal) and disabled people's organisations. In Somaliland, a much narrower range of actors delivered rehabilitation services. Specifically, two non-profit rehabilitation organisations (Disability Action Network (DAN), supported by Handicap International and the Somaliland Red Crescent Society (SRCS), supported by the International Red Cross Movement) were responsible for the entirety of rehabilitation service delivery. Both organisations in Somaliland were based in the capital city with complementary networks of partners and providers in the periphery. Disabled people's organisations were not involved in service delivery, nor did they play a role in advocating for rehabilitation resources. In 2010, Somaliland's system stakeholder network was four times more centralised than in Nepal. Nepal's network density was twice as great as in Somaliland (0.2 in Nepal compared to 0.1 in Somaliland) (Figures 1 and2). The density of a network is the proportion of all possible ties between actors that are actually present. A centralised stakeholder network, such as in Somaliland, is thought to facilitate communication and innovation, as only a limited number of key actors are involved [39,55]. On the other hand, centralized networks can easily generate bottlenecks if any of the key stakeholders (brokers) block diffusion of information and/or resources. In a dense network, such as in Nepal, the circulation of information between actors is also rapid but with a much lower risk of bottlenecks. --- The 2010 (baseline) self-defined sustainability indicators in Nepal and Somaliland Discussions that took place during the 2010 SAP workshops differed between the two countries. A comparison of 10 key self-defined sustainability indicators in each of the two countries is provided in Table 2 (the full list of indicators chosen is available in [56,57]). In Somaliland, discussions about indicators, their measurement, and recommendations for the system focused on the two rehabilitation facilities existing in that country. Being at the centre of the network, the sustainability of these organisations highly affected the sustainability of the overall system. Sources of instability in the system consisted of the lack of long-term financial resources for centres in the capital as well as poor access to service users outside the capital. In Nepal, a number of rehabilitation centres existed, but populations living in remote areas were not reached with the level of resources and investment at that time. Sustainability indicator discussions in Nepal therefore focused largely on mainstreaming physical rehabilitation into priority health and social programs, while also transferring some services to other actors at the community level. In terms of physical rehabilitation goals, network members in both Somaliland and Nepal focused on increased access to and coverage of rehabilitation services across regions (e.g., percent of people with disabilities by rehabilitation centre whose physical rehabilitation needs have been met). In Somaliland, the rehabilitation providers were concerned about the centralisation of services in the capital and the provinces being underserved due to insecurity outside Hargeisa, the capital, restricting both expansion of service provision and the ability of patients to complete referrals made from the periphery. In terms of service provision, both stakeholder groups recognized that limited numbers and poor geographic distribution of rehabilitation professionals would threaten the sustainability of their system. In Somaliland, network members emphasized the need for professionals to provide services outside the capital city by analysing human resources regionally. In Nepal, stakeholders took a more systemic view and identified the total number of rehabilitation professionals who needed to be trained in the country over the next few years as a sustainability indicator. In terms of organisational and financial capacity, Somaliland network stakeholders placed strong emphasis on the financial autonomy of rehabilitation service providers (e.g., number of different sources of funding) and team management (e.g., percent of staff with job descriptions or number of coordination meeting per year). One of the two service providers in Somaliland was approaching the end of a funding cycle and had no certainty that international support would continue after the end of 2011. Hence, sustainability indicators specified diverse funding sources and reduced financial risk. Some actors identified the emergence of donors in the domestic and diaspora private sector as an attractive means to diversification, particularly as trust in the political will of the Ministry of Health (a potential influential actor within the network) to intervene in rehabilitation was low. In Nepal, organisational and financial sustainability goals are aimed at integrating physical rehabilitation into national policies and other programmes (e.g., disability integrated into female community health volunteer activities). Mainstreaming physical rehabilitation into other social or health systems represented an opportunity to secure resources that were not available in an isolated rehabilitation system. Furthermore, network members in Nepal recognised the need to associate with actors outside their system working at the community level to increase coverage of services. In terms of community capacity, the choice of sustainability indicators in both countries reflected the level of cohesiveness between the rehabilitation services and community-based organisations. In Somaliland, network members defined "community" as the users of the rehabilitation services, and community participation was described in terms of the financial capacity of users to pay for services (e.g., percent of people with disabilities who contributed to the cost of the service) or participation of users in the planning of rehabilitation services (percent of assessment and planning exercises involving community membersi.e., people with disabilities, see full indicator list). In Nepal, the "community" was defined as the population living in areas served by rehabilitation centres rather than only existing or potential service users per se. Community capacity was perceived as the capacity of community organisations to organise themselves (e.g., percent of disabled people organisations that have action plans) and integrate disability and rehabilitation into their activities at decentralised levels (e.g., percent of districts with District Disability Rehabilitation Committees and Village Disability Rehabilitation Committee, see full indicator list). In terms of the enabling environment, in both countries, workshop participants recognised the importance of securing political commitment at the national level to develop and implement disability-related policies (e.g., in Nepal, the existence of a national action plan on rehabilitation) and allocate public financial resources to the rehabilitation sector (e.g., in Somaliland, percent of price covered by Government). --- Physical rehabilitation stakeholder networks in Nepal and Somaliland at 2-year follow-up The system stakeholder network in Nepal became slightly less decentralised but denser over the 2 years from 2010 to 2012 with the appearance of seven new actors (including international and local organisations) (Figure 3). In Somaliland, the major change was the disappearance of the relationship between the two principle brokers of the network (DAN and SRCS). Between the two SAP workshops, the two service providers never formally met to discuss the management of rehabilitation services or the governance of the system. The system became divided into two sub-systems with each service provider at the centre and surrounded by collaborative organisations. In spite of this system fracture, in 2012, the stakeholder network remained highly centralised (61%) and low in density (0.1) (Figure 4). --- Comparative 2-year sustainability progress and use of self-defined sustainability indicators At 2-year follow-up there was little progress towards the local vision of sustainability and almost no use of the self-defined sustainability indicators in Somaliland. System stakeholders individually had not attempted to undertake organisational measurements or use this type of information in decision making, although most still perceived the indicators to reflect their vision of sustainability of the system. During this period, no organisation took the lead to coordinate follow-up of the SAP. Handicap International had sponsored the workshop and was perceived as the "owner" of the initiative by some actors, who expected the international NGO to continue the lead role. Handicap International, however, was reluctant to maintain active involvement in coordination since their overall objective was to hand-over their support to rehabilitation services to local partners. The Ministry of Public Health had limited capacity and political will to fulfil this role. The two main service providers continued to be focused on the survival and viability of their own individual organisations. Several system stakeholders characterised sustainability as "unachievable" under current conditions in Somaliland, without sufficient funding and support from the Ministry of Public Health. In Somaliland, by 2012, apart from a tax break on land for rehabilitation facilities, there was still no government funding allocated to provision of physical rehabilitation services. In Nepal, all the sustainability indicators had been measured. A couple of months after the first workshop, Handicap International offered to take the lead and designate one of their project coordinators as the sustainability officer in charge of leading the sector on these issues. Through the initiative of this international organisation, an independent national consultant was commissioned in 2011 to collect further data to verify the estimates provided during the first workshop. During this assessment, 10 indicators could not be measured because of unclear definitions (i.e., no clear documentation on what the numerator and denominator were) and/or lack of existing data collection mechanisms. For example, data on the number of districts that have elaborated an action plan on disability is not routinely collected in information services primarily set-up to measure health service and human resource performance. Accessing this type of information would require comprehensively surveying district health offices and organisations, probably via field visits, which was beyond the financial resources available for the measurement exercise conducted in 2011. Data on the remaining indicators were published in a report circulated to the main actors of the rehabilitation sector (i.e., Ministry Officers, providers of rehabilitation services, and coordinators of rehabilitation programmes amongst international organisations). Although it is difficult to attribute the precise causes involved, evidence from qualitative discussions with stakeholders suggested that the SAP, through this process of discussion, consensus-building, data collection, and information-sharing, appeared to support the advancement of system sustainability in Nepal by encouraging the participation of major stakeholders outside the rehabilitation sector in sustainability initiatives between 2010 and 2012. Following the first workshop and lobbying from the main actors of the network, three Nepalese Ministries (whose representatives had been invited to the final presentation of the sustainability indicators) agreed to invest funds to improve the functioning of the rehabilitation system as a whole instead of targeting specific rehabilitation centres. Their initial idea of creating new rehabilitation centres in the country was changed after the rehabilitation actors presented their vision of the sustainability of the sector. As a result, the Ministries agreed to support existing facilities and initiatives. In contrast, in Somaliland, systems thinking and action was observed during this period only in an area peripheral to rehabilitation service delivery, on disability mainstreaming initiatives to increase government involvement in wider disability programming in the social sector [58]. This involved extensive collaborative work with actors across the rehabilitation system, under the auspices of the Ministry of Labour and Social Affairs. Partly, motivations for doing this work appeared to be in response to specific funded opportunities through government and international organisation channels. These, however, required a far lesser commitment of financial resources than opportunities for reform of rehabilitation services would have. There was also little evidence to suggest that information created during the SAP was used in these mainstreaming initiatives. While potentially laying the groundwork for systemic work on physical rehabilitation services in the long term, in the shorter term, over which this study was conducted, we found little evidence of systemic thinking helping to resolve the problems rehabilitation actors described facing to achieve their vision of sustainability in Somaliland. --- Discussion In this study, we compared the selection and use of self-defined sustainability indicators in two countries to analyse the influence of contextual factors and social network structure on the development of physical rehabilitation systems. Our assumption was that baseline differences between the two networks as well as the nature of relationships between actors would influence the way the sustainability indicators would be defined and used during follow-up. The definition of key sustainability indicators was implicitly influenced by network characteristics and actors' perception of their own system. In Nepal, the stakeholder network at baseline was decentralized and dense with a wide diversity of stakeholder types. Here, vision of the future system was inherently systemic, including concerns about the coverage of services but also how the actors of the system work together and how integration of new actors could increase system impact. The actors of the rehabilitation sector who were interviewed recognised the importance of creating unity between all the actors of the network in order to more effectively negotiate with national authorities and donors. Hence, a national body representative of all the rehabilitation providers (NASPIR) was created in Nepal. In Somaliland, where the stakeholder network was centralized in the capital city and low in density (few stakeholders and brokers), the vision of the future physical rehabilitation system was constructed around the two rehabilitation facilities, positioned at the very centre of the system, and mainly represented their perspective. They focused on the extension of the services towards the provinces. Social network analysis provides tools to identify knowledge brokers, i.e., individuals who create links between different groups within a system, such as between users and researchers, which was the case of the two rehabilitation centres in Somaliland [45]. The brokers in a health system also help coordinate actors in times of crises or shocks [59]. Other actors essential to the diffusion of innovations, such as opinion leaders, champions, or change agents, can variously be identified through the number of links they have with their peers or non-peer actors at different levels of the health system [60,61]. One assumption from social network analysis is that the position of actors in a network determines their capacity to access and diffuse knowledge and information or, in other words, control the flow of information [62,63]. A network with a central structure, such as Somaliland's, has more capacity to coordinate actors and provide a rapid response, which may be very important during humanitarian crises [64]. However, in Somaliland, during the 2-year post-conflict period that we observed, the central position of the brokers in this much centralised network blocked the circulation of information and the use of sustainability data. Promising developments within the wider disability social movement in the country may, however, help overcome some of these circulation blocks between brokers in the future if more actors are brought into the network, thereby de-centralising information and decision making in the system. The use of self-defined sustainability indicators by the system was also influenced by individual actors' survival strategies. At 2-year follow-up, the dense network in Nepal became even stronger as actors prioritised integration of services for organisational growth and survival and was an enabling factor in the utilisation of sustainability indicators [58]. The emergence of a local champion, the sustainability coordinator, who was granted legitimacy by professional organisations and financial support by an international organisation, facilitated communication necessary to continue system sustainability work in Nepal within the rehabilitation sector. On the other hand, in Somaliland, the changing nature of relationships between the two main brokers of the networks completely disrupted the circulation of information between actors due to the highly centralized, low-density structure of the rehabilitation sector. This resulted in no follow-up activities to monitor or use the self-defined indicators. The space and time horizons [11,32], which Somaliland stakeholders used to think about sustainability, shrank dramatically between 2010 and 2012 due to the interruption of international funding in the country. In formal network analysis terms, the "relationship" between the two main actors of the system disappeared in 2012 after they realised that their main and pressing priority was the survival of their own organisations. Midgley [65] showed that the decisions of individuals are primarily influenced by their survival instinct. Even well-documented evidence-based data cannot influence the decisions of an individual if the decision in conformity with the evidence represents a threat to his/her own interests and survival (e.g., professional career, family situation, or life threatening situation) [66]. When brokers shrank their sphere of intervention from the system to an organisation, the centralised stakeholder network in Somaliland, by nature of the relationships between brokers, suffered a bottleneck and therefore a barrier to systems thinking. As this study demonstrates, adopting a system thinking approach involves at least three elements. First, it is essential to understand the choices and decisions being made by individual actors; second, to understand the positions of actors within the system, recognising that the choices of some actors have disproportionate influence on the system as a whole; third, it is important to understand the wider context affecting changes in the system over time (i.e., the existing social networks and the relationships between actors), recognising that systems are dynamic, social entities which are in constant mutation or adaptation [67]. --- Conclusions The highly centralised structure of the social network in Somaliland had potential to help rapidly diffuse information between actors, which might be very useful in contexts of emergency (conflict or natural disaster). However, the rupture of relationship between the two central actors of the network completely disrupted the functioning of the rehabilitation sector and lead to the non-use of sustainability data in a sector that became the sum of dispersed actors. In Nepal, the cohesion between actors was maintained thanks to the role of a local champion and the injection of additional funds in the sector. The network remained very dense and decentralised and actors there appear to be gradually building a systemic vision of their sector, which takes account of data such as sustainability indicators for planning and negotiation purposes. These findings suggest that using sustainability indicators for a health system requires cohesion within the system between all (or most) actors, as well as an understanding, by actors, of the benefit of a collective vision for the sector. Contextual factors, such as the availability of funding for activities that primarily benefit the system rather than individual actors or organisations, can also support this. Further research is needed to analyse the different strategies that are required for health system interventions to alter the characteristics of social networks in social contexts for a collective good. --- Abbreviations DAN: Disability Action Network; SAP: Sustainability Analysis Process; SRCS: Somaliland Red Crescent Society. --- Competing interests The authors declare that they have no competing interests. Handicap International, Narayan Gopal Chowk Sallaghari, PO Box 10179, Kathmandu, Nepal. 3 Handicap International, 9 Rushworth Street, London SE1, UK. 4 Disability Action Network, Hargeisa, Somaliland. 5 Norfolk Community Services Board, 6401 Tidewater Dr, Norfolk, VA 23509, USA.

Background: Health systems strengthening is becoming a key component of development agendas for low-income countries worldwide. Systems thinking emphasizes the role of diverse stakeholders in designing solutions to system problems, including sustainability. The objective of this paper is to compare the definition and use of sustainability indicators developed through the Sustainability Analysis Process in two rehabilitation sectors, one in Nepal and one in Somaliland, and analyse the contextual factors (including the characteristics of system stakeholder networks) influencing the use of sustainability data. Methods: Using the Sustainability Analysis Process, participants collectively clarified the boundaries of their respective systems, defined sustainability, and identified sustainability indicators. Baseline indicator data was gathered, where possible, and then researched again 2 years later. As part of the exercise, system stakeholder networks were mapped at baseline and at the 2-year follow-up. We compared stakeholder networks and interrelationships with baseline and 2-year progress toward self-defined sustainability goals. Using in-depth interviews and observations, additional contextual factors affecting the use of sustainability data were identified. Results: Differences in the selection of sustainability indicators selected by local stakeholders from Nepal and Somaliland reflected differences in the governance and structure of the present rehabilitation system. At 2 years, differences in the structure of social networks were more marked. In Nepal, the system stakeholder network had become more dense and decentralized. Financial support by an international organization facilitated advancement toward self-identified sustainability goals. In Somaliland, the small, centralised stakeholder network suffered a critical rupture between the system's two main information brokers due to competing priorities and withdrawal of international support to one of these. Progress toward self-defined sustainability was nil.The structure of the rehabilitation system stakeholder network characteristics in Nepal and Somaliland evolved over time and helped understand the changing nature of relationships between actors and their capacity to work as a system rather than a sum of actors. Creating consensus on a common vision of sustainability requires additional system-level interventions such as identification of and support to stakeholders who promote systems thinking above individual interests.

Introduction Bullying is a pervasive and persistent threat to the well-being and school success of students. Bullying has been conceptualized a number of ways, with definitions varying slightly between countries, stakeholders (e.g., students, teachers, and parents), and scholars (Arora, 1996;Cheng, Chen, Ho, & Cheng, 2011;Cuadrado-Gordillo, 2012;Guerin & Hennessy, 2002;Mishna, 2004;Monks & Smith, 2006;Naylor, Cowie, Cossin, de Bettencourt, & Lemme, 2006; P. K. Smith et al., 2002;Vaillancourt et al., 2008). However, the most widely used definition of school bullying in the literature refers to it as unwanted aggressive behaviors enacted intentionally over time by a student or group of students using some form of power to cause physical and/or psychological harm to another student in a school setting (Gladden, Vivolo-Kantor, Hamburger, & Lumpkin, 2014;Olweus, 2013). A meta-analysis of 21 U.S. studies showed that on average, 18% of youth were involved in bullying The mere passage of a policy by legislators or a board of education does not mean that a policy will be immediately and efficiently put into operation precisely as intended. Indeed, implementation is a complex, dynamic, and ongoing process involving a vast assortment of people, resources, organizational structures, and actions. State education policies are implemented in school systems primarily by district officials (e.g., superintendents and central office administrators) and school personnel (e.g., principals, assistant principals, teachers, education support professionals [ESPs], counselors, psychologists, and social workers), who work directly with the ultimate beneficiaries of education policy: students. Like many public agencies, schools operate in an environment of local, state, and federal systems and the associated social, cultural, economic, and political factors, which can change over time (Fixsen, Naoom, Blase, & Friedman, 2005). These multiple systems and factors can facilitate or impede policy implementation, which is an already challenging process nested within a complex, multilevel education system. For a programmatic or policy intervention to accomplish its intended effects, it must be implemented with a high degree of fidelity (Carroll et al., 2007;Durlak & DuPre, 2008;Fraser, Richman, Galinsky, & Day, 2009). For policy interventions, fidelity refers to the extent to which a policy is implemented as intended based on the directives expressed in the policy document. Directives outlined in state anti-bullying laws vary somewhat but often require schools to formulate local bullying policies, train school personnel on the policy and bullying intervention, notify students and parents about the policy, establish procedures for reporting and investigating bullying incidents, establish appropriate consequences for bullies, and provide mental and behavioral health services for victims and bullies (Stuart-Cassel et al., 2011). Researchers have found considerable variability in the fidelity of implementation of policy interventions for bullying. For example, 51% to 98% of educators reported that their school systems had adopted a local anti-bullying policy in compliance with their state's policy (Bradshaw, Waasdorp, O'Brennan, & Gulemetova, 2011;Hedwall, 2006;Jordan, 2014;MacLeod, 2007;Robbins, 2011;Smith-Canty, 2010;Terry, 2010). In terms of training and notification regarding bullying policies, 46% to 94% of educators reported receiving training on the policy (Bradshaw et al., 2011;Hedwall, 2006;Holmgreen, 2014;Robbins, 2011;Smith-Canty, 2010;Terry, 2010), and 56% to 84% of educators reported that students were notified about the policy (Holmgreen, 2014;Jordan, 2014;LaRocco, Nestler-Rusack, & Freiberg, 2007;Robbins, 2011;Smith-Canty, 2010). Regarding school procedures, 60% to 94% of educators indicated that their school maintained procedures for reporting bullying (Holmgreen, 2014;LaRocco et al., 2007;Robbins, 2011), 78% to 92% of educators indicated that their school had procedures for investigating reports or complaints about bullying (Holmgreen, 2014;LaRocco et al., 2007;Smith-Canty, 2010), and 52% to 80% of educators indicated that their school provided mental health assistance to students involved in bullying (Hedwall, 2006;Holmgreen, 2014;Smith-Canty, 2010). These findings show that implementation fidelity varies across study locations and policy components. A policy must be implemented with a high degree of fidelity to have an effect and reduce bullying in schools. There are a number of possible reasons education policies are not implemented with a high level of fidelity: Financial and human resources were insufficient for implementation, parents and community members opposed the policy, the policy was written using vague or confusing language, school personnel do not support or do not know how to implement the policy, and the work environment may be overly demanding and constraining for school personnel (Fowler, 2013). Indeed, many educators are situated in schools with high-need students and limited resources where they are asked to respond to a host of student needs related to their physical, psychological, social, and educational development. In the current climate of high-stakes academic testing, any new mandate may feel overwhelming unless it is accompanied by budgetary and professional resources (Fowler, 2013). Thus, implementing a new policy on top of a multitude of existing responsibilities with insufficient resources may be quite burdensome for educators. Few studies have investigated the factors that act as barriers to or facilitators of school bullying policy implementation. Barriers to implementation included incomplete understanding of the policy by school members, poor agreement among personnel about what constituted bullying, bombardment of media attention about the policy, inadequate faculty and staff training, limited staff knowledge about bullying intervention strategies, lack of coordination among staff regarding protocols, lack of consistent follow-through by school personnel, lack of support from parents and school leaders, time constraints, and competing needs of students (Isom, 2014;LaRocco et al., 2007;Richman, 2010;Robbins, 2011;Schlenoff, 2014;Smith-Canty, 2010;Terry, 2010). Facilitators or drivers of bullying policy implementation include documents and tools developed by the district to assist school personnel with interpreting and implementing the policy (e.g., a flowchart of steps to take when investigating a bullying incident), prioritization of the policy by school and district leadership, and teacher commitment to stop bullying (Isom, 2014;Richman, 2010). --- Teachers Intervening in Student Bullying Teachers are the key actors involved in bullying intervention and prevention efforts (Newman, Frey, & Jones, 2010). In a national study, 92% of teachers indicated that bullying was problematic to some degree in their schools, and 98% of teachers agreed that it was their responsibility to intervene in bullying incidents (Bradshaw et al., 2011). However, almost half (45%) of the teachers had not received training on school bullying rules and procedures. Indeed, many educators have reported not feeling comfortable intervening or not knowing how to intervene in bullying (Bradshaw, Waasdorp, O'Brennan, & Gulemetova, 2013;Mishna, Pepler, & Wiener, 2006). Several barriers to educators addressing bullying have been identified, including lack of time, resources, and training (Bradshaw et al., 2013;Maunder & Tattersall, 2010;Mishna et al., 2006). In addition, teachers frequently felt both pressured to address student academic needs and exhausted from the demands associated with their many roles, which interfered with their capacity to effectively address bullying (Maunder & Tattersall, 2010;Mishna et al., 2006). Educators' intervening behaviors vary by individual and school characteristics. Compared with males, female educators were more likely to report responding to bullying (Bauman, Rigby, & Hoppa, 2008;Duy, 2013;Power-Elliott & Harris, 2012). Responsiveness may also differ by one's role in the school. Compared with teachers, school counselors were less likely to ignore a bullying situation (Bauman et al., 2008). And in terms of responses, teachers were more likely to discipline the bully and counselors were more likely to try and help the victim. No differences in responding to bullying were found by educators' age, education level, or years of experience (Bauman et al., 2008;Duy, 2013;Goryl, Neilsen-Hewett, & Sweller, 2013;Power-Elliott & Harris, 2012;Yoon, 2004). Results were mixed on the relationships between responding to bullying and teachers' empathy for victimized students as well as their self-efficacy in managing student behavior problems (Yoon, 2004;Yoon, Sulkowski, & Bauman, 2016). Teacher reports of socio-emotional variables related to the school climate have been positively associated with teachers' propensity to intervene in bullying, including feeling connected with the school, staff, and students; the quality of educators' relationships with students and parents; teacher trust in students, parents, colleagues, and the principal; feeling that the school environment is respectful and pleasant; perceptions of professional behavior among teachers; collegial principal leadership; and collective efficacy (Anderton, 2012;Hyde, 2014;Maunder & Tattersall, 2010;O'Brennan, Waasdorp, & Bradshaw, 2014;P. A. Smith & Birney, 2005;P. A. Smith & Hoy, 2004;Yoon et al., 2016). In addition, having resources available for bullying intervention in the school and receiving anti-bullying training were positively related to intervening (Bauman et al., 2008;O'Brennan et al., 2014). The relationship between teacher protection of students from bullying and the socioeconomic status of the school is unclear (Anderton, 2012;Hyde, 2014;P. A. Smith & Birney, 2005). The size of the student body (Hyde, 2014;P. A. Smith & Birney, 2005) and school type (e.g., elementary, middle, or high school) do not appear to affect teacher intervention in bullying (Bauman et al., 2008;P. A. Smith & Hoy, 2004). In sum, these findings illustrate that many individual and organizational factors can aid or impede educators' efforts to put bullying policies into practice and protect students from bullying; however, training, resources, intra-and inter-organizational coordination, competing needs and constraints, and the school climate may be particularly influential factors. Also, some factors do not appear to influence these processes, and the relationships between some explanatory factors and outcomes are still unclear. --- Purpose of the Current Study In this study, we intended to fill gaps in the literature by examining the relationships between school contextual variables that had not been used in previous studies (e.g., school geographic area, student to teacher ratio, and percent of students below grade level) and the outcomes of interest: fidelity of implementation of a bullying policy and teacher protection of students. This study also attempted to help clarify disagreements in the literature where some studies found significant relationships between contextual factors and outcomes and other studies found non-significant relations (e.g., school socioeconomic status and teacher protection of students). This study also improved on the methods used in other studies in the literature, which often relied on descriptive statistics and bivariate analyses as well as crosssectional designs, by using multivariate analyses, corrections for clustering, and data from two time points to examine predictive relationships between the independent variables and the outcomes. The current study used data collected from educators at the end of 2010 concerning the School Violence Prevention Act of 2009 (SVPA), which is the anti-bullying law in North Carolina, and school context data from the 2009-2010 school year. The purpose of this study was to examine the relationships between school contextual factors (i.e., school type, school geographic area, school size, student to teacher ratio, proportion of economically disadvantaged students, prevalence of student behavior problems, proportion of students above grade level in math and reading, student attendance rate, proportion of teachers with advanced degrees, teachers' years of teaching experience, teacher turnover rate, and the per pupil expenditure) during the outset of the implementation of the SVPA and two outcome variables: fidelity of implementation of the law and protection of students from bullying. The capacity of educators to implement components of an anti-bullying policy and protect students from bullying may indeed hinge on the school context. For example, some educators may be in schools where they are teaching and managing large groups of students who may present challenges in terms of missing school, struggling academically, and misbehaving. Such conditions may likely act as barriers to educators implementing a new policy and ensuring the protection of all students from aggressive behaviors. However, some educators may be in schools with smaller class sizes, higher levels of funding, fewer students from economically disadvantaged backgrounds, and fewer students with academic difficulties. Such conditions may likely facilitate educators' capacity for implementing new policies and intervening in student bullying. Based on the review of the literature above, the following hypotheses were developed: Hypothesis 1: Student to teacher ratio, proportion of economically disadvantaged students, proportion of students below grade level on end of grade tests, prevalence of student suspensions, and teacher turnover rate will be inversely related to teacher protection and implementation fidelity. Hypothesis 2: Student attendance rate and per pupil expenditure will be positively associated with teacher protection and implementation fidelity. Hypothesis 3: School type, school geographic area, school size, the proportion of teachers with advanced degrees, and the proportion of teachers with more or less years of experience will not be significantly related to teacher protection and implementation fidelity scores. --- Method Policy Design The SVPA was signed into law on June 23, 2009. In the law, bullying was defined as verbal, written, electronic, or physical actions that induced fear of harm or created a hostile environment for a student. Such behaviors were prohibited as well as bullying behavior based on actual or perceived race, color, ancestry, national origin, religion, gender, socioeconomic status, academic status, sexual orientation, gender identity, physical appearance, and disability. The law applied to behavior on school property, at schoolsponsored functions, and on school buses. According to the law, school personnel who witnessed or possessed information about bullying were required to report incidents to the appropriate school officials. However, students and school volunteers were encouraged but not required to report bullying incidents. The law also required that school districts adopt their own local anti-bullying policies by December 31, 2009 and train all school employees by March 1, 2010. Each local policy had to include the provisions described above in terms of the definition of bullying, prohibition of bullying behaviors, enumerated statuses protected, scope of the policy, and bullying reporting requirements as well as other components: --- 1. behavioral expectations for students and school personnel, --- 2. procedures for reporting bullying incidents, --- 3. identification of a school employee designated to investigate reports of bullying, --- 4. procedures for investigating reports of bullying incidents, --- 5. prohibition of reprisal or retaliation against individuals who reported bullying incidents, --- 6. consequences and appropriate remedial actions for students who committed acts of bullying, --- 7. plans to publicize and disseminate the local policy, --- 8. inclusion of the local policy in student and employee handbooks, and --- 9. inclusion of the local policy in employee training. The quality of the content of anti-bullying policies shapes their capacity to effectively reduce bullying. Two formal evaluations were completed on the content of the SVPA. First, the SVPA contains 13 out of 16 or 81% of key policy components identified in a national review of state anti-bullying policies by the U.S Department of Education (Stuart-Cassel et al., 2011). Second, a study found that the SVPA included 67% of protective factors identified in the literature as associated with reduced bullying behaviors, risk of bullying, or consequences from bullying (Weaver, Brown, Weddle, & Aalsma, 2013). The protective factor score for the SVPA was in the top 15% of state policy scores. These findings suggest that the content of the SVPA is good in that a majority of its components can potentially reduce or prevent school bullying. --- Study Design and Procedures This study involved a cross-sectional survey merged with administrative data on school contextual variables present the school year following the passage of the SVPA. Because school-level educators are the primary implementers of education policy, we surveyed members of a statewide professional association of educators and school employees in North Carolina. The survey was announced in an email message sent through the association's membership listserv. The email invitation contained a brief description of the survey, stating that it was focused on bullying, was optional and anonymous, and could be completed in 15 min. The email also contained a link to the welcome and informed consent page of the online survey. An online survey format was selected because of several advantages: Participants can respond to a Web survey at times and places convenient for them, participants can often complete Web surveys quickly, and participants may be less affected by social desirability bias in their responses because they are not directly disclosing the information to another person (Evans & Mathur, 2005;Granello & Wheaton, 2004;Rhodes, Bowie, & Hergenrather, 2003). In the survey, participants initially completed three demographic questions and were asked to identify the school and district in which they worked. Identifying their school allowed us to merge the survey data with school-level data. The remainder of the survey items assessed teacher protection of students and the implementation of the SVPA. No material incentives were used to solicit participation. The survey was available from mid-November 2010 to early January 2011. It can take 3 to 5 years from the time a school-wide policy or program is adopted to the time it can be implemented with fidelity and have a measureable effect (Bradshaw, Reinke, Brown, Bevans, & Leaf, 2008;Cooper, Fusarelli, & Randall, 2004). Evaluating fidelity may be more useful within the early stages of implementation to identify implementation problems and problems inherent in the policy design that may need to be addressed. Therefore, we decided to collect data on implementation a year following the date that school districts were required to enact local anti-bullying policies. --- Sample Of the approximately 5,000 educators who were invited to participate, 664 (13.3%) responded to the survey to some extent. However, 159 respondents were excluded because they did not complete the survey beyond the demographic items, worked in private or charter schools, worked in special education or vocational schools, or did not identify their school. These latter three criteria prevented merging the survey data with the school-level administrative data. Thus, a total of 505 participants were included for data analysis in this study, which was 10.1% of the educators invited to participate. Bivariate analyses comparing the 505 included and the 159 excluded respondents showed no significant differences in terms of the proportions of White, non-White, male, and female respondents. The sample of 505 educators included 78% teachers, 11% ESPs, 4% school administrators, 3% school counselors, 2% school social workers, and 1% school nurses. The racial/ethnic breakdown of the sample was 77% White/Caucasian, 17% Black/African American, 2% Hispanic/Latino/Latina, 1% American Indian or Alaska Native, and 3% multiracial/ multiethnic. The sample included 83% females and 17% males. These sample demographics are closely aligned with statewide representative demographic data of NC K-12 public school teachers, which shows that 81% of teachers were White, 16% were Black, 1% were Hispanic, 1% were American Indian or Alaska Native, 1% were Asian, 80% were female, and 20% were male (U.S. Department of Education, 2009). Respondents were employed in 324 schools in 85 (74%) of the 115 school districts in North Carolina. All of the participants worked in regular education K-12 public schools. The grade levels at the schools where participants worked varied with 40% in elementary schools, 2% in elementary-middle schools, 25% in middle schools, 3% in middle-high schools, and 29% in high schools. In terms of the geographic area of participants' schools, 62% were in small town or rural areas, 23% were in urban areas, and 15% were in suburban areas. These figures are similar to those among all NC K-12 public schools: 51% were elementary schools, 18% were middle schools, 21% were high schools, 5% were elementary-middle schools, 3% were middle-high schools, and 2% were K-12 schools (North Carolina Department of Public Instruction, 2012). And in terms of geographic area, 63% were in small town or rural areas, 25% were in urban areas, and 12% were in suburban areas. --- Dependent Variables Fidelity of bullying policy implementation-Fidelity of implementation of the SVPA was measured using nine items designed by a group of individuals who were involved in advocating for the passage of the SVPA, which included one educator, one parent, and two researchers. The items were constructed based on the content of the SVPA and assessed implementation fidelity of nine policy components. Fidelity of implementation related to protected social classes (i.e., race, national origin, gender, socioeconomic status, sexual orientation, gender identity, physical appearance, and disability status) was emphasized for two reasons. First, this aspect of the law was highly controversial during the formulation of the policy (Comer, 2009), and thus, might not be executed as intended. Second, youth who are vulnerable or members of minority groups are often targeted for bullying and report high rates of victimization (Elamé, 2013;Peguero, 2012). To assess implementation fidelity, participants were asked the following: 1. whether or not they had received training on the SVPA, with response options of yes and no; 2. how often they knew whom to report incidents of bullying to at their school, with response options of never, rarely, sometimes, most times, and always; --- 3. how often students at their school knew whom to report incidents of bullying to, with response options of never, rarely, sometimes, most times, and always; --- 4. which social statuses were protected from bullying in their school's local policy, and participants could select I don't know for the item or select yes or no beside each of eight social statuses; --- 5. whether they had received training about bullying based on the eight social statuses, and participants could select I don't know for the item or select yes or no beside each of the eight social statuses; --- 6. whether students in their schools had been informed that bullying was prohibited based on the eight social statuses, and participants could select I don't know for the item or select yes or no beside each of the eight social statuses; --- 7. how often employees at their school reported witnessing bullying incidents based on the eight social characteristics to the designated school official, with response options of never, rarely, sometimes, most times, and always; --- 8. how often school officials investigated reports of bullying based on the eight social status characteristics, with response options of never, rarely, sometimes, most times, and always; and --- 9. how often appropriate remedial action was given to students who perpetrated bullying based on the eight social status characteristics, with response options of never, rarely, sometimes, most times, and always. Fidelity scores are often expressed as percentages where 0% would indicate that an intervention was not at all implemented as intended and 100% would indicate that an intervention was completely implemented as intended (Linnan & Steckler, 2002). Using this logic, participants' responses were coded or calculated as percentages for the nine implementation variables. For Item 1, responses of yes and no or I don't know were coded as 100% and 0%, respectively. For Items 2 and 3, responses of never, rarely, sometimes, most times, and always were coded as 0%, 25%, 50%, 75%, and 100%, respectively. For Items 4 through 9, a percentage was calculated based on the number of yes responses selected out of eight. Thus, no yes responses received a 0% score, one yes response received a 12.5% score, two yes responses received a 25% score, and so on. Finally, an overall implementation fidelity score was calculated by averaging the nine percentages. Teacher protection of students from bullying-The protection of students from bullying was measured using a subscale from the Bully Index (P. A. Smith & Hoy, 2004), which is an educator-report measure assessing (a) perceptions of bullying among students at school and (b) teacher protection of students. Only the four-item subscale pertaining to teacher protection was used for this study. Participants were asked to think about the school in which they worked and rate their agreement with four statements (e.g., "Teachers in my school reach out to help students who are harassed by other students") using a 5-point Likert-type scale ranging from 1 (disagree) to 5 (agree). One item was reverse coded. A teacher protection score was calculated by averaging responses from the four items. Higher scores indicate higher levels of teacher engagement in protection of students in the school from bullying (P. A. Smith & Hoy, 2004). In other studies, this subscale has demonstrated acceptable to good internal consistency reliability (<unk>s =.73-.96) as well as evidence of convergent and divergent validity (Anderton, 2012;Hyde, 2014;P. A. Smith & Birney, 2005; P. A. Smith & Hoy, 2004). The internal consistency reliability of this subscale in the present study was <unk> =.77, which was acceptable. --- Independent Variables Individual-level variables-Three individual-level demographic variables of educators were measured: 1. type of educator, which included the following options: teacher, ESP, student service professional (i.e., school counselor, social worker, and nurse), and school administrator, which was the reference group; --- 2. educator race/ethnicity was recoded into a binary variable as person of color and White, which was the reference group; and --- 3. educator sex/gender included female and male, which was the reference group. --- School-level variables-School-level data collected through the North Carolina Department of Public Instruction for the 2009-2010 school year included the following variables: 1. school type (i.e., elementary, elementary-middle, middle, middle-high, and high school), with elementary as the reference group; --- 2. school geographic area (i.e., small town/rural, urban, or suburban), which was based on the coding scheme developed by the National Center for Education Statistics and the U.S. Census Bureau (U.S. Department of Education, n.d.), with urban as the reference group; --- 3. size of the student body in terms of average daily membership; --- 4. student to teacher ratio, which was attained by dividing the average daily membership by the total number of classroom teachers in the school; --- 5. percent of economically disadvantaged students (i.e., those eligible for free or reduced-price lunch); --- 6. number of short-term suspensions per 100 students; --- 7. percent of students scoring below grade level on the end of grade math test; --- 8. percent of students below grade level on the end of grade reading test; --- 9. student attendance rate; 10. percent of teachers with advanced degrees (i.e., master's, educational specialist, or doctoral degrees); --- 11. percent of teachers with less than 4 years of teaching experience; 12. percent of teachers with 4 to 10 years of teaching experience; 13. percent of teachers with more than 10 years of teaching experience; --- 14. teacher turnover rate (i.e., the percent of teachers in the school who left their positions in the past year); and --- 15. the total per pupil expenditure in dollars (i.e., the sum of local, state, and federal expenditures per student). --- Data Analysis Prior to analysis, a number of diagnostics were performed using Stata (Version 13) to examine the linearity between the independent and dependent variables, the distributions of the residuals, the distributions of the independent and dependent variables, influential outliers, heteroscedasticity, multi-collinearity, missing values, and clustering. Plots showed no clear departures from linearity, and the residuals were approximately normally distributed for both dependent variables. All of the non-categorical variables were approximately normally distributed except for the number of suspensions per 100 students. This variable had a positively skewed distribution, and thus, a natural log transformation was used to achieve a normal distribution. No cases of influential outliers (Cook's distance values > 1) were found, and no significant heteroscedasticity problems were found. However, two multicollinearity problems (variance inflation factor scores > 10) were found for the variables representing the proportion of students below grade level in math and reading. These two variables were highly correlated (r =.91, p <unk>.01), and thus, were averaged together to create one new variable. Eight percent of values were missing; thus, full information maximum likelihood (FIML) was used to handle missing data. This procedure allows for all cases to be included in analyses, even if they are missing values on some variables. FIML has been shown to perform better than listwise deletion, pairwise deletion, mean imputation, and multiple imputation in terms of generating unbiased estimates (Allison, 2012;Dong & Peng, 2013;Enders, 2001;J. W. Graham, 2009;Widaman, 2006). A final methodological issue that needed to be addressed in this study was the multilevel nature of the data-educators clustered within schools. Educators at the same school may share common characteristics on an outcome variable compared with those in other schools. Not accounting for clustering can lead to biased estimated standard errors and spurious results (Guo, 2005). Using the intraclass correlation coefficient (ICC) developed by Raudenbush and Bryk (2002), we examined the clustering effects for the two outcome variables. The ICC is the proportion of the total explained variation in an outcome that is attributable to differences between contexts, in this case, schools. Results showed that the clustering effects were low: ICC =.059 for implementation fidelity and ICC =.057 for teacher protection. These results indicate that less than 6% of the variation in the outcome variables is between schools. Therefore, problematic clustering effects were negligible. Generally, multilevel modeling is not necessary when the ICC is less than.10 (Heinrich & Lynn, 2001;Kreft, 1996;Lee, 2000;What Works Clearinghouse, 2008) because the results would most likely not be different than results from regression modeling. Nonetheless, the generalized Huber-White sandwich estimator (Rogers, 1993) was used to account for clustering in the models. Stata (Version 13) was used to analyze the data because it allows for correcting for clustering effects via the Huber-White sandwich estimator and FIML. --- Results Descriptive statistics showed that the extent to which the SVPA was implemented varied across schools and policy components (Table 1). To examine the relationships between school contextual factors and the outcome variables, we used multivariate robust regression modeling. Table 2 shows the means, standard deviations, and intercorrelations for the noncategorical study variables. School size was inversely correlated with teacher protection, and the prevalence of student suspensions was inversely correlated with both teacher protection and implementation fidelity. Fidelity of policy implementation was positively correlated with teacher protection of students. Two robust regression models were run predicting fidelity of policy implementation and teacher protection of students using the same set of individual demographic and school contextual variables for both models. Educator type, race/ethnicity, sex/gender, school type, and geographic area were dummy coded so that these categorical variables could be used as predictors in the models. Table 3 shows the results of the regression analyses, including unstandardized regression coefficients, standard errors, 95% confidence intervals, and R 2 values for the two models. The independent variables accounted for significant yet fairly small amounts of the variance in implementation fidelity (R 2 =.104) and teacher protection (R 2 =.130). In both models, school administrators rated policy implementation fidelity and teacher protection scores significantly higher than teachers, ESPs, and student service professionals. In addition, high school educators reported significantly higher implementation fidelity scores than those in elementary schools. Also, in this model, the number of students and prevalence of suspensions were significantly inversely related to implementation fidelity. Regarding the second model, elementary school educators had the highest teacher protection scores, and this difference was significantly higher when elementary school educators were compared with those in elementary-middle schools, which had the lowest teacher protection scores. --- Discussion Findings from this study indicate that the SVPA has not been implemented with a high level of fidelity in North Carolina schools. In fact, the results show considerable variability in the levels of implementation. For almost every policy component, scores ranged from 0% to 100%, which suggests that in some schools, educators are not implementing the SVPA at all, and in other schools, educators are implementing the SVPA as intended. A small part of this variability in implementation is due to school contextual factors that were present during the first school year following the passage of the SVPA into law. Two factors that acted as barriers to implementation included school size and student suspensions. Thus, as the number of students in a school increased, the fidelity of implementation of the SVPA decreased. Similarly, as the number of suspensions per 100 students increased, the fidelity of implementation of the SVPA decreased. One explanation for this finding rests on the assumption that suspensions are a consequence of a range of serious behavior problems among students. Historically, suspensions most often resulted from physical fighting, insubordination, class disruption, skipping class, drug use and selling, vandalism, and weapon possession (Cameron, 2006). Thus, educators in schools with high suspension rates may be facing a range of frequent student behavior problems and have less time to faithfully implement the components of a new policy. Another possible explanation for the finding is that suspensions are overused as a punitive response to serious and moderate student behavior problems, which contributes to an exclusionary school culture. In an exclusionary culture, certain students are excluded from fully participating in and benefiting from the education system (Brady, 2005). Research shows that Black and Latino/Latina students are more likely to be suspended and excluded from schools than White students for the same or similar behavior problems (Skiba et al., 2011). Thus, in schools where suspensions are frequently used for even minor behavioral infractions, which result in the exclusion of certain minority student groups, educators may be less inclined to implement elements of an anti-bullying policy that address bias-based bullying because there is a culture of exclusion at the school. Besides the current study, only one other study investigated the relationship between implementation of a bullying policy and school size. In this study of high school teachers, respondents from larger schools were more likely to report having a bullying policy at their school but were less likely to report understanding the policy, receiving training on the policy, being periodically reminded about the policy, and having school-wide systems in place to help victims and work with bullies (Hedwall, 2006). Being in a large school may hinder educators' capacity to consistently implement new bullying policy practices because larger organizational systems have more employees, which may involve challenges to communication, collective decision-making, and coordination of actions. Having a large number of school employees may also contribute to a diffusion of responsibility where educators may not take action in terms of following bullying procedures (e.g., reporting a bullying incident witnessed in the cafeteria to an administrator) because

Bullying is a significant problem in U.S. schools. Policies have been developed to reduce bullying, yet policy implementation by educators is an essential yet difficult and complex process. Few studies have investigated factors that act as barriers to or facilitators of bullying policy implementation and teacher protection of students. This study examined the influence of school context on educators' capacity to implement a statewide bullying law and protect students from bullying following the enactment of the policy. Data were collected from 505 educators in 324 schools. School administrators tended to rate fidelity of policy implementation and teacher protection of students higher than teachers, education support professionals, and student service professionals. Policy implementation fidelity scores were higher in high schools than elementary schools. School size and the prevalence of student suspensions were inversely related to implementation fidelity. Higher levels of teacher protection were reported in elementary schools.

). Thus, in schools where suspensions are frequently used for even minor behavioral infractions, which result in the exclusion of certain minority student groups, educators may be less inclined to implement elements of an anti-bullying policy that address bias-based bullying because there is a culture of exclusion at the school. Besides the current study, only one other study investigated the relationship between implementation of a bullying policy and school size. In this study of high school teachers, respondents from larger schools were more likely to report having a bullying policy at their school but were less likely to report understanding the policy, receiving training on the policy, being periodically reminded about the policy, and having school-wide systems in place to help victims and work with bullies (Hedwall, 2006). Being in a large school may hinder educators' capacity to consistently implement new bullying policy practices because larger organizational systems have more employees, which may involve challenges to communication, collective decision-making, and coordination of actions. Having a large number of school employees may also contribute to a diffusion of responsibility where educators may not take action in terms of following bullying procedures (e.g., reporting a bullying incident witnessed in the cafeteria to an administrator) because many other educators are present in the school and it is assumed that another adult will take action. Regarding teacher protection, scores differed by school type. Teacher protection scores were higher among elementary school educators compared with those in higher school grade levels; however, this difference was only statistically significant between elementary and elementary-middle schools. Compared with elementary schools, higher grade level schools generally have more students and larger student to teacher ratios, and students spend less time with teachers (Snyder & Dillow, 2013). In addition, after the elementary grades, the academic culture of school often becomes more focused on demonstrating high ability through testing and competing for grades, whereas the elementary grades focused on developing, mastering, and understanding knowledge and skills (Meece, Anderman, & Anderman, 2006). These systemic differences may influence the relationships and interactions between teachers and students as they progress out of the elementary grade levels. Studies show that relationships between teachers and students decline through elementary school and as students transition into middle school in terms of closeness and relationship quality (Jerome, Hamre, & Pianta, 2009;O'Connor, 2010;O'Connor & McCartney, 2007;Pianta & Stuhlman, 2004). Thus, teachers may become less nurturing and protective of students as they mature and transition out of the elementary grade levels. Results of the present study also showed higher levels of implementation fidelity in high schools as opposed to elementary schools. Higher levels of implementation fidelity in high schools may have been due to the focus on bias-based bullying in the measurement of fidelity. Six of the nine items assessing implementation of the SVPA focused on bias-based bullying (e.g., informing students that bullying based on race, national origin, gender, socioeconomic status, sexual orientation, gender identity, physical appearance, and disability status was prohibited). A nationally representative study showed that prevalence rates for bias-based aggression were significantly higher among high school-age students than elementary school-age students (Finkelhor, Turner, Ormrod, & Hamby, 2009). Physical bullying is most prominent among elementary school-age children, and biased-based attacks are quite rare (Finkelhor et al., 2009), which may be due to social-cognitive developmental differences. High school educators may have reported higher levels of engagement in implementing the SVPA because most of the survey items focused on bias-based bullying, which is more prevalent in high schools. We also found that school administrator scores on implementation fidelity and teacher protection were significantly higher than those among teachers, ESPs, and student service professionals. Two other studies of bullying policy implementation also found reporting differences between respondent groups. Compared with teachers and school counselors, school administrators reported higher levels of bullying policy implementation in terms of having a bullying policy, communicating the policy to members of the school community, reporting bullying incidents to appropriate officials, and disciplining perpetrators of bullying (Barnes, 2010;Jordan, 2014). In addition, compared with teachers and counselors, administrators were more likely to report that the school was effective at deterring and reducing bullying behavior (Barnes, 2010;Jordan, 2014). Findings from these studies as well as the present study suggest that school administrators' responses regarding actions to address bullying in their schools may be influenced by response bias. Administrators are the primary leaders of their schools and part of their identity as well as their job performance is likely tied to the successful operation of their schools. Thus, they may be influenced by a social or political desirability response bias in which it is advantageous to deny the presence of undesirable characteristics in their schools (e.g., failing to implement a new law) and to affirm the presence of socially desirable characteristics (e.g., teachers protecting students from bullying). --- Limitations This study has several limitations. First, this study did not use probability sampling, and thus, the sample may not be representative of educators across North Carolina. Another possible limitation was the somewhat low response rate; however, a low response rate does not necessarily lead to nonresponse error, and there are examples of surveys with lower response rates that were as accurate as or more accurate than those with higher response rates (Keeter, Kennedy, Dimock, Best, & Craighill, 2006;Krosnick, 1999;Visser, Krosnick, Marquette, & Curtin, 1996). The representativeness of a sample is more important than the response rate (C. Cook, Heath, & Thompson, 2000), and our sample demographics parallel those that are representative of teachers in the state. Second, numerous respondents were excluded from the analyses because they did not identify the school in which they worked, which prevented merging their data with school-level data. This resulted in a drop in sample size. Third, there may have been selection bias because educators who took the survey may have been more interested in bullying, and therefore, may have been overly critical in their assessment of the implementation of the SVPA and teacher efforts to protect students. However, participants' responses may have been influenced by social desirability response bias because educators were asked to report on legally mandated actions related to the SVPA and actions by teachers in their schools to protect students from bullying. Fourth, relevant explanatory contextual variables, such as the socio-emotional climate of a school, were not collected in this study, which could have provided richer assessments of school settings. Fifth, implementation was assessed at only one point in time, yet it is an ongoing process and additional assessments might have shown improvements in fidelity. A final limitation was that bullying was not explicitly defined in our measures, and therefore, some respondents may have included similar yet legally demarcated instances of other aggressive behaviors (e.g., discriminatory harassment) in their understanding of bullying. --- Future Research In the future, researchers should collect data from multiple respondent groups (e.g., administrators, teachers, and school mental health professionals) regarding bullying policy implementation and teacher protection of students to triangulate findings, and caution should be taken in relying exclusively on administrator responses. In addition, to attain larger, more representative samples, researchers should partner with state departments of education or public instruction and use some form of probability sampling. Studies examining bullying policies were more likely to have used probability sampling when researchers collaborated with educational agencies in their data collection (Hall, 2015b). Educational agencies have a vested interest in the implementation and success of anti-bullying initiatives, especially those codified as law. An area for future research could focus on differences in policy implementation and teacher intervention across types of bullying. Although there are several different types of bullying (e.g., physical bullying, verbal bullying, social/relational bullying, cyber-bullying, property bullying, and sexual bullying), anti-bullying laws vary in terms of which behaviors are specifically prohibited (Stuart-Cassel et al., 2011). Future research may reveal that addressing certain types of bullying may be more difficult than others (e.g., cyber-bullying vs. physical bullying). Future studies should also examine individual and school factors that may act as barriers to or facilitators of bullying intervention in terms of policy-related procedures and protective teacher behaviors. Individual factors could include educators' views of bullying as problematic or normative, support for anti-bullying policies and programs, and level of training and competency to intervene in bullying. School climate factors that may also influence anti-bullying efforts include respect for diversity, school connectedness, parent and community involvement, professional development, school resources and instructional support, and school leadership. Some states survey educators annually about the school climate because these data can be used to understand the quality and character of school life. Important school structural factors to include in future bullying-related studies concern levels of funding marked specifically for bullying initiatives and the presence of personnel in schools and district offices who are specifically responsible for overseeing or coordinating anti-bullying policies and programs. In addition to these variables, standard school characteristics (e.g., school size and teacher to student ratio) should still be collected and included in analytic models because they do account for some of the variance in the outcomes and such variables are uniformly collected from public schools across the United States and are publicly available. These contextual variables may moderate the relationships between individual, cultural, and structural factors and the outcomes. Additional research on the actions of educators as they continue to put bullying policies into practice in schools across the country and protect students from engagement in and the consequences from bullying is imperative to reduce the deleterious phenomenon of bullying. --- Author Biographies William J. Hall is a Postdoctoral Fellow in the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. His research focuses on the school experiences and mental health of lesbian, gay, bisexual, transgender, and queer youth. --- Author Manuscript --- Hall and Chapman Page 26 Note. School administrator is the reference group for educator type. Race/ethnicity was coded 0 = White, 1 = person of color. Gender was coded 0 = male, 1 = female. Elementary is the reference group for school type coded as 0. Urban is the reference group for geographic area coded as 0. CI = confidence interval. * p.05. Educ Policy (Los Altos Calif). Author manuscript; available in PMC 2018 June 19.

Bullying is a significant problem in U.S. schools. Policies have been developed to reduce bullying, yet policy implementation by educators is an essential yet difficult and complex process. Few studies have investigated factors that act as barriers to or facilitators of bullying policy implementation and teacher protection of students. This study examined the influence of school context on educators' capacity to implement a statewide bullying law and protect students from bullying following the enactment of the policy. Data were collected from 505 educators in 324 schools. School administrators tended to rate fidelity of policy implementation and teacher protection of students higher than teachers, education support professionals, and student service professionals. Policy implementation fidelity scores were higher in high schools than elementary schools. School size and the prevalence of student suspensions were inversely related to implementation fidelity. Higher levels of teacher protection were reported in elementary schools.

Introduction Population aging has become a global trend, which increases the demand for formal and informal care services for elderly people worldwide. To meet this demand, many developed countries in Europe and North America have promoted home-based elderly care, as this mode is preferred by clients [1,2]. Likewise, developing countries have also begun to provide community-based and home-based elderly care, since the traditional informal care provided by family members cannot meet the surging demand [3]. The global growth of the home-based elderly care industry has led to an increase in the number of in-home elderly caregivers in both developed and developing countries. Studies show that most in-home elderly caregivers in these countries are migrant women [4]. In contrast to formal care workers, i.e., nurses, who are well-studied as formal care workers in existing research, these in-home caregivers in the informal sector have not received enough attention from scholars [5][6][7][8][9][10]. To contribute to the current studies of care work, this paper explored the job satisfaction of elderly caregivers in home-based elderly care in developing countries, where the majority of people rely on the home-based elderly care system and the care work of in-home elderly caregivers. China is a typical rapidly aging developing country. According to the United Nations, the number of people aged 65 years or over in China accounted for 11.5% of the total population in 2019, and this proportion is expected to reach 16.9% by 2030 [11]. A variety of services is required to meet the needs of the increasing elderly population. In particular, China relies on the home-based care system to meet the rapid growth in demand for elderly care [12]. Although the public institutional care system is gaining prominence, homebased care is still the dominant form of elderly care in China [13]. Due to the influence of Confucian tradition, Chinese seniors prefer to spend their remaining years at home rather than in nursing homes [14,15]. A study also shows that only 1.16% of Chinese elderly people are covered by institutional care, while 98.84% still depend on in-home care [16]. Even long-term care in China is mainly home-and community-based and is provided through commercial and noncommercial community-based agencies [17]. Studies show that at least 10 million elderly care workers in the long-term care system have been trained and sent to urban families to provide service [18,19]. Therefore, in-home caregivers play a significant role in the elderly care system in China. These caregivers are formal and informal care workers employed by domestic service companies or agencies financed by the local government. With regard to home-based elderly care, current research revolves around whether the need has been met but has concentrated less on the quality of care [20][21][22][23][24]. However, the quality of care provided by the worker is key to guaranteeing older people's wellbeing and the quality of their daily life. Moreover, scholars find that the quality of elderly care is closely related to caregivers' job satisfaction [25,26]. Caregivers' job satisfaction refers to the extent to which a caregiver is satisfied with his or her job, reflecting their personal perception towards work and work experiences [27]. Previous studies have shown that caregivers with higher job satisfaction tend to have better job performance, which also have a positive effect on work commitment and workers' intent to remain in their current professions [28]. Caregivers' higher job satisfaction has been associated with higher efficiency and better quality of care service as well as higher care receiver satisfaction [29,30]. Furthermore, researchers find that job satisfaction is also directly and indirectly associated with their feelings of burnout, which refers to a psychological phenomenon including emotional exhaustion, depersonalization, and feeling of lacking in personal accomplishment [31]. To measure the burnout from these three dimensions, Maslach and Jackson developed the Maslach Burnout Inventory (MBI), which is frequently used in research on caregivers' burnout and job satisfaction [31]. With the MBA toolkit, researchers found that a complex relationship exists between caregivers' burnout and job satisfaction. Some scholars assert that burnout is a predictor of job satisfaction [10,32], while others argue that low job satisfaction might result in occupational burnout [33][34][35]. Both sides agree that high job satisfaction is associated with low burnout level [36,37]. Existing studies have examined the influence of multiple factors on caregiver job satisfaction, including personal characteristics, working conditions, training, and caregiverclient relationships. These studies have found that personal characteristics, such as gender, age, race, marital status, and education, have less of an effect on job satisfaction [38][39][40][41]. In contrast, working conditions play a more important role [42], among which the payment and benefit they receive, the length of working hours, work demands, promotion, supervision they face, and social relations with their colleagues all affect their job satisfaction [43][44][45][46][47]. It has been found that better working circumstances, such as opportunities for professional development and participation in decision-making, empower caregivers, contributing to their perception of support [48], which is beneficial for job satisfaction, resulting in positive job performance and high-quality care for care receivers [18]. Furthermore, studies show that training programs might improve caregivers' job satisfaction [49,50]. The information and technology received in training programs might improve caregivers' perception of support for their work. Moreover, the social relationship and interaction between caregivers and elderly people also affect caregivers' satisfaction and attitude [51,52]. Research findings show that caregivers were satisfied with their jobs if they received good feedback from the care recipients [53,54]. Although these studies have revealed the influence of personal characteristics, working conditions, training, and relationships with clients on job satisfaction, they are focused on institution-based caregivers, such as care workers in nursing homes. These findings may not be applicable for in-home elderly caregivers, because they are quite different from institution-based care workers. First, in-home elderly caregivers are mostly migrant women whose education is lower than that of institutional care workers such as nurses in the nursing home [55]. Second, the training received by in-home caregivers is less professional than that received by formal care workers. Third, their working conditions are different from those of formal care workers because their workplace, working time, and ways of promotion are unique. Furthermore, due to the COVID-19 pandemic lockdown, inhome elderly caregivers' job opportunities have become fewer compared with institutional care workers. During the pandemic, clients tend to reject the in-home elderly caregivers' attempts to enter their home, which interrupts these in-home caregivers' working arrangements, making their job more precarious [56]. However, the differences between in-home elderly caregivers and institutional care workers have not been adequately explored, as there are very few empirical studies examining the factors that are associated with job satisfaction among in-home elderly caregivers. Moreover, in contrast to care workers in the institutional care system, these in-home elderly caregivers are migrants, lacking social protection and welfare, which is also the most important difference between caregivers in institutional care and those in home-based care systems. Current studies of immigrants imply that the social protection and welfare they receive plays an important role in their work and daily life [57]. However, the relationship between welfare the caregiver receives and its influence on job satisfaction has not received enough attention from scholars. Therefore, this study explores the factors that affect the job satisfaction of in-home elderly caregivers using Respondent-Driven-Sampling of elderly caregivers (n = 285) from the Shanghai Domestic-work Professionalization Survey. It aims to facilitate policy makers such as Ministry of Human Recourse and Social Security of the People's Republic of China and the local government to develop policies to promote the elderly care system in China and to protect the elderly caregivers' social rights. It also contributes to the previous literature in two aspects. First, we focus on the job satisfaction of care workers who provide care to older people's families rather than to nursing homes. As in-home care workers in developing countries have been under-researched, our study may contribute to the discussion on the job satisfaction of care workers in countries where home-based elderly care is the foundation. Second, our work analyzes the influence of factors such as training, working conditions, and worker-client relationships in addition to discussing the effect of social protection and welfare on care workers' job satisfaction. In this way, our work may provide recommendations to enhance job satisfaction related to social welfare. --- Materials and Methods --- Data and Design This study utilizes data from the Shanghai Domestic-work Professionalization Survey (CDPS). CDPS was funded by The National Social Science Fund of China and conducted from early May to early September in 2021 in Shanghai based on the Respondent-Driven-Sampling approach. The aim of this research is to identify factors which may help improve the job satisfaction of elderly caregivers in a home-based elderly care program. This could help policy makers such as Ministry of Human Recourse and Social Security of the People's Republic of China and the local government to formulate policies to promote the quality of elderly care and guarantee the elderly caregivers' social rights. Three predefined respondent inclusion criteria include: (1) respondents must provide domestic work services for a private family, instead of purely for other organizations such as, but not limited to, a corporation and a government department; (2) prior to interview, respondents must have undertaken domestic work for more than three months; and (3) the geographical range of domestic work service is restricted to Shanghai. All interviews were conducted face-to-face. Twelve initial seeds were selected based on previous fieldwork among four occupations: maternal-child caregivers (6), houseworker (1), elderly caregivers (2), and cleaners (3). Each respondent was rewarded with 50 RMB (about $7.70) for answering the questionnaire, and with 10 RMB (about $1.50) for each successful recruitment. In order to record referral chain information, each participant was assigned three coupons labeled with a specific number. In this way, CDPS acquired a total sample size of 1000, and a design effect of each characteristic greater than two, which enhances confidence in the sample. For the purpose of this study, we selected the samples who were elderly caregivers, which resulted in a size of 285. The questionnaire was divided into seven blocks across 79 items, containing questions about personal characteristics, working conditions, employment status, job satisfaction, psychometric characteristics, use of internet, and home-based clients. --- Variables The personal characteristics variables included gender, age, level of education (no education completed, primary school, junior high school, high school, vocational high school, technical secondary school, college, undergraduate, and above), and marital status (married, divorced, widowed, single). In terms of working conditions, respondents were asked about annual income, number of rest days per month, and the type of care work (lived-in, day shift, hourly). With regard to employment status, respondents were inquired about the type of contract (no contract, labor contract, tripartite agreement, private agreement with clients) and how they received their job (relatives and friends, agencies, internet, others). In terms of training, respondents were asked about whether the company provided training, whether they have received training, and the number of certificates they have obtained. Respondents were also inquired about their relation with clients (very good, good, common, bad, very bad). In terms of welfare, respondents were asked about social insurances they have obtained. Lastly, in terms of work experience, respondents were acquired about in which year they started to work as in-home elderly caregivers. Some of the categories of these variables were merged in the regression model, to achieve a more balanced distribution of the sample size by category and a better model result. The merged categories are reported in the next section. Job satisfaction included four items, scored from 1 (not at all satisfied) to 5 (very satisfied): work income, relationships with clients, professional status, and working conditions. Considering the relevance of individuals' psychometric characteristics to job satisfaction, we examine the burnout levels of in-home elderly caregivers as a supplement to our analysis. We selected two types of items to reflect burnout. Type 1 included five items, scored from 1 (never) to 5 (always), regarding the frequency of feelings of lack of breaks, disruption of sleep, need for emotional adjustment, breakdown, and loss of interest. Type 2 included two items, scored from 1 (strongly disagree) to 5 (strongly agree), regarding whether the respondent likes the job, and whether the job can help the respondent meet more people. These items are an approximation to Maslach Burnout Inventory (MBI), although CDPS has not strictly adopted MBI. --- Statistical Analysis We first conducted a factor analysis on the job satisfaction variables and on the burnout variables to determine the specific factors associated with the level of job satisfaction and the level of burnout among elderly caregivers. Multiple regression models were then constructed to identify the personal and professional characteristics associated with job satisfaction followed by the correlation analysis between job satisfaction and burnout levels, as well as a supplementary multivariable analysis for burnout levels of in-home elderly caregivers. All the statistical analyses were conducted using Stata 16. --- Results Table 1 shows the descriptive analysis of the personal characteristics and employmentrelated status of the respondents. The majority (94%) of the respondents were women. The median age was 51 years. Almost 85% of the respondents had only completed junior high school and below. The most common marital status was married, accounting for more than 90%. On average, the sample received <unk>62,004 (equivalent to $9300) per year and rested 1.7 days per month. More than 61% of the respondents were hourly workers, and around 24% were lived-in workers. The most common ways for them to obtain their jobs were through relatives and friends (49.1%) and agencies (39.3%). Almost 55% of the respondents were in a labor contract, but almost 29% had no contract at all. Over 81% of the respondents had training experience, and the respondents had acquired 1.6 certificates on average. Nearly 59% of the respondents were working for companies which had provided training opportunities. Regarding the relation with clients, more than 54% of elderly caregivers had a very good relationship with clients. In terms of social insurance, a total of 88% of respondents were only covered by the new rural cooperative medical insurance, and only 12% were able to enjoy the three or five insurances provided by the state and companies. The average work experience of the elderly caregivers was 6.2 years. The results for the levels of job satisfaction are reported in Table 2. We first performed correlation analysis using the KMO and Bartlett Sphericity tests. The KMO value was 0.715 and the p value was below 0.05, indicating that the original variables were suitable for factor analysis and the principal component analysis (PCA) could be conducted. Furthermore, the Cronbach's alpha was 0.6898, which provided evidence for the scale reliability. Using the varimax rotation approach with the threshold of eigenvalues of principal components as 1, we obtained one factor that captures the majority of variation in the job satisfaction of elderly caregivers in the home-based elderly care program (Table 3). The results of PCA show that the cumulative contribution ratio of the first principal component variance is 52.65%, indicating that we could use only one factor to capture most variations in individuals' job satisfaction levels. The psychometric characteristics related to burnout are reported in Table 4. The KMO and Bartlett Sphericity tests showed that the KMO value was 0.724, the p value was below 0.05, and the Cronbach's alpha was 0.7206. Then, using the varimax rotation approach with the threshold of eigenvalues of principal component as 1, we obtained two factors that capture the majority of variation in burnout of caregivers in the home-based elderly care program (Table 5). Factor 1 is related to emotional exhaustion, and factor 2 is related to lack of personal accomplishment. The cumulative contribution ratio of the first two principal component variances was 55.61%, which indicates those two factors explain the majority variations in burnout levels. In order to analyze the impact of each independent variable more intuitively and to enhance the interpretability, we standardized the factor scores to construct indices of job satisfaction and burnout (emotional exhaustion and lack of personal accomplishment) ranging from 0 to 100, on which the following regression analysis will be based (Table 6). The conversion adopts the following formula: Standardized factor value = (factor valuefactor (min)) <unk> 100 <unk> (factor(max)factor(min)). Table 7 shows the results of two multivariable linear regression models using the index of job satisfaction dependent variable with a confidence level of 95%. Model 1 includes independent variables regarding personal characteristics, working conditions, employment status, training, relation with clients, and social insurance, while model 2 includes all these independent variables as well as work experience. We first examined the results of model 1. In terms of personal characteristics, gender and marital status are significantly associated with job satisfaction. Men were less likely than women to have a higher level of job satisfaction, and divorced elderly caregivers were less likely than those married to have a higher level of job satisfaction. Age and the education level showed no significant association. All the independent variables regarding working conditions (annual income, number of rest days per week, the type of care work), and training (whether the company provided training, whether they have received training and whether they have obtained certificates) were not significantly associated with the level of job satisfaction. In terms of employment status, ways to find jobs were significantly associated with job satisfaction, while the type of contract showed no significant association. However, independent variables regarding the relation with clients and the social insurance were found to be significantly associated with the level of job satisfaction. Elderly caregivers who have a very good relation with clients were more likely to enjoy a high level of job satisfaction than those who do not have a very good relation with clients. In terms of the social insurance, those who were covered by five insurances were more probable to have a higher level of job satisfaction compared with those who were only covered by new rural cooperative medical insurance. Five insurances are the most complete type of social insurance for the workers that are provided by the state and the company, while the new rural cooperative medical insurance is the most basic health social security that is purchased by rural residents themselves. As the results of model 2 show, work experience was significantly associated with higher job satisfaction. When including work experience as an independent variable, marital status, relation with clients, and social insurance were still significantly associated with job satisfaction, while gender and ways to get jobs no longer showed significant association. Different from model 1, those who were covered by three insurances, rather than five insurances, were found to be more likely to have a higher level of job satisfaction, compared with those who were only covered by new rural cooperative medical insurance. We also explored the correlation between job satisfaction and burnout. As Table 8 shows, emotional exhaustion and lack of personal accomplishment are negatively associated with the level of job satisfaction with very high statistical significance. Thus, it is necessary to take burnout levels into account when analyzing job satisfaction. We have carried out multivariable linear regressions to identify factors related to emotional exhaustion and lack of personal accomplishment, which showed that those who were covered by five insurances, rather than three insurances, were found to be less likely to suffer from lack of personal accomplishment, compared with those who were only covered by new rural cooperative medical insurance. The detailed analysis is included in Appendix A. The complex relations between job satisfaction, burnout, and other factors are worth more nuanced analyses in the future. --- Discussion This study scrutinizes factors that influence the job satisfaction of elderly caregivers in a home-based elderly care program, including personal characteristics, working conditions, employment status, training, relationship with clients, social protection and welfare, work experience, and burnout. These caregivers provide home-based elderly care in Shanghai. More than half work on an hourly schedule, but some still work as live-in workers. Coinciding with the findings of previous studies, most of the in-home elderly caregivers in Shanghai are rural married migrant women who have low levels of education [55]. Consistent with the results of studies on migrant workers, low levels of education play a less important role in job satisfaction [58]. Social insurance, which represents social protection and welfare from the state, plays the biggest role [59]. This result is consistent with findings of research on migrant workers that these workers from rural regions are treated as second-class citizens in cities because of the household register system in China [60]. However, marital status does affect their job satisfaction, which is different from the results of research on caregivers in other countries [38][39][40][41]. This might be a result of the influence of familialism in China [61]. Divorced rural migrant women tend to encounter stigma in their working environment, which might result in a negative perception of their job. Moreover, our research contributes to the current discussion on caregivers' job satisfaction by finding that social insurance plays an important role in in-home elderly caregivers' job satisfaction, which has seldom been discussed in previous studies. Filling in this blank, the results of our model show that the job satisfaction of caregivers with Five Insurance or Three Insurance plans is higher than those with new rural cooperative medical insurance. In China, social insurance represents the social protection and welfare provided by the state. Since 1958, the Hukou (household registration) system has assigned Chinese citizens either a rural or urban Hukou status [62]. Although migrant workers leave their village to work in cities, they are still regarded as rural residents with rural Hukou in this system. The socioeconomic differences between rural and urban residents have been reflected in inequalities in the welfare they receive. As an important component of welfare, rural and urban residents are often covered by quite different social insurance schemes. According to the Hukou system in China, rural residents only participate in new rural cooperative medical insurance, which is heavily subsidized by the government of their hometown, while urban citizens participate in Five Insurance programs (pensions, housing provident funds, work injuries, unemployment, and medical insurance), which are heavily financed by the cities in which they live [63]. Due to the household registration system, migrant workers moving from rural areas to urban regions have difficulty participating in the Five Insurance programs. Not recognized as urban citizens, they do not have urban Hukou and are not entitled to urban social insurance schemes [62]. Gao, Yang, and Li's study showed that only a small proportion of rural-to-urban migrant workers with long-term contracts are allowed to participate in the Five Insurance programs [59]. These workers are often regarded as a privileged group among migrant workers. Moreover, the number of workers participating in the Three Insurance programs is also limited. These are also heavily subsided by the urban government, but only include three types of insurance: pensions and medical and unemployment insurance. As the welfare provided by the state, the Three Insurance programs is superior to the new rural cooperative medical insurance but inferior to the Five Insurance programs. Most migrant workers still participate in new rural cooperative medical insurance. Not covered by either the Five or Three Insurance programs, most migrant workers lack work and life security. Their basic work and life rights are not well-protected. As rural-to-urban migrant workers, only a small proportion of in-home elderly caregivers participate in Five Insurance or Three Insurance programs [55]. Our research shows that most of these caregivers are still covered by new rural cooperative medical insurance. The in-home elderly caregivers participating in Five Insurance or Three Insurance programs, who have more welfare to guarantee their work security and labor rights, have a higher level of job satisfaction than those with rural cooperative medical insurance. This highlights that the relationship between job satisfaction and welfare, such as social insurance, should not be neglected by researchers. Relationships with clients were significantly associated with in-home elderly caregivers' job satisfaction. The results of our models show that in-home elderly caregivers who have a very good relationship with clients have a higher level of job satisfaction than those who do not have a very good relationship with clients. The results imply that a better relationship with clients might contribute to a higher level of job satisfaction among caregivers. These findings coincide with the literature on in-home caregivers' labor process, which concludes that frequent conflict between clients and in-home caregivers might result in the distress of caregivers [60]. Home-based elderly care relies on face-to-face interaction between clients and caregivers. The clients' strict labor control of caregivers tends to engender a feeling of alienation and burnout among caregivers [64]. Previous studies show that in-home caregivers sometimes encounter emotional abuse and sexual harassment from their clients, which leads to trauma, undermining their devotion to care work [65][66][67][68]. In contrast, the semi-familial relationship between clients and in-home caregivers might convey emotional feedback and support, which reinforces caregivers' work identity and enthusiasm [69]. Therefore, relationships with clients play an important role in the job satisfaction of in-home elderly caregivers. Work experience in the profession also showed significant association with in-home elderly caregivers' job satisfaction. The model results demonstrate that those who have been working for more years in the profession are more likely to enjoy a higher level of job satisfaction [70]. This is different from the findings of research on home care in Taiwan, which revealed that caregivers with more years of working experience were more likely to have a lower level of job satisfaction. However, this coincides with the findings of other studies, which suggest that formal caregivers in hospitals with more work experience have a higher level of job satisfaction [71][72][73][74]. One reason might be that senior caregivers tend to adjust better to the work environment than their younger colleagues [71][72][73][74]. Another reason for this might be that healthcare professionals who have found more strategies to maintain their satisfaction are more likely to survive in their profession [75]. However, the results of this research show that working conditions, including income, rest days, and type of work, have no significant effect on in-home elderly caregivers' job satisfaction in Shanghai, which is not consistent with the findings of previous studies on caregivers in institutional care systems, such as nursing homes, in other countries. In contrast to caregivers in nursing homes, most in-home elderly caregivers in Shanghai are middle-aged rural migrant women who lack opportunities for professional development and decision-making in their working environment. According to ethnographic research, these middle-aged rural migrant women are a homogeneous group whose status in the labor market is low and whose length of work is long [76,77]. Furthermore, home-based elderly care is deemed "dirty" and "bad" work, in contrast to other types of care work, such as childcare [77]. Like other migrant workers, they depend on their social network, such as relatives and friends, to seek job opportunities [78]. Their ways of finding work and their contractual status have no significant effect on their job satisfaction. In addition, the training programs were not significantly associated with the in-home elderly caregivers' job satisfaction. This is different from the results of previous studies, which have shown that whether companies provide caregivers with continuous training and whether the caregivers receive training are positively related to the level of job satisfaction [5,79]. In contrast, our model shows that 81.8% of respondents have received training, but the experience of receiving training is not significantly associated with the job satisfaction of the in-home elderly caregivers. Furthermore, there is also no significant association between whether the company provides training or not and the job satisfaction of in-home elderly caregivers. In addition, our research shows that the number of certificates and the in-home elderly caregivers' job satisfaction are not significantly associated. The reason for this might be that the training they receive tends to be irrelevant to their work demands. This has been largely discussed in previous studies on in-home caregivers' training, which reveals that the training received by in-home caregivers is often not related to their work and thus is deemed useless by caregivers [4]. Lastly, our research reveals the complex relationship between in-home elderly caregivers' job satisfaction and their psychological status such as burnout. The results demonstrate that the level of job satisfaction is negatively associated with emotional exhaustion and lack of personal accomplishment with very high statistical significance, which implies that in-home elderly caregivers' job satisfaction is negatively associated with their burnout level. This is consistent with the findings of previous studies, which suggest that emotional exhaustion and lack of personal accomplishment might lead to low job satisfaction [10,32], and high job satisfaction could relieve the emotional exhaustion and contribute to a low level of burnout [33][34][35]. --- Limitations This study has certain limitations. First, this study used the Respondent-Driven-Sampling approach and, therefore, has the limitation inherent to this type of sampling method. Although RDS sampling is most suitable for the group of migrant workers who have no sampling frame, some sampling error is still difficult to avoid. Second, the sample is limited to Shanghai, which is one of the largest metropolises in China; therefore, the results should be complemented by research on in-home caregivers in other types of cities before being generalized to a national scale. In-home elderly caregivers in small cities are not migrant workers; therefore, their welfare, such as the social insurance scheme they participate in, is different from those in large cities such as Shanghai. However, our research could serve as a foundation for future studies on in-home elderly caregivers in other cities and even countries. Thirdly, this study has not adopted the Maslach Burnout Inventory to explore the psychometric characteristics of the respondents, although the existing items are an approximation to some of the items in MBI. Separate studies on burnout of in-home elderly caregivers can be carried out in the future using MBI. --- Conclusions Examining the job satisfaction of in-home elderly caregivers in Shanghai is essential for promoting the quality of home-based elderly care in the long-term care system and enhancing the elderly care system in developing countries. As the most important type of workers in the long-term care system, in-home elderly caregivers' job satisfaction affects their work performance, retention, and elderly clients' satisfaction. In our research, job satisfaction includes four aspects: satisfaction with work income, relationships with clients, employment status, and working conditions. We analyzed the relationship between job satisfaction and personal characteristics, working conditions, training, relationships with clients, welfare, work experience, and burnout. We found that, for these in-home elderly caregivers, one of the most important factors that contributes to a higher level of job satisfaction is the social protection and welfare that these migrant workers receive from the state. Coinciding with previous studies, our research shows that personal characteristics play a less-important role, while the relationship with clients and work experience have a significant influence on the job satisfaction of in-home elderly caregivers. It also found that in-home elderly caregivers' job satisfaction is negatively associated with their burnout level. Our results contribute to the current literature on long-term care in two dimensions. The first dimension is that improving working conditions and providing training programs may not be enough to increase the job satisfaction of in-home elderly caregivers, who are mainly middle-aged migrant women in developing countries. Another dimension is that social protection and welfare, such as social insurance, are important factors for improving the job satisfaction of in-home elderly caregivers, which may also contribute to better work performance among these workers and better quality of home-based elderly care. These two dimensions of results are relevant to policy makers such as the Ministry of Human Recourse and Social Security of the People's Republic of China and the local government. Due to the future need of in-home elderly caregivers in the long-term care system, a more comprehensive understanding of factors affecting these caregivers' job satisfaction would be helpful for formulating supportive policies in the elderly care sector. In addition, welfare from the state, such as social insurance, should be considered if policy makers want to enhance in-home elderly caregivers' work performance and the quality of long-term care, particularly in large cities. --- Data Availability Statement: Data are not available due to confidentiality. --- Acknowledgments: The authors are grateful to the reviewer's constructive comments, which have helped improve the quality of the paper. --- Author Contributions: Y.S. and X.R. conceived the study and designed the concept. Y.S. and Z.Z. collected the data. Y.S. and X.R. were responsible for the manuscript. Z.Z. analyzed the data and was responsible for the providing the results. All authors contributed to the discussion. All authors have read and agreed to the published version of the manuscript. Institutional Review Board Statement: All the participants were informed of the aims of this study and participated voluntarily. The study worked with anonymized information. --- Informed Consent Statement: The completion of the questionnaire was considered to imply informed consent. --- Conflicts of Interest: The authors declare no conflict of interest. --- Appendix A

Population aging has increased the demand for elderly care worldwide. The home-based elderly care system plays an important role in meeting this demand in developing countries. The quality of home-based elderly care is associated with the job satisfaction of caregivers in home-based elderly care programs, which has rarely been studied. This paper explores the factors that affect the job satisfaction of these elderly caregivers, including personal characteristics, working conditions, employment status, training, caregiver-client relationships, welfare, work experience, and burnout. It utilizes data from the Shanghai Domestic-work Professionalization Survey (SDPS), which was conducted among four types of in-home caregivers (n = 1000) in Shanghai over the period from May to September 2021. This paper selected a sample of elderly caregivers (n = 285) to examine their job satisfaction. The results show that gender, age, marital status, how they earned the job, relation with clients, social insurance, and work experience are significantly associated with the job satisfaction of in-home elderly caregivers, and their job satisfaction is negatively associated with their burnout levels. However, training and working conditions have no significant effect on the job satisfaction of in-home elderly caregivers, which is different from previous studies on formal care workers, such as nurses, in the institutional care system.

INTRODUCTION Contemporary urbanization is a global multidimensional process, which manifests itself through changes in human population densities and land cover that are so rapid that we lag behind in understanding the process and its consequences. At the same time, we are facing an increasing uncertainty due to climate change, migration of people, and changes in the capacity of ecosystems to generate goods and services. In an urban context, this means that the traditional paradigm of planning for a predictable future is not only insufficient, but it may, in some ways, also be destructive. This article strives to lay a foundation for transitions in urban planning and governance, which enable cities to navigate change, build capacity to withstand shocks, and locate sources of experimentation and innovation in face of uncertainty. The city can be thought of as an agglomeration of contested spaces that generate a range of urban services, from transport, housing, and medical aid, to jobs and financial markets (Harvey 1996). A presumption in this article is that such services are inextricably linked to ecological processes and the focus lies on such ''ecosystem services,'' i.e., the benefits urban inhabitants and cities derive from ecosystem processes including, e.g., improved water and air quality, storm protection, flood mitigation, sewage treatment, micro climate regulation, and recreation and health values (Daily 1997;Bolund and Hunhammar 1999;Elmqvist et al. 2008). As ecological processes are in turn modified and entangled in social, and therefore political processes (most obviously through competing landuses), the city comes into view as constituted out of political social-ecological processes (Swyngedouw 2006;Pickett et al. 2008;Grimm et al. 2008). Based on this, a normative strategy for urban governance would be to maintain or even enhance essential ecosystem services and to accomplish this in ways that recognize the spatial distribution of ecosystem services and their relation to social equity. The two-fold proposition of this article is that resilience theory from ecological research can contribute to our thinking on this normative goal, and that cities can help challenge traditional propositions used by resilience theorists when addressing human-dominated ecosystems. Our belief is that a resilience theory for human-dominated ecosystems is critically needed because such ecosystems are spreading across Earth. In order to facilitate our discussion, we employ three important case studies-New Orleans, Cape Town, and Phoenix-these cities being suitable since they bring forth some of the most challenging issues of contemporary urbanization: climate change and rising sea levels, growing inequity in the access to resources, conflicts over water use between urban growth and agriculture, and the challenges of energy use and urban sprawl. Through pairing insights from our ongoing research in these cities, with ideas from geography and sociology, we will make four arguments that together aims to broaden the theoretical discussion regarding urban resilience: • First argument will exemplify how urban socialecological processes often work at different scales and how cross-scale interactions can be a key in driving changes in slow variables to push urban systems across thresholds; • Second argument will utilize findings from geography, which position cities as part of ''systems of cities'' and reconceptualize cross-scale interactions as interdependencies between technical and social networks that tie cities together and sustain flows of energy, matter, and information; • Third argument will draw upon findings that demonstrate that cities are extreme innovation hubs, with important impacts on technology, economy, and social organization; • Fourth argument will discuss how to harness urban innovation, in the context of the politicized environment of the city, so as to make urban governance more sensitive to ecosystem dynamics and proactive in facing interlinked social-ecological uncertainties. The last argument implies a call to combine systemic and functional understanding of cities (through resilience theory), with cultural critique and political perspectives. We limit our discussion to the quite well-resourced cities in high-and middle income countries. Resilience theory-in its current form closely linked to complex adaptive systems theory (Levin 1998)-models reality as consisting of identifiable parts that through localized interaction (process) produce stable patterns (structure) across temporal and spatial scales (e.g. Holling 1973;Gunderson and Holling 2002;Berkes et al. 2003;Folke 2006). These patterns could be plants and pollinators that interact to produce landscape patterns, or the extension of a city through car transport generating sprawl. A key thought is that ''positive feedbacks,'' i.e., processes and structures that mutually reinforce one another sustain dynamic and path-dependent stability regimes that shape and govern system dynamics (and thus influences localized interaction). Indeed, these processes of self-organization create systems far from equilibrium, characterized by external input and multiple possible outcomes of system dynamics (Levin 1998). Through often unnoticed slow changes in these structuring processes (indicated through changes in ''slow variables''), the system can pass thresholds and reorganize-often triggered by a period of rapid change or disturbance-into a new regime in which system dynamics are qualitatively different. This is depicted in Fig. 1 where changes in two slow variables (along the x and y axes) are seen as ''moving'' the system on an ''equilibrium surface'' that is folded upon itself generating inherent thresholds (Zeeman 1977). As the system moves, its current stability regime changes shape (Fig. 1b), demonstrating that as resilience declines, systems are exposed (a) shows a simplified image of how changes in slow variables can produce a regime shift. An example trajectory of a regime shift is followed from A to B. Even in A', there is no great noticeable change in system dynamics, but as the system moves through a threshold at X, a rapid reorganization into a new stable regime with qualitatively different system dynamics occurs (see Holling 1973;Zeeman 1977;Levin 1998;Gunderson and Holling 2002). It is consequently not necessary for a system to experience a disturbance to ''fall into'' regime B. However, and as illustrated in bottom figure (b), as the system looses resilience (lower and lower depth of valley A), it takes smaller and smaller disturbances for the system to be ''pushed'' across the threshold X (i.e., to be pushed over the middle peak x) so as to fall into state B. The combination of changes in slow variables (e.g., sea level rise, duration of dry spells) can thus move the system closer to thresholds, where disturbances (e.g., tsunamis, droughts) can trigger disasters. For coupled social-ecological systems, the set of ecosystem services in A can be markedly different from those in B to greater risks, uncertainties, and surprises; it often takes progressively smaller shocks for that system to lose its capacity to sustain a certain regime. Often disturbances and changes in slow variables are influenced by cross-scale interactions and likewise should ecosystem services be seen as emergent from interlinked processes at different scales. Ecosystem services are thus not controllable in themselves, but different regimes uphold distinct sets of ecosystem services, and some ecosystem services could be lost (and others emerge) when a new regime is established (Folke et al. 2004). From a resilience perspective (Folke et al. 2005), governance can be thought of as purposeful collective action (among state, private, and civil society stakeholders) to either sustain and improve a certain regime, or to trigger a transition of the system to a more preferable regime; these are referred to as adaptive capacity and transformative capacity, respectively. While our shorthand definition of resilience is to sustain a certain dynamic regime, urban governance also needs to build transformative capacity to face uncertainty and change (cf. Berkes et al. 2003). Several elements of resilience theory are highly relevant to cities (cf. Batty 2008). However, given its origins in ecology, it is not surprising that most resilience scholars have historically been interested in empirical analyses of non-urban areas (e.g., shallow lakes, production forests, and small-scale agriculture, see Berkes and Folke 1998;Gunderson and Holling 2002;Berkes et al. 2003), and have devoted less attention to the specifically human and social elements of human-dominated systems, such as cities. In order to address urban resilience, we propose a distinction between at least two scales that can aid in aligning analysis, governance and urban politics. 1 The first concerns ''resilience in cities,'' which operates at the city scale and deals with sustaining local-to-regional ecosystem services. The second is ''resilience of cities,'' which instead operates at the scale of a ''system of cities,'' which is a concept from geography meaning a set of cities tied to each other through relations of exchange, trade, migration, or others that sustain the flow of energy, matter and information among the cities (Pumain et al. 1989;Batty 2008). The resilience in cities, which has been the main preoccupation of most urban ecologists (Alberti and Marzluff 2004;Pickett et al. 2004;Andersson 2006;Colding 2007), is tightly linked to urban form and land-use patterns on the one hand, and local and spatial ecological processes on the other. This involves stakeholders like urban planners and housing companies, but also housing, squatter and urban social movements, along with those influencing and/or have knowledge about urban ecological processes. The latter group importantly includes, apart from conservation managers, also user groups engaged in local level socialecological interactions such as urban community gardening, farming, and forestry that simultaneously meet social needs while improving ecosystem function (Stanvliet et al. 2004;Barthel et al. 2005;Borgstro <unk>m et al. 2006;Colding et al. 2006;Andersson et al. 2007;Tidball and Krasny 2007;Krasny and Tidball 2009;Barthel et al. 2010;Ernstson et al. 2010). The second scale, resilience of cities, involves a broader category of stakeholders, but particularly those associated not only with technical networks like water, electricity, sewage, waste disposal, and telecommunications, but also with agriculture, mining and other broader interests in society. Along with our four arguments, we will use these scales to broaden the discussion on urban resilience. --- FIRST ARGUMENT: SLOW VARIABLES AND THRESHOLDS Although not in the strict sense specific to resilience theory, an important part in its development has been the idea that slow variables may push systems over a threshold, first developed by Rene <unk>Thom and then elaborated by Christopher Zeeman (Zeeman 1977) (Fig. 1). In this section, we will, therefore, take the city as an example of the ways in which slow variables and thresholds may combine to precipitate irreversible changes. Urban populations worldwide continue to aggregate in areas that are vulnerable to combinations of slow variables (e.g., sea level rise, periodic flooding, etc.) that can move the system closer to thresholds (situations where ''disasters are waiting to happen''), where disturbances (e.g., tsunamis, hurricanes, etc.) can trigger disasters (Fig. 1). As a deltaic city, New Orleans has always been situated in a dynamic landscape, and its recent history-with Hurricane Katrina in 2005 devastating the city leaving 1,500 dead and tens and thousands without homes-therefore provides an important case study to illustrate the interaction between thresholds and changes in slow variables (Fig. 2). After achieving its peak urban population in the early 1960s, during the 40 years before Hurricane Katrina, New Orleans was experiencing trends in multiple slow variable indicators that, in combination, worked to make the city increasingly vulnerable; rising seas, a compacting deltaic landscape, population decline, suburban sprawl in areas below sea level, coastal wetland loss, economic decline, and low maintenance of levee systems (Campanella et al. 2004;Kates et al. 2006). In terms of most of these indicators-that were well known at the time (Westrum 2006)-New Orleans was heading toward crucial thresholds, but Hurricane Katrina provided a shock to the New Orleans urban social-ecological system that pushed the system state half a century into what its future would have been had the hurricane, or a similar shock, not struck the city during that period (Fig. 3). With the spark of academic, private, and civic engagement that the hurricane created, New Orleans provides valuable clues for how urban planning can transition to sustain and build resilience, especially in vulnerable deltaic cities. How do prevailing gradual environmental trends (e.g., relative sea level rise and coastal wetland loss) and acute threats (e.g., hurricanes and flooding) impact urban and rural coastal carrying capacity in Louisiana? The pre-Katrina trend was already one of dramatic historical wetland losses, since these regions are the vestiges of former Mississippi River delta lobes, and subject to natural compaction and deterioration. Historically, despite compaction, this deltaic habitat had a net gain of land due to the sediment contributions from the Mississippi River Basin, which built these deltas as well as the sediments, sands, silts, and clays that nourished adjacent wetlands through seasonal flooding over the natural levees. However, human interventions that have reduced or eliminated these sediment contributions (e.g., upstream dams and enhanced leveeing/channeling of the Mississippi River) or have resulted in other direct and indirect wetland losses (e.g., oil and gas exploration, wetland conversions to agriculture and other developments, and introduction of invasive nutria species that eat and kill wetland vegetation) have eliminated the ability of these wetlands to maintain their elevations relative to contextual sea level rise, which in turn have increased vulnerability of human settlements and infrastructure to storm surge events. One fundamental change in perspective that resilience theory brings to case studies like this is that, rather than defend against slow changes by means of man-made changes in the landscape, it is less costly and more sustainable to adapt and integrate human settlement to promote restoration of larger-scale biophysical (or ''natural'') processes (e.g., large-scale freshwater and sediment diversions) and long-term trends that threaten the landscape (e.g., sea level rise). From this viewpoint, one can examine New Orleans' local and regional habitats in terms of the ecosystem services they provide, or could provide, and aid prioritization of interventions so as to generate certain ecosystem services at different scales. Together this leads to a re-conceptualization of the geographical and socio-cultural idea of the city; rather than taking the city as starting point and transforming the physical environment to suit it, a reciprocal relationship can be nurtured, which integrates the city as part of dynamic landscapes and regional ecosystems. In New Orleans, the multiple changes in a set of slow variables allowed for a sudden shock to create great devastation. Especially, the loss of coastal wetlands in the river delta proved important. In Cape Town, should such a trajectory be in play, we suggest a combination of slow variables including the growth of water consumption (climbing both per capita and through immigration with 80,000 more inhabitants per year), the rate and pattern of land use transformation (including loss of agricultural land, natural habitat, and biodiversity), coupled with deeply embedded social inequity rooted in colonialism and apartheid (Besteman 2008).2 There are certainly other parameters that could be considered (HIV/AIDS, unemployment, etc.), but we suggest these are indicative for this exploration. Fresh water for human use is a limiting resource for the growth of Cape Town. Public data indicate that an almost exponential growth of dammed water over the last century and per capita water use has grown from 7 m3 per inhabitant in early 1900s to 350 m 3 in the 1980s. 3 With little opportunity left for further damming of rivers, plans are considered to mine deep aquifers in the Table Mountain Group, a large mountainous region along the west and south coasts of South Africa. This is a process involving great uncertainties regarding the calculation of recharge rates, and the effects of penetrating deep artesian structures on for instance wetland ecosystems (Xu et al. 2007;WRC 2008;TMG 2008). Although higher water consumption may reflect (unequal) economic growth in manufacturing, agriculture (especially wine industry), and tourism (OECD 2008), it has also led to a deepening of unequal access to water that follows old apartheid era patterns. In parallel, there are indications of slow ecological deterioration on regional river ecosystems and the capacity of estuaries to function as re-production sites for coastal fish (P. de Villiers, pers. comm.), and possibly also impacts on the habitat of ''scenic'' mammals like penguins that are important for tourism. In order to further understand the change of slow variables in Cape Town, the quest for urban space linked to oppressive social inequity can be used as a lens. Conditioned by the legacies of racist urban structures, Cape Town has extended fast, occupying 40% more space today than 25 years ago (City of Cape Town 2006). Since Cape Town lies within the Cape Floristic Region, a hotspot of plant biodiversity based on fynbos vegetation, one effect is rapid conversion of fertile farmlands on the one hand, and space for biodiversity on the other, into urban uses. The former vineyards and rich granite-derived soils of Constantia Valley have all but disappeared under the houses, lawns, swimming pools, and golf courses of wealthy suburbs. In parallel, the well-drained, slightly acidic sands of Cape Flats east of the city center, which for decades were used for vegetable farming, have increasingly been utilized for high-density/low-rise and low-cost housing, including informal shack settlements undermining urban food security. In general, wealthy (and mostly white) home-owners have sprawled into attractive mountain and costal areas, while poor black citizens have been concentrated (first by apartheid laws, and then by neo-liberal market constraints) in the wind-swept and flood-prone marginalized areas of Cape Flats, poorly serviced with water, sanitation, education, and public transport (Turok 2000;Besteman 2008). The apartheid-era-planned township of Khayelitsha illustrates how this oppressive social inequity erodes the capacity to sustain ecosystem services. Here citizens place their shack dwellings on the last remaining strip of coastal dunes, which erodes natural protection to strong prevailing winds while undermining access to recreational space and open air classrooms for learners, and the possibility to collect traditional medicinal herbs (Fig. 4). While the dunes also represent an important fynbos biodiversity system, urban inequity undermines conservation interests and reduces the dunes' socio-economic values; the lack of sanitation infrastructure increases pollution, while urban poverty drives up crime, diminishing the area's recreational and tourism value. Linked to over-consumption of space by wealthy Capetonians, the capacity to sustain ecosystem services in Khayelitsha is eroding. Taken together, we might witness a convergence of the interlinked factors of higher water consumption, rapid land-use changes, and increasing inequity that could induce shifts in Cape Town's regional and local ecosystems and undermine resilience to future disturbances. These could comprise both global food crisis, but also those of climate change, which is expected to give less overall rainfall in shorter bursts (Midgley et al. 2005), the latter pushing the system to cope with less amount of dammed and controlled fresh water (craved by more inhabitants), and more flooding events (affecting more marginalized people). In Phoenix, the most apparent candidates for slow variables that structure its dynamics are the low-density urban form along with increasing consumption levels of water, agricultural land, and biodiversity. Phoenix lies in a flat alluvial basin at the confluence of the Salt and Gila Rivers. Historically, the cradle of the Hohokam civilization (500-700 AD to 1400 AD), human settlement did not return until the reintroduction of agriculture in the 1860s, which led to almost exponential population growth as agricultural interests tapped into ground and canal water (Redman and Kinzig 2008). Today, Phoenix is the fifth largest city in the USA and one of the two fastest growing (Fig. 5). Growth and geographic expansion of Phoenix (and many western US cities) from the 1950s was spurred by national scale changes; the development of air conditioning and the ''suburban lifestyle'' with a high cultural value of single family homes. The widespread ownership of detached homes was enabled by the availability of vast stretches of inexpensive land, the ubiquitous use of motor vehicles and the subvention of highways, cheap motor fuel, and home ownership. This cultural-political-economic complex can be viewed as a slow variable that has led to the dispersed urban layout of cities like Phoenix and the peripheries of cities around the world. However, this pattern has engendered several vulnerabilities that undermine its resilience. First, it requires the conversion of vast stretches of land that had previously been used for agriculture or as open space, each providing a variety of ecosystem services, while also producing urban spaces with exotic plants in sharp contrast with the undeveloped desert with native vegetation. Second, the dispersed pattern is highly consumptive of materials for infrastructure and residential construction. Third, and the most threatening, are the energy requirements of both the residences themselves and the distances that must be travelled, largely in single individual-occupied automobiles. As the price of energy increases, there is a risk of crossing a threshold and entering a downward economic spiral. Urban expansion in this arid region (average annual rainfall of 180 mm) has been supported by water-supply projects. Reservoirs that impound surface runoff from the local Salt and Gila River catchments are paired with a canal transporting Colorado River water 500 km to Phoenix, and groundwater pumping that substantially exceeds natural recharge (Kupel 2003). Each of these was introduced as a ''fix'' to the water situation and yet cannot indefinitely support the urban system on its current trajectory (Gober 2007). The challenge increases with the uncertainty created by inter-annual variability of rainfall patterns, along with the specter of most climate change scenarios projecting significant reductions in precipitation and increasing temperatures. In this situation, urban water managers have come to rely on securing water through that farmers can profitably sell irrigated farmland. Hence, the growth of urban areas is linked to the retirement of irrigated lands, which is part of a global trend with serious implications for global and local food security further undermining resilience. We note that in New Orleans, Cape Town, and Phoenix, there are cross-scale linkages that seem to erode resilience and bring to bear new types of positive feedbacks that will be difficult, if not impossible, to undo. While, for example, oil companies eroded the coastline of New Orleans to gain Fig. 4 Inequity as slow variable in Cape Town. Linked to overconsumption of space by high-income citizens, other citizens are pushed to build their shack dwellings in marginal and vulnerable ecosystems, as in these sand dunes in Khayelitsha, Cape Town. With 3.9 million inhabitants, the city grows by 80,000 people per year, mainly due to migrants from rural countryside, and other parts of Africa. City poverty lies at 32% (household income less than 150USD), unemployment at 22%, and there is extreme levels of income inequality (gini coefficient at 0.68). Khayelitsha, with 12% of the population, contributes to just 0.70% of the city's GDP (OECD 2008). Photo by Henrik Ernstson, 2008 Fig. 5 Urban sprawl as slow variable in Phoenix, Arizona. From 1990 to 2000, Phoenix grew by 47% to over 3.5 million people (US Census Bureau, 2000), with expected increase to go up to 7-8 million by 2030 (Berling-Wolff and Wu 2004). There has been a rapid conversion of agricultural land to urbanized land that earlier supported vast lowland of Sonoran desert and riparian vegetation. Source: Photo by O <unk>rjan Bodin, 2008 profit, the public (most of all poor citizens) lost the crucial ecosystem service of storm protection. In Cape Town, the economic legacies of oppressive apartheid policies have allowed the rich to overconsume space and water, undermining ecosystem services, while poorer citizens are forced to place their shacks in areas that cause them to erode biodiversity and local ecosystem services. In Phoenix, national policies, subventions, and technological innovations have created a dispersed urban layout requiring great consumption of energy, land, and water. In these humandominated ecosystems, there are close relationships between social dynamics, structure and inequity, and the ability to sustain ecosystem services at different scales. --- SECOND ARGUMENT: CROSS-SCALE INTERACTIONS BETWEEN TECHNICAL AND SOCIAL NETWORKS Again, not exclusive to resilience theory (Allen et al. 1986), the idea that ecological systems are hierarchically organized in such a way that processes which operate on more or less the same timescales are more closely impacting on each other than those that operate at different timescales is one of the very powerful elements in the study of the principal resilience theorists. Indeed, Gunderson and Holling (Gunderson and Holling 2002), in their book Panarchy, make the nature and role of the interactions between processes operating at different scales the focus of attention. Leaving our three cities for a while, how would this relate to urban resilience? First, it underlines the important shift made by geographers to view urban phenomena as occurring in ''system of cities'' where close relationships, whether through exchange, trade, migration, or other, permit the flow of energy, matter, and information among the cities in the system (e.g., Pumain et al. 1989;Batty 2008). This emphasizes that cities need to be viewed as loci in multiple networks of relationships at different scales, rather than as entities. How does that apply to the idea of cities as being composed of nested sets of social-ecological processes, and how could the dynamic interlinkages or panarchies among these multiple networks be related to resilience in urban and human-dominated ecosystems? Social networks are different from ecological networks. Whereas the latter take the form of food-webs (or plantpollinator networks, or species-habitat networks) that transfer energy and genetic information, social networks are self-constructed by society in a process of ''alignment'' or ''co-ordination,'' best described as a continual recursive communication process that eventually allows different people to understand each other, share values and beliefs, and generally work together to achieve their aims. Through continual interaction with each other, transaction costs for communication are lowered, and more effective human collective action can emerge, alongside social structures and division of labor. Such social networks of recursive communication depend upon flows of matter, energy, and information that provide stakeholders (whether individuals, firms, or agencies) access to resources distributed throughout society. However, while matter and energy may provide people with necessary means of survival, they cannot be shared like information. In other words, flows of matter and energy alone could never have created durable human social institutions, let alone towns or societies. Indeed, human societies are held together by shared expectations, institutions, world-views, ideas, technical know-how, in short by a shared culture (van der Leeuw 2007), enacted and shaped through social networks. As a consequence, it is the sharing of information that creates the channels through which energy and matter flow. Through recursive alignment and communication processes, material and energetic resources are identified by urban stakeholders in distant local places and ecosystems, channeled into society and transformed by human knowledge and labor in such a way that they are suitable for use, and again transformed during use into forms with higher entropy, which are then disposed of. In order to do all these activities, the hinterland is structured by socially networked urban stakeholders, which extend ''tentacles'' or organized channels beyond the city boundaries to collect the needed energy and material (e.g., oil in New Orleans, dammed water in Cape Town and Phoenix). The ''fabric of society,'' then, consists of flows through multiple technical networks, held together by different kinds of social relations (kin, business, friendship, exchange, client-patron, power, etc.), and transmitting different combinations of the three basic commodities (matter, energy, and information). This is one way of viewing the hybridity of cities, as processes enacted through networks of social, cultural, ecological, and technical relations (Swyngedouw 1996). In coming to grips with the resilience of cities (as parts in systems of cities), the idea of panarchies helps bring forth the fact that although the networks for various commodities overlap, it is not necessarily so: water, electricity, petroleum, and coal are transported, processed, and delivered in different ways (which is true of virtually all goods in everyday life that we do not collect or process ourselves, e.g., food). This indicates that the network dynamics out of which cities (and societies) emerge involve many different temporal rhythms and spatial distances played out in different configurations and domains. A crucial insight for urban planning and governance is that the resilience of cities should be viewed as determined by the interplay between different types of networks across spatial and temporal scales, including the social networks (of managers, technicians, policymakers, etc.) that create and maintain technical networks. --- THIRD ARGUMENT: URBAN INNOVATIVE CAPACITY Pursuing how social networks of recursive communication are channeling resources to the city, supporting and molding its reproduction and development, our third argument involves how such urban social networks also underpin innovation. Innovation is here seen as novel ways of doing things, or how new things can be made useful, and refers to incremental or radical changes in ideas, practices, and products; including novel ways of organizing society, changing its rules and institutions. Innovations can be framed as technical, social, socio-technical, or as we would argue, social-ecological, but are embodied and implemented through social networks of recursive communication and alignment. Drawing upon sociology, we will argue that innovation sits at the heart of understanding resilience and transformative capacity in human-dominated systems, a statement further developed and exemplified in the fourth argument. In support of our third argument, we turn to Bettencourt and colleagues (Bettencourt et al. 2007) who recently measured how the size of a city scales with a range of different indicators reflecting the role of energy, population and information in urban dynamics. Using population as the measure of city size, these indicators revealed three important patterns: • Proxies for energy consumption scale sub-linearly with urban size, indicating that when cities grow, they become more energy efficient; • As is to be expected, the number of basic service providers (bakeries, schools, etc.) scales linearly with urban size; • Surprisingly however, the proxies related to innovation and new wealth creation (such as number of patents, number of employees in research, and wealth per capita) scale super-linearly with urban size, i.e., increase faster than the population (along with more negative social indicators such as crime rate and HIVinfected persons). This indicates that a key driver behind urban growth is innovation (not just economies of scale in energy consumption). Further, through its tight linkage to economic value creation, urban innovation, especially technical innovation as measured here, is in large part responsible for the attractiveness of a city, i.e., the degree to which individual stakeholders are willing to locate there, to invest in it, and to collaborate with others in it; a process that consequently drives the emergence and development of social networks. Also social innovation, for instance the organization of public transport or day-care for children, can improve city life and the attractiveness of a city. Taken together, urban innovation influences the ability to sustain ecosystem services, both locally and far from urban areas, and in positive and negative ways. On the one hand, urban innovation drives urban growth, which in turn structures local ecosystems regionally and throughout the world (and increasingly so through the rapid urbanization worldwide). On the other hand, urban innovation, embodied through recursive communication among various stakeholders, holds a potential to identify novel ways of sustaining resources to cities and systems of cities, or as put in the previous section, to change the alignment between technical and social networks. This, we believe, underlines the need for a re-consideration of resilience theory when considering cities and human-dominated ecosystems because it introduces the role of recursive information processing in all aspects of system dynamics (e.g., van der Leeuw 2007). Furthermore, this socially structured information processing could ultimately change our perspective on social-ecological dynamics altogether, including in landscapes not dominated by humans but in which they nevertheless play a role. --- FOURTH ARGUMENT: HARNESSING URBAN INNOVATION ACROSS SCALES The argument thus far leads to two complementary conclusions. On the one hand, we believe that sustainability and resilience depend on a society's innovative capacity, and on the other, we see clearly that solutions must be found by innovating in urban systems at different scales and across sectors. This firmly frames the urban system as an opportunity for sustainability and drives us to recognize that the answer to increased resilience might not lie in its ecological dimension, but rather in the social. In order to build resilience and face uncertainty and change means to harness the interactions between stakeholders. This requires an involvement of society in its broadest sense towards a change of culture that makes ''collaboration'' between society and the environment (rather than mere ''interaction'') the central focus of attention. However, to harness urban innovation, we need to understand why innovation is more pronounced in cities than in rural areas. The answer lies in the concentration of population in cities: the more people interact through recursive alignment processes, the more cognitive dimensions exist within the interactive group, leading to that more problems can be tackled with quicker accumulation of knowledge. This in turn allows the cognition of new problems and even more generation of knowledge in a continuous feedback loop (cf. van der Leeuw and McGlade 1993;van der Leeuw and Aschan-Leygonie 2005). Based on a social network model of cities, Arbesman, Kleinberg and Strogatz (Arbesman et al. 2009) take this explanation further. They argue (with reference to Granovetter 1973) that bigger cities generate more innovations because they generate more interaction between people that are socially distant to each other (i.e., not family or friends). Such long-distance (or weak) ties means that information that has not met before, meets more frequently the bigger the city is, which aggregates to increased innovation at the urban level (Arbesman et al. 2009). 4Two lessons seem clear: there is a need to nurture an overall cultural criticism of policies and knowledge production that de-link nature from society, and a need to develop meeting arenas that can generate long-distance ties between stakeholders at different scales and sectors. The arenas should serve to nurture ''experiments'' to engage with social-ecological dynamics, and as construction sites for discourses that articulate cities as reciprocal parts in dynamic landscapes and as constituted out of social-ecological processes. These discourses should serve to steer innovations toward more sustainable solutions, practices, and institutions. Although our case cities are by no means ideal, we have found telling efforts on how to harness urban innovation in such ways. In New Orleans,

Urbanization is a global multidimensional process paired with increasing uncertainty due to climate change, migration of people, and changes in the capacity to sustain ecosystem services. This article lays a foundation for discussing transitions in urban governance, which enable cities to navigate change, build capacity to withstand shocks, and use experimentation and innovation in face of uncertainty. Using the three concrete case cities-New Orleans, Cape Town, and Phoenix-the article analyzes thresholds and cross-scale interactions, and expands the scale at which urban resilience has been discussed by integrating the idea from geography that cities form part of ''system of cities'' (i.e., they cannot be seen as single entities). Based on this, the article argues that urban governance need to harness social networks of urban innovation to sustain ecosystem services, while nurturing discourses that situate the city as part of regional ecosystems. The article broadens the discussion on urban resilience while challenging resilience theory when addressing human-dominated ecosystems. Practical examples of harnessing urban innovation are presented, paired with an agenda for research and policy.

reference to Granovetter 1973) that bigger cities generate more innovations because they generate more interaction between people that are socially distant to each other (i.e., not family or friends). Such long-distance (or weak) ties means that information that has not met before, meets more frequently the bigger the city is, which aggregates to increased innovation at the urban level (Arbesman et al. 2009). 4Two lessons seem clear: there is a need to nurture an overall cultural criticism of policies and knowledge production that de-link nature from society, and a need to develop meeting arenas that can generate long-distance ties between stakeholders at different scales and sectors. The arenas should serve to nurture ''experiments'' to engage with social-ecological dynamics, and as construction sites for discourses that articulate cities as reciprocal parts in dynamic landscapes and as constituted out of social-ecological processes. These discourses should serve to steer innovations toward more sustainable solutions, practices, and institutions. Although our case cities are by no means ideal, we have found telling efforts on how to harness urban innovation in such ways. In New Orleans, hurricane Katrina sparked novel collaborations and an interdisciplinary knowledge production that meshed urban planning with coastal science, ecology, engineering, architecture, and landscape architecture (Birch and Wachter 2006;Costanza et al. 2006;Laska and Morrow 2006;Lopez 2006;Blakely 2007;CPRA 2007;LRA 2007;Rodiek 2007;Meffert 2008;To <unk>rnqvist and Meffert 2008). Given that deltaic cities like New Orleans will likely experience 3-10 mm per year of relative sea level rise in the next 50 years (To <unk>rnqvist et al. 2008), current expert debates concerning the re-organization of the city emphasize: planning with the regional hydrology and propensity for flooding in mind (high-density residential areas on higher ground and lower in floodable areas); remake landscapes through ''natural'' processes (e.g., divert the Mississippi River to rebuild coastal wetlands in protection of storm surges); increase local flood disaster preparedness through landscape interventions on a neighborhood scale with terraces, polders, and drainage enhancements (bayous, canals, and permeable surfaces); and maximize community participation to restore and nurture social capital (CPRA 2007;LRA 2007). All of these reflect the change of perspective to which we have referred above, placing the city as a reciprocal part of a dynamic landscape and a regional ecosystem. However, the transitioning of social-ecological systems toward increased resilience and a fair distribution of ecosystem services needs to also engage in the culture and politics of space. While a general idea in New Orleans is to transform lower lying areas to historically marshy states (or to urban parks), such expert laden suggestions are fiercely contested and contains racial and political tensions since African-American communities have historically been pushed into those vulnerable areas below sea-level. Not merely social arenas of deliberation, but also political and social movements, which can broker these conflicts and negotiate more equitable and fair solutions, seems crucially important in New Orleans. More generally, social movements seem important in any social-ecological system going through a re-organizational phase, since otherwise, the resilience being built post-disaster, will be conditioned and entangled with systems of oppression and an unequal distribution of ecosystem services (Ernstson 2008;Ernstson et al. 2008). In this respect, the residents of New Orleans, who form part of self-organized communities-of-practices that engage in tree planting and community greening projects, are important features of the social dynamics that interact to constitute the post-Katrina social-ecological system (Keith Tidball, pers. comm.). These evolving ''civic ecology'' practices (Tidball and Krasny 2007), which are partly supported by universities and the City of New Orleans, not only seem to empower their participants, build social capital and sense of place, but also play a role in generating ecosystem services such as improved mitigation of flooding, better air quality, cooling houses (with lower energy consumption), and re-introducing habitats, and landscape ecological functions. They furthermore represent a possibility for collaborative ecosystem management as they forge social-ecological feedbacks through localized learning of ecosystem dynamics (Krasny and Tidball 2009;Barthel et al. 2010;Ernstson et al. 2010), and could be key collective agents in nurturing a cultural change in how residents enact the city as a culture-nature space. Cape Town follows a similar trajectory with a mix of top-down planning and community-based initiatives. In order to protect natural resources within the city, the City of Cape Town used conservation planning to identify a ''biodiversity network'' of threatened green area ecosystems and species. In order to counter degradation of these sites by invasion of alien plants, illegal dumping, urban development projects, and land invasions by informal settlements, the City of Cape Town engaged with a range of partners to nurture a culture of civil society involvement in conservation of biodiversity through community use of green open areas. One such partnership is the project Cape Flats Nature developed together with the parastatal South African National Biodiversity Institute (SANBI). This project has focused on a small selection of sites in the biodiversity network, aiming at ''developing an alternative, social nature conservation practice in impoverished urban areas'' that places ''people's needs and basic human rights [...] at the centre of nature conservation'' (CFN 2006). The project engages local organizations and schools to explore how local ecosystems provide ecosystem services such as flood mitigation (involving wetland restoration), wind protection, and offering educational and recreational space. In order to achieve this, the project facilitates formation of local ''champion forums'' to develop local and credible leadership, as well as working with the City of Cape Town on developing a people-centered orientation for municipal nature conservation officers. Another approach to involve local people in conservation activities is to address it via poverty alleviation. For instance, the ''Working for Water'' and ''Working for Wetlands'' national job creation programs, provide work and training in projects that remove invasive non-indigenous plant species (Fig. 6), and restore aquatic ecosystems (van Wilgen et al. 1998;Falkenmark 2003). Less interventionist, but also an important contribution of civil society, is the involvement of voluntary care groups, often as middle-class ''friends'' groups motivated to maintain the local neighborhood environments by aesthetic, ethical, and heritage considerations. Many urban ecosystems such as river corridors, wetlands, or even open commonage providing habitat for iconic species of plants, birds, or amphibians, receive conservation benefit from this type of engagement. At a larger scale, guided by the Water Act of 1998, sustainable management of water resources (Falkenmark 2003) is facilitated by input from many sectors of society through establishment of structures such as Water User Associations. These link water users and stakeholders, including wine farmers, nature conservation organizations and urban municipalities such as the City of Cape Town, in negotiating shared long-term plans for the generation and protection of ecosystem services. Deliberative arenas such as these are potentially potent in addressing broader social, ecological, and economic dynamics in the region, including incentives for development of a functional model for ''payment for ecosystem services'' (Turpie et al. 2008), and in forging novel social networks across sectors and scales. The newly formed African Centre for Cities at the University of Cape Town, with its CitiLabs engaging in on-the-ground urban problems, provides another emergent arena for cross-scale and cross-sector engagement between academics and practitioners (ACC 2009). In Phoenix, efforts have been made to organize the 20 separate municipalities in the region to face social-ecological uncertainties. A ''Sustainable Cities Network'' is convened and staffed by the Arizona State University and administered by member cities and used as a forum for sharing ''best practices'' such as on installing more solar power, or developing new mobility options. Another response relates directly to the uncertainties of water provisioning. While water managers work to meet demand at the scale of individual municipalities or even smaller units, and at a time frame of the next few years, the supply of water is being driven by global patterns that will take decades to play out and with impacts at region-wide scale. In an effort to develop decision-support tools under these conditions of climate uncertainty and to form a bridging organization between university researchers and the many entities that manage water allocations and establish policy, the Decision Center for a Desert City (DCDC 2009) was established with funding from the US National Science Foundation. A central scientific activity of DCDC has been to develop at systems dynamics modeling representation (WaterSim) of the interactions of climate variability, climate change scenarios, population growth, land use patterns, agricultural retirement, and conservation measures to project water availability. WaterSim has been presented to numerous groups of citizens, public officials, and managers including a front page article in the largest newspaper and a scaled down version Fig. 6 Re-creating wetlands in the Tokai Forest, Cape Town. Through forging novel social ties across sectors and scales, biodiversity rich wetlands are re-created through collaboration between local civil society groups, the South African National Biodiversity Institute, and the Working for Wetlands program that employs unemployed low-skilled workers. Source: Photo by Henrik Ernstson, 2008 available on the web (DCDC 2009). Two efforts seem to directly engage in generating novel ''long-distance ties'' and forge novel social networks across sectors and scales. The first being a group of 60 water managers and policy makers that have participated in multiple small group meetings to evaluate and help refine WaterSim given each of their own perspectives (White et al. 2008). DCDC has, moreover, convened a second set of meetings, Water Dialogues, with a more loosely defined membership of university faculty and students, and various water managers and interested citizens who attend a monthly meeting to share information and ideas in response to an invited speaker on local issues. --- CONCLUSION Contemporary urbanization is riddled with uncertainty. Interlinked with climate change, migration, and economic crisis, urbanization has become a dynamic, multi-scalar, and complex process where no actor, or set of actors, can have full knowledge or full control. In this article, we have visited three cities and drawn upon systems analysis to shape an argument that uncertainty needs to be faced with experimentation, learning, and innovation, and-since innovation reaches extreme levels in cities-that the urban should be framed as an opportunity for sustainability. Furthermore, since urban innovation is a driver of urbanization, it influences (often negatively) ecosystems across the globe, which places urban innovation at the heart of resilience for well-nigh all ecosystems. The challenge lies in harnessing urban innovation toward sustainability and learning at various scales and across sectors. This implies the need to construct discourses that undermine the artificial and culturally biased notion that society and cities are separated from nature and countryside, and instead view cities as reciprocal parts of regional ecosystems and dynamic landscapes, constituted out of social-ecological processes from ecosystems across the globe (Luccarelli 1996). 5An immediate task for research is, therefore, to explore how uncertainty and ecosystem services can be integrated into the social practice of urban planning. Here, framingthe construction of narratives explaining the nature of a problem and how it might be addressed-seems to be a key issue (Snow et al. 1986;Leach 2008). What are the social practices of framing that tend to cut out uncertainties and present systems as stable and society as de-linked from nature? What actors, institutions, and practices sustain a static bi-polar world and preclude resilient social-ecological approaches to urban problems? And what arenas, experiments, and practical interventions run counter and instead sustain uncertainty and hybrid social-ecological world-views? Frameworks for addressing the city-scale and resilience in cities exist. From the (non-urban) resilience discourse, we have ''co-management'' and ''adaptive governance'' (Carlsson and Berkes 2005;Folke et al. 2005), that could fruitfully be merged with ideas of ''ecologizing planning'' (Murdoch 2006), and''communicative'' and''collaborative'' planning (Graham andHealey 1999;Goldstein 2009) taken from post-structuralist geography and urban planning theory. However, there is a lack of theory that links the scale of the city (resilience in cities), to the scale of ''systems of cities'' (resilience of cities). More explicitly, we lack theory to analyze the panarchies of urban networks, i.e., the dynamic interlinkages between social and technical networks that sustain energy, matter, and information, and how these dynamic networks influence ecological networks and the capacity to generate local-to-regional ecosystem services (but see Alberti and Marzluff 2004;Pickett et al. 2008). For instance, how do technical networks shape urban land-use patterns and influence urban ecosystems? Efforts in these directions should also integrate urban political ecology (Heynen et al. 2006) to make explicit that planning and governance is always entangled in politics (Flyvbjerg 1998). The immediate task for policy is to push for a radical shift in the mode of knowledge production and application. Given the stressed ecosystems of the planet (MA 2005), we need an institutional shift from yesterday's industrial economy and current innovative economy (that accepts waste and the erosion of ecosystems), to an ''ecological economy'' where competitiveness should also lie in how effectively one uses and/or support the generation of ecosystem services (C. Wilkinson, pers. comm.). Simultaneously, policy should move toward (i) defining the scales and places of intervention (resilience in and of cities) and bring together a wide array of stakeholders; (ii) changing the role of scientists vis-a <unk>-vis policy through funding research that value processes and methodologies over scientific breakthrough and technological fixes (i.e., providing incentives for scientists to move from being ''data providers'' to become connective actors across scales and sectors); (iii) creating a sense of urgency among stakeholders and the public on immediate dependencies on ecosystems locally, regionally, and globally through building institutions that monitor ecosystem services, and foster on-the-ground experiments and learning; and (iv) placing access and equity to ecosystem services-and therefore politics-at the heart of resilience building (Armitage and Johnson 2006;Ernstson 2008). In order to do this, time and resources must be invested in the very process of knowledge networking. As this implies devolution of power and potential weakening of control by governments, there is bound to be stiff resistance to this process. Here, civil society organizations and social movements, who also concentrate in urban areas-from Slum Dwellers International, Transition Towns, and those mobilizing on climate change and unjust globalization, to urban farming and protection of green space-will be key factors in forging structural social change (Carley et al. 2001), and in co-constructing framings that interlink injustices with the distribution of ecosystem services (Ernstson 2008). As we have argued, the urban arena provides a public space for the cross-fertilization of minds and disciplines, enabling a new perspective on human-in-nature, one that could undermine the divide between society and nature, the pristine and the human-dominated, and contribute to the creation of a new language, with signs, concepts, words, tools, and institutions that could facilitate meaningful politics to broker conflicts and establish responsible environmental stewardship at the heart of public interest. We indeed believe that there is a potential in developing new forms of knowledge, creating new arenas and a new set of norms and institutions to nurture urban resilience. --- AUTHOR BIOGRAPHIES Henrik Ernstson (&) is an ecologist/sociologist, who draws on systems ecology, sociology, and political ecology to explore the governance and politics of urban ecologies. He is currently a research fellow at the Department of Systems Christine Alfsen has a long-term experience in international policy making toward sustainable cities. She is a director and coordinator of the Columbia University/UNESCO Joint Program on Biosphere and Society (CUBES) and involved in the Urban Biosphere Network (URBIS).

Urbanization is a global multidimensional process paired with increasing uncertainty due to climate change, migration of people, and changes in the capacity to sustain ecosystem services. This article lays a foundation for discussing transitions in urban governance, which enable cities to navigate change, build capacity to withstand shocks, and use experimentation and innovation in face of uncertainty. Using the three concrete case cities-New Orleans, Cape Town, and Phoenix-the article analyzes thresholds and cross-scale interactions, and expands the scale at which urban resilience has been discussed by integrating the idea from geography that cities form part of ''system of cities'' (i.e., they cannot be seen as single entities). Based on this, the article argues that urban governance need to harness social networks of urban innovation to sustain ecosystem services, while nurturing discourses that situate the city as part of regional ecosystems. The article broadens the discussion on urban resilience while challenging resilience theory when addressing human-dominated ecosystems. Practical examples of harnessing urban innovation are presented, paired with an agenda for research and policy.

Background Mining in India is an important developmental activity and has a manifold impact on population dynamics, development and environment. Men and women are differentially exposed or vulnerable to determinants of health [1,2]. Vulnerable groups, especially women, the elderly and children, often live in poorer socio-economic conditions and have poorer literacy skills compared with their urban counterparts [3]. Rural health status in stressed communities (e.g. mining) is lower than for non-stressed communities (e.g. agricultural) and limited access to health and welfare support services can further jeopardise the health status of rural women in India [4]. Studies also show that women's interaction with the biophysical environment within their own 'life spaces' reveals that they are exposed to the hazards of environmental illness in a manner that is clearly environmentally-differentiated (socio-economic, cultural and biophysical) from less stressed communities [5][6][7][8][9]. Health-related quality of life (HRQOL) is a perception of the degree of contentment with and capability to perform and control different facets of one's life [10][11][12]. For the purpose of our study HRQOL is defined as the perceived health status and daily functioning including physical and mental health, role limitations, and social functioning. Coping with stimuli is an important indicator of positive health status and is linked to healthrelated quality of life [13]. Coping strategies refer to behaviours adopted by women during stressful situations [14,15]. Coping is conceptualized as being an important personality variable representing cognitive, behavioural and emotional coping strategies targeted at modifying the cause of a stressful problem. Women differentially select particular coping strategies across stressful events [16,17]. This empirical research is a study of women's perceived health that could possibly be exerted by the structural (demographic, socio-economic), health (cultural, illness) and psychosocial (support, coping) factors contingent in mining and agricultural communities. Living in mining communities exposes disadvantaged groups to health problems related to contamination of air, water, food, soil and river beds with toxic chemical and metallic discharges [18]. Women employed in the mines or collieries are exposed to toxic and hazardous substances due to poor safety, lack of control and monitoring measures and, as a result, and are susceptible to risks from several occupational illnesses [19]. Women living near coal and uranium mining in Bihar have succumbed to illness like malaria, typhoid and hepatitis, which were not prevalent before the mining activities. High infant mortality and deteriorating health among women were also common [20]. Women living near the Kolar gold fields travel far for meager wages to support their families, while most of the men are sick, depressed and unemployed due to the closure of the mines or have died in occupational accidents [20,21]. Most of the rural/tribal women due to mining-induced exploitation suffer from the social and particularly ill effects of mining-related hazards, pollution, poor waste disposal, denial of access to natural resources (water, forest, agriculture, land), incomplete rehabilitation, poor housing facilities, mine disasters, lack of livelihood, accidents, chemical spillage and closure [22,23]. These effects culminate in poor health and well-being among women depending on the thresholds of exposure in the mining communities compared to the less stressed communities. --- Review of literature Women face torture from security guards as they collect mud from the tailings to retrieve minute specks of gold. Unemployment has also led to the growth of anti-social activities like theft, fights and murder causing insecurity to women [20,21]. Incidences of alcoholism, drug addiction, prostitution, gambling, incest, wife swapping, infidelity, and domestic violence against women, have resulted in an increased risk of AIDS and STD among women living in mining areas [18]. The problems of the adivasi (local tribe) women due to the mining induced exploitation are poor quality of drinking water, roads, housing, agriculture produce, wife-battering, alcoholism, desertion, unemployment, starvation, gambling, infidelity, and AIDS [22]. In the coal mines of Hazarbagh, women are often scared, harassed and assaulted by the "coal mafia" [24]. Mining activities tend to reduce opportunities for women in Orrisa, thus increasing their levels of dependency and vulnerability. AIDS have a specific impact on women in the mining town of Timika (West Papua, Indonesia) due to increasingly high levels of alcohol-related violence, infidelity, rape and prostitution. Most of the women in the mining areas are malnourished, prone to AIDS/STD infections, family violence, rape and prostitution, fueled by alcohol abuse [25]. The local women in the Soroako gold mining areas (Sulawesi, Indonesia) received welfare benefits like food packages after delivery, literacy classes, and medical services. There were also growing incidence of teenage pregnancy, alcoholism, rape and other forms of violence against women [26]. Hence stress and stressful life events are related to a number of disorders, both psychological and physical, among women [27,28]. Effective coping strategies such as support from social networks, and spirituality, can reduce stress, promote physical and mental wellbeing, and improve health. There is no review of literature regarding domestic violence, cultural beliefs, physical or mental health status and coping among women in the local mining community. A few local studies record high air, water and noise pollution, dumps, silt and loss of agricultural fields and poor quality of life among communities living in the mining regions [29][30][31]. This paper focuses on perceived women's health, use of coping strategies and health related quality of life. This is the first paper highlighting perceived women's health, coping and predictors of health-related quality of life in the mining villages compared to a non-stressed economic community (i.e. agricultural village). --- Conceptual framework Roy's adaptation model views the biopsychosocial individual as an adaptive system that must adapt to environmental stimuli [32]. Adaptation is considered to take place in one biological and three psychosocial modes as responses to the environment and to a particular situation which entail a great deal of motivation from the one involved [33]. In our study, a women's adaptive system (structural, health and psychosocial) coupled with coping processes through cognator and regulator subsystems act to maintain adaptation in the four adaptive modes: physiologic-physical, self-concept-group identity, role function, and interdependence (Figure 1). We assessed the women's self-perceived health (dimensions) in each of the adaptive modes and the relevant internal and external stimuli (focal, contextual, and residual) influencing those adaptive abilities in the mining and agricultural communities (Appendix A). Relationships between the adaptive modes occurs when stimuli affect more than one mode and coping processes are used to expand those abilities and to enhance environmental interactions to attain the goal, i.e., health status (adaptation). This identification leads to goal setting to promote adaptation in the four adaptive modes to enhance women's interaction with her immediate environment. Women's adaptive responses occur through use of adaptive process or coping strategies (cognitive, social, emotional, and behavioural) that help her integrate mutually with the environment resulting in adaptation. When all sub systems function well, adaptive behaviour (health related quality of life) occur, otherwise maladaptation (ineffective response) occurs. Nursing interventions should focus on altering these stimuli or strengthening adaptive processes to result in adaptive behaviours. --- Methods --- Aim The aim of the study was to examine the relationship between health-related quality of life and possible predictors of HRQOL among Indian women in mining and agricultural communities. --- Design A descriptive cross-sectional research design was selected for the study. --- Settings and sampling This study has been conducted in the active iron ore mining villages in Goa which has a high air pollution index in 2008 [29,30]. A two-stage random sample was obtained from census tracts, electoral lists and family list from the Directorate of Health Services, local panchayats and the primary health centres respectively from the villages in the mining and agriculture communities (Figure 2). The sample size was initially determined using G*Power software with the intention of using a linear multiple regression analysis [34,35] for the mining community. The sample size was calculated at a power of 0.9 with an effect size of 0.15 using 10 predictors (independent variables) with an alpha of 0.05. The effect size was computed assuming a correlation coefficient of 0.3-0.4 between the number of years living in a mining community (metric/variable) with Physical and Mental Health. It was found that a minimum sample size of 147 would be needed for these input parameters (rounded to 150). A matching sample size of 150 was decided for the agricultural community, A multi-stage simple random sampling was used to select the women for the study (Figure 2). In the first stage in the North Goa district, Goa, five mining and five agricultural villages were selected randomly from the census tract from the Directorate of Health Services. In each selected village, 150 households were selected randomly from the electoral list from the local panchayats in both the communities. From the family registration list was obtained from the primary health centre, one woman was selected randomly from each household to make a total of 150 women in the mining and agricultural communities respectively. Women who met the eligibility criteria were included in the study. Five women dropped out of the study, so the actual sample size was reduced to 145 women in the mining community. Among the 150 randomly selected households in the agricultural community, 8 women declined to participate and 9 women dropped out due to time and personal constraints, making it 133. The inclusion criteria included local married women in the reproductive age group of 15-45 years who had borne at least one child, and women who are able to understand, converse, and communicate in Konkani and who would provide voluntary participation. We excluded women working in the mines. --- Data collection procedures The investigators reviewed validated and standardized tools on health status and coping. One standardized tool was selected to achieve the objectives of the study based on the background of the women. --- The SF-36 health survey (SF36) The SF-36 Health Survey (Version 1.0) also known as the Medical Outcomes Study, has been adapted for this study population after carefully considering the items and adaptation process [36][37][38][39][40][41][42]. It is a self-administered questionnaire of 36 items with closed-ended, structured questions and has 8 multi-item scales, which concentrate on the respondents' experiences, feelings, beliefs, perceptions and convictions concerning their healthrelated quality of life during the past four weeks [43][44][45][46]. The SF-36 Health Survey items and scales were constructed using the Likert scale method of summated ratings (Table 1). The first five scales make up the "Physical Health" or functional status dimension (subscale 1-5), and the last five form the "Mental Health" or well-being dimension (subscale 4-7). Hence, each dimension includes three specific and two overlapping (Vitality and General Health) scales. The SF- 36 (3 items). The scores of the two dimensions and the total SF36 score are based on mathematical averaging of the scale components (summated ratings) which assume that items within a hypothesized scale can be summed up without score standardization or item weighting [47]. A higher score indicates better level of HRQOL. The SF-36 W Health Survey items and scales were constructed using the Likert method of summated ratings. Answers to each question are scored (some items need to be recoded). These scores are then coded and summed to produce raw scale scores for each health concept which are then reweighted/transformed to a 0 (worst health) -100 (best health) scale. Each scale score ranges from 0 to 100, with a higher score indicating a better level of QOL. The SF-36 can also be divided into two aggregate summary measures the Physical Component Summary (PCS) and the Mental Component Summary (MCS). Scoring algorithms can then be applied to produce the PCS and MCS scores. (These two summary scores have the major advantage of being norm based. They also have reduced floor and ceiling effects.) --- Coping strategy checklist The investigators reviewed the Coping Orientation for Problem Experiences (COPE) Inventory [16], Ways of Coping Questionnaire [48,49] and the Revised Ways of Coping Checklist [50] and Reproductive health semistructured interview [51] --- Social and health status This demographic or socio-economic status tool (15 items) include age, years of stay, family type, socio-economic status, education, employment status, family economic status, house ownership and health problems of women. --- Ethical considerations Institutional Ethics Committee formed by Goa University approved the study and provided human and ethical clearance [52]. During the household visits the researchers interacted with the household members, built rapport with the family members, and sought participation among women and their spouses. This helped to gain co-operation with the women and their spouses during the data collection period in the area. In the mining and agricultural villages, 150 women selected randomly in each waddo (unit in each of the randomly selected village) were informed of the study by the research assistants through the primary health centres (Figure 2). They visited each woman participant in their houses to ascertain their participation, to develop a rapport and trusting relationship. The purpose, procedures and ethical concerns of the study were informed to the local women. An introductory letter explaining the kind of research and the questionnaires was given to each woman randomly selected with the inclusion criteria from mining and agricultural villages. A verbal and a written informed consent document were obtained from the women indicating their voluntary participation and prerogative to withdrawal at any time. All women were assured that participation was voluntary, their anonymity, confidentiality of their responses, a blind analysis and a genuine use of the data would be adhered to. All the respondents were interviewed by the trained research assistants using the Konkani version of the tools. The women were interviewed in the privacy of their homes for 2 hours during convenient times from March-July 2008. Women were informed that the results would be reported accurately and that all shortcomings in the research, such as errors and limitations, would be disclosed [53][54][55]. Data were collected by trained interviewers directly from the selected women using pre-coded questionnaires. After the data collection the women were appreciated for their time and participation. All the tools were stored in locked cabinets with access to the researcher only. --- Data analysis Data quality was satisfactory, with a high response rate and use of all response categories, suggesting that there were no problems related to the translation of items and categories in the Surveys. Using Microsoft Excel 97, Version 9.0 (Microsoft, Redmond, WA), we used a method for the SF36 scoring of the subscales/dimensions and the total SF36 [56], multivariate analysis of variance and General Linear Model [57][58][59]. For trustworthiness and validation of the appropriateness of the survey tools, some women were interviewed after the data analysis to discuss the results and findings of the study. The data interpretation was according to the women's perception and experiences. --- Validity and reliability The SF36 Health Survey, Coping Strategy Checklist and the Social Health Status (English and Konkani versions) were validated with the content blueprint and threepoint evaluation criteria. These tools were adapted by forward and backward translation, iterative revision, and consensus by experts. Each translation was reviewed by three independent health-care providers, psychologists and sociologists who were proficient in both English and Konkani. The accuracy of the translations was certified. There was 100% strong agreement about the items in each domain among these subject experts. The SF-36 was administered to 20 randomly selected women in both the mining and the agricultural communities in early January 2008 for pre-testing and a try-out. All participating women were able to answer the questionnaires independently within 90 minutes. The tools were found to be culturally sensitive, clear, relevant, and did not have any problems with its format or any aspects of the SF36 Health, Coping Strategy Scale and Social and Health Surveys. The internal consistency of items was evaluated by analysis of correlations between the items and their respective scales. The internal consistency of the scales was calculated using Cronbach's alpha <unk> coefficient. It is a measure of the extent to which items within the same scale correlate with each other. The <unk> coefficient ranges from 0 to 1: values greater than 0.70 are considered acceptable for group comparisons, and 0.90 for person-level comparisons [40]. The response rate for the scales was 100%, i.e., all questions were answered by all women. Internal consistency reliability was high across most of the SF-36 subscales (> 0.70) indicating a high level of correlation amongst items within the same subscale. The overall Cronbach's <unk> coefficient of the SF-36 questionnaire was 0.76. Results showed that the SF-36 questionnaire demonstrated good reliability. A pilot study was conducted in the February 2008 to assess the feasibility of the study, plan for the analyses and to determine the flaws in the design, using a random sampling technique with ten selected married women in the mining and agricultural communities. The pilot study did not show any problems or flaws in the design of the study. --- Results --- Social health status A half-percentage of the women had a secondary education (53.4% and 40%), while a quarter percentage of the women were illiterate (23.3% and 24.8%) in the agricultural and mining communities respectively (Table 2). Only a few women were working after marriage (13.8% and 46.6%) compared with those before marriage (35.2% and 44.3%) in the mining community compared with the agricultural community. A substantial portion of the women had good (62.1% and 36.1%) economic status in the mining community compared with the agricultural community respectively. More women in the mining community reported domestic violence (19.3% and 16.5%) compared to the mining community. A greater percentage of women in the agricultural community used social (80.5% and 69.7%), cognitive (60.2% and 20%), emotional (53.4% and 29%) and behavioral (31.1% and 26.2%) coping strategies compared with to the women in the mining community respectively. The women in the mining community reported more eye (54.48% and 42.86%), upper respiratory (30.34% and 24.06%), lower respiratory (49% and 19.55%) and psychosomatic (52.41% and 35.34%) illnesses compared to those in the agricultural community (Table 3). Women in the agricultural community (58.65%) reported more musculoskeletal illness than those in the mining community (48.28%). --- Dimensions of the SF36 To examine the mean values of the 8 dimensions of selfperceived health (HRQOL) among women in the mining and agricultural communities, ANOVA were used (Table 3). H01 There is no significant difference between the SF36 mean scores among women in the mining and agricultural communities. Among the 8 scales, women reported significantly higher scores on Physical Role Limitations (mean = 79.9 and 57.8, p <unk> 0.05) and Emotional Role Limitations (mean = 78.7 and 73.1) in agricultural and mining communities (Table 4). Significantly higher differences were found in General Mental Health (mean = 69.8 and 63.6, p <unk> 0.05) and Social Functioning (mean = 72.7 and 65.9, p <unk> 0.01) among women in the agricultural and mining communities. Higher mean scores were observed for Physical Role Limitations (mean = 79.9), Emotional-Role Limitations (mean = 78.7), Bodily Pain (mean = 73.2), Social Functioning (mean = 72.7), General Mental Health (mean = 69.8), Vitality (mean = 61.8), General Health Perceptions (mean = 59.6), and Physical Functioning (mean = 53.7) among women in agricultural compared with women in the mining community. Women in the agricultural community achieved a significantly higher SF36 (mean = 68.7 and 62.7, p <unk> 0.05), Physical health (PH) (mean = 65.6 and 59.8, p <unk> 0.001) and Mental health (MH) scores (mean = 68.5 and 64.9, p <unk> 0.05) compared to women in mining community. The Physical role limitations, Social functioning, Wellbeing/General Mental Health subscales, Physical Health, Mental Health and Total SF36 scales were the most valid measures of SF36 among women in the agricultural community. These items showed higher mean scores than Bodily pain, General health perceptions or Vitality and Emotional-role limitations, suggesting that these problems did not lead to significant impairment in the faily activities or under-reporting of sensitive issues related to impairment. The mean scores in all the scales were higher among women in the agricultural community than among women in the mining community. --- Predictors of HRQOL ANOVA was used to examine each of the predictors of Physical health, Mental health, and the total SF36 scores (Table 5). To reduce the number and size of the tables, all the categories of the predictors and the 8 sub-scales of the SF36 are not shown. H01 There is no significant association between Physical and Mental Health means scores with Social Health Status and Coping Strategies among the women in mining as well as in the agricultural community. There is a significant association between years of stay, education and employment status with the Physical Health, age, education, enduring illness, employment and behavioural coping with Mental Health and years of stay, education and employment with total health (SF36) and among women in the agricultural community (Table 5). A higher tendency to positive perception on HRQOL was observed with marital status, increased age, stay in the community, education, economic, employment status and ownership asset among women in the agricultural community. For SF36 a better perception of HRQOL is associated with absence of domestic violence and illness among these women. The existence of illness and domestic violence among women in the mining community promotes a less positive perception of HRQOL. The Physical Health component summary measure of the SF36 appeared to better explain differences in HRQOL among women in these communities. A further General Linear Model (GLM) procedure was applied to investigate the relationship between PH and MH, interdependent variables with the predictors (independent variables) as seen in Tables 6 and7. From the ANOVA tests (Table 5) factors such as younger age, marriage, shorter duration of stay in the community, employment, education, economic status, domestic violence, enduring illness, house ownership, social, cognitive, emotional and behavioral coping among women significantly predicted better Physical Health among women both in the agricultural and mining communities. Age, marriage, economic status, education, employment, ownership, domestic violence and illness significantly predicted better Mental health among women across both communities. Younger age, marital status, economic status, domestic violence, enduring illness, cognitive and behavioral coping among these women significantly predicted better SF36 scores. In addition, years of stay, education and work influenced Physical Health; age, education, enduring illness, work and behavioral coping led to better Mental Health and the SF36 scores was also influenced by years of stay, education and work among women in the agricultural community. Social coping improved Physical Health, cognitive coping affected Mental Health, and social and emotional coping predicted higher SF36 scores among women in the mining community. The MANOVA models were used with all the variables in the ANOVA tests as predictors of PH and MH to test the combined effects of all independent variables together (Table 6). The MANOVA results are explained with the test of overall model significance and the test of overall individual effects of predictors. 39% (33%) and 40% (26%) of the variance in Physical and Mental Health among women was found in agricultural and mining communities respectively and was predicted by the structural, health and psychosocial coping variables. The Physical and Mental Health components were strongly correlated with the demographic (marital, employment status), cultural (domestic violence), health (enduring illness) and coping (social and cognitive) predictors. Though the R 2 values were low, these results were used as indicative support of the relationship among the predictors. Physical and Mental Health have had a significant positive effect on HRQOL. The test of overall model significance showed that the model is significant for each dependent variable (PH and MH) in the mining and the agricultural community. The "Tests of Between Subjects Effects" applies F test of significance to the relation of each covariate (age, illness, coping etc.) to each of the dependent variables (PH and MH). From the MANOVA test (Table 6) age, marriage, employment, economic status, domestic violence, social and cognitive coping significantly predicted Physical Health. Age, marital status, employment, economic status, social and cognitive coping predicted Mental Health among women across both the communities. Women in the agricultural community had better Physical Health related to age, economic status, emotional and cognitive coping and better Mental Health related to age, ownership and economic status. Women in the mining community had better Physical Health predicted by marital status and social coping and Mental Health predicted by employment. The combined effect of predictors on PH and MH using Wilk's Lambda Multivariate Tests (Table 7) show illness, domestic violence, employment, social and cognitive coping among women in the mining and agricultural communities were significant predictors with this test (Table 7). Marriage and employment is the only other variable significant among women in the mining community whereas age, economic status and emotional coping emerged as other significant predictors among women in agricultural community. Marital status, domestic violence, social and cognitive coping were found to be significant predictors of the SF36 among women across both communities (Tables 6 and7). In addition, age, economic status and emotional coping were significant predictors among women in the agricultural community. --- Discussion We could have employed an ethnographic qualitative research approach to assess the coping strategies used among women at different points in time to uncover explanations related to the why and how of the perceived health status. Future research should consider the use of a prospective longitudinal design to gather data for a better understanding of how women adapt over time with stress in economically stressed communities and how this affects various dimensions of their healthrelated quality of life. Women in the agricultural community scored higher on all dimensions of Physical functioning (PF), Physical role limitations (RP), Bodily pain (BP), Vitality/energy/fatigue, General health (GH), Mental health (MH), Social functioning (SF) and Emotional role limitations (ER) compared with women in mining. The perception of decreased illness and domestic violence is a significant predictor of health status among women in agriculture. They had higher education, employment, ownership and more coping strategies which paralleled a marked increase in PH, MH and SF36 scores among these women. These women perceived more role functions, a better self-concept and interdependence and felt the need to return to gainful employment and family roles. This shows a reciprocal relationship between physical role limitations, social functioning and general mental health among women that supports the higher order components (Physical health, Mental health and Total health). This stipulates that their good physical health presupposes good mental health and vice versa among women in the agricultural community. Coping strategies were significantly higher and positively related to the HRQOL among women in the agricultural community. Higher capacity for coping are positively associated with HRQOL [60][61][62][63] which showed higher capacity for coping and positively associated with quality of life [64]. Women in the mining community reported higher levels of eye, upper and lower respiratory and psychological illness as well as higher percentage of domestic violence. This can be explained by less exposure to education, employment, experiencing stressful events (environmental stress like dust and air pollution) and lack of power, control and autonomy [65,66]. Stress and stressful life events are related to a number of disorders, both psychological and physical, among women [27,28,67,68]. Clinical variables (symptoms, demographic, biological, physiological factors) are linked to and are predictive of HRQOL [69,70]. The connection between domestic violence and illness is a significant predictor of poor Physical and Mental Health. Age, economic status, years of stay, domestic violence and illness are significantly associated with quality of life and reproductive health index among women in the mining community [51]. Age, marital duration, poverty, gender inequities, husband's employment [17] and gender-based power dynamics [71,72] emerged as the risk factors of victimization and the perpetration of all types of domestic violence. Educated [73] and regularly employed women are typically more autonomous and possess the resources and skills necessary to better recognize and terminate a potentially abusive relationships and were less likely to report ever having experienced physical domestic violence than unemployed women [71]. The SF36 correlates were high with decreased illness, age, marital status, ownership asset, domestic violence, emotional, social and cognitive coping among women in the agricultural community. In our study, role functions, social valuing of role expectations and mental health has been identified as motivators in the development of good HRQOL among women in the agricultural community. Women's health differs in various communities because they also react in different ways to predictors that determine health. Health status in stressed communities (mining) is lower than for non-stressed communities (agricultural), and limited educational and employment can further jeopardise health status. The socio-cultural environment exerts a constraining impact on coping and the SF36 among women in mining communities, leading to a stressful life; while limited educational and employment opportunities may compound to aggravate Physical and Mental Health. --- Conclusion In our study Physical and Mental Health have significantly positive and direct influence on the HRQOL among women. HRQOL is determined by complex layers of intertwined forces, with structural (age, marital status, economic, family type, ownership), health (illness, domestic violence) and psychosocial (social, emotional, cognitive and behavioural coping strategies) predictors of Physical and Mental Health among women in the agricultural and mining communities. Psychosocial resources, health and stressful events are rooted in the social structural context of women's lives. In addition years of stay, education and employment are significant predictors among women in the agricultural community. Cognitive-perceptual factors and self-efficacy were significant predictors of health promoting lifestyle and HRQOL [74]. The differential pattern of responses related to cultural and health (domestic violence, illness), socio-economic factors (education, employment, economy) and coping strategies (social, emotional, behavioural and cognitive) signifies exposure to focal (unsupportive relationships, violence), contextual (job stress, financial instability) or residual (environmental stress) stimuli, are positively associated with the SF36 dimensions among women in the mining and agricultural communities. These stimuli have both direct and mediating responses on HRQOL which explain the differences in perceived health among women across both communities. This perspective helps to illuminate those aspects of the adaptive system that contribute to a differential exposure to stimuli and to the coping strategies (resources) that women mobilize against stimuli or problems [2,5,75]. Coping strategies or resources (cognitive and emotional) vary in their benefits and are positively related to better HRQOL among women in various communities. Women's coping strategy (psychosocial predictors) is an important factor which affects health outcomes and influences HRQOL. The SF36 dimensions (HRQOL) were found to reflect the health status of women and were also significantly associated with coping with stress which plays a key role in women's physical and mental health. Coping style has a strong association with life satisfaction and well-being [76]. Coping strategies and resources play an important role in determining adaptation to health related quality of life, but their effects have been stronger for women in the agricultural compared with the mining community. Women apply specific coping strategies when encountering stimuli, for example cognitive coping attempts to alter and manage the stressor, whereas emotional/social coping attempts to regulate the emotional response to the stressor. Our results contribute to an increase in awareness of coping as important indicators of successful adaptation. Cognitive coping improves health status and was positively related to better quality of life among women in the agricultural community. Women who are not able to maintain physiologic-physical needs (polluted environmental, mental stress), poor self-concept, inadequate role function as a family member, spouse, interdependence (poor self-esteem, poor communication), find it difficult to maintain daily activities and interaction with significant others such as family members. Women in the agricultural communities are at a greater advantage with better biopsychosocial, coping processes and adaptive modes leading to effective responses and adaptive behaviours. This study shows that structural, health and psychosocial predictors determine HRQOL among women in both the communities. --- Implications for nursing SF-36 is a diagnostic tool for nurses to assess the functional health patterns and perceived health needs of high-risk women subgroups in vulnerable populations and settings. Self-assessment of health is important to facilitate more individualized nursing care to promote HRQOL among women. Identification of stimuli and coping strategies that are predictive of health status are critical to the development of coping strategies in these populations of women. Nurses can address the importance of valuing role functions among women and this information can be used for designing appropriate nursing interventions. Thereby women can be empowered to make informed decisions and to act on them. This ability to discriminate across vulnerable populations means that nurses can use SF36 health scores to better understand functional status and the health care needs of atrisk women sub-groups. This will enable health policy makers to evaluate the health status and outcomes among women for enhance policy making towards optimum resource management and provision of safe environment. --- Appendix A --- Definition of terms Focal stimuli are those most immediately confronting the person. Contextual-all other stimuli present that are affecting the situation and Residual-those stimuli whose effect on the situation are unclear. Adaptation: the process and outcome whereby thinking and feeling persons, as individuals and in groups, use conscious awareness and choice to create human and environmental integration Adaptive Responses: responses that promotes integrity in terms of the goals of the human system, that is, survival, growth, reproduction, mastery, and personal and environmental transformation Ineffective Responses: responses that do not contribute to integrity in terms of the goals of the human system An adaptive system with coping processes, cognator and regulator subsystems acting to maintain adaptation in the four adaptive modes: physiologic-physical, self-conceptgroup identity, role function, and interdependence. Regulators regulate four adaptive modes through neuro chemical or endocrine activities. Cognator are the control subsystem. Roys view the regulators and cognator as method of coping. When all six sub systems function well adaptative behaviour will occur otherwise ineffective response or maladaptation will occurs. --- Adaptive modes Physiologic-physical. Physical and chemical processes involved in the function and activities of living organisms; the underlying need is physiologic integrity as seen in the degree of wholeness achieved through adaptation to change in needs. Five needs-oxygenation, nutrition, elimination, activity and rest, protection. For complex processes-senses; fluid, electrolyte, and acid-base balance; neurologic function; endocrine function Self-concept-group identity. Focuses on psychological and spiritual integrity and sense of unity, meaning, and purposefulness in the universe. Need is psychic and spiritual integrity so that one can be or exist with a sense of unity, meaning, and purposefulness in the universe Role function. Roles that individuals occupy in society, fulfilling the need for social integrity. It is knowing who one is in relation to others. Need is social integrity; knowing who one is in relation to others so one can acct; role set is the complex of positions individual holds; involves role development, instrumental and expressive behaviors, and role taking process Interdependence: The close relationships of people and their purpose, structure and development individually and in groups and the adaptation potential of these groups. Need is to achieve relational integrity

Background: Women facing social and economic disadvantage in stressed communities of developing countries are at greater risk due to health problems. This paper investigates the relationships between structural, health and psychosocial predictors among women in mining and agricultural communities. This paper is a report of a study of the predictors of the health-related quality of life among Indian women in mining and agricultural communities. Methods: A descriptive cross-sectional research design was used. The instruments used are SF-36 Health Survey and Coping Strategy Checklist. ANOVA, MANOVA and GLM were used in the analysis. The study was conducted between January-September 2008 with randomly selected women in a mining ( 145) and an agricultural community (133) in India. Results: Women in the agricultural community had significantly increased Physical Health, Mental Health and SF36 scores compared with those in the mining community. Years of stay, education and employment were significant predictors among women in the agricultural community. 39% (33%) and 40% (26%) of the variance in Physical and Mental health respectively among women in agricultural and mining communities are predicted by the structural, health and psychosocial variables.Perceived health status should be recognised as an important assessment of Physical and Mental Health among women in rural stressed communities. Cognitive, emotional and behavioural coping strategies are significant predictors of health related quality of life. Implications. Nurses should use the SF-36 as a diagnostic tool for assessing health related quality of life among women and discuss coping strategies, so that these can target women's adaptive behaviour. This should be an essential part of the nursing process for facilitating adaptive process for improved health related quality of life.

physical. Physical and chemical processes involved in the function and activities of living organisms; the underlying need is physiologic integrity as seen in the degree of wholeness achieved through adaptation to change in needs. Five needs-oxygenation, nutrition, elimination, activity and rest, protection. For complex processes-senses; fluid, electrolyte, and acid-base balance; neurologic function; endocrine function Self-concept-group identity. Focuses on psychological and spiritual integrity and sense of unity, meaning, and purposefulness in the universe. Need is psychic and spiritual integrity so that one can be or exist with a sense of unity, meaning, and purposefulness in the universe Role function. Roles that individuals occupy in society, fulfilling the need for social integrity. It is knowing who one is in relation to others. Need is social integrity; knowing who one is in relation to others so one can acct; role set is the complex of positions individual holds; involves role development, instrumental and expressive behaviors, and role taking process Interdependence: The close relationships of people and their purpose, structure and development individually and in groups and the adaptation potential of these groups. Need is to achieve relational integrity using process of affectional adequacy, i.e., the giving and receiving of love, respect, and value through effective relations and communication. --- Research highlights <unk> Physical and Emotional Role Limitations are motivators to promote coping among women for health related quality of life. <unk> Age, marital status, economic status, family type, ownership, illness and domestic violence are predictors among women. <unk> Cognitive, emotional and behavioural coping strategies influence women's Physical and Mental health and health-related quality of life. <unk> SF-36 Health Survey should be used to assess and plan nursing interventions for improving health-related quality of life. --- Competing interests The authors declare that they have no potential competing interests. --- Authors' contributions All authors meet the criteria for authorship, have designed, provided analysis and interpreted the data, drafted, revised and approved the final article and those entitled to authorship are listed as authors. MSD conceived of the study conception and design, data collection/acquisition, and provided analysis and interpretation. KSN participated in the data collection/ acquisition and provided analysis and interpretation. GS carried out the study conception and design. All the authors drafted the manuscript, provided critical revision of manuscript for important intellectual content and final approval of version to be submitted. MSD-Melba Sheila D'Souza; KSN-Karkada Subrahmanya Nairy; GS-Ganesha Somayaji.

Background: Women facing social and economic disadvantage in stressed communities of developing countries are at greater risk due to health problems. This paper investigates the relationships between structural, health and psychosocial predictors among women in mining and agricultural communities. This paper is a report of a study of the predictors of the health-related quality of life among Indian women in mining and agricultural communities. Methods: A descriptive cross-sectional research design was used. The instruments used are SF-36 Health Survey and Coping Strategy Checklist. ANOVA, MANOVA and GLM were used in the analysis. The study was conducted between January-September 2008 with randomly selected women in a mining ( 145) and an agricultural community (133) in India. Results: Women in the agricultural community had significantly increased Physical Health, Mental Health and SF36 scores compared with those in the mining community. Years of stay, education and employment were significant predictors among women in the agricultural community. 39% (33%) and 40% (26%) of the variance in Physical and Mental health respectively among women in agricultural and mining communities are predicted by the structural, health and psychosocial variables.Perceived health status should be recognised as an important assessment of Physical and Mental Health among women in rural stressed communities. Cognitive, emotional and behavioural coping strategies are significant predictors of health related quality of life. Implications. Nurses should use the SF-36 as a diagnostic tool for assessing health related quality of life among women and discuss coping strategies, so that these can target women's adaptive behaviour. This should be an essential part of the nursing process for facilitating adaptive process for improved health related quality of life.

Background At the end of 2014, an estimated 955,081 people were living with human immunodeficiency virus (HIV) infection in the USA. While in its early years the epidemic affected primarily males and young people [1], nowadays, the population living with HIV/AIDS is approximately 24% women and its age composition has shifted [2]. The percentage of people living with HIV/AIDS aged 50 years and older grew from 24% in 2005 to 45% in 2014. This number is projected to top 50% by 2020 [2,3], but may have already done so [4]. People aged 40 and over comprise 72.5% of the population [2]. Thus, the management of this population who live with HIV/AIDS represents a relatively new challenge. It is well understood that the population of older people who live with HIV (for this report, all people over the age of 40) is heterogeneous with respect to a multitude of factors that are associated with length and quality of life [2]. Age at HIV infection, rather than age at diagnosis, may be important, because the natural history and prognosis of HIV and acquired immunodeficiency syndrome (AIDS) among those with HIV surviving into older age and those who were diagnosed at an older age appear to be distinct [5]. Further, compared to people who were infected young, people contracting HIV at an older age are not diagnosed as promptly and tend to start treatment at a more advanced stage of the disease. Of the 428,724 people aged 50 and above living with AIDS at the end 2014, only 1.6% were diagnosed at age 50 and above; for those age 40 and above, the percentage was 1.9. Aging with HIV infection presents special challenges for preventing and managing comorbid conditions. Older women with HIV/AIDS may have an increased risk for cardiovascular disease, osteoporosis, and certain cancers than their uninfected counterparts [6][7][8][9]. According to a 2013 study by the CDC, the most common conditions among women infected with HIV were viral hepatitis B or C coinfection (29.0%) or were related to cardiovascular disease or metabolic syndrome, including dyslipidemia (67.3%), hypertension (57.4%), obesity (31.7%), and low high-density lipoprotein cholesterol (27.3%). They also noted that 73.7% of women across races and ethnicities had more than one comorbidity [10]. HIV-positive antiretroviral-treated older women who achieve viral suppression are in a generalized status of immune activation and therefore may be at an increased risk of ageassociated end-organ diseases compared to uninfected age-matched controls [11]. Polypharmacy is another common concern [12,13]. Women over 40 living with HIV/AIDS also face issues related to the interaction between reproductive hormones, HIV/AIDS, and antiretroviral treatments. Some women may still have childbearing potential and will have unique contraceptive or fertility needs [14,15], and there have been inconsistent reports regarding HIV and menopause [16][17][18][19]. Older women with HIV face challenges related to mood and psychosocial wellbeing. Compared to older women without HIV, older women with HIV infection are more likely to be depressed and lonely [20,21], and many are burdened with taking care of elderly parents or grandchildren [22]. Stigmatization can also contribute to depression and worry and may prevent women from disclosing their HIV status or from seeking care [23]. African American/Black women are disproportionally affected by HIV, compared to women of other race/ethnicities. An estimated 61% of women who were living with HIV/ AIDS in 2014 were African American [2]. Race is often a marker of socioeconomic and demographic factors related to health inequities, which may have a bearing on the comprehensive management of women living with HIV/AIDS. HIV rates are also highest among women living in areas where more than 21% of residents were below the federal poverty level [2]. Special consideration should be given to women who identify as lesbian, bisexual, or transgender (assigned male sex at birth but identify as women). For women who identify as lesbian, HIV infection may be diagnosed belatedly, and transgender women are a vulnerable subgroup for a number of medical and social reasons [24][25][26][27][28][29]. Ideally, the care of older women living with HIV/AIDS should support patient-centered approaches to managing HIV and comorbidities; incorporate patient goals, including quality of life issues; and integrate biomedical, behavioral, and social interventions [13,30,31]. Because people with HIV/AIDS may have an accelerated aging process and often suffer from multiple comorbidities, a geriatrics approach may be appropriate, even for those who are not chronologically geriatric [30,31]. However, the current system of care in the USA does not support a comprehensive model that can provide a tailored approach for older women living with HIV/ AIDS. This paper comprises an evidence map of the published literature on questions pertinent to older women, aged 40 and above, who live with HIV/AIDS to serve as a compendium of the evidence base (enabling further systematic study of specific questions) that can be used to identify and prioritize gaps in the evidence, without recording what the findings were or assessing risk of bias and the strength of the evidence (which was infeasible given the scope and heterogeneity of interventions and outcomes). --- Methods The protocol for this project was not registered with PROSPERO, but was posted prospectively on the Agency for Healthcare Research and Quality (AHRQ) Web site (https://effectivehealthcare.ahrq.gov/topics/women-hiv/ research-protocol/). --- Key informants We assembled a panel of eight Key Informants that included experts in the care of HIV patients, nationally recognized researchers, policy makers, state government (Department of Health) officials, and nationally recognized advocates for women who live with HIV/AIDS to share their perspective on the issues that the guiding questions address. Based on these discussions, we refined study eligibility criteria and data extraction items for the evidence map of empirical studies that apply to women over 40 who live with HIV/AIDS. We grouped the studies into three areas of interest: (Area 1) studies that measure the impact of or describe barriers to engaging with existing resources; (Area 2) studies that measure the impact of insurance coverage on outcomes related to engaging with a program or accessing care; and (Area 3) studies that assess the performance of diagnostics for co-occurring disease or assess the effects of treating co-occurring diseases or risk factors. --- Eligibility criteria Eligible studies reported results stratified by age and included at least 75% of the participants were women 40 years and older who live with HIV, an operational age cutoff to identify premenopausal women who are less likely to bear children, and peri-and postmenopausal women. All patient-level and system-level outcomes were eligible. Eligible services provided medical, behavioral, or social support or were programs that bundled several such services. All study designs were eligible, including qualitative studies, which informed on barriers to accessing care. We excluded studies that analyzed fewer than 10 women who are older than 40 and live with HIV/AIDS, because they were unlikely to yield precise or broadly applicable conclusions. We also excluded studies completed longer than 10 years ago, because older empirical data are less likely to be relevant to today's setting. Because the main focus of the evidence map is to inform about the US setting, we did not include studies conducted exclusively in other countries. Finally, we excluded studies not reporting empirical data. --- Literature identification and data abstraction A medical librarian designed and implemented searches in PubMed, PsycINFO, CINAHL, and SocINDEX for terms related to HIV or AIDS, crossed with terms on interventions, policies, services, or programs. We limited the search to English language reports published after January 01, 2005, having at least one author with a US affiliation. The search was last run on February 10, 2016, and is reported in full in Additional file 1: Appendix 1 in the full report of the project [32]. After a pilot phase to ensure that the eligibility criteria was being correctly and uniformly applied, abstracts were single-screened by a human reviewer and double-checked against the predictions of the machine learning algorithms implemented in Abstrackr [33]. All potentially eligible citations were retrieved and screened in full text for eligibility. For these papers, we recorded reasons for exclusion. For papers on studies that were excluded only because they did not report subgroup-specific information or pertinent interaction analyses, we recorded the area of interest the paper fell into. All data were extracted in a predefined electronic form by a single investigator. The form recorded bibliographic information; demographic details for women over 40 where available, and for all women in the study where not; along with details about the programs, barriers, insurance impact, and comorbidities. Due to the nature of the project, we did not extract results, nor did we make strength of evidence assessments for individual studies or for the whole evidence base. --- Results We screened 9054 unique abstracts for eligibility, of which 1763 were selected for full text review. In the end, 32, 7, and 8 papers were eligible for the three areas of interest, respectively (Fig. 1). Of the citations that were excluded in full text review, 854 were excluded because they did not provide information on strata of women who live with HIV/AIDS and are at least 40 years old or did not analyze interactions between gender and older age. Details on these studies are available in Additional file 1: Appendix B. Area 1: studies measuring the impact of strategies for engaging resources or describing barriers to accessing resources Thirty-two papers were eligible in Area 1; 16 quantified the impact of strategies for engaging resources, and 18 were about barriers to accessing resources (one paper was about both). Additional file 1: Appendix B, Table S1 summarizes the characteristics of the women enrolled in these studies. Most studies were conducted in urban centers, though a few focused on rural populations or examined differences between rural and urban populations. Studies included an average of 70 women (nine included more than 200 women). Mean ages ranged between 36 and 57 years, and no study provided results in the elderly. No study reported the women's menopausal status or the age at which they were diagnosed with HIV. Among the 28 studies that reported information on the race/ethnicity of participants, the median proportion of African American, Latino/Hispanic, and White women was 78, 15, and 14%, respectively. Three studies enrolled a small proportion of Native American women, Fig. 1 PRISMA literature flowchart [61]. * "Not relevant": these studies were excluded on the grounds of more than one reason (e.g., did not describe eligible outcomes of eligible programs in an eligible population) and one included Pacific Islander women. No study enrolled Asian women. On average, 20% of women reported having a spouse or partner, 58% perceived having adequate social support, and 31% cared for a dependent, but such information was provided in less than a third of the studies. Among studies listing such information, the average proportion of women who had annual income less than approximately $10,000 were unemployed, had not finished high school, used illegal substances, or faced mental health challenges ranged between 31 and 75%. Only one or two studies reported on the proportion of women who were undocumented immigrants (one study), experienced violence (two studies), or had a history of incarceration (one study). Cumulative data from seven studies reported that a median of 73% of women had some form of public insurance (Medicare or Medicaid), 15% had private insurance, and 27% had no insurance. However, this may have changed or be changing as the Affordable Care Act is implemented. Finally, the vast majority of studies did not explicitly report information on sex of women's sexual partners or gender self-identification. No study reported the proportion of women who have more than one concurrent sexual partner, four studies included women who were identified in the study as lesbian or bisexual (ranging from 6.6 to 33% of the study population), and one study enrolled only transgender women. --- Studies measuring the impact of strategies for engaging resources Sixteen papers on 13 unique studies measured the impact of engaging with various services or with programs bundling several services. Eight RCTs (described in 10 papers) randomized between 30 and 184 participants to receive a specific program or an alternative (no program or a different program). An additional six studies qualitatively assessed the impact of engaging with programs. Three were based on interviews of 15 to 21 participants [34][35][36], a fourth examined a cohort of 364 participants in a stress-management intervention [37], and two examined programs aimed at reducing substance use in 46 and 76 participants, respectively [38,39]. Details of all programs and measured outcomes are listed in Table 1. --- Studies of barriers to accessing resources Eighteen observational studies evaluated barriers to care in populations ranging from 17 to 1701 women. Almost all of the barriers studied involved engaging or retention in HIV care, though three studies exclusively assessed outcomes not related to HIV, including cancer screening (one study), accessing program services online (one study), and using the internet (one study) (Table 2). Of the 14 studies that evaluated barriers to accessing care or retention in care, the barriers were sociodemographic in 12, cultural in 6, psychosocial in 11, having to do with experience with incarceration in 1, having to do with medical history in 12, and having to do with mental history in 6. Two studies reported on barriers to cancer screening that were sociodemographic, psychosocial, and medical in nature [40,41], and a third evaluated barriers to adherence to treatment in the context of a pharmacy program that were psychosocial and medical [35]. Two studies, both by Blackstock et al., evaluated barriers having to do with using the Internet, either in general or to access social support. These studies identified barriers from nearly every aspect (sociodemographic, cultural, psychosocial, medical history, and mental history) [42,43], which may inform the design of Web-based programs, as well as strategies to enhance their uptake and use. The most commonly cited system-or provider-level factors were lack of transportation and logistical challenges, including navigating, wait times, clinic hours, insurancerelated bureaucracy (six studies), and relationship with the provider (four studies). --- Area 2: studies measuring the effect of insurance Seven eligible papers evaluated the overall effect of insurance coverage levels on outcomes related to engaging with a program or accessing care. Six of these are included among the studies of barriers described in the previous section. Full details for the population are in Additional file 1: Appendix B, Table S2. Of these, six studies reported the impact of different insurance coverage on engagement with or retention in care, satisfaction with care, antiretroviral adherence, and Internet use. The seventh study evaluated the association between insurance coverage and successful management of major depressive disorder [44]. In no study did more than 18% of the women have private insurance. Where it was reported, between 60 and 100% of women had public insurance and between 7 and 35% had no insurance. In all studies, insurance coverage was one of several factors in a regression model for engaging with or accessing care. Although we did not perform risk of bias assessments, we deem it unlikely that such analyses can yield good estimates of the causal effect of insurance on outcomes. These studies were not designed to estimate the causal effect of insurance, and each study considered and controlled for different variables. --- Area 3: studies on the diagnosis or management of comorbidity, or on predictive models Eight papers (seven studies), with sample sizes between 46 and 1234 participants, were deemed eligible. Full details for the population are in Additional file 1: Appendix B, Table S3. No study informed on diagnosis or screening for Table 1 Characteristics of studies of strategies to promote women's engagement with resources comorbidities among older women living with HIV/AIDS; six reported information on the management of comorbidities; and two reported on predictive models of HIV progression or overall mortality in the presence of comorbid conditions. Of the six studies that included information on management of comorbidities, two pertained to depression, three to alcohol and other substance abuse, and one to cardiovascular disease. Of the two studies on depression, one examined whether psychopharmacologic and psychotherapeutic treatment of depressed HIV-women met standards defined in the best practice literature and assessed predictors of standard-concordant care [44], and the other examined whether antidepressant use by HIV-positive patients results in better employment rates [45]. Among the three studies of drug and alcohol abuse, one evaluated a family-based intervention (Structural Ecosystems Therapy) compared to a psychoeducational intervention [46,47]. A second looked at associations between heavy alcohol consumption and antiretroviral treatment initiation and mortality [48], and a third evaluated a brief intervention to reduce or eliminate alcohol consumption in seropositive women with heavy drinking problems [49]. Finally, a cohort study reported rates of acute myocardial infarction among HIV-positive patients with cardiovascular risk factors [50]. Two eligible cohort studies described models predicting HIV progression or overall mortality among older women living with HIV/AIDS who also have comorbidities. The first predicted clinical progression of HIV disease based on illicit drug use and various sociodemographic factors (such as age, race, and sexual history) and medical history factors (such as antiretroviral use, CD4 cell counts, and CDC category of HIV disease at baseline) [51]. The second predicted all-cause mortality among older women living with HIV/AIDS who also have substance and alcohol abuse problems based on sociodemographic factors (age and race), medical history factors (including using various drugs, alcohol and tobacco, having hepatitis C, prior antiretroviral therapy, CD4 counts, and viral load), and mental health factors (including a history of depression, anxiety, or psychosis) [48]. --- Discussion We identified 890 citations that address questions in the three areas of interest and have enrolled women age 40 and over, who live with HIV/AIDS. Of these, only 37 (4%) studies reported results of interest among older women who live with HIV/AIDS or examined interactions between gender and older age that would allow extrapolation to this subgroup. An additional 494, 114, and 390 papers would have been eligible for the three areas of interest, had they reported the required information on women age 40 and over. This observation is not surprising, because the page restrictions on journal articles limit the examination of the many subgroups of interest. It is, however, congruent with the prediction of the Key Informants that evidence for age grouping would be sparse. While some of the 37 eligible studies focused on populations facing obvious challenges, such as immigrant women [52], women who had suffered physical abuse [53], transgender women [54], and women recently released from prison [55], more studies are needed in these subgroups. No study focused on women caring for dependents, those diagnosed in old age, or those who face less obvious challenges. For example, no published data have assessed the safety and efficacy of hormone therapy on symptoms of menopause, cardiovascular risk, and bone disease among women living with HIV/AIDS [56]. The pharmacological interactions between hormone therapy and antiretroviral treatments are not well understood, with some studies reporting menopause at an earlier age among women living with HIV/AIDS compared to uninfected women [16][17][18][56][57][58][59], and other studies suggesting that women with HIV have more vasomotor symptoms (e.g., hot flashes, night sweats) and mood issues during menopause [56]. We identified eight generally small randomized trials that examined the impact of strategies for promoting healthy family and social relationships and healthier lifestyle. Most included psychosocial and health education components, but none included a comprehensive casemanagement-based approach. A handful of nonrandomized studies also evaluated the effectiveness of strategies for promoting care. We identified 18 studies of barriers to accessing care, which most commonly examined barriers related to sociodemographic, psychosocial, and medical factors. A minority examined barriers related to cultural factors, experience with incarceration, or mental health. Several studies identified system-level barriers to engaging with care, including transportation, scheduling, insurance referrals, financial issues, and practical challenges, such as navigating a hospital building. Finally, very few studies examined the overall impact of insurance on outcomes, or the impact of comorbidity on the management of HIV infection or its progression. Thus, although we did not analyze the findings of the aforementioned studies in all clinical areas, it is highly unlikely that the identified body of evidence is close to maturity. --- Limitations This work has several limitations. We developed an evidence map to describe the amount and type of practically available evidence, but did not summarize findings of eligible studies. For feasibility, we did not consider research completed longer than 10 years ago, because older empirical data are less likely to be relevant to today's setting and for informing the future research agenda. We decided not to search EMBASE or any other large, international general database, because we deemed that the added benefit of searching multiple targeted databases was more cost and time efficient and would yield more relevant studies than a second large general database search [60]. We did not conduct a detailed analysis of the 37 eligible papers, prioritize outcomes by their importance, or do a detailed analysis of the risk of bias or the strength of evidence of individual studies or of the entire evidence base, because these tasks were not relevant to the goal of this project, which was to describe the literature in broad terms. Because the main focus of the evidence map was to identify studies that inform about the US setting, we did not consider studies conducted exclusively in other countries. To operationalize this, we limited our search to papers in which at least one author had a US affiliation. In screening, we excluded a study only if it reported that it had been done exclusively outside the USA. Because of limited time and resources, screening and data extraction were done by a single experienced reviewer. We believe that the overall picture of the research is accurate. --- Research needs The 37 eligible studies do not represent a mature evidence base. The evidence base is even more sparse if one considers that the identified studies focused on different research questions and cannot possibly cover the range of practically implementable interventions that should be examined. By their nature such interventions are complex, in that they have many versions, and their implementation and deployment can depend on the targeted population. More generally, when the range of questions of interest is so large, and the directly applicable evidence base is so limited, most, if not all, questions can be characterized as under-researched. The following are some general observations, which may help those looking to prioritize this research: 1. There is a need for better quality demographic information for women over the age of 40 living with HIV/AIDS in the USA, to allow better understanding of their care needs. 2. A large amount of data have already been collected on women who are over 40 years and live with HIV in the context of studies that enrolled broader populations, but have not been analyzed for this subgroup. Substantial economy of resources can be had by encouraging re-analyses of existing datasets, with a focus on older women who live with HIV/AIDS. --- Conclusions The population of women over 40 living with HIV/AIDS is both growing and under-researched. More research is needed to learn about the challenges faced by these women and how they differ across demographics. It is important to identify the needs of women over 40 living with HIV/AIDS and engage them in the prioritization, design, and interpretation of research. This research should be aimed at facilitating a comprehensive model of care that can provide a tailored approach for older women living with HIV/AIDS across the continuum of care. --- Additional file Additional file 1: Appendix A. Complete search strategies and Appendix B. Characteristics of women in included studies. (DOCX 428 kb) --- Availability of data and materials The full report with all related data is available at: https://www.ncbi.nlm.nih.gov/ pubmedhealth/PMH0091591/ --- Abbreviations AHRQ: Agency for Healthcare Research and Quality; AIDS: Acquired immunodeficiency syndrome; HIV: Human immunodeficiency virus Authors' contributions GA, Sc-U, TT, and SI designed the study and wrote the protocol. GA designed the search. GA, MD, CH, and BS screened the citations and extracted the data. GA, Sc-U, and TT analyzed the data and wrote the report. All authors read and approved the final manuscript. --- Authors' information Not applicable --- Ethics approval and consent to participate Not applicable --- Consent for publication Not applicable --- Competing interests The authors declare that they have no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details

Background: While in its early years the HIV epidemic affected primarily the male and the young, nowadays, the population living with HIV/AIDS is approximately 24% women, and its age composition has shifted towards older ages. Many of the older women who live with HIV/AIDS also live with the medical and social conditions that accompany aging. This work aims to identify and characterize empirical studies of strategies for the comprehensive management of women over 40, including transgender women, who live with HIV/AIDS. Forty was chosen as an operational age cutoff to identify premenopausal women who are less likely to bear children, as well as peri-and postmenopausal women. Methods: We conducted a literature search after discussions with a diverse panel of content experts and other stakeholders and developed an evidence map that identified 890 citations that address questions having to do with programs and barriers to engaging with programs, as well as the role of insurance and comorbidities, and have enrolled older women who live with HIV/AIDS. Results: Of these, only 37 (4%) reported results of interest for women over 40 who live with HIV/AIDS, or examined interactions between gender and older age that would allow predictions in this subgroup. Few of the 37 eligible studies focused on women facing obvious challenges, such as immigrants, transgender, physically abused, or those recently released from prison. No studies focused on women caring for dependents, including children and grandchildren, or those diagnosed after age 40.The evidence base that is directly applicable to women over 40 who live with HIV/AIDS in the USA is limited, and the research need is broad. We propose research prioritization strategies for this population.

INTRODUCTION Suicide is a global phenomenon, with nearly 800,000 people dying each year and 79% occurring in low-and middle-income countries (1). In 2017, it is estimated that 47,173 Americans died by suicide, and around 1.4 million attempted suicide; men died by suicide 3.54 times more often than women and firearms accounted for 50.57% of all suicide deaths (2). Society has viewed suicide through the lens of religion and politics, and this has historically undergone dramatic changes over time and has shifted public opinion in myriad ways. In the ancient Roman times, self-killing was recognized with the Epicureans acknowledging man's fundamental right to dispose of his own life (3). In 1897, Durkheim published "Suicide: a study in Sociology" (4), which highlighted social conditions that were identified to be the root cause and shifted the focus away from suicide being considered an irredeemable sin or moral crime. Durkheim proposed four different types of suicide based on social integration and regulation: egoistic suicide, altruistic suicide, anomic suicide, and fatalistic suicide (5)(6)(7). In the past several decades, the pendulum has swung in the direction of a psychological model, with the assumption that nearly all suicides result from mental illness, although this is often diagnosed after the fact from psychological autopsies (8). Joiner's interpersonal theory of suicide has received widespread recognition (9,10), but has faced some criticism (11). Across different cultures, suicide has also been perceived to result from overwork or occupational burnout (12,13), serious financial problems (14), lack of support (15), problems with mandatory military service (16), interpersonal relationship problems (17), and marital problems (18). Suicide has been associated with the stress of dealing with chronic medical conditions such as epilepsy and stroke (19,20). It is helpful to gauge the attitude of the public towards suicide, its acceptance, condemnation, and preventability, and whether it can be encompassed in the argument for a person's right to die. Suicide has been steeped in stigma for centuries, and there are vestigial remnants of it to this day, mostly perceived by suicide loss survivors and suicide attempt survivors. Stigma is an overarching term that contains three elements: problems of knowledge (ignorance), attitudes (prejudice), and behavior (discrimination) (21). Public stigma is a social phenomenon that refers to the negative attitudes held by members of the public about people with devalued characteristics, while selfstigma is the internalization of these public attitudes which leads to numerous negative consequences (22). Stigma and discrimination in relation to diseases such as HIV can be measured through many dimensions such as blame/judgment (23), shame (24), discrimination in different settings, and disclosure of disease status (25). Common stereotypes about suicide are emotional weakness, attention-seeking, selfishness, malingering, and immorality. Those who attempt or die by suicide are perceived to be impious (not praying enough, believing enough), or as betraying family and others through cowardly or selfish acts (26). In addition to stigma, survivors' guilt often compounds and reinforces the stigma either imagined or accurately perceived by bereaved friends, family, and therapists (27). With the rapid technological advances, the use of social media platforms has grown exponentially, with Facebook, one of the platforms used for the study, having 2.41 billion active users per month (28). Social media platforms can offer several potential benefits in suicide prevention, which include reach, accessibility, nonjudgmental, and anonymous nature of such platforms. However, these platforms have also been used to spread information about how to die by suicide, help make cyber-suicide pacts with strangers, and access unregulated online pharmacies. There is the increased risk of media contagion effect, with peer pressure from online forums that are pro-suicide, swaying those who are ambivalent (29). Accessing and utilizing social media platforms can be a huge boon in prevention of suicide, but there are numerous ethical and methodological challenges surrounding privacy in the digital age for clinicians and researchers (30,31). Our study aims to understand the attitudes of social media platform users towards suicide, whether there are correlations with demographics and other factors such as having lost someone close to suicide, and whether these platforms for help. --- MATERIALS AND METHODS --- Questionnaire Development To better understand how the public views suicide in this current era, we developed a short survey to gauge the perception of suicide in social media. While at least 14 suicidal attitude scales have been identified, there is no gold standard due to the implicit instability of attitudes, the varied dimensions of attitudes, and a lack of consensus (32). The Attitudes Towards Suicide (ATTS) questionnaire has 34 items which include 10 dimensions (suicide as a rightjustifiability, incomprehensibility, noncommunication, preventability, tabooing, normal-common, suicide as a process, relation caused, preparedness to prevent, and resignation) (32). The Suicide Opinion Questionnaire (SOQ) has 100 items assessing different domains, with a 5-factor structure: 1) Acceptability (AC): "People with incurable diseases should be allowed to commit suicide in a dignified manner."; 2) Perceived Factual Knowledge (PFK): "Most suicides are triggered by arguments with a spouse.", willingness to accept as fact inaccurate statements related to suicide; 3) Social Disintegration (SD): "The higher incidence of suicide is because of the lesser influence of religion."; 4) Personal Defect (PD): "I would feel ashamed if a member of my family committed suicide."; and 5) Emotional Perturbation (EP): "Most persons who attempt suicide are lonely or depressed.", that those who attempt or die by suicide are emotionally distraught or mentally ill (33). The Cognition Concerning Suicide Scale (CCSS) has three factors, the first is "right to commit suicide" (CCSS-S 8 items: "Everyone has the right to commit suicide", "When life consists of intolerable pain, suicide is an acceptable alternative"); the second factor is "interpersonal gesture" (CCSS-I 5 items: "I sometimes think suicide would be a good way to pay back people who have hurt me deeply", "Taking my own life would be a good way to make sure I would always be remembered"); the third factor is "resiliency" (CCSS-R 4 items: "Even if I got tired of living, I would not seriously consider suicide as a way out", "Even if I could not be with the person I love, I would not consider suicide") (34). The brief questionnaire we developed had items under these main themes: 1. Demographic characteristics (age, gender, ethnicity, level of education) 2. Had someone close to you died of suicide 3. Whether media glorifies suicide 4. Whether social media is viewed as a platform where people could get help and support 5. Whether suicide is preventable 6. Does one have the right to die by suicide 6. Attitudes about suicide that explore themes of acceptability, interpersonal gesture, stigma (it is a way to escape, a selfish act, a selfless act, an impulsive act, a sign of weakness of cowardice, a sign of strength or courage, a revenge act). In an effort to keep the survey short, we did not request open and qualitative comments (35). --- Administration The survey was posted on social media forums of Facebook and Reddit, explaining the purpose of the survey and requesting voluntary and anonymous participation. There was no advertisement and no incentive for participation. Participants were advised to not take the survey if it in anyway was a trigger or caused discomfort. The survey included information about The National Suicide Prevention Lifeline which offers great resources, and can be reached by calling 1-800-273-TALK(8255) or chat online at https://suicidepreventionlifeline.org/. No personal data, such as name or other identifying information, were collected in the survey as a measure to protect personal information. The data was stored in a database accessed through surveymonkey, which was continuously updated during the survey period. Ethical approval was sought from the Institutional Review Board (IRB) of Stanford University School of Medicine, and all procedures were in compliance with the Helsinki Declaration. The first page of the survey asked for participants' consent, and if the person consented, they were taken to a second page with 10 questions with the focus on perceptions regarding suicide. It was posted on social media for one week and we had a total of 152 respondents. --- Data Analysis Descriptive statistics of the characteristics of respondents and responses to each question are presented. Analyses are based on the respondents' age, ethnicity, level of education, and their perception of suicide. Normally distributed data were presented as a mean and 95% confidence interval (95% CI) or standard deviation (SD), whereas data that were not normally distributed were presented as a median and 95% CI. Analysis of Variance (ANOVA) was conducted separately to assess the individual associations of demographics, with attitudes towards suicide. Variables that were found to be significantly associated in the univariate ANOVA (p <unk> 0.05) were highlighted. --- RESULTS The respondents were predominantly white (59.33%) and in the age group 18-29 (63.09%). The majority had attended college: 23.84% had some college, 27.15% had a bachelor's degree, and 25.17% had a graduate degree. 31.79% reported that someone close to them had died of suicide. Most (59.60%) did not believe that the media glorifies death by suicide and 52.03% of the respondents believed that social media is a good platform for people to ask for help. Of the respondents, 86% believed that suicide is preventable, and 72.85% believed that it a person's right to die by suicide. Most of the responders (87%) viewed suicide as "an escape", 47.6% as an impulsive act, 27.89% as a selfish act, 18.37% as a sign of strength, 14.97% as a revenge act, 13.61% as a selfless act, and 12.93% as a sign of weakness. Please see Figures 12345. Significant findings (p <unk> 0.05) included the following: those who identified as female found social media to be a good platform for people to ask for help (61%) while males did not (60.61%). Both whites (79.78%) and Asians (61.29%) believed it was a person's right to die by suicide. Whites and Asians also viewed suicide to be a sign of weakness. Regarding education, those who had some college (83.33%) and those with a bachelor's degree (78.05%) both believed that it was a person's right to die by suicide. Interestingly, the opinion was split 50-50 among those with a graduate degree. Those who believed it was a person's right to die to die by suicide viewed suicide as a sign of strength (23.36%) as opposed to those who did not (5%). Those who responded that someone close to them died by suicide believed that the media glorified suicide (56.25%) while those who did not lose someone close to suicide did not believe that (66.99%). Those who believed that media glorified suicide, also has a more stigmatizing view of suicide as a selfish act (41.67%) as opposed to those who did not (18.39%). Respondents who did not think suicide was preventable also viewed suicide as either a sign of strength (42.86%) or a revenge act (33.3%). --- DISCUSSION The study respondents were predominantly young and educated, and their view of suicide was overwhelmingly non-stigmatizing, with majority choosing responses such as "escape" (87%) or an impulsive act (47.6%). Overall, there were less of stigmatizing views of suicide, such as a selfish act (27.89%), revenge (13.61%), and a sign of weakness (12.93%); and less of glorifying, with only 14.97% viewing it as a sign of strength and 13.61% as a selfless act. The view of suicide as being an "escape" is somewhat neutral, a theory which can be ascribed to Shneidman (36) who described the "psychache" that one wants to escape from, and Baumeister (37). This approach does not blame the individual or others/society who supposedly failed the individual, rather the concept of "escape" is one that frees everyone to accept the inevitable. Survivors' guilt can also compound and reinforce the stigma either imagined or accurately perceived by bereaved friends, family, and therapists (38). We did not find any correlation in our study that those who had lost someone close to suicide had greater stigmatizing attitudes. Those who did not think suicide was preventable viewed suicide as either a sign of strength or as a revenge act. Our study found that 31.79% had lost someone close to them to suicide, and this is in keeping with the data that a third of Americans know someone who has died of suicide (39). We did not explore how the closeness impacted them. It has been shown that younger age at time of exposure to the suicide, time since the event, female sex, relationship with the deceased, and multiple exposures had greater personal impact (40). Those who had lost someone close to them to suicide believed that the media glorified suicide (56.25%) while those who did not lose someone close to suicide did not believe that (66.99%). Exposure to the suicide of a close friend or relative can influence attitudes to suicide which can impact own risk of suicide attempt; four key themes have emerged with a sense of gaining or losing control: 1) Suicide as a more tangible option; 2) Identification with the deceased and awareness of shared vulnerabilities to suicide; 3) Personal determination to avoid suicide; and 4) Beliefs regarding safeguards against suicide. Those who are determined to avoid suicide seek to exercise control over a perceived risk, aware of the devastating grief caused by suicide; others who perceived their own susceptibility to suicide described a sense of inevitability, which they either battled against or submitted to (38). Positive attitudes towards suicide, the "right to commit suicide" subscale can be predictive of suicide risk (41). Of the respondents 40.4% believe that the media glorifies death by suicide. The "Werther Effect" or copycat phenomenon refers to the media reporting of suicides by celebrities and wellknown figures which leads to an increase in suicide deaths in the general population (42). The exact mechanism of how celebrity suicides act to increase suicidal risk in the wider public is unknown, but emotional reactions may play a part (43). After the release of the Netflix series, "13 reasons why" about the aftermath of a 17-year-old's suicide, there was an increase in suicide rate about 10-19-year-olds which appeared to be consistent with a contagion by media (44). It is important to train journalists in responsible professional media coverage: avoiding sensationalism and glorification, martyrification, and mystification of suicide; avoiding detailed descriptions of suicide methods used (45). Women (61%) found social media to be a good platform for people to ask for help while only 39.39% of men did; on the other hand, 38.96% of the women did not find social media to be good platform to seek help, compared to 60.61% of men. Part of dispelling the stigma surrounding suicide is to get more people to talk about it. Our societies have perpetuated longstanding gender roles which are changing, however dominant masculine norms still exist which had led to men to avoid being emotional, and likely linked to lower likelihood of seeking help. The Australian "Man Up" Twitter campaign successfully influenced the social media conversation about masculinity and suicide, was gamechanging in shifting attitudes toward expressing emotions and reaching out to others for help (46). It is encouraging that 86% of the respondents believe suicide is preventable. We need to continue to raise awareness of it being a public health concern and to promote prevention efforts. A major intervention that needs ongoing support is restricting public access to lethal means of suicide: including firearm control legislation, restrictions on pesticides, detoxification of domestic gas, restrictions on prescription and sale of barbiturates, packaging analgesics in blister packets only and reducing number of tablets per package, mandatory use of catalytic converters in motor vehicles, construction of barriers at jumping sites (47). More than half of the respondents (52%) feel that social media platforms are a good place to ask for help and seek support from others. Because of this, we need to harness technological advances such as machine learning to create safer spaces on social media platforms for those at risk for suicidality. Linguistic pattern recognition of stigma expressions around suicide attempts in Weibo (social media in China) posts have confirmed that social media mining can help improve stigma reduction programs (48). Machine learning is currently used to automatically identify and score helpful comments in a subreddit suicide watch forum to assist moderators with immediate feedback for help with online suicide prevention (49). Suicide happens because of numerous factors coming together, and it is hard to precisely pin down ways it can be prevented. Rather than to focus on risk factors, we need to shift emphasis on risk algorithms by employing machine learning algorithms to form complex, albeit robust and replicable combinations of many potential risk factors within large data sets (50). Limitations of this study include the fact that those who respond to a survey voluntarily might have an interest in the topic, and this might not accurately reflect the public attitude. Because it is an anonymous online survey, there is no way to verify data. We did not perform further analysis of the data. In addition, we only surveyed those who are Facebook and Reddit users, and did not post on the numerous social media platforms available --- CONCLUSIONS The social media is a medium with boundless possibilities, which melds together an individual's biological and psychological uniqueness in the collective wisdom of a group that reflects the sociocultural mores of the time-we need to better understand the views held within such forums before we can tap in to bring about meaningful changes in how we approach public health concerns such as suicide. We gauged the perception of suicide on social media platforms and found among the sample of mostly young white respondents, suicide is not as stigmatized, most believed it is preventable, while also supporting the right to die by suicide. While women found social media a good platform to ask for support, men did not, which reflects data that women tend to be more willing to seek help. A third of the group had lost someone close to them to suicide which was the national average and they tended to believe that media glorified suicide. More research is needed to better understand how the social media influences its users, and whether it could be utilized as a forum to reduce stigma, promote open and nuanced discussions that promote wellness. Social media platforms need to use machine learning algorithms more for intervention purposes. --- DATA AVAILABILITY STATEMENT All datasets generated for this study are included in the article/ supplementary material. --- ETHICS STATEMENT The study involving human participants was reviewed and approved by Stanford University Institutional Review Board. The participants provided their written informed consent to participate in this study. --- AUTHOR CONTRIBUTIONS NN designed the study, implemented it and collected data. Both authors, NN and KN, collaborated on the data analysis and wrote the paper together. --- Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Introduction: Suicide, a multifaceted complex outcome that arises from numerous biopsychosocial factors, is a public health concern which is growing in numbers despite valiant prevention efforts. There is still a lot of stigma surrounding suicide that needs to be addressed. Social media is growing exponentially and there are many forums where suicidality is being discussed. As a result, we conducted a brief survey on the perception of suicide on social media platforms of Facebook and Reddit in order to gather more information. Results: Of the 152 respondents, 86% believed that suicide is preventable, and 72.85% believed that it is a person's right to die by suicide. About a third (31.79%) had lost someone close to them to suicide. Respondents who did not think suicide was preventable also viewed suicide as either a sign of strength (42.86%) or a revenge act (33.3%). Those who responded that someone close to them died by suicide believed that the media glorified suicide (56.25%) while those who did not lose someone, did not believe that (66.99%). Women (61%) found social media to be a good platform for people to ask for help while men did not (60.61%).We utilized the social media platforms to gauge the perception of suicide and found among the sample of mostly young white respondents, suicide is not stigmatized, most believed it is preventable and it is a person's right to die by suicide. While women found social media to be a good platform to ask for support, men did not, which is in keeping with the trend that women tend to be more willing to seek help. A third of the group had lost someone close to them to suicide which was the national average, who tended to believe that media glorified suicide. Limitations of this study include the fact that those who respond voluntarily to a survey likely have an interest in the topic, and this might not accurately reflect the public opinion and attitude.

Introduction In the first eighteen months of the SARS-CoV-2 (COVID-19) pandemic, there have been over 150 million cases and over 3 million deaths attributable to the upper respiratory virus [1]. More specifically, Canada has reached a stark milestone of one million cases and over 20,000 deaths in a little over a year (May 2021) [2]. Although the physical health effects of the virus tend to dominate the literature and the media, it is well established that outbreaks, including the current pandemic, have significant impacts on the mental health of those involved. For example, healthcare workers and patients affected by previous outbreaks such as SARS-CoV-1 [3], H1N1 influenza [4], and Ebola [5] have poorer psychosocial outcomes during the onset of societal alarm. Public health measures put in place due to the COVID-19 pandemic have had a negative impact on the mental health of peoples worldwide [6,7]. Levels of depression [8], anxiety [8], loneliness [9], alcohol use [10,11], and cannabis use [12] have all increased relative to pre-pandemic levels. Additionally, there is mounting evidence highlighting the secondary effects of public health measures on specific populations during the pandemic [13]. For example, younger populations [14] and those of lower income [14] have experienced disproportionate psychosocial outcomes because of the COVID-19 pandemic. There is a growing realization that a gender lens needs to be applied to COVID-19 research, not only regarding biomedical outcomes, but for psychosocial outcomes as well [15]. This aligns with increasing efforts, across North America, to include sex and gender based analyses in all research. Sex is defined as birth assignment and is usually established by genital anatomy at birth with female, male, and intersex as typical response options in queries about sex. Gender identity is defined as one's personal feelings about being a woman, man, transgender, gender-diverse individual, or another expression of gender that does not align with that person's birth assigned sex. When sex is considered in the context of psychosocial issues, it is well established that females are more likely to present symptoms of depression and anxiety in general [16], and face greater job losses than males during the COVID-19 pandemic [17]. Thus, it is not surprising that studies to date have found that females reported more anxiety, depressive symptoms, and post-traumatic stress symptoms relative to males during the COVID-19 pandemic [14,[18][19][20]. Age also plays a large role in sex differences in the risk for neuropsychiatric disorders [21], but thus far the interaction between age and sex has received little attention with regards to how age may interact with sex to impact psychosocial outcomes throughout COVID-19. In addition to the paucity of sex-based analyses, studies examining psychosocial outcomes from the standpoint of participants' self-identified gender are sparse. Most of the research on gender and the COVID-19 pandemic have compared responses between women and men, while ignoring the experiences of individuals who experience gender on a spectrum, beyond the binary classification of man and woman. A recent cross-sectional survey by Hawke et al. [22] found that despite no clear significant differences in mental health between cisgender, transgender and gender diverse youth before the pandemic, those identifying as gender diverse were two times more likely to report experiencing mental health challenges relative to the cisgender group during COVID-19. These findings were associated with an unmet need for mental health and substance use services. However, this study was limited to those aged 14-28, thereby reducing the generalizability of the findings to the larger population. To our knowledge, no studies have taken a genderbased approach to understanding the mental health sequelae of COVID-19 pandemic control measures across a general population sample. Given the current data as well as previous findings on the poor mental health outcomes of gender diverse individuals [23], focused empirical attention on this population is critical. Other social determinants of health, including education, ethnicity, and income, impact physical and mental health outcomes [24] and have shaped the risk and consequences of COVID-19 in communities across North America [25]. Additionally, minority stress theory has posited that those who are part of more than one marginalized societal group may experience even greater health disparities [26]. Given this, we posited that it would be crucial to explore how gender interacted with these social determinants to influence mental health, in particular also because these social factors might moderate the effects of gender. Many governments have tailored public health interventions throughout the pandemic based on infection incidence and hospitalization rates, resulting in a series of lockdowns (and prescribed regulations), followed by periods of relaxed restrictions, which have generated defined "phases" of the pandemic. While it is now widely known that lockdowns impact mental health [27], what remains unclear is how the tightening and easing of these social restrictions impacts psychosocial factors, by gender. As such, we sought to assess our psychosocial outcomes, cross-sectionally, across various phases of the pandemic retrospectively aligned with provincial changes in public health orders. We were particularly interested in self-reported symptoms of depression, anxiety, stress, and loneliness, given recent reports of how these have worsened over the pandemic [8,9], and in addition to our primary interest in how gender impacted these outcomes, we also examined the interaction of gender with age, ethnicity, income, education, rurality, and sexual orientation. We predicted higher scores (i.e., more symptomatic) on depression, anxiety, stress, and loneliness in women and gender diverse individuals compared to men, and that this would be influenced by age, ethnicity, and income. We also hypothesized that during phases of increased social restriction psychosocial symptoms would increase. Our secondary interest was in self reports of alcohol and cannabis use, again given data on the pandemic's effects of substance use behaviors [10][11][12], and again, we explored the impact of gender, as well as how gender interacted with various social variables, on alcohol and cannabis use. Our analyses of gender and alcohol and cannabis use were exploratory. Using a large cohort of the general population in British Columbia (BC), we assessed participants cross-sectionally, and asked them to retrospectively report on these outcomes across different phases of the pandemic, which again corresponded to stages of pandemic control changes in the province of BC. --- Materials and methods --- Participant recruitment and study design Participants, aged 25-69 years, were invited to participate in this study from previously established cohorts from research teams at the Women's Health Research Institute, representing both general and priority populations of BC who had consented to being contacted for future research [28]. The original cohorts represented healthy women aged 25-65, women living with HIV/AIDS, men and women over age 18 living with a complex chronic disease, and individuals over age 18 with pelvic pain and/or endometriosis [28]. The largest cohort was recruited to reflect a broad and representative sample of BC women. Participants were stratified into nine five-year age strata, and using a SARS-CoV-2 population seroprevalence of 2% (<unk>1, 95% CI), the target recruitment for each stratum was 750. The seroprevalence statistic was used to target recruitment for analyses in a separate manuscript. Those identified as potentially eligible from the established cohorts (Index Participants) were sent an email invitation to participate via an online survey. To improve the sample size and gender diversity of the study sample, Index Participants were asked to pass the invitation on to one household member who identified as a different gender as the respondent (Household Participants). All potential participants were sent up to three email reminders to participate in the study. The inclusion criteria were: current residents of BC, aged 25-69, any gender, and able and willing to fill out the online survey in English. Ethics approval was obtained from the BC Children's and Women's Research Ethics board, and all participants provided consent to participate. Survey responses were collected anonymously, with the exception of three-digit postal codes, which were used to determine rurality for analyses. After two months of data collection from existing research cohorts, recruitment was expanded in order to meet our target sample of n = 750 per age cohort. This expanded recruitment included participants obtained from public recruitment through the REACH BC platform, social media (i.e., Facebook, Twitter and Instagram), posts on the Women's Health Research Institute website (www.whri.org) and engagement of community groups who are affiliated with the Women's Health Research Institute, a provincial research institute focused on gender and women's health. All respondents in the study were invited to enter a draw to win a $100 e-gift card for completing the survey. Recruitment was continued until a target of n = 750 was reached for each of the nine age-based strata, with the exception of the 25-29 year age group. Recruitment was open from August 20, 2020 -March 1, 2021. --- Survey design and measures The survey was tested for face validity, pilot tested, and a final version was designed using REDCap (Research Electronic Data Capture) [29]. While the survey consisted of multiple modules, this study focuses solely on the outcomes from the psychosocial module, which included questions about mental health outcomes such as depression, anxiety, stress, loneliness, alcohol use, and cannabis use. Demographic information was collected from all respondents including age, sex, gender, sexual orientation, ethnicity, Indigenous status, income, education level, if the participant was currently a student and rurality by postal code. Sex referred specifically to the sex assigned at birth and included the option of male, female or intersex. Gender referred to the respondent's current gender identity and included the options man, woman, or another option grouping non-binary, transgender, GenderQueer, agender or any other similar identity together. Sexual orientation options included asexual, bisexual, demisexual, gay/lesbian, heterosexual, or pansexual. Participants were given the option to identify as the following ethnicities: White, Chinese/Taiwanese, Black (African, Caribbean, or Other), South Asian (e.g., Indian, Bangladeshi, Pakistani, Punjabi, and Sri Lankan), and several other ethnicities who were analyzed an "Other" category. Indigenous status was assessed separately from ethnicity. Self-reporting of Indigenous status provided participants the option to identify as First Nation, Metis, Inuit, non-status First Nations, other Indigenous or not Indigenous, and they were then asked about Two Spirit identity. Rurality was determined based on three-digit postal codes and were classified into one of the follow categories: census metropolitan area, strong metropolitan influence zone, moderate metropolitan zone, or weak to no metropolitan influence zone. The study design was cross-sectional in nature, whereby participants completed the survey at one time point. However, several questions asked participants to retrospectively refer to different periods of time: pre-pandemic (before March 2020) as well as across five different phases of the pandemic in BC that corresponded with changes in the public health orders regarding social distancing in the province of BC. In the original version of the survey, Phase 1 lasted from mid-March 2020 to mid-May 2020, Phase 2 lasted from mid-May 2020 to mid-June 2020, and Phase 3 lasted from mid-June 2020 until the end of November 2020. Given that data collection continued past November 2020, we added Phases 4 and 5, as well as modified dates for Phases 2 and 3 (mid-May to end of August 2020; denoted by Phase 2/3_2). Phase 4 lasted from September 2020 to the end of October 2020 and Phase 5 lasted from November 2020 to the date our survey closed (March 1, 2021). We have included a S1 Table that explains the public health recommendations in more detail, through every phase of the pandemic in BC. Depression. Depression was measured across the phases of the pandemic using the Patient Health Questionnaire (PHQ-9). The PHQ-9 questionnaire was used to measure selfreported symptoms of depression on a Likert scale from zero (not at all) to three (nearly everyday). Scores for this questionnaire range from 0-27 with a score of 0-4 indicating minimal depression, 5-14 indicating mild to moderate depression and 15-27 indicating moderately severe to severe depression [30]. The PHQ-9 has been validated across age and gender, as well as among diverse populations [30,31]. Internal consistency across data collection and Cronbach's alpha for the PHQ-9 in the current sample was very good at <unk> = 0.848. Anxiety. Anxiety was measured across the phases of the pandemic using the Generalized Anxiety Disorder questionnaire (GAD-7). The GAD-7 was provided to respondents to selfreport feelings of anxiety on a Likert scale from zero (not at all) to three (nearly everyday). Scores for this questionnaire range from 0-21 with scores above 10 indicating a clinical diagnosis for anxiety [32]. The GAD-7 has been validated in the general population and is frequently used in primary care settings to screen for anxiety symptoms [33]. Internal consistency across data collection and Cronbach's alpha for the GAD-7 questionnaire in the current sample was very good at <unk> = 0.889. Pandemic stress. General pandemic stress was measured across the phases of the pandemic using the CoRonavIruS Health Impact Survey (CRISIS) V0.3. This survey was developed and validated early in the COVID-19 pandemic to provide a general measure of mental distress and resilience [34]. The CRISIS is found to have strong validity and reliability, and has been recommended for use in population-based studies of mental health during COVID-19. Participants were asked to self-report feelings of stress on a Likert scale from one (not at all) to five (extremely). Scores for this questionnaire range from 10-50 with higher scores indicating greater COVID-related stress. Internal consistency across data collection and Cronbach's alpha for CRISIS in the current sample was very good at <unk> = 0.882. Loneliness. Loneliness was also measured across the phases of the pandemic where respondents were asked to self-report feelings of loneliness on a Likert scale from one (not lonely at all) to five (extremely lonely). This item was taken from the validated Coronavirus Health and Impact Survey (CRISIS), where individual items on the CRISIS have been found to have high Intraclass Correlation Coefficients [34]. Previous studies have found loneliness to be positively correlated with both PHQ-9 and GAD-7 scores [35] and to be a significant predictor of suicide [36,37]. Alcohol use. Change in alcohol use was asked for all post-COVID time points (i.e., Has your consumption of alcohol changed since March 2020?). Change in alcohol use was defined as "none" (which included no alcohol use, decreased alcohol use, and same alcohol use) vs. increased alcohol use. Therefore, a single, non-time-varying alcohol change variable was created and used to compare the retrospective responses across the different time points, with time. Cannabis use. Change in cannabis use was asked for all post-COVID time points (Has your consumption of cannabis changed since March 2020?). As with alcohol, change in cannabis use was defined as "none" (which included no cannabis use, decreased cannabis use, and same cannabis use) vs. increased cannabis use. A single, non-time-varying cannabis change variable was created and used in a longitudinal model with time. --- Statistical analyses Analyses were carried out using R v.4.0.3. Analyses of psychosocial outcomes across the pandemic control phases were conducted using mixed-effects linear regression models with individual and household IDs as random effects. This allows for correlations among individuals in the same household, and separately, correlations over time among responses within the same individual, allowing for a longitudinal assessment. We included pairwise interactions to assess non-additive effects between age and gender, and age and ethnicity, sexual orientation, income, and Indigenous status. Significance was assessed using likelihood-ratio tests, and interactions were removed from the models if non-significant at p <unk>.05. Post-hoc pairwise tests were conducted to further explore main or interaction effects with Bonferroni correction for multiple tests. To explore associations between increase in alcohol and cannabis use with sex/gender and other demographic variables we used mixed-effects logistic regressions with household ID as a random effect. We also examined increase in alcohol and cannabis use and psychosocial outcomes across the phases as described above. Interactions and post-hoc tests were handled as above. Missing data were excluded from analyses. --- Results --- Survey participants Between August 2020 and March 2021, 16,056 survey invites were emailed to prospective Index Participants and 1,872 participants were recruited from the public, for a total of 17,928 prospective participants. Of these participants, a total of 5,415 responded to the invitation to participate in the study and met the analysis inclusion criteria (Fig 1). Of these participants, 1,434 forwarded the survey invitation to a household member of a different sex or gender and we received 661 participants via this method. The present analyses includes the 6,076 Index and Household participants who completed psychosocial measures of anxiety, depression, stress, and loneliness. --- Demographic characteristics of participants A total of 6,426 individuals responded to the question about sex; there were n = 820 males (12.7%) and n = 5,606 females (87.1%). A total of 6,076 responded to the question about gender; including men (n = 750; 12.3%), women (n = 5,254; 86.4%), and gender diverse (n = 72; 1.2%) individuals. Table 1 presents the demographic characteristics of the sample by gender, according to women, men, and gender diverse. --- Effect of pandemic phase, age, ethnicity and gender and sex on psychosocial outcomes Controlling for household income, we found no significant interactions between age and gender, age and sex, age and ethnicity or rurality on any of the psychosocial measures. For all psychosocial outcomes, there was a significant relationship with pandemic phase (all p <unk>.0001, Table 2), with the greatest increases in mental health symptoms in Phase 1 compared to pre-COVID. The scores in all subsequent phases remained significantly higher (i.e., more symptoms) than in the pre-COVID phase across all outcomes (Figs 2-5, Table 2). Gender was significantly associated with all outcomes (all p <unk>.0001, Figs 2-5, Table 2), and pairwise comparisons showed that men had lower scores than both women and gender-diverse participants, while women had lower scores than the gender-diverse participants. Age was significantly negatively associated with all the outcomes, with older participants having lower scores on average (i.e., fewer psychosocial symptoms) (p <unk>.0001, Table 2). Finally, there was a significant relationship between ethnicity and all outcomes (GAD-7 and PHQ-9 p <unk>.0001, CRISIS and Loneliness p =.005, Table 2), with scores lower in Chinese/Taiwanese participants compared to the White, South Asian, and Other ethnicity participants. When sex was included in the model in place of gender, there were no differences to the findings, indicating the overlap in our participants self-reported sex and gender. Given our intention to explore outcomes separately for gender-diverse individuals, all subsequent analyses were done by gender (not sex). --- Psychosocial outcomes by indigenous status Controlling for household income, there was no significant interaction between Indigenous status and age or gender. There was a significant interaction between Indigenous status and time for all four psychosocial outcomes (p <unk>.0001, Table 2) and follow-up post-hoc pairwise tests suggest that at all time points except pre-COVID, those who identified as Indigenous had significantly higher GAD-7, PHQ-9, CRISIS, and loneliness scores (i.e., more mental health symptoms) than those who did not identify as Indigenous. --- Psychosocial outcomes by sexual orientation Across all outcomes, the non-heterosexual group (which included asexual, bisexual, demisexual, gay/lesbian, pansexual, and other) had significantly more mental health symptoms than the heterosexual group for all phases, and the magnitude of the difference between the groups was largest in Phase 1 of the pandemic. --- Associations between psychosocial outcomes and alcohol by gender A total of 23.3% of the sample reported an increase in alcohol use. Increased alcohol use was negatively associated with age (p <unk>.001, Table 3), with older participants having lower odds of increased alcohol use. There was no significant difference among genders in the odds of increased alcohol use, but there was a trend of increasing odds as household income increased. Additionally, those residing in census metropolitan areas were found to have increased their alcohol use relative to those outside of these dense urban areas (p =.03, Table 3). Controlling for household income, and across all psychosocial outcomes, there was no interaction between gender and increased alcohol use, suggesting that the differences among genders in these psychosocial variables was the same between those who did and did not increase alcohol use since the start of the pandemic (Table 4). There was a significant interaction between increased alcohol use and pandemic phase (all p <unk>.0001, Table 4). Pairwise tests indicated that at all phases, with the exception of pre-COVID, those who reported increased alcohol use had significantly more psychosocial symptoms on all measures (p <unk>.0001, Table 4). --- Associations between psychosocial outcomes and cannabis use by gender A total of 5.9% of the sample reported an increase in cannabis use since the start of the pandemic. Increased cannabis use was negatively associated with age (p <unk>.001, Table 3), with older participants having lower odds of increased use. There was a significant relationship with gender (p =.02, Table 3, Fig 6), where women had a significantly higher odds of increased cannabis use compared to men, and there was no significant difference between men and gender diverse, and women and gender diverse groups. Controlling for household income, there was a significant interaction between change in cannabis use and pandemic phase (p <unk>.0001 for GAD-7, PHQ-9, and CRISIS, p =.04 for Loneliness, Table 5). Post-hoc pairwise tests suggest that across all phases, including pre-COVID, those who increased cannabis use had significantly higher anxiety, more depressive symptoms, and higher COVID-stress scores than those who did not have increased cannabis use. Loneliness scores were significantly higher across all phases of the pandemic for those who increased cannabis use compared to those who did not. There was no interaction between gender and increased cannabis use for GAD-7, PHQ-9, or CRISIS scores. However, there was a significant interaction between gender and increased cannabis use on Loneliness (p =.008, Table 5). For both men and women, those who increased cannabis use had more loneliness symptoms than those who did not have increased cannabis use. Conversely, among the gender-diverse participants, there was no difference in loneliness between those who increased cannabis, and those who did not. --- Discussion This large Canadian study recruited 6,076 women, men, and gender diverse people across the province of British Columbia. Our main findings indicated that age, sex, gender, ethnicity, Indigenous status, sexual orientation, and phase of the pandemic have distinct effects on psychosocial outcomes. Across outcomes, women had more symptoms of depression, anxiety, loneliness, and stress than men, regardless of their age or ethnicity, while the gender diverse group (n = 72) had even more symptoms than women. An analysis by sex revealed the same findings as for gender, except that the gender diverse group was now absorbed into one of the two binary sex categories and obscuring their findings. Our results highlight the greater negative outcomes on all psychosocial variables in gender diverse individuals, which would have been obscured in an analysis by sex alone and adds to the literature highlighting the value in analyzing data by gender. It is important to underscore that being a woman was a significant factor that determined higher anxiety, depression, stress, and loneliness-a finding mirrored in the literature across all continents [38,39]. The novelty of this study, however, is that this effect of being a woman was not impacted by participants' age, ethnicity, or other sociodemographic variables. In other words, having a woman gender was sufficient to place individuals at higher risk for depression, anxiety, stress, and loneliness over the pandemic. Given that women and gender diverse individuals are more likely to be diagnosed with mood disorders or score lower on mood surveys outside of a pandemic [16,40,41], it is not surprising that these populations are experiencing mental health inequities during COVID-19. However, our results should be interpreted with some caution as our gender-diverse cohort accounted for only 1% of the sample. Nonetheless, our results are striking and consistent with many other studies focused on gender using larger cohorts [42,43]. Our study also benefited from examining the effects of other sociodemographic variables, such as age, to determine how they might play a role in the effect of sex and gender on mental health. Across all the psychosocial measures, younger participants were more likely to have anxiety, depression, pandemic stress, and loneliness, irrespective of their gender. These findings are consistent with others in smaller cohort studies that indicated younger ages were associated with more psychosocial symptoms [44]. There may be several reasons for these findings such as restricted social engagements, barriers to employment, and living conditions. Lockdowns across the globe have resulted in restricted social gatherings, closing of restaurants, bars and clubs, as well as recreational sporting activities (gyms, sports clubs, exercise classes, yoga and dance). In addition, younger adults are more likely to either live on their own, or with unrelated roommates and have greater perceived lack of social support. Indeed, findings from a larger cohort in China found that greater loneliness was associated not only with younger age (16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29) but also in unmarried individuals [36]. Physical activity is another important factor as a large survey across fourteen countries found that decreased physical activity during restrictions and lockdowns, as well as high physical activity pre-pandemic, were associated with poorer mental health scores [45]. Other studies have also noted that suicide and suicidal ideation have increased during the pandemic in younger adults [46], related partially to job losses. Taken together, the underlying reasons for this significant effect of age are of great importance and require further study. At a minimum, these findings suggest that mental health resources tailored to younger individuals are required in any pandemic relief measures taken by government. It might not be sufficient to increase all mental health supports, but rather have tailored ones to young adults that are cost effective and accessible. In addition to age, ethnicity was associated with psychosocial outcomes with Chinese/Taiwanese participants reporting significantly lower scores (i.e., fewer psychosocial symptoms) on anxiety, depression, pandemic stress, and loneliness. These data are consistent with findings from other studies, such as a survey of more than 46,000 Canadians which found that Chinese individuals were less likely to report symptoms consistent with moderate to severe generalized anxiety disorder than other visible minority groups during the COVID-19 pandemic [47]. It is possible that the lower rates of mental disorders seen in Asian or Chinese immigrants [48] may be due to cultural stigma associated with mental illness leading to lower rates of disclosure of psychological symptoms [48,49]. It is also possible that the lower rates of psychological symptoms may be due to differences in the validity of these measures cross culturally [34,50], leaving open the possibility of a measurement bias [51], although it was concluded to be a reliable measure across some cultural groups [51,52]. In sum, our findings suggest that our Chinese/Taiwanese sample experienced fewer psychosocial symptoms throughout the pandemic relative to other groups, and of note, ethnicity did not interact with gender or income to impact these outcomes. Similarly, gender did not interact with income to impact these outcomes. We found that those who self-identified as Indigenous had significantly more psychosocial symptoms than non-Indigenous participants across all four scales for all phases of the pandemic in BC. Importantly, there was no difference in psychosocial outcomes between Indigenous and non-indigenous groups pre-COVID, which underscores the disproportionate impact of the pandemic on this community. While investigations on the mental health impacts on Indigenous peoples during the COVID-19 pandemic have been limited, our results are consistent with the available data. For example, other data from Australia (Aboriginal or Torres Strait Islander) [53] as well as Canada [54] showed more psychosocial symptoms among Indigenous respondents during the COVID-19 pandemic. The lack of interaction between Indigenous status and gender suggests that the higher psychosocial symptoms occur regardless of an Indigenous persons' gender, standing in contrast to another study finding that Indigenous women were particularly impacted by mental health issues (severe generalized anxiety, worse mental health, and stress) during COVID-19 [54]. Future studies should explore the extent to which variables such as rurality (which can contribute to barriers accessing care) and income may account for these higher rates of psychological symptoms among Indigenous communities [44]. In the meantime, these findings point to the need for culturally-safe mental health resources being made available to Indigenous communities in any COVID relief efforts. Findings on the relationship between anxiety, depression, pandemic stress, and loneliness, with increased alcohol and cannabis use, align with previous studies [12]. Given the poorer self-reported mental health among younger populations, it was not surprising to observe an increase in alcohol and cannabis use among this group, which suggests that alcohol use may be a form of coping for younger persons. We cannot attribute directionality to this association, nor eliminate the possibility that increased alcohol and cannabis use may be contributing to the increased psychosocial symptoms observed among younger populations during the pandemic. The lack of a gender difference in increased alcohol use is in contrast with a previous American study [55] which found that females had increased their alcohol use compared to males. It may be that differences in the samples accounts for these contrasting findings. It is also possible that the increase seen in men in our sample was higher than in previous studies, thus rendering the gender difference void. In contrast, we saw a gender effect on increased cannabis use, which was expressed by women, but not by men or gender diverse persons. In recent surveys, 28% of British Columbians had engaged in cannabis use in the past twelve months, compared to the Canadian average of 11%, suggesting that British Columbians are more likely to engage in cannabis use, and therefore may be more likely to use cannabis as a form of coping [56,57]. Although cannabis use has been associated with male typicality and may go against gender norms typical to women [58], it may be that the social isolation disrupted these social norms and facilitated women's more active engagement in additional cannabis use, relative to pre-pandemic levels. Our findings align with the global trend of increased substance use, as recent studies have demonstrated that alcohol, cannabis, and opiate use changed during and post-lockdown [59]. Alcohol use has remained elevated relative to pre-pandemic levels, and though opiate use seemed to have dropped during lockdowns, a return to regular dosage post-lockdown has helped to drive overdoses, due to diminished tolerance [59]. It is possible that deteriorated mental health could be attributed to overuse of certain substances, though studies with multiple follow-up points are needed to determine a causal pathway for the increase in psychosocial symptoms demonstrated in our study. Future studies should aim to elucidate potential mechanisms by which substance use can influence mental health in the context of a pandemic and lockdowns to mitigate the consequences of public health interventions on well-being. As predicted, psychosocial symptoms worsened over the course of the pandemic, with some of the highest symptoms observed early on, aligning with previous studies that found a higher prevalence of mental health disorders during the initial COVID-19 lockdown in March 2020 [60,61]. Phases 2 and 3 of COVID restrictions in BC were characterized by an easing of restrictions, permitting outdoor gatherings and small social events, and the summer season. This loosening of public health measures was associated with a slight improvement in mental health, more than likely due to an increase in perceived social support and optimism regarding the state of the pandemic. Mental health outcomes then worsened in Phases 4 and 5 as BC entered wave 2 of the pandemic and public health orders tightened once again. It is important to note the average PHQ-9 and GAD-7 scores did not meet the criteria for clinical depression or anxiety, but that these levels increased relative to pre-pandemic levels as well as over time. --- Strengths and limitations Our study benefitted from a large, population-based sample size, and, despite known mental health disparities by gender, as far as we are aware, was one of the few that sought to explore findings from a gender lens by including gender-diverse groups as well, given known mental health disparities by gender [17]. That said, our sample size for gender diverse individuals was still limited [17]. Future studies should further investigate mental health in the gender diverse community during the COVID-19 pandemic with a focus on people of all ages, in contrast to previous studies [22]. Another limitation of the present study was the retrospective, cross-sectional nature of the survey, where participants completed the survey at only one time point, and were asked to retrospectively recall their mood and anxiety during different time points. This may have increased the likelihood of recall bias and reducing our capacity to examine causality and directionality of poor mental health outcomes. Finally, this study was confined to the general population of BC, and only individuals who had access to email and internet, and therefore results may only be generalizable to the Canadian population, and populations with similar demographics to the present study, and to individuals who have access to email and internet. --- Implications Our study has important implications for public health policy. These findings illustrate that government policies and interventions for future pandemics should place on emphasis on young adults, low-income populations, women, Indigenous, and gender diverse communities. Additionally, our study was one of the first to measure mental health outcomes across different phases of the pandemic, directly examining the effect of increased public health measures on mental health. At the time of writing, the vaccine rollout is well underway in BC with experts predicting an end to the pandemic in the months ahead, however, it is unclear whether mental health will return to pre-pandemic levels, or when life will return to "normal." Moving forward, policy makers and leaders need to consider our findings when planning future public health measures. In future pandemics, the mental health of marginalized populations needs to be considered proactively. As vaccination efforts continue and case counts fall, it will also be critical to monitor the health status of these populations to ensure that they are not left behind. Additionally, for future pandemics and outbreaks, mobilizing resources to these communities early on can aid in mitigating these inequities from the beginning, rather than as an afterthought. --- for researchers who meet the criteria for access to confidential data. --- Supporting information --- S1

The SARS-CoV-2 (COVID-19) pandemic has had profound physical and mental health effects on populations around the world. Limited empirical research has used a genderbased lens to evaluate the mental health impacts of the pandemic, overlooking the impact of public health measures on marginalized groups, such as women, and the gender diverse community. This study used a gender-based analysis to determine the prevalence of psychosocial symptoms and substance use (alcohol and cannabis use in particular) by age, ethnicity, income, rurality, education level, Indigenous status, and sexual orientation.Participants in the study were recruited from previously established cohorts as a part of the COVID-19 Rapid Evidence Study of a Provincial Population-Based Cohort for Gender and Sex (RESPPONSE) study. Those who agreed to participate were asked to self-report symptoms of depression, anxiety, pandemic stress, loneliness, alcohol use, and cannabis use across five phases of the pandemic as well as retrospectively before the pandemic.For all psychosocial outcomes, there was a significant effect of time with all five phases of the pandemic being associated with more symptoms of depression, anxiety, stress, and loneliness relative to pre-COVID levels (p < .0001). Gender was significantly associated with all outcomes (p < .0001) with men exhibiting lower scores (i.e., fewer symptoms) than women and gender diverse participants, and women exhibiting lower scores than the

s, the mental health of marginalized populations needs to be considered proactively. As vaccination efforts continue and case counts fall, it will also be critical to monitor the health status of these populations to ensure that they are not left behind. Additionally, for future pandemics and outbreaks, mobilizing resources to these communities early on can aid in mitigating these inequities from the beginning, rather than as an afterthought. --- for researchers who meet the criteria for access to confidential data. --- Supporting information --- S1

The SARS-CoV-2 (COVID-19) pandemic has had profound physical and mental health effects on populations around the world. Limited empirical research has used a genderbased lens to evaluate the mental health impacts of the pandemic, overlooking the impact of public health measures on marginalized groups, such as women, and the gender diverse community. This study used a gender-based analysis to determine the prevalence of psychosocial symptoms and substance use (alcohol and cannabis use in particular) by age, ethnicity, income, rurality, education level, Indigenous status, and sexual orientation.Participants in the study were recruited from previously established cohorts as a part of the COVID-19 Rapid Evidence Study of a Provincial Population-Based Cohort for Gender and Sex (RESPPONSE) study. Those who agreed to participate were asked to self-report symptoms of depression, anxiety, pandemic stress, loneliness, alcohol use, and cannabis use across five phases of the pandemic as well as retrospectively before the pandemic.For all psychosocial outcomes, there was a significant effect of time with all five phases of the pandemic being associated with more symptoms of depression, anxiety, stress, and loneliness relative to pre-COVID levels (p < .0001). Gender was significantly associated with all outcomes (p < .0001) with men exhibiting lower scores (i.e., fewer symptoms) than women and gender diverse participants, and women exhibiting lower scores than the

Introduction This article is based on an analysis of data from the Horizon 2020 ySkills project, with two phases of longitudinal research in Poland in 2021 and 2022. The study focused on adolescents aged 12/13 to 18, thus covering both early (12-14/15) and late (15)(16)(17)(18) adolescence. During early adolescence, significant changes occur in the parent-child relationship, resulting in a shift towards a more egalitarian and partnership-based relationship between the teenager and their parent/s. Adolescents spend less time with their parents and an increasing amount of time with their peers. The peer group plays a crucial role in the development of interpersonal competencies, by providing opportunities for interaction with individuals of similar status, fulfilling the need to belong and enhancing self-esteem (Piotrowski et al., 2014). Throughout adolescence, social relationships become increasingly important, and positive relationships with family, peers and teachers are crucial for healthy development (Somerville, 2013;Crone & Dahl, 2012). Communication skills, both online and offline, become particularly sinificant at this stage. Adolescence also brings cognitive changes, including the development of formal thinking, specifically hypothetical and deductive reasoning (Piotrowski et al., 2014b). Adolescents actively develop their information skills and display eagerness to search and verify information. Information and communication technologies (ICTs) play a key role in adolescents' lives, as they support everyday communication and provide access to information and entertainment (Py<unk>alski et al., 2019). With the development of technology, relationships have changed in contemporary society. Online platforms and mobile applications are widely used for initiating, maintaining, and transforming relationships, which makes communication one of the most prevalent online activities among youth (Smahel et al., 2020). Therefore, this article focuses primarily on the digital information and communication skills that teenagers acquire and improve at this stage of development. The central notion of the ySkills project and this article revolves around digital competences, with a particular focus on digital skills. Competences encompass knowledge, skills and attitudes, while skills are measurable and necessary for applying knowledge to tasks and problem-solving situations (Walter & Py<unk>alski, 2021). Digital skills are defined based on objectives, audiences, and context, with the International Telecommunication Union (ITU) defining them as the ability to use information and communication technologies (ICT) effectively to achieve beneficial outcomes while minimizing potential harm (ITU, 2018). Digital competence, as recognized by the European Commission, involves the confident, critical, and responsible use of digital technologies to learn, work and participate in society (Council Recommendation on Key Competences for Life-long Learning, 2018). It includes skills and issues such as information and data literacy, communication and collaboration, media literacy, digital content creation, security, intellectual property, problem solving and critical thinking. The European Commission's Digital Competence Framework (DigComp 2.2) identifies five areas of digital competence: information and data literacy, communication and collaboration, digital content creation, security, and problem solving (Vourikari, Kluzer, Plunie, 2022). In addition, these areas overlap with the concept of 21st century skills, which places considerable emphasis on soft digital skills, which are considered crucial for the future labor market (van Laar et al., 2017). The concept of digital competences is understood in a similar way in Polish studies. For example, Batorski et al. (2012) believe that the concept of digital competence covers a broad set of skills that determine the efficient and informed use of new technologies and active participation in the life of the information society. These include digital and information competences. Pleba<unk>ska (2021) additionally notes that a digitally competent person is now expected to think independently, take initiative, solve problems creatively and use technology in a way that fits in with the current labor market situation or, more broadly, the current industrial revolution. She also pays attention to digital emotional intelligence. According to Ester van Laar and co-authors (2018), digital skills include technical skills, information management, communication, collaboration, creativity, critical thinking and problem solving. In the ySkills project, we define them as the ability to use information and communication technologies in ways that help individuals achieve beneficial, highquality outcomes in everyday life for themselves and others, and reduce potential harms associated with the more negative aspects of digital engagement (Donoso et al., 2020, p. 9). Based on previous research and literature analysis by van Deursen and Helsper (2018) and van Deursen, Helsper and Eynon (2016), a conceptual model has been created with indicators corresponding to four dimensions of digital literacy. These dimensions include functional and critical aspects and are as follows (Helsper et al., 2021): 1. Technical and operational skills, or proficiency in managing and operating ICT, including the technical skills of using devices, platforms and applications. It entails knowledge of using buttons, adjusting settings and programming. 2. Information navigation and processing skills, or the ability to critically search and select digital sources of information. It also includes the ability to critically evaluate information. 3. Communication and interaction skills, or the ability to use various digital media and technological features to interact with others, build networks and critically evaluate the impact of communication and interpersonal interactions. 4. Content creation and production skills, or the ability to create highquality digital content, comprehend how it is produced and published, and how it impacts others. As mentioned earlier, in view of the developmental characteristics of adolescents, communication skills, as well as information navigation and processing skills are the key themes in our analysis. --- The Importance of Information and Communication Skills in Youth Development -Selected Results of a Study of European and Polish Adolescents Young people use information and communication technologies extensively, and digital media can facilitate the development and maintenance of their social relationships. However, while these technologies can be a valuable source of information, they can also cause anxiety, provide misinformation and disrupt one's well-being. Additionally, the internet can be beneficial, as it provides young people with a vast source of information and tools to assess their credibility and biases, by using search engines and critical thinking methods. These skills can help them learn effectively, make informed decisions and succeed in various aspects of life. Developing digital skills also enables young users to be independent and proactive in identifying and avoiding risks associated with their online activities. According to the EU Kids Online research concept, young people play both the role of recipients and actors in online interpersonal relationships and digital tasks (Py<unk>alski, 2019). Moreover, using technology requires a combination of various skills, such as translation, innovation, learning, communication and collaboration (Elphick, 2018). Despite commonly held beliefs, research shows that young people's digital skills are not always as strong as they are given credit for. (European Commission, 2012). ITU's 2018 Measuring the Information Society report presents information from the European Commission's 2016 data on the distribution of digital skills among children aged 4-14 in eight European countries, namely the UK, Poland, Spain, Germany, Sweden, France, Italy and the Netherlands. The data was collected by asking parents to assess their children's social, operational, information navigation, mobile and content creation digital skills. The findings reveal a diverse landscape, with Polish children scoring highest on information navigation skills, but lower on mobile skills and content creation skills. Moreover, parents from all countries surveyed reported lower levels of digital skills related to content creation compared to other digital skills investigated. According to the Polish part of the EU Kids Online survey conducted by Py<unk>alski et al. (2019), only 37% of young people aged 11-17 rate their online information search skills as strong. However, 66% of young people know what information should and should not be shared on the internet. The survey also found that less than 16% of young people feel that they can be themselves online, while slightly less than 17% communicate differently online than in face-to-face meetings. Additionally, only 7% discuss personal matters online that they do not discuss offline. Common findings from all countries participating in the study are as follows: 1) a high percentage of children and adolescents use social media for a variety of communication activities, 2) children rate their online communication skills highly but lack critical evaluation of online interactions, 3) children rarely meet offline with people they meet online, and 4) families play an essential role in supporting children's digital information and communication skills (Smahel et al., 2020). The Teenagers 3.0 report by Lange (2021) confirms that the internet is a popular tool for accessing information and doing homework, with 64% of students using it for studying. Furthermore, 27.3% of students collaborate with their peers online when doing homework several times a week. Developing information and communication competencies in children and young people is an important educational goal today. Communication skills are fundamental to learning, emotional development and establishing and maintaining social relationships, both at school and later in the workplace. Strong communication skills enable individuals to adapt to an increasingly diverse social environment while ensuring a good quality of life. Poor communication skills, on the other hand, can exacerbate personality problems, distrust of others, social isolation (which can affect mental health), and even risky behavior, especially at a young age (Martinek & Hellison, 2016;Teryushkova, 2016). The internet provides children and adolescents with an online space to interact with others, exchange views and ideas, and meet people who think like them. Research shows that individuals who are comfortable with online communication can also form deep offline relationships (Bargh et al., 2002). The psychological well-being of children and adolescents increasingly depends on their existence in digital spaces and on having a circle of friends and acquaintances online. The influence of online and offline peers is critical to the development of children's and adolescents' communication and information skills. The literature uses the term "cyber-socialization" to describe learning how to function in the digital world, including communicating with others through new technologies. Cyber-socialization is gaining prominence as more and more people, especially young people, spend time online and use digital media to communicate, study, work or entertain themselves. Researchers suggest that, on the one hand, ICT can have a positive impact on communication, the development of information competencies, and the well-being of individuals (Verduyn et al., 2017;Timnea et al., 2018). On the other hand, this communication can effectively disrupt, distort and violate the mental well-being of internet users (Hudimova, 2020;Valtonen et al., 2021). One factor in such disruption may be the lack of non-verbal communication that is characteristic of text-based digital media (e.g., instant messaging), which can have a disruptive effect on the understanding of emotional signals conveyed in face-to-face communication, thereby limiting the mastery of critical social skills (Giedd, 2012;Knapp & Hall, 2010). --- Methods These results are partial outcomes of the larger ySkills project (ySkills.eu -European Union's Horizon 2020 Research and Innovation Programme under grant agreement no. 870612), which focuses on the digital skills of young people across the European Union. A standardized online questionnaire prepared by the ySkills research consortium was distributed in 6 countries (Estonia, Finland, Germany, Italy, Poland and Portugal) between April and November 2021, and then repeated with the same sample after roughly a year (in 2022). Data was collected in cooperation with high schools. Convenience sampling was used. However, participating schools were selected based on their socioeconomic status to ensure a diverse sample. Students completed the questionnaires individually during school hours (either traditionally or online depending on the circumstances of the pandemic at the time and in the country). Informed consent was obtained from all respondents and their legal guardians in all participating countries, and the ethics committee issued a positive decision. The questionnaire was standardized across all countries and was presented in the language of each country. The questionnaire in each country was subjected to cognitive testing and piloting. The article is limited to results on a sample of Polish adolescents. There were 609 participants in both waves of the survey. The sample consisted of 292 boys (47.9%), 301 girls (49.4%) and 16 participants who did not indicate their gender (2.6%). In the first stage, the age of participants ranged from 11 to 16 years old. 4.1% of participants were 11 years old, 12.6% were 12 years old, 21% were 13 years old, 15.8% were 14 years old, 23.5% were 15 years old, and 23% were 16 years old). We report both results from the first wave (N=1161) (sample statistics are shown in the corresponding tables) and comparative results from the two waves. In the article, we present both the outcomes of the entire skill subscales (as described below in the methodology section) and the results for individual items. The t-test for independent variables was used to describe comparisons between subgroups in one wave, and the t-test for dependent variables when comparing results between two waves. --- Digital Skills Scales In the project, we measured four dimensions of digital skills, as described in the introduction (technical and operational skills, information navigation and processing, interaction and communication, content creation and production). Data for the four dimensions of the digital skills scales were transformed as follows: Those who answered "I don't understand what you mean by that" were assigned a score of 0. Thus, answers about individual skill received scores ranging from 0 to 6, with "I don't want to answer" options (DWTA) marked as missing (-99). To calculate the high skill level, the number of items for which respondents reported the strongest skill (i.e., 5 "Very true for me") was counted for each dimension. This procedure was repeated for the overall skill scale, including a separate programming skill score. High skill scores were divided by the number of a person's answers in a given category, excluding items with DWTA answers. This meant a score of 0 if the person had no strong skills, 0.5 if they had half of the strong skills, and 1 if they had all of the strong skills. Cases were excluded if they had a missing score (including DWTA) in three or more items in separate skill categories. For the overall skill scale, anyone excluded on a separate category was also excluded from the overall skill scale. Because some individuals gave fewer than six answers on separate skill scales, the proportional scores were irregular, resulting in multi-modal distributions with several peaks. To prepare the scales for analysis, a smoothing procedure was applied. Scores of.20 were divided into scores of.1666 (1/6), scores of.25 into.333 (2/6),.40 into.50 (3/6),.60 into.666,.75 into.666 and.80 into.8333. All items were qualitatively validated through cognitive interviews, and the composite scales showed good statistical properties (acceptable levels of skewness and kurtosis), as well as high levels of reliability (alpha above 0.70 for all scales). Additionally, the frequency of digital communication with peers and parents was measured using a scale with the following cafeteria: Never, Several times, At least once a week, Daily or almost daily, Several times each day, Almost all the time. --- Results In 2021, the first phase of the survey was carried out among teenagers from six European countries, including Poland. The Polish sample consisted of 1,161 (N=1161) participants between the ages of 11/12 (sixth grade of primary school) and 16/17 (second grade of secondary school). During the survey, young people were asked about two main ICT areas. Our analysis started from frequency of digital communication with people who are important in teenagers' lives. Firstly, we asked about their communication practices via the Internet with different audiences. Secondly, we sought to identify key aspects of communication skills and information search and processing skills. As shown in Table 1, the adolescents surveyed in this study mainly engage in online communication with their peers. Specifically, 75.9% of the respondents communicate online with their acquaintances/friends at least once a day. In contrast, 52.2% of the teens surveyed communicate online with their parents/guardians on a daily basis. Regarding digital skills in the area of information navigation and processing, in the first wave of the survey, participants answered questions about their individual skills, as shown in Table 3 After conducting the second wave of the survey in 2022, we compiled the findings from the adolescents who took part in both phases. This is the percentage of strong skills in a specific category, calculated on the basis of at least 3 items. The process of calculating this indicator is described in the Methods section of the article. A statistically significant increase in the mean was observed in almost all categories, with the exception of programming During the first wave of the survey (all teenagers), a statistically significant difference in mean scores was found between boys and girls. In particular, boys outperformed girls in the category of information navigation and processing skills (M=0.42 in boys, M=0.26 in girls; p<unk>0.001), as well as in the category of communication and interaction skills (M=0.57 in boys, M=0.56 in girls, p<unk>0.01). In the second wave, boys outperformed girls in the category of information navigation and processing skills (M=0.42 in boys, M=0.26 in girls; p<unk>0.001). In the second wave of the survey, boys continued to score higher in information literacy (M=0.45 in boys, M=0.31 in girls; p<unk>0.001), but there were no statistically significant differences in communication skills. --- Discussion The study revealed that Polish teenagers use the internet mainly to communicate with their peers, with 75.9% of them interacting with their friends on a daily basis, and only 52.2% communicating with their parents on a daily basis. This is in line with the developmental needs of adolescents, as positive peer relationships strengthen their social bonds, safety, self-esteem and social skills (Piotrowski et al., 2014). Technology has transformed relationships, with online platforms and mobile apps being common tools for initiating, maintaining and transforming relationships, particularly among young people (Smahel et al., 2020). Polish adolescents exhibit strong digital communication skills, with over 87% of them declaring proficiency in using various digital tools. They are able to use emoticons, internet slang and acronyms appropriately, recognize online bullying, and report negative content. This is consistent with previous studies showing increased use of technology and better handling of digital media among young people (Batorski, 2015;Py<unk>alski, 2019). However, critical evaluation of online information and distinguishing between credible sources is an area where confidence is lower. Young people may lack critical thinking skills and resources to verify the accuracy of information (Swanson et al., 2017). OECD's PISA findings indicate that less than 10% of students can differentiate between fact and opinion (Schleicher, 2019). Higher indicators of individual digital competences are associated with the age of the respondents. This suggests that children and teenagers are gradually becoming more proficient in using technology. This phenomenon can be attributed to their exposure to more advanced media technologies and more frequent ICT use, as well as the influence of their school education. It is worth highlighting that the overall results on the level of digital skills (percentage of strong skills across all categories) did not show significant improvement during the second wave of the survey. However, this does not mean that individual competencies were not rated higher by the respondents compared to previous assessments; rather, they did not consistently reach the highest level to a greater extent. Further analysis will be necessary after the next wave of surveys to delve deeper into this issue. In terms of gender differences, boys outperformed girls in information navigation, processing and communication skills in the first wave of the study. In the second wave, boys maintained higher information literacy scores, while communication skills showed no significant differences. These findings underscore the need for further research on gender differences in digital skill development. Self-report questionnaires suggest greater confidence in digital skills among boys, but objective performance tests yield inconsistent results. Differing cultural norms and individual preferences may contribute to different strengths in digital skills between genders (Haddon et al., 2020). Overall, Polish teenagers value their digital communication skills, particularly with their peers. While they navigate and search the internet effectively, additional education on how to critically evaluate information and identify credible sources would be beneficial. --- Conclusion The results presented here have important limitations. First of all, as discussed above, digital skills were measured using a self-assessment methodology that may be subject to some bias due to subjectivity and different benchmarks used by respondents. Such results should be triangulated with other methods, preferably a performance test, which was partially done in this project, although not reported. Additionally, the first wave of surveys was carried out during the educational crisis caused by the COVID-19 pandemic that resulted in high rates of absenteeism, as well as the inability to include some students in the sample due to problems reaching their parents/guardians. This may have caused sampling biases on some sociodemographic variables that were difficult to estimate. Nonetheless, the results obtained are valuable since they were collected within a large sample with high variance, as well as a longitudinal model that allowed the same respondents to be reached and identified in two stages (waves). --- Van Deursen, A. J., & Helsper, E. J. (2018). Collateral benefits of Internet use: Explaining the diverse outcomes of engaging with the Internet. new media & society, 20(7), 2333-2351. Van Laar, E., Van Deursen, A. J., Van Dijk, J. A., & De Haan, J. (2017). The relation between 21st-century skills and digital skills: A systematic literature review. Behavior, 72, 577-588. doi: 10.1016Behavior, 72, 577-588. doi: 10. /j.chb.2017.03.03 (pp. 145-164) --- Computers in Human

Research objectives: This study examines the role of digital skills in the personal and social development of young people. It aims to measure and understand these skills among the younger generation, while identifying ways to improve their development.The data comes from the ySkills project under Horizon 2020, a longitudinal study conducted in six countries, including Estonia, Finland, Germany, Italy, Poland and Portugal. Specifically, we have analyzed data on Polish youth from 2021 and 2022. The sample includes 609 individuals aged 11 to 18, i.e. in the entire age range. Self-report scales assess

Introduction In recent years, gastronomy has become one of the main attractions at tourism destinations (Gálvez et al., 2017). Visitors attend food and wine festivals worldwide out of a desire to experience the local gastronomy, spend time with others, or experience a sense of community and belonging. In support of this notion, Gacnik (2012) highlighted that demand for gastronomy at heritage destinations significantly increased among international visitors. Food and wine gatherings were considered the primary or secondary factors in visitors' choice of a destination. Visitors with a profound interest in gastronomy are found to be motivated by discovering new cuisine, learning about a destination's local food, and tasting typical local dishes to experience cultural enrichment (Fields, 2002;Gálvez et al., 2017;Mgonja et al., 2017). Whereas prior studies have highlighted the importance of food and wine festivals in the development and enrichment of a tourism destination, more research is needed to understand the effects of these events in generating a sense of community, identification, and attachment to the destination. Furthermore, gaining a better understanding of the perceived authenticity of food festivals and their entertainment value is particularly relevant to answering questions about why individuals visit food festivals, the perceived psychological benefits of such events, and their ultimate effects on the hosting destination. As more travelers are now visiting destinations for the purpose of enjoying their food variety; food tourism not only brings different cultures together (Van Westering, 1999), but also encourages bonding among diverse people and strengthens their identification as they link gastronomy destinations to a specific meaning in their lives (Dimache et al., 2017;Fisher, 1984). Prior research suggests that customer interactions enhance the tourist experience (Torres, 2016). Furthermore, researchers have argued that attracting homogeneous consumers to the service setting can increase the likelihood of a satisfying service encounter (Martin and Pranter, 1989). A destination's authentic food and wine offerings contribute to visitors' unique experiences and food and wine festivals enhance those unique experiences in a positive manner (Cracolici et al., 2008;Gálvez et al., 2017). Numerous global regions have succeeded in identifying with food and wine tourism as a result of integrating local food and beverage authenticity into their branding strategies (Bruwer, 2003;Kim and Bonn, 2016). Not only do visitors attend because of the food, but also as a means to obtain new experiences, witness entertainment, and spend time with friends and family (Hede, 2008). Formica and Murrmann (1998) posited that visitors associate food and wine festivals with the desire for escape, excitement, and event novelty. Other reasons for attending such social gatherings are influenced by the visitors' lifestyle, educational level, cultural differences, and ethnic identity (Isaykina, 2001;Park, 2015;Wilcox and Busse, 2017). Food and wine festivals often have meanings beyond their core product (i.e. food and beverage). As visitors, culinarians, and locals experience a food and wine festival's offerings, they develop a strong sense of community. Furthermore, a well-executed food and festival could potentially lead to visitors' identification with these special events and attachment to the hosting destinations. Food and wine festivals attract enthusiasts who desire to experience local food and beverage, especially tasting and learning about regional wine (Gets, 2008;Isaykina, 2000;Wan and Chan, 2013;Yang et al., 2020). Furthermore, they bring people together and help visitors experience and learn about local cuisine, authentic food, local chefs' culinary talents and skills, and other locally produced goods, such as wine and microbrewery beverages. Prior studies asserted that food and wine festivals provide visitors with opportunities to taste authentic food and local wines, engage in cultural activities, as well as learn about the traditions and lifestyle of the hosting destination (Wan and Chan, 2013;Yang et al., 2020). More importantly, spending time with others and cherishing memorable experiences with friends and family are essential motives for attending these special events. Consequently, food and wine festivals have a significant influence on visitors' behavioral intention to revisit them as well as their attitudes toward the hosting destination (Kim and Bonn, 2016;Mitchell et al., 2000). The organization of a welcoming and hospitable food and wine festival not only provides visitors with satisfying experiences, but also enhances their sense of bonding while it strengthens the local economy (Del Chiappa et al., 2018;Fredline and Faulkner, 2000;Gursoy et al., 2002). The growing literature on food and wine festivals highlights their importance to the local economy, culture, and destination image. However, more research is needed to ascertain how these events impact the social fabric of the communities, the image of the destination, and the overall customer experience. Furthermore, the impact of these events in generating attachment and loyalty toward both the event and destination deserves more research attention. Seeking to contribute to the existing literature as well as to create new knowledge, the researchers proposed the following objectives: 1. To investigate the extent to which food festival experiences impact visitors' sense of community, identification with the event, and attachment to the hosting destination. 2. To analyze the extent to which visitors' experiences of authenticity, entertainment, and spending time with others at food and wine festivals enhance their identification with the event and attachment to the hosting destination. 3. To measure the mediating effect of sense of community on the relationship between visitors' experience of a food and wine festival (e.g. authenticity, entertainment, and spending time with others) and their identification with the event and attachment to the hosting destination. --- Literature review Identification with food and wine festivals and place attachment to destinations The intention to visit a food and wine festival is heavily influenced by the visitor's level of their satisfaction with these events as well as similar gatherings in the past (Anwar and Sohail, 2004;Kruger et al., 2013;Lee et al., 2017;Okumus and Cetin, 2018). Consequently, visitors who find meaning in these special events become fully engaged in the event activity which results in strengthening their sense of identification with these special events. Other major appeals toward attendance include the excitement and thrill of new experiences as well as the event novelty. Many visitors are motivated to attend food and wine festivals to achieve at least one of the following objectives: escape of their day-to-day routine, socialization with other festival visitors, and being with friends and family (Lopez-Guzman et al., 2017;Maeng et al., 2016;Rezaei et al., 2018;Yolal et al., 2009). Food tourism is considered an important and a powerful force in shaping cultural identity among food and beverage event attendees (Hillel et al., 2013;Okumus and Cetin, 2018). In many cases, when participants become part of the identity of these events, they become ambassadors of the hosting destinations by promoting both the food and wine festival as well as the destination itself (Uchinaka et al., 2019;Young et al., 2007). In fact, Williams et al. (2015) revealed that food and wine festivals serve as motivators to electronic word-of-mouth, which in turn helps to promote the destination. In addition to the aforementioned motivators, food and wine festivals bring social benefits to their attendees. When successful these festivals create a welcoming atmosphere for a large number of visitors who gather with the intention of having fun. As individuals with different backgrounds come together, they gain a mutual understanding of other subcultures within these communities and more awareness of the cultural richness of the hosting destinations (Li et al., 2020;Yolal et al., 2009). Having conducted research in Australia, Derrett (2003) concluded that 'community festivals can reflect the community's sense of itself'. Furthermore, researchers in the field of festivals argue that these allow minority and marginalized communities to enhance their sense of self-worth and promote crosscultural understanding (Hassanli et al., 2020). Thanks to these events' authenticity, the hosting destinations' cultural diversity, and other attendees' contributions at these events, visitors express a high level of connectedness to the destinations and appreciation of the destinations' cultural and gastronomic offerings (Adongo et al., 2019;Beverland and Farrelly, 2010;Jepson and Clarke, 2016). As food and wine festival visitors fulfill their need for experiencing new places or events, they develop a personal connection and a sense of attachment to these events' hosting destinations (Brockmeier, 2002;Dimache et al., 2017). The success of many events such as this often hinges on the interactions and sense of community they help to create. In fact, Hahm et al. (2016) discovered that creating a sense of community is a strong predictor of satisfaction with the event and simultaneously increases the likelihood of return. --- Food and wine festival experience, authenticity, and community Visitors seek authentic experiences to find meaning in their lives or to reinforce their current or desired identity (Beverland and Farrelly, 2010). The aspect of food authenticity at a festival setting has been described as the process of associating food with a specific place concerning the ingredients and method of preparation (Emmons, 2005;Hughes, 1995;Robinson and Clifford, 2012). Sims (2009) argued that 'tourists are seeking products that they feel will give them an insight into the nature of a place and its people'. The concept authenticity can be rather complex and ultimately subject to human perception. Seeking to deconstruct the components of authenticity, Grayson and Martinec (2004) conducted mixed-mode research on visitors to two attractions with connections to past literary figures. The authors argued that two main types of authenticity exist: indexical and iconic. Indexical authenticity refers to attribution of'real' or 'original' attributes to a product, service, or experience. In this regard, indexical authenticity sets apart the'real thing' from copies. In contrast, iconic authenticity entails resembling something that is ironically authentic. A product, service, or experience can be high on iconicity and low on indexicality; low on iconicity and high on indexicality or have both iconic and indexical features (Grayson and Martinec, 2004). In the food and beverage context, consumers might be seeking indexical, iconic, or both kinds of authenticity. For instance, some consumers might want the use of local ingredients, or for the cuisine to adhere to traditional recipes and methods of preparation. For other consumers, the authenticity of food and beverage might have to do with the resemblance or careful reproduction of the appearance and taste of food. Finally, consumers might also make attributions about whether the event is an authentic representation of the destination or region and its culinary traditions. At food and wine festival events, visitors become engaged in non-everyday activities of self-expression and interaction with other individuals, which creates a positive feeling toward the authenticity of these experiences (Girish and Chen, 2017;Kim and Jamal, 2007;Wang, 2000). Similarly, Park (2015) concluded that authenticity in a festival context contributes to attendees' positive emotions (i.e. pleasure and arousal) which translate into a stronger sense of community, identification with the event, and attachment to their hosting destinations. In light of the previous research findings and seeking to contribute to further theoretical development of the field, the researchers proposed the following hypotheses: H1a: Food and wine festival authenticity positively influences visitors' sense of community. H1b: Food and wine festival authenticity positively influences visitors' identification with the food and wine festival. H1c: Food and wine festival authenticity positively influences visitors' attachment to the hosting destination. At food and wine festivals, entertainment and experiential value are important contributors to increasing visitors' overall experience and attachment (Lee et al., 2017). At the present time, debate exists concerning the role of entertainment during festivals. Whereas a stream of research establishes a strong positive relationship between entertainment quality and visitors' satisfaction, as well as their attachment and identification with jazz festivals and sporting events (Carneiro et al., 2019;Petrick et al., 2013;Tanford and Jung, 2017;Thrane, 2002), another set of studies argue that entertainment offerings at similar event settings were not significantly influential to attendees' attitudes, nor to their behavioral intentions (Savinovic et al., 2012;Tanford and Jung, 2017). Prior to these studies, Van Zyl and Botha (2004) investigated the impact of different aspects of entertainment on art festival visitors: high quality of shows, music, and performances, in addition to meeting celebrities, positively influenced visitors' levels of satisfaction and sense of community. In the same regard, Cole and Chancellor (2009) concluded that entertainment is one of the main drivers for attachment to the hosting destinations and intention to revisit future events. Accordingly, the type of entertainment offered in a food and wine setting, such as live music, shows, and other activities, creates a happy mood among visitors and enhances their overall satisfaction with their experience. Based on the above discussions, this study predicts a positive effect of entertainment on the visitors' sense of community and satisfaction with their overall experiences. Therefore, the following hypotheses were proposed: H2a: Food and wine festival entertainment offerings positively influence visitors' sense of community. H2b: Food and wine festival entertainment offerings positively influence visitors' identification with the food and wine festival. H2c: Food and wine festival entertainment offerings positively influence visitors' attachment to the hosting destination. Visitors are attracted to food and beverage events for the opportunities to relax, socialize with other visitors, and enjoy authentic food and beverage from different cultures (Axelsen and Swan, 2010;Nicholson and Pearce, 2001;Yoo et al., 2015). Spending time with family and friends, as well as family togetherness, are additional factors that influence special event attendance (Maeng et al., 2016); as a result, family kinship and togetherness with friends strengthen the visitors' sense of community and increase their loyalty and identification with these events (Jepson et al., 2019;Patwardhan et al., 2020). In addition to spending time with friends and family, socializing with cooks, event organizers, and vendors contribute to increasing visitors' satisfaction, identification with the event, and attachment to the hosting destination of food and wine festivals. Such interactions can also promote value co-creation, which further enhances the event experience. Prior research in the events field argues that consumers actively invest time, effort, and other resources into the event (Lugosi et al., 2020). Having studied event visitors, Van Zyl and Botha ( 2004) concluded that meeting new people, building new relationships, and being around people who enjoy the same things were important motives for visiting a festival (Van Zyl et al., 2004). Being part of a large crowd, whose members share common values, and interacting with other visitors are also important satisfaction factors for festival visitors (Banyard et al., 2017;Tanford and Jung, 2017;Yürük et al., 2017). To predict the impact of interacting with other visitors and vendors and socializing with friends and family on food and wine festival visitors' sense of community and overall experience and satisfaction, the following hypotheses were proposed: H3a: Spending time with others at food and wine festivals positively influences visitors' sense of community. H3b: Spending time with others at food and wine festivals positively influences visitors' identification with the food and wine festival. H3c: Spending time with others at food and wine festivals positively influences visitors' attachment to the hosting destination. In the past, food festivals were celebrated by agricultural communities in rural regions to commemorate harvest time and strengthen their sense of community and heritage. In modern times, food and wine tourism offer similar benefits as it appeals to all kinds of communities and helps bring diverse communities together. These special events not only attract visitors from other areas, but they also encourage the locals or 'intra-urban tourists' to visit sections of their town that they normally do not visit (Selwood, 2004). Consequently, food and wine festivals bring people with different backgrounds together to share their community's gastronomy and cultural heritage with various visitors. When food and wine festivals offer traditional folk dance, ethnic music, and authentic food, individuals from these sub-cultures feel encouraged to share their multicultural background beyond their small community. As a result, their heritage becomes more accepted by the mainstream community (Jupp and Jupp, 1996;Lee et al., 2012). Visitors at food and wine festivals bring with them existing knowledge and prior experiences accumulated from prior or similar events (Dimache et al., 2017). These encounters and expectations influence their collective experience of these events as one group. Therefore, their collective behaviors and experiences as a community reconstruct a new meaning to these events and increase their loyalty to these special events. Furthermore, food festivals allow visitors to learn directly from the vendors and suppliers about local food and beverage products and methods of preparation. Consequently, the following hypotheses were proposed: H4a: Sense of community mediates the relationship between food and wine festival experiences and visitors' identification with these events. H4b: Sense of community mediates the relationship between food and wine festival experiences and visitors' attachment to the hosting destination. Following the theoretical background, the researchers developed a structural model to visualize the study. Figure 1 shows how the elements of authenticity, entertainment, and interactions with others positively contribute to the customer experience and ultimately result in visitors identifying with the festival and the destination. The sense of community is adopted as mediating variable in this model. --- Methodology --- Sample and data collection To achieve the research objectives and have a representative sample of food and wine festival visitors in the United States, Amazon Mechanical Turk was utilized to distribute a web-based questionnaire to reach these food and wine festival attendees within different regions of the United States. Previous research demonstrated that deploying MTurk for the purpose of collecting data from a diverse pool of participants, over a large geographical region, has proven to be useful (Lefrid, 2021;Stritch et al., 2017). Besides, it has been stated that MTurk is a trusted crowd-sourced consumer panel (Yang et al., 2021). From a psychometric standpoint, prior research concluded that the quality of data collected online through MTurk is not different than other data that is collected using paper and pencil surveys (Buhrmester et al., 2016;Yang et al., 2021). To ensure data quality, the survey data were verified following Buhrmester et al. (2016) methodology recommendations. Furthermore, to ensure the quality of the data, a cut-off period of 12 months was chosen because most food and wine festivals are held once a year and to avoid the risk of memory decay. Consequently, participants who did not attend a food and wine festival within the past year were directed to the end of the questionnaire. Similarly, individuals who were under the age of 18 years old or and dropped off the study. Moreover, screening questions were used in the questionnaire to increase the reliability of the data collected. In addition, data collected for the purpose of this study were inspected to ensure completeness and only qualified responses were retained for analysis. A total of 350 responses were collected for this study and 304 responses were determined usable after removing all the unsuitable questionnaires. Consequently, this survey had a response rate of 86%. --- Measures The questionnaire utilized in this study consisted of four sections; first, it started with explaining the purpose of this study and requirement to participate in this survey. The second section of the questionnaire asked questions on visitors' experiences at food and wine festivals; the third section inquired on their perceptions of these events in relation to sense of attachment, identification, and sense of community. The final section of the questionnaire included questions on demographic information of the participants. Questions in sections two and three were rated on a 5-point Likert-style scale, ranging from 1 = Strongly disagree to 5 = Strongly disagree. Items to measure the constructs introduced in this study were adopted from the existing literature. Authenticity was measured using three items developed by Liu and Jang (2009), which included questions about 'how genuine and real the food and beverage items tasted'; <unk> = 0.78. Entertainment was measured using two items: asking the participants on their opinion of 'quality of entertainment' as well as the 'variety of entertainment.' Interaction with others was measured with three items based on togetherness and quality of experience with friends, family, and vendors from Van Zyl and Botha (2004) as well as Axelsen and Swan (2010); <unk> = 0.78. Six items to measure sense of community were selected from Delamere (2001) as well as Van Winkle and Woosnam (2014) and included items such as 'the ambiance and culture displayed in this festival increased my pride of the local community' and 'being with other visitors who are enjoying themselves provided me with a strong sense of community'; <unk> = 0.85. Identification with the event was measured using three items from Williams and Roggenbuck (1989) and Williams and Vaske (2003); <unk> = 0.81. Attachment to hosting destinations was measured with three items also from Williams and Roggenbuck (1989) and Williams and Vaske (2003) and used items such as 'I am very attached to the destination because of events like this one'; <unk> = 0.86. To establish the validity of these measures, both face validity and content validity of items included in this study's survey were verified and confirmed by hospitality professionals and professors with expertise in event management. Moreover, the reliability of the survey measures was also verified using Cronbach's alpha test, as indicated above. --- Results --- Participant demographics Descriptive statistics were utilized to summarize the demographics of respondents. First, 304 respondents were qualified to participate in this survey using screening questions. Data collected for this research were analyzed using SPSS 24. Out of the total number of respondents, 49.7% were men and 50.3% were women. The age of the participants ranged from 18 to 56 years and over. Roughly, 50% of the participants were between 26 and 35 years old, followed by 21.4% who were between 36 and 45. Also, the results indicated that 48.7% were White and 37.5% were Asian. In regards to their household income, over 48.2% claimed to make less than $50,000, and 28.4% earned between $50,000 and $75,000. More importantly, over 47% of the participants stated that they were visiting with family members and 43.6% were visiting with friends. Regarding the group size during their visit to a food and wine festival, 23.6% expressed that they had been visiting in a group of four individuals, followed by 20.3% who indicated being in a group of three visitors, and 19% visiting in a group of two individuals. The full demographic profile of the respondents is included in Table 1. --- Assessment of model using partial leaststructural equation modeling (PLS-SEM) To analyze the proposed framework, a two-step approach was followed. The research framework included six reflective constructs (e.g. authenticity, entertainment, spending time with others, sense of community, identification with the event, and attachment to the hosting destination). To evaluate the reflective measurement models, the researchers tested outer loadings, composite reliability (CR), and average variance extracted (AVE) for reliability and convergent validity, in addition to discriminant validity. Moreover, convergent validity was assessed through factor loadings, CR, and AVE (Ali et al., 2018;Chin, 2010;Hair et al., 2017). Table 2 shows the results of the assessment of the measurement model for the reflective constructs of this study. All the outer loadings presented in Table 2 exceeded the recommended value of 0.5 (Hair et al., 2017). Also, CR values were greater than the recommended value of 0.7 (Hair et al., 2017), while AVE, which reflects the overall amount of variance in the indicators accounted for by the latent construct, was in the range of 0.624 and 0.857, which exceeded the recommended value of 0.5 (Hair et al., 2017). Consequently, the results showed the acceptable reliability and convergent validity for the reflective constructs. To assess the discriminant validity, Fornell-Larcker criterion and the heterotrait-monotrait (HTMT) ratio were used in this study. Table 3 shows the results of the Fornell-Larcker criterion assessment as well as the square roots of the AVEs for the constructs along the diagonal, which were higher than the correlations among the constructs. The HTMT ratio has been established as a conservative method for assessing discriminant validity (Henseler et al., 2015;Voorhees et al., 2016 ). To establish discriminant validity, the value of HTMT for all constructs in the model should be lower than 0.9 or 0.85 for more conservative results (Henseler et al., 2015). Table 4 shows that the value of HTMT for all constructs was lower than 0.802. Accordingly, using both Fornell-Larcker criterion and HTMT.85, this study's measurement model can establish discriminant validity. --- Assessment of structural model PLS-SEM was utilized to assess the structural model by analyzing the linear relationships between the latent variables of this study. Results of the analysis indicated the following R 2(r-squared) values: Sense of community (R 2 = 0.46), identification with the event (R 2 = 0.61), and attachment to destination (R 2 = 0.52). Table 5 shows the results of the structural model assessment using SmartPLS. To produce the statistical significance of the path coefficients for the model, a bootstrapping procedure with a resample of 5000 was used in this process (Hair et al., 2017). This study hypothesized that food and wine festivals' authenticity has a positive effect on visitors' sense of community, identification with the event, and attachment to hosting destinations. The results show that (H1c) authenticity had a positive and significant effect on attachment to destination (<unk> = 0.117; p<unk>0.05); meanwhile, (H1a) the effect of authenticity on sense of community was not statistically significant as this study anticipated. Similarly, the relationship between authenticity and identification with the event (H1b) was not supported in this study. Furthermore, this study theorized that food and wine festivals' entertainment offerings have a positive influence on visitors' sense of community, identification with the event, and attachment to hosting destination. Therefore, the hypothesis the second hypothesis (H2a) was supported; hence, entertainment positively affected sense of community (<unk> = 0.256; p<unk>0.001). Similarly, (H2b) was supported as entertainment positively affected identification with the event (<unk> = 0.177; p<unk>0.05). Also, (H2c) was supported in this study as the results indicated that entertainment positively affected attachment to the hosting destination (<unk> = 0.171; p<unk>0.001). Similarly, this study proposed that spending time with family and friends at food and wine festivals has a positive effect on visitors' sense of community, identification with the event, and attachment to hosting destinations. The outcome of this study supported (H3a); spending time with others positively affected sense of community (<unk> = 0.427; p<unk>0.001). Likewise, (H3b) was statistically significant; spending time with others positively affected identification with the event (<unk> = 0.139; p<unk>0.05). However, (H3c) was not supported in this study as spending time with others did not have a statistically significant effect on attachment to the hosting destination. Moreover, this study predicted a positive effect of sense of community among food and wine festival attendees have a positive influence on their identification with the event and attachment to hosting destinations. As expected, (H4a) was supported as the construct of sense of community had positive effect on attachment to the hosting destination (<unk> = 0.502; p<unk>0.001). Correspondingly, (H4b) was statistically significant; thus indicating that creating a sense of community had positive effect on identification with the event (<unk> = 0.535; p<unk>0.001). This study also investigated the mediating effect of sense of community on the relationship between authenticity, entertainment, and spending time with others in relation to the identification with the event and attachment to the hosting destination. Therefore, the indirect effect of entertainment on identifying with the festival was statistically significant (<unk> = 0.137; p<unk>0.001); also, the indirect effect of entertainment on attachment to the hosting destination was found to be statistically significant (<unk> = 0.128; p<unk>0.001). In the same manner, the indirect effect of spending time with others was statistically significant on identification with the event (<unk> = 0.228; p<unk>0.001) and on attachment to the hosting destination (<unk> = 0.214; p<unk>0.001). On the other hand, the indirect effect of authenticity was not statistically significant on either identification with festival or attachment to the hosting destination. Once the statistical analysis and hypotheses testing were conducted, the results are displayed in the structural model presented underneath. In Figure 2, the reader will identify the straight lines as supported hypotheses, whereas the dotted lines represent those hypotheses that did not receive statistical support. --- Discussion --- Discussion and theoretical implications The concepts of sense of community, attachment, and identification have extensively been investigated in the psychology, hospitality, and urban studies literature by Pretty et al. (2003); Obst and White (2005); Higgins (2007); Mannarini The present research demonstrated the role of entertainment, time spent with others, and sense of community on various relevant festival and destination-related outcomes. First, the provision of entertainment and food and wine festivals served to create a sense of community and enhance visitor's identification with the festival and attachment to the destination. This finding helps to settle a debate concerning the value of entertainment in evets. Whereas some researchers advocate for entertainment and assert its importance to the success of an event (Cole and Chancellor, 2009), other scholars argued that entertainment is not a driver of consumer attitudes (Savinovic et al., 2012;Tanford and Jung, 2017). Throughout the present research, the authors revealed that entertainment generates two positive effects for events: increased identification with the destination and an enhanced sense of community. Rudolph (2016) asserted that a variety of musical bands, performing artists, and shows at festivals are much more than simple entertainment bookings; they play a role in community bonding and help with identity formation. Additionally, Davis (2017) emphasized that live music and other entertainment offerings at festivals help consumers with their identity formation-a harmonious identity between the individual, other attendees, and the event itself. Consequently, identification with the event encourages visitors' full participation and optimal enjoyment of these events. In the context of art collection, a study by Pitt et al. (2020) suggested that collectors may be motivated to seek stimulation in the company of other art collectors. These behaviors can in turn enhance the value they derive from their art collection endeavors by adding a community aspect. Similarly, the results of this study imply that a sense of community and interactions with other attendees and event organizers enhance the sense of community and the value proposition for visitors. These interactions can further the perception of authenticity in the event. The researchers also sought to analyze the importance of time spent with others and sense of community during food and wine festivals. As hypothesized, time spent with others served to create a sense of community and fostered identification with the festival. This supports and expands the literature concerning the role of community in events. More specifically, prior studies indicated that creating a sense of community increases the likelihood to return to an event (Hahm et al., 2016). Furthermore, the present study supports the literature which advocates for the important role of connections with friends, family, and other customers in creating added value for festivals (Maeng et al., 2016;Van Zyl et al., 2004). Although visitors were more likely to identify with the festival, this did not significantly predict an attachment to the destination itself. This stands in contrast with the literature which argues that festivals create greater connectedness to a destination (Adongo et al., 2019;Jepson and Clarke, 2016). The creation of a sense of community was a critical aspect and important contribution of this study. The authors revealed that creating a sense of community promoted both identification with the festival and attachment to the destination. Importantly, time spent with others predicted creating a sense of community. However, as noted time spent with others and a sense of community had differential effects on destination attachment. Consequently, the authors posit that to generate attachment to the destination, festival organizers need to do more than just get people together; they need to take extra steps to create a genuine sense of community. In relation to the present research, the findings of this study support prior research findings indicating that when participants engage with one another, they experience a strong sense of community and identification with other places outside their homes (Stevenson, 2019). Furthermore, prior studies asserted that interactions with others are an important motivator to attend a festival (Maeng et al., 2016). Additionally, interactions with both family and other visitors have the potential to strengthen the sense of community and increase tourist loyalty and identification with these events (Jepson et al., 2019;Patwardhan et al., 2020). The present research supports the findings related to customer-to-customer interactions in festival and adds that creating a sense of community goes beyond simply putting people together in the same physical location. The element of authenticity had mixed results with regards to the outcome variables. While it significantly predicted destination attachment, it did not help tourists identify with the event nor did it create a sense of community. In the past, Grayson and Martinec (2004) categorized authenticity along two dimensions: indexical and iconic. Consequently, it is possible that visitors to a food and beverage experience might stress one dimension more than the other. Future research can help clarify this dilemma and bring light to the role of authenticity in creating community and attachment to a destination. Prior research explained that authenticity and nostalgia positively influence place identity among visitors (Park et al., 2018). Additionally, storytelling and authenticity are important for visitors' satisfaction and future visits. As a result, visitors experience higher levels of attachment and loyalty to hosting destinations. Similarly, another study by Park et al., (2018) stated that authenticity is a strong indicator of visitors' satisfaction and loyalty at cultural heritage destinations. Importantly, the concept of authenticity is highly perceptual in nature. Furthermore, researchers have at times struggled to define what is indeed an authentic food and beverage offering. Consequently, the researchers of this study argue that what is most critical for these festivals is to manage the visitor's perception of authenticity, which as observed can be highly subjective. One of the key findings of this study relates to the indirect effect of sense of community as a mediator between visitors' experiences at food and wine festivals in the United States (e.g. authenticity, entertainment, and spending time with others) and identification with the events and attachment to the hosting destinations. Specifically, this study's outcome establishes that sense of community fully mediates the relationship between spending time with others and attachment to the hosting destination. Meanwhile, this study's results also indicated that sense of community partially mediates the following relationships: 1. Spending time with others and identification with the events. 2. Entertainment and identification with the events. 3. Entertainment and attachment to the hosting destination. Food and wine festivals help visitors achieve a higher level of satisfaction when all the aspects of their experiences-food and beverage, entertainment, and spending time with friends and family-meet or exceed their expectations. The present research also indicated that when visitors and locals are satisfied with their overall experiences at food and wine festivals and express a high level of sense of community, they develop a deep identification with these events as well as attachment to the hosting destinations. It is important to acknowledge the role that the COVID-19 pandemic is having on the hospitality and tourism industry in general and festivals in particular. Davies (2021) exposes some of the key questions the events industry is facing concerning the future of festivals. One possibility is that events become smaller and more exclusive. This can potentially have negative implications for creating a sense of community and making events affordable to visitors. On the positive side, smaller events could potentially have less impact on the environment. A key question also remains concerning whether events are an 'essential' part of society (Davies, 2021). The answer to this could have either positive or negative consequences for the future of events. Other scholars argue that the gradual

The present study explored the effects of various food and wine festival experience elements (e.g. authenticity, entertainment, and spending time with others) on visitors' sense of community, identification, and place attachment. The authors conducted survey research with 304 former visitors to food festivals. Data were analyzed using partial least squarestructural equation modeling. Results revealed that food and wine festival experience elements (e.g. authenticity, entertainment, and spending time with friends and family) positively influenced visitors' sense of community, identification with the event, and attachment to the hosting destination. Significant findings relating to the mediating effect of sense of community were also disclosed throughout this study. The present research exposes some of the expectations held by visitors to food and wine festivals. Furthermore, this study contributes to the literature by exposing the role of community and customer interactions in creating the overall food and beverage experience and forming a destination's image.

events. 3. Entertainment and attachment to the hosting destination. Food and wine festivals help visitors achieve a higher level of satisfaction when all the aspects of their experiences-food and beverage, entertainment, and spending time with friends and family-meet or exceed their expectations. The present research also indicated that when visitors and locals are satisfied with their overall experiences at food and wine festivals and express a high level of sense of community, they develop a deep identification with these events as well as attachment to the hosting destinations. It is important to acknowledge the role that the COVID-19 pandemic is having on the hospitality and tourism industry in general and festivals in particular. Davies (2021) exposes some of the key questions the events industry is facing concerning the future of festivals. One possibility is that events become smaller and more exclusive. This can potentially have negative implications for creating a sense of community and making events affordable to visitors. On the positive side, smaller events could potentially have less impact on the environment. A key question also remains concerning whether events are an 'essential' part of society (Davies, 2021). The answer to this could have either positive or negative consequences for the future of events. Other scholars argue that the gradual reopening of borders and events creates an opportunity for a transformed festival experience that relies more heavily on co-creation (Rowen, 2020). Seraphin (2021) posited that events will gradually return to the daily lives of people amid strict controls. Furthermore, it is argued that instead of mega events, smaller scale country or regional events will replace them. All of the results put together indicate that the festival industry will have to adapt as the pandemic continues. However, the demand for events and the resiliency of the industry will likely keep festivals viable in the future. --- Practical implications Food and wine festivals present an opportunity for vendors and event organizers to showcase their menu offerings and culinary skills to a large group of visitors. As food and beverage special events expose visitors to local food and regional wines, they enhance the hosting destinations' brand image and support regional wine sales and promotions (Kruger and Viljoen, 2019;Lee et al., 2017;Peter and Anandkumar, 2016;Yang et al., 2020). Based on the study results of this study, several practical implications are presented. First, the authenticity of food and wine festivals plays an important role in creating long-lasting memories and enhancing the hosting destination's image among visitors. Therefore, event managers and festival organizers should consider authenticity a priority during their planning and execution of these special events. Authenticity is a complex construct; therefore, it might be worthwhile conducting market research concerning what specifically consumers consider authentic. Second, the quality of live entertainment and shows at food and wine festivals has a critical role in creating a happy environment. For instance, entertainment offerings at these special events increase the levels of sense of community, identification with these events, and attachment to the hosting destination. Therefore, event managers and food and wine festival organizers should include quality entertainment to meet visitors' expectations and tastes. Third, spending time with others at food and wine festivals proves to be influential in improving visitors' overall satisfaction with these events and demonstrates to strengthen their sense of community. Therefore, event managers should create spaces and allow for opportunities for visitors to socialize with family members, friends, and other visitors, as well as games and interactive activities to engage these visitors. Other suggestions include implementing name tags for the event workers and providing memory-making opportunities like photo booths or meet-and-greet areas with the event participants and entertainment crew. From a managerial standpoint, the practical outcome of this study helps event planners and food and wine festival organizers understand the importance of promoting local businesses, such as restaurants, wine vendors, and other related products, to attract more visitors and to create an attachment to both the festival and the destination itself. It is also through food and wine festivals that food service operators have presented the opportunity to build new relationships with their potential customers. While visitors get more exposure to a variety of local food and beverage and how these are produced, they also get the opportunity to sample different types of food and interact with the vendors. To help with branding and promoting such events, this study provided event managers and festival organizers with a clear insight on the value of improving food and wine festivals' offerings, such as food and beverage authenticity, quality and variety, live entertainment, and opportunities to socialize and spend time with relatives, friends, and other event attendees. From a policy-making perspective, city and county leaders should encourage hosting food and wine festivals at the local level by making special event permits easier to receive, in addition to providing logistics and consulting support to event managers and festival organizers. Meanwhile, government officials, at the state and country levels, should support budgets that promote food and wine festivals, especially in countries that heavily depend on international tourism. Festivals present an excellent opportunity to attract new visitors to a destination. Furthermore, guests from the surrounding area have the opportunity to meet and become better acquainted with their community. Festival organizers should evaluate various target markets based on geography, psychographics, and demographics. More specifically, people whose AIO (activates, interests, and opinions) closely match the affinity for food and wine whose personality gravitates toward adventurous eating, can be a prime target for the marketing of food and wine festivals. While some customers might visit for the food, others might be more interested in the social connections which ensue from festivals. Given the social isolation emerging from the COVID-19 pandemic, visitors (especially those with high levels of extroversion) might be hungry for social interactions. Therefore, food and festival events have a great opportunity as the virus subsides to market and promote social interactions which foster a sense of community. Generating loyalty toward food and wine festivals is yet another important goal for organizers. Therefore, organizers should seek to create the tastes, sounds, scents, entertainment, and design that would differentiate one food festival from the other. By creating a unique event with a sense of authenticity, whether indexical or iconic, visitors might be more prone to revisit. Once loyal to a festival, destination marketers have a great opportunity to promote other parts and attractions within their destination and establish longer lasting relationships with their guests. --- Limitations and future research Despite its contributions, the present research has several limitations which could open avenues for further research inquiry. First, participants in this research survey might have had different experiences based on the purposes, planning, and execution of the food and wine festivals they attended. There might be less emphasis on authenticity at local events than at popular touristic destinations. Second, this inquiry was conducted in unspecified regions within the United States; therefore, the outcome of similar research at international touristic destinations could differ based on participants' sophistication and the festival offerings at authentically rich and wellestablished food tourism destinations. This study anticipated the authenticity of food and wine festivals in the United States to have a significant effect on visitors' sense of community and identification with these events; however, the results of this study proved these anticipations to be untrue. This could be attributed to the scale used to measure authenticity. Since authenticity is complex a complex construct, this study suggests utilizing other scales, such as Chhabra (2008) which was confirmed by other studies, including Ramkissoon and Uysal (2010). Even though food and wine festivals are vital to both visitors' satisfaction and hosting communities' appeal, no prior research measured the effect of economical spillover on local communities within the hosting destinations. Although attendees are primarily attracted to a touristic destination through food and wine festivals, they end up visiting local bars, restaurants, and shopping centers. Hence, future studies should investigate the correlation between the attendance of special events and increased tourist monetary spending at local businesses. Finally, this quantitative study, which is cross-sectional in nature, took place at one specific point in time; therefore, future research should consider longitudinal investigations of food and wine festivals at other global food tourism destinations with strong cultural or historical heritage. --- Conclusions Recently, food tourism destinations have become more competitive in branding special events to attract more visitors. Because visitors are increasingly seeking unique experiences, touristic destinations have become motivated to diversify their offerings to meet these visitors' needs. Both locals and food and wine festival visitors have been identified in prior research as important stakeholders and promoters of both these special events and their hosting destinations (Boley et al., 2014;Braun et al., 2013;Palmer et al., 2013;Strzelecka et al., 2017;Uchinaka et al., 2019). Locals and returning visitors add more value to a special event like a food and wine festival as they bring with them cultural diversity and share information and knowledge with others on the destination and the festival specifically (Braun et al., 2013;Uchinaka et al., 2019;Young et al., 2007). More importantly, food and wine festival visitors are very effective in promoting such an event by spreading positive word of mouth since their opinions are more organic and trustworthy than advertising messages generated by the festival's management or DMOs (Uchinaka et al., 2019;Xiang and Gretzel, 2010). Food and wine festivals play an important role in bringing people from within the community together, including visitors from neighboring areas as well as international visitors. Therefore, organizing food and wine events encourages visitation among individuals who desire different experiences, escape from day-to-day routines, spending time with friends and family, or meeting new people with similar interests. As visitors reach a high level of satisfaction with their experiences at food and wine festivals, they become more attached to these events and plan on attending in the future. In a study on international visitors at major heritage destinations, Ram et al. (2016) established a positive correlation between the authenticity of major visitor attractions and place attachment, which is in line with this study's findings. In addition, the same study established that the stronger the relationship between place attachment and authenticity, the more valuable these visitors find heritage tourism destinations. This study aimed to explore the effect of food and wine festival experiences (e.g. authenticity, entertainment, and spending time with others) on visitors' sense of community, identification with the event, and attachment to the hosting destination. Indeed, the outcome of this study has concluded that visitors' experiences at food and wine festivals are vital for improving their sense of community, identification with the event, and attachment to the hosting destination. Moreover, this study confirmed that sense of community mediates the relationship between visitors' experiences at food and wine festivals (e.g. authenticity, entertainment, and spending time with others) and identification with the event and attachment to the hosting destination. --- Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. --- Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. --- ORCID iDs --- Mohammed Lefrid https://orcid.org/0000-0001-7746-9083 Edwin N. Torres https://orcid.org/0000-0001-7834-8515

The present study explored the effects of various food and wine festival experience elements (e.g. authenticity, entertainment, and spending time with others) on visitors' sense of community, identification, and place attachment. The authors conducted survey research with 304 former visitors to food festivals. Data were analyzed using partial least squarestructural equation modeling. Results revealed that food and wine festival experience elements (e.g. authenticity, entertainment, and spending time with friends and family) positively influenced visitors' sense of community, identification with the event, and attachment to the hosting destination. Significant findings relating to the mediating effect of sense of community were also disclosed throughout this study. The present research exposes some of the expectations held by visitors to food and wine festivals. Furthermore, this study contributes to the literature by exposing the role of community and customer interactions in creating the overall food and beverage experience and forming a destination's image.

Introduction The global population of older individuals is continuously growing in both absolute numbers and relative proportions. As reported by the World Health Organization (WHO), in 2010, there were 524 million people aged 65 and above, and this number is projected to reach 1.5 billion by 2050 (1). Similarly, the age composition of the population in Kazakhstan is also experiencing a transformation in line with these global patterns. By 2050, the population of individuals aged 65 and older is expected to double from the 2019 figures, increasing from 1.4 million to 3.4 million. Consequently, their share of the total population of the country will rise from 7.5% in 2019 to over 14% by 2050 (2). The United Nations (UN) Population Fund (UNFPA) notes that the demographic situation in the northeastern region of the country and certain parts of central Kazakhstan bears resemblance to that of European countries (3). Recent statistics indicate that approximately one in every five older adults individuals surveyed in Kazakhstan requires some form of assistance. The need for assistance is particularly prevalent among those aged 60-69 years (22%) and those above 70 years (31%). When faced with the need for physical support, 69% of individuals over the age of 65 seek assistance from their children, while a mere 0.8% seek help from social services (4). This trend may be attributed to sociocultural factors and the underdeveloped nature of the formal care system (5,6). The growing number of older individuals with specific needs subsequently amplifies the demand for both formal and informal caregivers. Informal care emerges as a viable substitute for formal long-term care in the context of older adults individuals. By relying on informal caregivers, older adults can maintain their residence in familiar surroundings, thereby mitigating the strain on healthcare and social welfare systems, while concurrently alleviating the burden on the state budget (1). However, it is important to acknowledge that assuming caregiving responsibilities can yield both advantageous and detrimental effects on the mental and physical well-being of informal caregivers (2). Table 1 presents a comprehensive list of these effects. Various nations have different approaches to providing assistance and services to caregivers responsible for the well-being of older adults individuals in need of care. These approaches are primarily influenced by factors such as the country's income level, legislative and sociocultural characteristics, and the type of funding allocated to the long-term care system. Primary healthcare plays a pivotal role in this system, encompassing comprehensive aspects of individuals' physical, mental, and social well-being. Adopting such an approach enables the delivery of integrated care across individuals' lifespans, including health promotion, disease prevention, treatment, and rehabilitation, all tailored to align with their everyday lives. Such considerations hold particular significance for informal caregivers who undertake the responsibility of caring for the older adults (3). State support for informal care in Kazakhstan is in the developmental stage and requires substantial improvements. The strategic documents of the Republic of Kazakhstan related to health and social support lack adequate provisions for identifying and assessing caregivers' burden and needs, as well as providing financial support and ensuring occupational health conditions for these individuals. Previous studies conducted in Kazakhstan have primarily focused on the needs of older individuals (4-6) or assessing the competencies of caregivers in caring for critically ill patients (23). Significantly, there is a lack of official data on the current number of formal and informal caregivers operating in the Republic of Kazakhstan. Presumably, the majority (95%) of caregivers are informal and do not receive sufficient medical and social support tailored to their specific needs. This analysis is significant in facilitating the effective development of support mechanisms for familial care of the older adults and individuals with disabilities in Kazakhstan. --- Methods --- Search strategy In our scoping review, relevant articles and grey literature were identified through manual searches on Google and Google Scholar, as well as electronic searches using indexed databases like PubMed, Web of Science, and Scopus. Additionally, the reference lists of all identified sources and the websites of government ministries were thoroughly reviewed. Figure 1 presents the details of the screening process, indicating that a total of 14 records out of 166 were included in our final synthesis. The websites address of government ministries is presented in Supplementary Table S1. The search was conducted using Medical Subject Headings (MeSH) and keywords, both separately and in combination, with the use of Boolean operators (AND/OR). The search strategies are presented in Supplementary Table S2. All records had to be in full text and written in English, providing comprehensive information regarding the policies supporting informal caregivers of the older adults in the Republic of Kazakhstan. The review period spanned from January 28, 2023, to June 1, 2023. We used the reference manager software program EndNote to download relevant citations and subsequently eliminated any duplicate articles. Following this, we exported the obtained data to Excel for further examination and analysis in the review process. --- Study selection and data extraction Two authors (AZ and AT) conducted a rigorous analysis of the titles and abstracts of all identified articles and legal acts to ascertain their eligibility according to the inclusion criteria. Subsequently, the full-text articles and relevant legal acts were meticulously reviewed by three authors (AZ, AT, and AG) for potential inclusion. In cases where differences of opinion arose, they were resolved through deliberative discussions led by a fourth author (GK). Data synthesis in this study was conducted following the Arksey and O'Malley framework, utilizing a descriptive approach to concisely summarize the primary findings and identify common themes and patterns among the selected studies (24). The evaluation of the included studies and legal acts was based on their relevance to the research question and their legal significance, thereby assessing their quality. --- Assessment of policy This review highlights the limited research conducted on support measures for caregivers in Kazakhstan, as evidenced by the scarcity of peer-reviewed articles on this topic. To bridge this research gap, we have explored the "grey literature" to gather relevant information. Our analysis entails summarizing the key laws, standards, and regulations pertaining to the medical and social challenges associated with informal caregiving for the older adults. Furthermore, we have examined the availability of support for informal caregivers of the older adults within the legal framework of the Republic of Kazakhstan. Additionally, we have scrutinized the legal aspects concerning the support provided to employees who care for their family members, including provisions for reduced working hours, paid or unpaid leave, and financial compensation. Through our search process, we have identified the primary legal acts addressing the medical and social issues concerning caregivers in Kazakhstan. The key provisions are presented in Supplementary Table S3. Moreover, we have analyzed and ranked the state policies regarding caregiver support in our country, making comparisons with international experiences. --- Introduction of the term caregiver Older adults individuals who face functional impairment, disability, or chronic illness rely on assistance to compensate for their reduced ability to carry out daily activities. This support can be obtained through both formal and informal care. Formal care is administered by governmental organizations, local, national, or international non-governmental organizations (NGOs), or commercial entities. It often involves professional caregivers such as nurses, doctors, social workers, and hired nurses. On the contrary, informal care entails the support provided by family members, neighbors, friends, and volunteers. Until recently, the term "caregiver" was absent from the legislative documents of the Republic of Kazakhstan. However, with the recent addition of the Law of the Republic of Kazakhstan "On Special State Benefits" in 2022, the concept of a "caregiver" was introduced for the first time. According to this law, a caregiver is defined as an individual who directly provides care to a person with a first-degree disability, irrespective of their familial relationship. The status of a caregiver is granted to only one individual upon the request of a person with a first-degree disability, and it is based on a disability certificate (25). According to the legislation of the Republic of Kazakhstan, individuals are classified as having a first-degree disability if they exhibit persistent, significant, or pronounced impairments of bodily functions resulting from diseases, consequences of injuries, or defects. These impairments lead to a pronounced limitation in their ability to perform one or more categories of life activities (26). In the classification system, limitations in life activities are categorized into three degrees based on their severity. The first degree signifies a partial limitation in performing life activities. The second degree indicates that an individual is capable of carrying out life activities partially or with the assistance of unauthorized individuals. The third degree pertains to individuals who are completely dependent on others to carry out life activities. To determine a first-degree disability, the criteria for life activities should be assessed at the third degree for one or several the following indicators: self-service, mobility, work capacity (labor activity), ability to learn, orientation (or inability to orientate, or disorientation), communication, and self-control. --- Legislative norms in older adults care provision Article 27 of the Constitution of the Republic of Kazakhstan emphasizes the significance of family values and social welfare, explicitly stipulating the duty of able-bodied children to assume the responsibility of caring for their disabled older adults parents and grandparents (27). Additionally, Article 145 of the Code of Marriage and Family elaborates on the legal obligations imposed on children to fulfill their caregiving duties. Failure to meet these obligations can result in various repercussions, as outlined in in Article 146 of the Code on Marriage and Family. These consequences may include the requirement for children to contribute to alimony payments and cover additional expenses arising from parental illness or the need for external caregiving services (28). --- Social welfare Social support in the Republic of Kazakhstan operates within the legal framework established by the Social Code. As per this Code, special social services are defined as a comprehensive range of services designed to address objective barriers that impede individuals or families from leading fulfilling lives. The primary objective of these services is to promote equal opportunities for community integration, fostering social cohesion among citizens (29). The legislation governs the provision of specialized social services, specifically targeting individuals or families facing challenging life circumstances. These circumstances may arise from factors such as illness, injury, age, or disability, resulting in a complete or partial loss of self-care ability, mobility, or access to necessities. The Code encompasses a range of services, including social and household support, socio-medical assistance, socio-psychological counseling, socio-pedagogical interventions, social and occupational guidance, socio-cultural activities, socio-economic aid, and socio-legal assistance (29). However, delivering the full range of services necessitates a multidisciplinary team comprising not only healthcare and social welfare professionals but also legal experts, economists, and psychologists. This is due to the complex nature of the required assistance, which extends beyond the scope of a social worker's capabilities alone. Persistent challenges exist, including low qualifications of social workers, substandard quality of care and support services provided to those in need, inadequate development of home assistance programs, and a shortage of trained social workers Currently, a mere 1.3% of the older adults population in the Republic of Kazakhstan receives social services and home care, underscoring the limited reach of these services. The home-based services primarily encompass household cleaning, grocery shopping, and medication procurement, with the associated expenses borne by the clients themselves (30). Notably, that older adults individual facing difficult life circumstances, who have able-bodied adult children or a spouse, are ineligible for special social services at home (31). In addition to the provision of home care services, the Republic of Kazakhstan offers specialized social services in the realm of social welfare for the population in hospitals and semi-hospital settings. These services are designed for individuals who require long-term or temporary (up to 6 months) daytime stay and, and their funding is provided by the government (31,32). However, it is noteworthy that Kazakhstan has a limited number of institutions, amounting to only 13, that provide palliative and medical care, encompassing hospices, nursing centers, and departments for symptomatic treatment and palliative care. The collective bed capacity of these facilities does not exceed 500, potentially indicating inadequate resources to accommodate all patients in need. Furthermore, individuals residing in remote areas often face challenges in accessing palliative and nursing care, thereby exacerbating the barriers to care for those who require it (6,33). The development of alternative palliative care options such as mobile teams, home hospices, and day care centers, remains relatively insufficient (6). This situation can be attributed, in part to the relatively lower allocation of state budget expenditures in the Republic, which range from 3.5 to 4.5 times lower in the social sphere compared to more socially and economically developed countries. In situations where additional private care services are necessary, the recipients of social services bear the responsibility of covering the associated costs (31). In accordance with the key documents concerning social support, caregiver support involves providing essential training to family members regarding the fundamental aspects of home healthcare. Furthermore, health and social service professionals have the responsibility of delivering social and psychological assistance to family members who reside with individuals benefiting from these services. The ultimate objective is to create a nurturing psychological environment while effectively addressing and resolving conflicts (29, 34). --- Older adults care leave The Labor Code of the Republic of Kazakhstan includes provisions for paid parental leave (35). However, it does not extend the same support to individuals taking leave to care for older adults relatives. In contrast, France has implemented a family leave policy that considers regular caregiving for older adults relatives on par which childcare (36). In Kazakhstan, similar to Russia, employees have the option to take unpaid leave for family and other valid reasons, with the duration determined through agreement between the employee and employer (35,37,38). It is crucial to highlight that caregivers for the older adults in Kazakhstan are ineligible to obtain sick leave on behalf of their older adults relatives (39). This particular circumstance can present supplementary difficulties for individuals who are obliged to fulfill caregiving responsibilities for their older adults relatives. Frontiers in Public Health 05 frontiersin.org --- Caregiver allowance In the Republic of Kazakhstan, caregiver allowances are exclusively provided to individuals who care to those classified as having a firstdegree disability (40). The enactment of the Social Code (41) has resulted in an increase in the amount of the caregiving allowance, now set at 1.61 times the subsistence minimum, compared to 1.4 times the subsistence minimum in 2021 (40). The subsistence minimum refers to the minimum cash income per person, reflecting the cost of a basic food basket. According to the Law on Minimum Social Standards and their Guarantees, the subsistence minimum denotes the minimal monetary income per individual, equivalent in value to the expenses associated with the basic food basket. The basic food basket represents a basic assortment of essential food items, commodities, and services required to sustain human life, both in tangible and monetary terms. It comprises of: (a) the food basket; and (b) a fixed portion of non-food items and services. The determined value for the minimum subsistence amount, used for calculating the extent of social payments for the year 2023, stands at 40,567 tenge (42). --- Healthcare support In Kazakhstan, the provision of medical services operates through a dual system consisting of both public and private sectors. The public healthcare system functions under the framework of compulsory health insurance, where in both employers and employees contribute to the health insurance system to a certain extent. As per the legislation of the Republic of Kazakhstan, individuals who are not employed but are responsible for caring for a person classified as having first-degree disability have their medical service contributions paid by the state (43). However, individuals caring for the older adults who do not meet the criteria for disability classification do not have access to planned public health services. In such instances, caregivers are required to make private health insurance payments, which can pose challenges if they encounter unemployment and subsequent loss of income. --- Actionable recommendation --- Policy changes • A crucial step towards recognizing and supporting caregivers who are not affiliated with formal medical or social organizations is to develop and incorporate the concept of "informal (family) care" into legislation. By introducing this concept into the legislation, Kazakhstan can acknowledge the valuable role played by informal caregivers and establish a legal framework that safeguards their rights and provides the necessary support. • It is essential to develop and introduce the term "caregiver" into the legislation, which should extend beyond individuals caring for first-degree disabled individuals. This development will help determine the specific individuals who qualify as caregivers. • It is necessary to develop comprehensive criteria for assessing the caregiving needs of individuals aged 65 and older. Based on these assessments, various levels of medical and social support should be formulated. This approach ensures that older adults individuals and their caregivers receive the appropriate range of medical and social services according to the severity of their condition. • It is crucial to establish clear criteria for transitioning to part-time work and caregiving leave. Additionally, it is necessary to include caregivers who provide temporary supervision for older adults individuals when they fall ill in the list of individuals eligible for sick leave. This inclusion will grant caregivers the required flexibility in their employment while fulfilling their caregiving responsibilities. Prioritizing the establishment of these criteria is imperative for effectively supporting caregivers. Raising public awareness and changing societal attitudes toward caregiving • Raise awareness about the indispensable role of caregivers and the challenges they encounter to foster understanding, empathy, and recognition within society. • Increase the involvement of volunteers in the provision of social services, enhance accountability, and engage capable family members in supporting and caring for older adults individuals. • Collaborate with media outlets to promote positive depictions of caregivers and share their stories, highlighting their contributions and inspiring others to support and appreciate caregivers. --- Strengthening collaboration between healthcare and social service providers • Establish interdepartmental collaboration between medical and social services, including the consolidation of client databases and the creation of a legal framework to facilitate this cooperation. • Develop joint training programs that bring together healthcare professionals and social service providers, enhancing their understanding of caregivers' needs and promoting effective teamwork. • Implement integrated care plans involving both healthcare and social service providers, facilitating joint assessment, planning, and the delivery of comprehensive care for older adults individuals. --- Development and implementation of a comprehensive caregiver support program • Provide specialized training programs for caregivers, focusing on topics such as caregiving techniques, self-care, and managing the needs of older adults individuals. This training will equip caregivers with the necessary knowledge and skills to effectively care for both themselves and the older adults, ultimately reducing stress and anxiety. • Establish support groups and counseling services to offer emotional support and guidance to caregivers, allowing them to share their experiences and seek advice from professionals. Introduce respite care services that temporarily relieve caregivers from their responsibilities, enabling them to take breaks and attend to their own needs. • Providing financial assistance is essential to alleviate the financial burden experienced by caregivers. This support can be facilitated through the utilization of legal and economic mechanisms such as care allowances, tax deductions, health insurance, and pension contributions. Financial support becomes particularly crucial when caregivers are compelled to forego employment in order to fulfill their caregiving responsibilities. • It is imperative to develop a comprehensive process for the identification, screening, assessment of the caregiving burden and quality of life, and provision of specialized medical and psychological assistance to caregivers, while simultaneously guaranteeing their access to essential support and resources. --- Discussion We conducted a scoping review and synthesis of policies and practices related to informal care in the Republic of Kazakhstan. Throughout our review, we identified six main themes, which include the introduction of the term "caregiver, " legislative norms in older adults care provision, social welfare, work-care balance, caregiver allowance, and healthcare support. Revision of legislation to incorporate the concept of "informal (family) care" is of utmost importance, along with the development and implementation of legal norms that regulate informal (family) care in the Republic of Kazakhstan, drawing upon the best global practices. The most commonly used definition of an informal caregiver in the literature is as follows: "An informal caregiver refers to a non-professional individual who voluntarily provides care or assistance, at any given time, to a family member, friend, neighbor, or any other person with a long-term mental or physical illness, disability, or age-related condition" (44). As per the German Social Code, informal caregivers are defined as "individuals who provide non-professional care to individuals who are unable to care for themselves due to health issues. " Additionally, the requirement for care must be continuous for a minimum duration of 6 months and reach a certain level of severity (45). In Portugal, Decree 2022 outlines the criteria for recognizing informal caregivers and establishes support measures for them. The status of an informal caregiver can only be granted to one applicant per household, provided that they reside with the care recipient and offer full-time care. Moreover, the caregiver must not be engaged in any paid professional or other activities that would conflict with their responsibility of providing continuous care to the individual in need (46,47). The legal obligation of providing care for older adults family members being the responsibility of their children is a widely acknowledged norm in numerous countries, such as China, Bangladesh, India, Singapore, Brazil, Mexico, Russia, Turkey, Algeria, Argentina, Chile, Singapore (48,49). This norm is also observed in the Republic of Kazakhstan. In Japan, under the previous civil code, the eldest son was entitled to inherit the family's property, and his wife, as the daughter-in-law, bore a legal and moral responsibility to care for her husband's parents. However, with the introduction of the New Civil Code in 1947, the responsibility for parental care was extended equally to all children. This legal provision remained the societal norm until recently, when the National Long-term Care Insurance Act was enacted. This act establishes a comprehensive set of measures for older adults care, funded through insurance premiums (50). However, in Scandinavian countries such as Sweden, Denmark, Netherlands, and Norway, long-term care has been recognized as a social risk factor since 1980. As a result, the primary legal responsibility for older adults care has been assigned to the state. In these countries, the contribution of the family to informal care provision is relatively lower compared to countries where family care is the predominant approach. On the other hand, countries like Austria, Belgium, Canada, Germany, France, Switzerland, the United Kingdom, and the United States share the responsibility for care between the state and the family. Their systems combine government-provided universal benefits and means-tested caregiver's allowance (51). In addition to legislation, the cultural and social characteristics of each country play a significant role in shaping the perception of older adults care. In Asian culture traditional values and cultural norms continue to emphasize the sons' responsibility for older adults care alongside state policies (52)(53)(54)(55)(56). Similarly, in Kazakhstan, national family traditions still serve as an important source of support for the older adults (5). However, there has been a recent shift towards a change in family composition, with a transition from extended families to nuclear families and the older adults living separately from their children. This change may lead to an increased demand for formal care services. In Kazakhstan, to be eligible for special social services, certain criteria must be met, including reaching retirement age and living alone within a community or being disabled (29). However, in countries such as the United States, Germany, and Japan, publicly funded long-term care services are established based on a comprehensive care needs assessment, which plays a crucial role in determining the provision of social services (57,58). The competency framework considers functional disability, which is assessed based on the individual's ability to perform activities of daily living (ADL), instrumental activities of daily living (IADL), and cognitive tasks. In Germany, for instance, there are five levels of care needs depending on the degree of functional disability, each corresponding to a different package of medical and social assistance (59). It is important to highlight that the right to part-time employment for informal caregivers in Kazakhstan applies exclusively to family members and relatives. Consequently, if the caregiver is assisting a distant relative, friend, or neighbor, transitioning to part-time work may present certain difficulties. Similar situations are observed in countries such as Germany (60), Japan (61), Great Britain (62), and France (36), where the scope of informal care recognized by employers is limited to family members and relatives. Nonetheless, unlike the legislation in the aforementioned countries, the Labor Code of Kazakhstan does not specify the conditions for part-time employment. It does not provide information regarding the length of employment required at a specific enterprise or company before exercising this right, the duration of the permitted part-time arrangement, or the types of enterprises and job positions eligible for this right. Furthermore, the Labor Code does not mention the possibility of transitioning to remote work if deemed necessary. In Kazakhstan, unlike many countries where implemented leave systems specifically designed to cater to the long-term care of close relatives, such provisions are not currently in place. Generally, the policies regarding payment for sick leave differ from those for caregiving leave, with sick leave typically providing a limited number of days with full wage restoration. For instance, several states in the United States, including California, Connecticut, Massachusetts, Oregon, and Vermont, have implemented paid sick leave laws that allow workers to use sick leave when caring for sick family members (63). While some states offer unpaid leave, others provide compensation to address caregiving needs. For instance, Austria, the Czech Republic, Luxembourg, and Germany have established paid leave for older adults care (46). In Germany, workers can avail themselves of a shortterm leave program for up to 10 days when nursing care is required, with 90% of their wages covered through a caregiver allowance (64). In Canada, individuals caring for terminally ill close relatives are entitled to up to 28 weeks of unpaid family leave per year (65). The US Family and Medical Leave Act (FMLA) allows for up to 12 weeks of unpaid leave within a 12-month period to address short-or long-term caregiving needs (66). Some states, like California and New York, have introduced paid family leave at the state level (67), wherein workers receive 67% of their wages during care leave (68). In Japan, a system exists where two-thirds of the salary is compensated for a certain period through unemployment insurance for individuals on care leave (61). In France, workers have the right to up to three months of unpaid care leave, which can be renewed within one year (36). Paid leave is considered one of the most effective and practical ways to support long-term care workers. Having access to paid care leave offered by employers significantly facilitates the ability to provide regular or temporary informal care to older adults parents and relatives (69). Unfortunately, in countries where such policies are lacking, caregivers may face challenges in balancing their caregiving responsibilities with their work obligations. In Kazakhstan, benefits are primarily designated for the support and assistance of individuals classified as belonging to the first-degree disability. However, it is noteworthy that over two-thirds of the member countries in the Organization for Economic Co-operation and Development (OECD) have implemented schemes to provide financial compensation to informal caregivers. These care allowances are distributed either directly to caregivers in the form of a caregiver allowance or as compensation to care recipients. Several nations, such as Netherlands, Sweden, the United Kingdom, and Germany, have adopted a dual approach, offering both types of care allowances to aid their citizens in the provision of care for their loved ones (46). In Germany, caregivers are eligible to receive a caregiver allowance if they provide regular care for a minimum of 10 hours per week to one or more individuals requiring assistance (45). In Canada, caregivers are provided with a caregiver allowance amounting to 55% of the average weekly wage for the duration of their leave. It should be noted that individuals receiving this benefit are not permitted to engage in full-time employment during this period (65). In Russia, the allowance for older adults care is provided to individuals who care for those over the age of 80, regardless of their family relationship or cohabitation. The allowance, amounting to 1,200 rubles, is credited monthly to the recipient's pension account. The caregiver must be unemployed but capable of working according to pension legislation and should not be receiving unemployment benefits from the employment service (70). In the United States, Medicaid offers care allowances to adult children, relatives, or grandchildren who provide care. The caregiver is expected to receive compensation ranging from 1,550 to 2,550 dollars per month, depending on the level of care required by their aging parent and their state of residence (71). The current healthcare system in the Republic of Kazakhstan lacks consideration for the challenges and requirements of individuals providing home care for the older adults. There is a lack of established legal framework addressing the identification, assessment, and provision of specialized medical and psychological assistance for these caregivers. Within the strategic documents of the Ministry of Health of the Republic of Kazakhstan, which govern the provision of medical and psychological assistance, the term "guardian" is solely acknowledged in relation to individuals responsible for caring for individuals classified under the first-degree disability. Consequently, caregivers receive healthcare services as regular patients, without consideration for their specific needs. Family members who are providing care for an older adults individual are perceived merely as individuals offering assistance to their older adults relative (72). In Germany, if a caregiver decides to cease employment in order to provide care, their health insurance benefits will continue throughout the duration of their caregiving responsibilities, as long as they were enrolled in the insurance system prior to assuming their caregiving duties (73). In the United States, the CARE Act (74) mandates that healthcare providers recognize and register family caregivers, inform them about procedures performed on the older adults, and provide instructions on the tasks expected of caregivers. In Portugal, the assessment of the quality of life and the burden experienced by informal caregivers is legally mandated. Health and social development services also aim to provide psychosocial support to informal caregivers. The importance of rest for informal caregivers is also emphasized. Health services have established self-help groups facilitated by healthcare professionals to foster mutual support and the sharing of experiences among individuals who have lived or are currently experiencing similar situations and challenges, thus minimizing potential feelings of isolation (47). --- Conclusion Ensuring high-quality medical and social care should be the primary focus in the development of legal regulations and state policies in the medical and social sectors in the Republic of Kazakhstan. The current system of medical and social support for informal caregivers of the older adults in Kazakhstan requires significant reforms. It is crucial to revise the legislation to incorporate the concept of "informal (family) care" and to develop and implement legal norms that regulate informal (family) caregiving. Additionally, establishing a robust legal framework that governs informal (family) caregiving relationships is essential for both caregivers and employers to establish employment relationships that consider the needs of longterm caregivers. Moreover, implementing a caregiver registration system and conducting screenings to assess care-related burden, as well as the physical and mental health and care-related needs are important for effective monitoring. --- Author contributions AZ, GK, and AG contributed to conception and design of the study. AZ wrote the first draft of the manuscript. AZ, GK, and AT wrote sections of the manuscript. All authors contributed to the article and approved the submitted version. --- Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. --- Publisher's note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. --- Supplementary material The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2023.1247684/ full#supplementary-material

The demand for informal caregivers to support the older adults has grown worldwide in recent decades. However, informal caregivers themselves require support. This article aims to examine existing support measures for caregivers of the older adults in the Republic of Kazakhstan. Relevant articles and grey literature were identified through manual searches on Google and Google Scholar, as well as electronic searches using indexed databases like PubMed, Web of Science, and Scopus. Moreover, the reference lists of identified sources and government ministry websites were meticulously scrutinized. This review highlights the scarcity of research on caregiver support measures in Kazakhstan, supported by the lack of peer-reviewed articles on this subject. A comprehensive analysis of the literature shows that in Kazakhstan's legislative framework, "caregivers" exclusively refers to individuals providing care for a first-degree disability. The responsibility of caring for older adults parents lies with able-bodied children. However, there is a lack of registration and assessment procedures to evaluate the burden and quality of life of caregivers. As a result, the medical and social support provided to caregivers is standardized, failing to adequately address their unique needs and requirements. The analysis of current support measures for informal caregivers highlights the need to develop support mechanisms and recognize individuals providing informal care as key figures in the long-term care system.

Introduction What if we lived in a world where people who needed organ transplants did not need to wait for years and worry about getting life-saving surgery to survive? And if we have a name bank with many possible donors, we can confer supplementary organs whenever necessary? Nevertheless, if science could do it without any concerns about ethical questions because these donors are clones, would be considered non-human despite the fact of having enough human organic features created specifically for this function? This scenery is portrayed by Kazuo Ishiguro in "Never Let Me Go" (2005) in which Kathy H., the protagonist, narrates how this world would have been if cloning humans were possible in the past. Kathy is a female clone who, through her diary, tells her life <unk>s trajectory, about what happened in the past, set in the 1980s and 1990s, in England. She reports how it is to be a clone, how her destiny was traced before she was even born, and how she developed her friendship with Ruth C and love relations with Tommy D., who is also a clone. "Never Let Me Go" is a British fiction that contains science fiction and or speculative traces but here we opted to regard the narrative as the utopia/dystopia subgenre. Since romantic love is represented in bodies considered inherently human, the main objective of this study is to analyse how the clones, considered non-human bodies, can represent romantic love in that dystopian society. To this, the novel was considered a postmodern rereading of the tragedy of Tristan and Isolde by considering some relevant traces such as passion, turnarounds, jobberies, and the impossibility of achieving love in the end through a long-term relationship. Johnson (1987) states the phenomena of romantic love can be traced back to Tristan and Isolde's tragedy in Western culture; since then, it has influenced literature and other artistic productions. This article is the result of a bibliographical study, structured into three sections, in the first the notions of utopia, dystopia, and heterotopia were discussed to explain the setting, and place of a fictional society where the feeling, especially love can have reflections and projections with different meanings when it comes to relationships established by humans or by clones. The second focuses on the discussion of the non-human, non-place, and non-time notions to understand the clones as an invisible category of people who are considered to be less human and therefore defined simply as organ repositories for real humans. The third centres on the love between the so-called non-humans, the clones, and how it is developed, viewed, and rejected in the dystopian society. The social relevance of the study is centred on the reflection on how people understand, define and reproduce romantic love over time and on media as a human feeling. However, by categorizing it according to the influences of technology and the consumer market, romantic love has become either something easily achieved or hard to grasp in every love story. --- Inside the cave This section resorts to the metaphor of Plato's Allegory of the Cave, to deepen the understanding of how society is divided between humans and clones. Clones are created, nourished and educated to serve human society. Inside the school, they study, play, eat, talk, live and grow up, unaware of their final fate as organ donors. Clones live entrapped inside a school that represents Plato's cave, where humans are chained and can just glimpse the projected reality made of shadows. Ironically, in the dystopian society, ordinary human beings live in the outside world, not knowing about the clones or caring about the origin of the available organs, being also fooled by the system. The clones are apparently kept in a place surrounded by the walls of Hailsham, the school. The rigorous rules, the class schedule, the medical evaluations, and the care for their healthy bodies are part of their routine because they are born with the purpose of serving human society. Hailsham represents their world. Through Kathy's eyes, the narrative conveys how people learn to be what they ought to be, the future organ donors for human society. In this world, Hailsham is a different school from others, thus another type of school or even a nonschool, for not serving the purpose of educating students to develop free minds. In this boarding school, Kathy H., Tommy D., Ruth C., and other children are born without family ties, thus, without a surname. This is one of the depersonalization strategies through which clones develop their consciousness of their inhuman condition by subordinating their bodies to the system completely, thus becoming distinguished from the so-called real humans. Their education in Hailsham, based on psychological and physical coercion and control of their actions, makes them accept their future as organ donors. It becomes clear that the human beings' dream of prolonging life expectancy means exactly the imprisonment of others, the clones. In order to discuss dystopia, it is necessary to resort to utopia, a term coined by Thomas Morus, and published in 1516. His famous work entitled "Utopia" depicts a fictional island where its inhabitants led a harmonic life. This perfect place is also a non-place, as it is fictional and exists only on the pages of utopia. Utopia also denotes a kind of literature that according to Vieira (2010, p.6) depicts "the desire for a better life, caused by a feeling of discontentment towards the society one lives in (utopia is then seen as a matter of attitude)". According to Trousson (1990), utopia is a literary genre centred on a narrative that departs from real-life problematics to construct or imagine another world with better structures and a possible solution to common social problems. The author highlights that this parallel world encompasses scientific, architectural, philosophical, political, pedagogical, and other perspectives that help readers understand it as an alternative society in fiction by following the space and the chronology in the work. Unlike the classical utopia set in the future, the selected narrative has science fiction traces, as "Never Let Me Go" ( 2005) is set in England in the mid-1990s. Thus, it is a retrodystopia, as the story is set in the past to reflect how the world would have been if the cloning process had been possible. To Vieira (2010), utopian literature allows us to reflect upon an imaginary society or a good place where some particular social disturbance appears with a possible solution. Thus, utopian literature conveys hope to find a solution to realworld problems. In "Never Let Me Go", hope is also seen as the clones are born and become adult organ donors, probably as an answer to the contemporary medical matter of the need for organ transplants by ordinary people. Utopia shows another side of the story with contradictions and dissatisfaction in a distorted path because it does not include all entities to reach happiness. The fact that the utopian project might not work leads the author to produce another type of fiction, the dystopia (Vieira, 2010). In the book, organ donors would have to sacrifice their lives for society's great good. In this sense, Vieira (2010) points out that science and technology are frequently used in dystopian literature as a discourse to justify social advances. Still, the negative consequences leave us to confirm humans' incapacity to get a better world for all in essence. For Claeys (2010), the classical dystopia centres on socio-political critiques, and oppressive systems that control the individuals. In "1984", by George Orwell, Winston Smith lives in an oppressive society, watched and controlled by a telescreen. His work is to continuously change the historical accounts to fulfil the political interests of the present. Contemporary dystopia, on the contrary, involves critiques of capitalism centred on the corporal element. The body becomes the last frontier of the capitalist market to conquer. In Ishiguro's novel, the body is presented as a thing to be used and discarded according to its validity in the economic system (Marques, 2013;2014). For Fitting (2010), social critique expresses the encouragement for change, and utopianism, when assumed as a dystopia, means a way to defend the maintenance of the status quo. "Never Let Me Go" (2005) conveys a dystopia, thereby reflecting the suffering of a group of individuals considered non-humans, created to sustain the real human class. It is a tense reading that might sound both a social critique of current society, thus with the will to change, and a utopianism, a fatalistic reading of maintenance of the status quo. The clones' bodies do not belong to them but to the institution/ corporation/ state, which is why Kathy speaks from a place of silence. Her silent voice echoes from her written testimony, conveying the message of an erased body, from a past that no longer exists, thus nowhere, towards a dead future. Also, her writings from her body raised within the walls of an institution establish a dialogue with heterotopia, a conception drawn by Foucault (2013). Contrary to a utopia, which is a non-place and a perfect place, a heterotopia is a real place, a topology with a function, which is not always clear to us. Heterotopia, according to Foucault, is called another place. It can present features of two or more places in one, being a juxtaposition of places that can convey a mix of chronology, images, and rituals found in museums, cemeteries, and others that must bring a feeling of isolation or a distancing from the outworld such as observed in boarding schools, hospitals, and prisons. The presence of somebody in a heterotopia requires an adaptation or knowledge of it and mainly respect for its own rules. Hailsham has denied its existence in the real world as an ordinary school because it was created with the objective of keeping children's clones far from the public eye. The clones are cast from ordinary social life until adulthood when they are allowed to go out to accomplish their objectives. Thus, Hailsham represents a heterotopia for being a place cast from society and overlapping functions of orphanage, hospital, and prison. It functions as an institution through which repression, domination, and alienation are instilled in the clones, being central to their socialization as organ donors. Thereby, Hailsham simulates being a school allowing the students to perform their daily lives as if they were considered almost humans. Thus, it is considered a heterotopia because it also presents itself as an antithetical space where similarities between clones and humans are attested and contested, given the opposition between clones and humans. Hailsham is the location where students/clones are presented and nurtured, it is the visible physical place, but also it is the place where no one can be seen and thus exist in reality. Thus, it is the location where the clones cannot live fully active in a society, which is invisible and unachievable for them, ironically it also reflects the outside world by simulating the society's daily rituals such as art class. --- Outside of the cave Plato's "Allegory of the Cave" can also help explain the process through which the clones become aware of their condition as organ donors and resist their own fate. When Kathy, Ruth, and Tommy grow up, they finally leave Hailsham to meet and live with other clones in Cottages1 before starting the organ donation or becoming a temporary carer2, a caretaker. But, out of Hailsham, the behaviour of Kath's friends remains the same, they do not question their positions or even rebel against their fate, they simply follow their central purpose in life. The conditioning time in Hailsham is enough to make them comfortable with their lives. Even when they are out of the cave, their bodies remain as shadows in society. According to Marques (2014), the dystopian novels from the 1960s are centred on the body and its relation to social, political, cultural and economic aspects of society heavily controlled by market relations. Such centrality is observed in Ishiguro's dystopia. According to Foucault (2013), utopias are originated from the discussions around the bodies and can be turned against them. In this way, in the novel, the human utopia of keeping a body healthy by replacing the ill organs leads to the creation of Hailsham and an educational system that controls the clones. The control is performed both physically behind the walls and emotionally, keeping the clones entrapped within their own bodies. Marques (2014) states that contemporary dystopia depicts the sterile body conveying its inability or evident defect. Society's non-acceptance of an unfit body in the narrative is conveyed in the discourse about the need to enhance the body's functioning through science. Such a view can explain the discourse about the fear of having/assuming an unable and the desire for an able body. Human beings avoid becoming considered as unable bodies and pay the price of sacrificing their clones, considered to be non-human bodies. The power relationship is established as human beings are seen as superior in relation to clones, needing their help and assistance to keep their status as able bodies. As the clones are harvested, their bodies become increasingly unable, to be dependent on a carer. In this sense, this perverse mechanism of consuming fresh and healthy organs harvested from clones aids the maintenance of the relationship between human beings and clones, able bodies and unable bodies in the novel. Also, infertility is a clear trace that differentiates the human body from the so-called non-human body in dystopia. Sterility justifies discarding young and healthy bodies in a capitalist society since reproduction becomes an elementary human practice, allied with the concept of building a family and growing old. The social and natural life cycle of birth, maturity and death are denied to clones, as, after school years, they do not become fully functioning citizens or humans with rights. Still, their bodies become a source for organ harvesting, being denied rights and even humanity. Conversely, Parrinder (2010) points out castration as a price of happiness in utopian literature. Clones' living is associated with the absence of romantic and sexual involvement. Their castration and sacrifice, in this sense, signifies the price of happiness in human society. To Foucault (2013), the mirror in a heterotopia presents itself as an inaccessible virtual space where another place or world exists. Besides that, it reflects the entities and constitutes their bodies and their boundaries, thickness, and weight. A mirror is a physical object placed in the real space of a heterotopia, while the reflection creates an unattainable local, the utopia of bodies. In the mirror, the body is always in another place. Similarly, the clones exist and live as the reflection of human beings in the "mirrors" constructed by society as it conceals and reveals the clones as organ donors. The biological clone bodies are created without the pretension of being original, they can be seen as "sterile" bodies as they must grow and live without leaving descendants. In this way, Ishiguro's dystopian fiction conveys the relationship of two or more dimensions that constantly clash provoking tension in the narrative. As the clones leave Hailsham, they start nourishing the original humans' desire for a healthy body, sharing the same outside space of society. Nevertheless, the clones must stay away from being so close to the real humans, otherwise, they would approach the "mirror" to see their original humans in order to free themselves. When Ruth receives the news that other clones have seen her "possible", the human being from which she was cloned, she convinces her friends to help her find her. But, when she finally sees the "possible", she discovers it is not exactly how she has imagined it. Also, she supposes it was the wrong "possible". But the "possible" might seem different because it is real, and real human beings are not perfect. According to Marques (2013), the original human body can present features that we can call inhuman, being, thus, a living contradiction. Foucault (2013) says it is from the body which derives the real and the utopic. Therefore, the clone friends understand that humans are not better or worse than them, but they are simply equally imperfect beings as the clones, with different representations and positions in society. At this moment, Ruth perceives her absence in society, since she has been somewhere else in the Hailsham, she understands she can exist in one version of herself, in the real dimension. Nevertheless, as Ruth is the virtual image of the "possible", she cannot face the real image, she visualizes her "possible" from afar because she herself is considered as the virtual counterpart dependent on the real image to exist. Making an analogy with the mirror, the human beings as considered real thing requires the clones to remain virtual to continue to live in the real world. This fact is enough for Ruth to accept her destiny as an organ donor, she ultimately sacrifices herself so that her "possible" remains alive. Foucault (2009) calls it the retroactive effect, which is a derivative of mixed experience provoked by the mirror. To Foucault (2009), heterotopias bind the occupation of spaces and our representation in social positions within society. It does not limit the occupation of geographical spaces but focuses on the relation between social positions that must be visible, irreducible and cannot be overlapped. Clones and humans occupy distinct spaces in the narrative that cannot be changed or overlapped. The heterotopia of illusion is portrayed in "Never Let Me Go" (2005) by using objects similar to the real world to simulate their performance and get accustomed to the existence of another world. For Foucault (2009), each heterotopia has a functioning within society and the heterotopia of illusion presents its characters as simply passing guests who would never be part of reality. The narrative's protagonists will never be invited to participate in real society's events and rites, and their attempt to participate in real society generates their immediate exclusion. And finally, the rejection of the traditional time to adopt a time distinct from reality is defined as heterochrony. According to Foucault (2009), in heterotopias, time is perceived as distinct from real-time, that is, it supposes a non-time, symmetrical and in agreement with a heterotopic view. The location of time in Kathy <unk>s narrative suggests the 1980s and 1990s. However, it does not have the commitment to the chronological time. Kathy has chosen to narrate her story in the past time, focusing on her experiences because the non-time can be any time. By concealing ideas of a pessimistic future, she opens up space for hope for the future and resists her fate. --- Love, memories and humanity After the death of Kathy <unk>s friends, provoked by successive donations, Kathy, who is still a carer and has not started her donations, decides to write her memories as she remembers the events from the past. Fitting (2010) states that in a dystopia, the use of language is seen as a resistance strategy facing alienating contexts of coercion and consent. To Baccolin and Moylan (2003), diaries, memories, and epistolary novels that narrate the protagonist's life portray a selfreflexive way of conveying an emancipatory discourse that questions the political and social future of humankind. Varsam (2003) points out that it is common to identify the slavery voice in autobiographical texts presented in dystopian fiction. When the narrator is a female voice, the main themes are the question of freedom, relationship, and sexuality, and the concerns about body control. In a world where the domain of science is in charge of establishing and maintaining order, clones were not created to practice forced labour, but they are considered slaves because they are denied the freedom of choosing their own fate, enjoying life or even getting involved in romantic relationships. They are simply products that result from scientific investment. Kathy's discourse contests her position and the role assigned to her and her supposed lack of humanity. Before Tommy starts his process of harvesting organs, Kathy gets involved with him. They have been in love since childhood. However, Ruth disturbed them in the past, splitting them. Being supported by Ruth, the couple searches for guardians who worked in Hailsham to ask about postponing their donation process for some time so that they can live their romantic relationship. In order to live their romantic relationship, they must prove their humanity. Initially, Tommy was very excited, because the education in Hailsham was centred on humanities and arts. From time to time, their guardians used to take some artwork samples to display at the madam <unk>s gallery. Thus, Tommy believes that their artwork and other productions can prove they are special, proving their capacity to love each other. When Kathy and Tommy finally meet Madame and Mrs. Emily, the ladies clarify to them the utility of the Gallery: Why did we do that? You said an interesting thing earlier, Tommy. When you were discussing this with Marie-Claude. You said it was because your art would reveal what you were like. What you were like inside. That's what you said, wasn't it? Well, you weren't far wrong about that. We took away your art because we thought it would reveal your souls. Or to put it more finely, we did it to prove you had souls at all. (Ishiguro, 2005, p. 264) In the narrative, it becomes clear that the clones are seen as empty being, whose humanity need to be attested through the capacity of expressing themselves through arts. Those productions are not capable of proving their capacity to love or even get involved in a romantic relationship. For the guardians, it was important to demonstrate the results of the scientific investment to the sponsors and nothing else. Hailsham has been a model of experiment based on ethical principles that according to the ladies promoted education and instructions to the clones: "Most importantly, we demonstrated to the world that if students were reared in humane, cultivated environments, it was possible for them to grow to be as sensitive and intelligent as any ordinary human being" (Ishiguro, 2005, p. 265). Even with all the efforts to be raised as real humans, the clones Kathy and Tommy cannot live together or enjoy their romance. The guardians' endeavours to treat clones ethically do not implicate the recognition of their humanity. The artworks do not prove that the clones have souls, they simply prove that clones can become as sensitive as human beings becoming suitable donors. This scene portrays the tyrannical nature inserted into the dystopia, the human insensibility to recognize the clones' feelings for each other as romantic love. Karandashev (2017) points out that romantic love is a social construction and depends on four spheres: ideas, institutions, social interaction, and individuals. Thus, for romantic love to be recognized it is necessary to be accepted in these four spheres. The guardians controlled and permeated these spheres, living in other spaces far from the clones' social and cultural space, which made them unable to see the clones as beings capable of loving. Also, according to Karandashev (2017, p. 12), "People have difficulty to see the life from another culture's view, especially when they know little about that culture. People tend to attribute their view to the people of another culture", In this dystopia, it is possible to understand romantic love as undervalued when it comes to a clone couple. Clones and humans seem to belong to distinct cultures and categories of people. Guardians place science in the first place, not accepting that clones would fall in love or even feel human feelings. The ladies do not fear seeing the clones as the same as humans, but the consequences of recognizing their humanity would be their damnation as the worst vicious murderers. After the ladies deny giving more time to Kathy and Tommy to enjoy their love relationship, it becomes evident that the clones are living in true romantic love. Despite all the disappointments and conflicts in their lives Kathy and Tommy could not live together ever after. In the end, Kathy understands she has more human qualities than the guardians and the people who consider themselves real humans, Kathy understands the close relationship between love and death, and her self-sacrifice for love has made her a noble soul. In sum, this society replaces romantic love in favour of scientific advances. The clones' feelings represent their resistance to the system. We can even question all the processes the clones are submitted, to become the perfect human organ harvesting site. Victims of the system, which categorized the ones who could live and the ones who would die, Kathy and Tommy resist their own fate by loving each other. --- Final Words "Never Let Me Go" (2005) presents a society in which the creation of clones is possible as a solution to the health issue of organ transplantation. However, the supposed solution becomes an ethical matter when Kathy H., the protagonist, narrates the clones' suffering (Ishiguro, 2005). This dystopian fiction set in the past revealed how science, when allied to the system can categorize people according to their bodies, labelling them as inhumane and denying the capacity to love and be loved. The notion of heterotopia, drawn by Foucault (2009) allows understanding Hailsham's structure crucial to the maintenance of the dystopic society centred on the control of clones' bodies. This dystopian society described in the fiction defines who can be considered human and non-human at birth categorizing individuals according to their bodies (Marques, 2013;2014). The projections of love portrayed by Kathy and Tommy are not recognized as legitimate, and their attempts to prove their feelings through art production fail to work. But guardians, considered humans, are unable to understand the clones' true love feelings that transcend humanity. The clones' attempt to prolong their lives evidences their resistance to a dictatorial system that has suppressed them from assuming behaviours and feelings considered human as romantic involvement and love, respectively. By doing so, the clones are denied their humanity, and love loses its value and space in society. Nevertheless, Kathy and Tommy resist the dictatorial system through love.

Este estudo é uma pesquisa bibliográfica que analisa o conceito de amor romântico entre clones em uma sociedade distópica retratada em "Never let me go" (2005) de Kazuo Ishiguro. A discussão sobre a sociedade e a posição dos clones foram baseadas na teoria da utopia (Trousson, 1990), da distopia (Vieira, 2010) e da heterotopia (Foucault, 2009). Os clones são considerados um grupo de entidades que são vistas como menos humanas ou mesmo não humanas criadas para serem consumidas como repositórios de órgãos e descartadas pelos humanos reais. Este trabalho debate como a construção do amor Miguilim -Revista Eletrônica do Netlli | v. 12, n. 2, p. 83-93, maio-ago. 2023 romântico (Johnson, 1987) é desenvolvida nesta ficção, principalmente entre os clones. A narrativa expõe como os corpos são despersonalizados, controlados e subordinados pelas estratégias de coerção naquele espaço distópico. O amor romântico torna-se o meio por meio do qual os personagens clones pensam a sua própria sobrevivência e uma tentativa inconformista de enfrentar aquela sociedade, ou seja, o amor romântico significa uma reação e resistência contra aquele sistema social.

INTRODUCTION The financial performance of Small and Medium Enterprises largely depend on the ability of such firms to utilize certain resources appropriately. These resources are in terms of credit and noncredit services. Sources of these resources are numerous to large companies however to SMEs they are limited with the major provider being microfinance organizations (ILO, 2006). Small and Medium Enterprises (SMEs) play a crucial role in uplifting the living standards of the low income earners and the poor both in the urban and rural in the developing countries. In these less developed countries, SMEs constitute roughly 90% all firms and hence play important role in economic development, job creation and poverty reduction. It therefore follows that the financial performance of these SMEs is important if the advantages accruing from SMEs is to be realized (Ciper, 2008). Webster (2007) defines the term micro to mean small, tiny or trivial. Micro-finance describes the range of financial products such as micro-loans, micro-savings and micro-insurance products that micro-finance institutions (MFI's) offer to their clients. Micro-finance began in 1970's when social entrepreneurs begun lending money on a large scale to the working poor, Grameen Bank (2007). Therefore, micro-finance is the provision of financial services to low income clients or solidarity lending groups including consumers and the self-employed who traditionally lack access to banking and related services. --- Historical background of MFIs in Kenya Operations of the micro finance in Kenya can be traced to 1984 with the start of Kenya Rural Enterprise Programme (K-Rep) as an NGO support programme for Small and Micro Enterprises founded by World Partners. In 1989 K-Rep changed its services to micro-credit lending which has become its core business since (ILO, 2006). Microfinance industry in Kenya is so diverse and its size cannot be accurately estimated. The Association of Micro Finance Institution of Kenya (AMFI) has a total of 59 member institutions serving approximately 6,500,000 (AMFI Website, 2013). The mix market data on the other hand estimates that the number of micro finance clients in Kenya was 10.5 million by 2012. Both AMFI and Mix Market may not be accurate because they do not take into account small and informal players in the field of micro finance. If therefore all players were taken into consideration the number of industry players would be much bigger (Ciper, 2008). Micro finance players in Kenya are divided into formal, sub-formal and informal sectors of the economy. The informal sector is mainly characterized by small players while the formal sector has large players such as banks and registered institutions (Word Bank, 2005). Faith based organizations (FBOs), community based organizations (CBOS), non-governmental organizations (NGOs) and charitable institutions are classified as sub-formal sector and usually they play the role in helping the poor rise to the mainstream. The informal sector basically includes the ROSCAs, ASCAs groups and individual money lenders (AMFI Website, 2013). Nakuru town has almost all the major microfinance institutions in Kenya such as KWFT, Equity bank, Co-operative Bank, KCB and Faulu Kenya. Other organisations operate through agents for example SMEP, Equity Bank, Ushirika bank, Mwalimu Sacco, Nakuru Teachers Sacco, Metropolitan Sacco, among other. The youth can access financial assistance from all these organizations. Youths' have established businesses in all sectors ranging from manufacturing, service industry, farming, Jua kali, pottery, fishing and many others. There are no records of the exact number of youths' involvement in SMEs as some are not even registered. --- Statement of the problem MFIs have been known to provide a channel for increasing the efficiency, depth, breadth and reach (access) of financial systems (Goyal et al., 2011). Microfinance is seen as a solution to include on a large-scale previously excluded poorer groups like the youth without access to capital into the financial system so that they may "rise out of poverty" by on their own (Banco, 2006). According to Kiberenge (2013) the Government of Kenya has initiated a number of programmes to address the access of finances to the youth such as Youth Enterprise Fund and Uwezo Fund. The Kshs.6 billion Uwezo fund is the latest government bid to uplift youth through enterprise. However much the government has tried these initiatives, it is reported that many youth have no access to financial services because of problems like, lack of collateral security, inadequate information about financial services and fear to lose their property after failing to pay back the loans among others (AMFIU, 2013). In many Kenyan microfinance institutions youth forms only 24% of the customers while over 40% are individuals aged over 40 years (Mueni, 2012). In Kenya 90% of youth micro enterprises collapse in their first year of start-up, due to lack of financial resources. Although many financial institutions have been vigorously marketing their credit facilities, few youth enterprises have been accessing them (Ataya, 2012) --- Objectives of the study The main objective of the study was to assess the factors influencing accessibility of microfinance services among the youth in Nakuru County. The specific objectives of the study were; to outline the influence of entrepreneurship education and training and government policies on accessibility of microfinance services among the youth in Nakuru County. --- Research questions The --- THEORETICAL REVIEW a) Agency theory This is a theory that looks at how to ensure that agents (executives, managers) act in the best interests of the principals (owners, shareholders) of an organization. This happens because of the separation of ownership and control, when the owner of the company or the board of directors (the 'principals') have to employ managers ('agents') to run the business and need to monitor their performance to ensure they act in the owner's interest (Luhman & Cunliffe, 2012). The main concern of agency theory as proposed by Jensen and Meckling (1976) is how to write contracts in which an agent's performance can be measured and incentivized so that they act with the principal's interests in mind. Many MFIs were established to reduce poverty and make financial services more accessible to the unbanked and poor. In the early days when MFI started they were financed by donor funds that had a poverty eradication goal. Hence the performance of the MFI was measured on how much MFI reached to the poor (outreach) and impact (how far the lives of those who got financial services were changing as compared to those who didn't get these services). But as the MFI industry grew in size, the need for increased financing coupled with unpredictability of donor funds triggered the issue of building sustainable MFIs that stand on their own leg i.e. --- Review of the variables Empiricism is a concept that emphasizes the role of experience and observation in acquiring knowledge (Keeton, 1962). Empiricism focuses on those aspects of scientific knowledge that are closely related to experience, especially as formed through deliberate experimental arrangements. It is a fundamental requirement of scientific method that theories must be tested against observations of natural world, rather than resting sorely on a prior reasoning, intuition or revelation (Mugenda, 2008). a ) Entrepreneurship education and training on accessibility of microfinance services Sexton and Similor (1997) defined entrepreneurship education as a formal structured instruction that conveys entrepreneurial knowledge and develops focused awareness relating to opportunity, recognition and the creation of new ventures among students. The major objective of enterprise education is to develop enterprising people and inculcate an attitude of self-reliance using appropriate learning processes. The role of entrepreneurship education is mainly to build an entrepreneurial culture among young people and in turn improve their career choices towards entrepreneurship (Deakins, et al. 2005). Entrepreneurship education should be mainly focused on starting a business and subsequent sustainability of such business seeking affordable finances from microfinance institutions. Entrepreneurship is not an easy option for everyone; it is only best suited to those with the necessary skills and acumen. According to Schoof (2006) entrepreneurship education is not only a means to foster Youth Entrepreneurship; it also seeks to equip young people with entrepreneurial attitude and skills. Schoof (2006) further suggested that entrepreneurship education is crucial in assisting young people to develop entrepreneurial attributes, behaviors and develop enterprise awareness to understand and realize entrepreneurship as a career option. Since the 1990s, entrepreneurship education has grown substantially especially in countries already known to be entrepreneurial such as the US, Canada and Australia as well as in Nordic European countries (Schoof, 2006). According to OECD (2010) many experts believe that entrepreneurial education and training should begin as early as possible for two main reasons; first in that it forms an essential component in the preparation of potential young entrepreneurs to go into business by themselves. Second is that it instils entrepreneurial habits in the mind and work skills which can serve equally well for successful employees in the new, globalised, post-industrial economy and those who actually choose to establish their own enterprises. Entrepreneurship education has expanded gradually over the past few recent years. The European Commission (EC) in 2004 for instance proposed that all EU member states should introduce entrepreneurship education into their national curriculum and in all institution of learning. Lundström (2005) confirmed that there has been a rapid development in the area of enterprise education in the Nordic countries (Denmark, Sweden, Norway, Finland and Iceland) over the last decade. However, a report by European Network on youth employment (2010) suggested that in many European countries entrepreneurship education is not yet sufficiently integrated into the curriculum of higher education institutions particularly in some of the Member States that joined the EU after 2004. Providing entrepreneurship training at secondary schools can be regarded as an element of life-skills education, but it also aimed at sensitizing young people to entrepreneurship as a career option (ILO, 2006). Ryan (2003) states that as traditional job-for-life career paths become rarer, youth entrepreneurship is regarded as an additional way of integrating youth into the labour market and overcoming poverty. Supporting this shift in policy is the fact that in the last decade, most new formal employment has been created in small enterprises or as self-employment. Given global demographic trends, it is important that the social and economic contributions of young entrepreneurs be recognized. Entrepreneurship can unleash the economic potential of young people since it enables them to have the capacity to plan and seek financing from micro finance organizations. Much of the youth entrepreneurship in Africa may be attributed to necessity (Rogerson, 2001). Empirical evidence indicates that young people get involved in enterprise to solve socio-economic problems such as lack of employment, income generation and contending with poverty (Chigunta, 2001). Youth entrepreneurship reduces crime, poverty and income inequality. This indirectly induces an environment for national and regional economic growth and development (Mutezo, 2005). The drive for youth entrepreneurship in Kenya is premised on the need to get young people gainfully employed and contributing economically, despite the inevitable challenges like financing. To support the assertion, the government of Kenya has come up with programmes like the Youth Enterprise Fund and Uwezo fund to complement the youth entrepreneurs by channeling the funds though micro financial institutions for easier access by the youth (Kiberenge, 2013). --- b) Government policies and accessibility of microfinance services Youth entrepreneurship policies are fairly recent and hence have not been widely tried and tested. Schoof (2006) observed that owing to their crosscutting nature, youth entrepreneurship policies require collaboration between different ministries, such as education, labour, industry, youth and finance, and the development of a collaborative multi-stakeholder approach. According to the World Bank ( 2005) administrative and regulatory burdens on youth entrepreneurship especially on access to micro financing are among key barriers for start-ups of young people in high-income and developing countries. To access financing from reputable micro financial organizations, bureaucratic demands like business registration processes for instance are still cumbersome in most developing countries. World Bank (2005) observed that business registration procedures and costs can be a major obstacle for young people lengthening the process of acquisition of financial services and products. De Sa, (2005) revealed that in developing and transition countries particularly, these procedures are often associated with bureaucracy, corruption and lack of transparency or accountability. In this context, young people get easily tied up in red tape and lose their entrepreneurial enthusiasm. The Africa Youth Report (2011) revealed that several African countries have adopted youth entrepreneurship policies to encourage youth delineation from the economic mainstream. However, according to the CDE (2007) small business development in countries such as South Africa remains weak despite the government's insistence that encouraging emerging entrepreneurs are central to transforming the business sector and tackling poverty. Nasser (2003) revealed that South Africa's micro financial institutional and regulatory frameworks prevent entrepreneurial creativity among young people. A World Bank (2007) report has revealed that there are continuing problems with most government support for youth programmes in this area. Ugwu (2006) argued that most entrepreneurship related policies and programs in Nigeria fall short of appropriate development frameworks. Mostly, financers require collateral from the youthful entrepreneurs as a preliquisite to funding. The risk of losing one's property right is one of the second most important financial risks for young people when starting a business though loans from financial organizations. Lacks of collateral and high interest rates are an impediment to access to loans from Micro finance institutions (MFIs) by the youths (Mushimiyimana, 2008). --- c) Accessibility of microfinance services amongst the youth The Government of Kenya recognizes that greater accessibility to and sustainable flow of MFI services, particularly credit to the youth as critical to poverty alleviation. Therefore, appropriate policy, legal and regulatory framework to promote a viable and sustainable system of microfinance in the country was developed under the microfinance Act of 2006 and microfinance regulation issued there under setting out legal, regulatory and supervisory framework for the industry in Kenya. Across the world there are over 10,000 microfinance institutions serving in excess of 150 million customers, and over 100 million being the poorest. Global demand stands at 500million families meaning that there is still a long way to go (World Bank, 2005). The major players in the microfinance sector in Kenya include, Microfinance Banks i.e. Equity bank and K-Rep bank. Micro finance institutions registered by Central Bank of Kenya with permission to take deposit i.e. Faulu Kenya, Kenya Women Finance Trust,, Small and Medium Enterprise programme Rafiki DTM. Others includes Kenya Small Traders and Entrepreneur Society, Ecumenical Loans Fund, Jitegemee Trust, Kenya post and savings bank, Pride limited, Jamiibora, Makaomashinani, Platinum Credit, Yike, Yehu,Realpeople among others (CBK, 2013). Micro finance products refer mainly to small loans; savings mobilization and training in micro enterprise investment services extended to poor people to enable them undertake selfemployment projects that generate income. Micro finance came into being from the appreciation that micro entrepreneurs and some poorer clients can be 'bankable', that is, they can repay both the principal and interest, on time and also make savings, provided financial services are tailored to suit their needs (Von, 1991). Micro products include savings, credit, payment facilities, remittances and insurance. The non-financial services mainly entail training in micro enterprise investment and business skills. There is also a belief that microfinance encompasses micro credit, micro savings and micro insurance (Roth, 2002). --- Empirical studies Past studies have focused on entrepreneur characteristic including entrepreneur's age, gender; previous work experience and education level as key factors influencing accessibility to micro finance services leading to the growth of micro and small enterprises. These factors are chosen because various researchers had found a significant relationship between the factors and the growth of SMEs (Storey, Wiklund & Shepherd 2003). Education qualification is an asset to a person in every field. It not only gives confidence but also help in solving various problems. According to Hirsch, Krueger (1993), a higher education level helps the entrepreneur to have better knowledge and skills on financial issues which contribute to the success of their venture. In addition, Lussiers & Pferfer (2001) empirically found that entrepreneurs with higher levels of education and competencies were more successful accessing financial services and growing their businesses as compared to entrepreneurs with little or no education. Similarly, a study conducted by Kim (1996), involving entrepreneurs in Singapore, demonstrates that, after entering the entrepreneurial world, those with higher levels of education were more successful in acquisition of micro financial services and products because university education provided them with knowledgeable and modern managerial skills, making them more conscious of the business world and thus in a position to use their learning capabilities to negotiate for favourable products and services from financiers. Working experience in accessing finances is generally considered to be an important asset as it provides an individual with useful knowledge and skills. According to Reynolds (2002) experience is the best predictor of business success especially when the new business is related with vast experiences. Entrepreneurs with more experiences in financial and managing business are more capable of finding ways to acquire financial aid to start new business compared to employees with different pathways. Correspondingly, a study in Kenya found that Kenyans with at least seven years of work experience expanded their firms through seeking micro financial products more rapidly than those without such experience (Mead & Loedholm, 1998). Work experience contributes to SME growth by expanding the capabilities of SME owners and employees through the acquisitions of skills and knowledge and by expanding entrepreneur's social network with financiers (Nichter, 2005). --- Critique of existing literature Microfinance has become an important tool for poverty reduction in many parts of the world. Microfinance institutions target the poor especially the youth who form the largest global population of the unemployed through innovative approaches which include group lending, progressive lending, regular repayment schedules, and collateral substitutes. The literature above has considered the key parameters like the microfinance services, entrepreneurial characteristics of the youth, entrepreneurship education and training as well as the government policies and the relationship to accessibility of a micro finance services to the youth. The provision of entrepreneurship education at primary and high school level is also inadequate and needs to be addressed and linked to the knowledge to access financial assistance as offered by micro financial institutions. The government policies on youth entrepreneurship according to reviewed literature are key barriers for the success of enterprises owned by young people in developing countries Kenya and needs to be reformed. Reviewed literature revealed that there has been little effort to look at the determinants of accessibility to microfinance services amongst the youth from a youth perspective. Unavailability and inaccessibility of micro financial services among the youth has also been a major problem for those intending to engage in entrepreneurship as an alternative source of self-employment. The youth entrepreneur characteristics like age inhibit the youth from accessing the micro finance assistance and support thus limiting youth participation in entrepreneurship. --- Research gaps In Kenya various researchers have addressed different aspects of accessibility microfinance services to the youth. Mugori (2012) assessed the effects of access to microfinance on the financial performance of SMEs owned by youths in Nairobi. The variables studied were financial services, entrepreneurial skills and government policies. James (2007) studied the role microfinance in economic empowerment of the youth in Mombasa County. The variables studied were economic empowerment of the youth, loan repayment and inadequate training of borrowers. Muricho (2013) studied the factors influencing the accessibility to micro-finance services by persons with disability in Kimilili sub-county. The variables studied were the social and health issues of persons with disability, access to information and financial and management skills. This study will fill this gap by looking at dependent variable being accessibility to microfinance services and its effect on the independent variables, availability of microfinance services and products, entrepreneur characteristics, entrepreneurship education and training together with the government policies. --- RESEARCH METHODOLOGY --- Research Design The research design adopted was survey research design. Survey research design describes the phenomena or characteristics associated with a subject population; to estimate proportions of a population that have these characteristics and to discover association among different variables (Cooper & Schinder, 2011). The descriptive design enabled collection of data without manipulation of the research variables. The descriptive survey design optimizes on the strengths of both qualitative data and quantitative research methodology. The design allowed collection of data from a large sample population like the youth groups in Nakuru County and generated findings that were a representative of the whole population at a lower cost, (Saunders, et al 2007). --- Population The study population was the youth entrepreneurs in Nakuru County. A list of youth groups in Nakuru County formed the sampling frame for this study. The target population was the 154 registered youth groups that were active in the Nakuru County and which formed the main respondents. --- Sampling procedure and sample size Purposive sampling was used to identify the 154 registered youth small businesses which were operating at the time of the study. The study was narrowed down to the 15 registered youth groups in Nakuru County. The youth groups were then clustered into 5 strata representing the 5 subcounties in Nakuru County. Stratified random sampling was done with 3 youth enterprises in each sub-county. Finally, simple random sampling was applied to select 5 respondents from each of the 15 youth enterprises giving a total of 75 respondents. The sample size for this study was the 75 registered youth groups who were selected by simple random method from the sampling frame. According to Bartlett, (2004) the sample size of a statistical sample is the number of observations that constitute it. --- Data collection instruments The questionnaire was used as a tool if the data correction. The instruments incorporated Likert scales to measure perception and attitude. The questionnaires largely consisted of open and closed-ended questions for ease of analysis. --- Data Collection procedures Primary data was collected through a selfadministered questionnaire. The researcher sought for a research permit from Jomo Kenyatta University of Agriculture and Technology. Introductory letters were attached to the questionnaires and appointments sought with respondents for the purpose of creating rapport, confidence and removing any suspicions by assurances of confidentiality on the data that the study generated. Each member selected was briefed on how to fill in the questionnaire. The respondents were given a time frame within which they were expected to respond to the questionnaires after which the questionnaires were collected by the researcher on the same day. This was to ensure that respondents did not discuss and modify their responses. The researcher obtained informed consent from any subjects used in the study and ensured that all subjects participated voluntarily. --- Data analysis and presentation The data collected was edited, coded and analysed using descriptive statistics with the aid of SPSS program. Data analysis was done by use of tabulations, scoring by hand, manual tallying, totalling and grouping as appropriate. The researcher computed the relevant frequencies and presented percentages in rates as appropriate. The data was presented using tables and narrative form in order to bring out the information in line with the research objectives. The data collected from open ended questions was analysed qualitatively to meaningfully describe the distribution of measurements under study. --- FINDING AND DISCUSSION --- Response rate The sample size was 75. The researcher distributed 75 questionnaires to the respondents. Response rate was 56 questionnaires returned and were found to be useful for data analysis. The questionnaires return rate was 80%. According to Nachmias and Nachmias (2000), 70% return rate is adequate. --- Reliability test Cronbach's coefficient alpha which is one of the most common methods in gauging reliability (Bryman, 2011) for each variable was done. --- a) Entrepreneurship education and training A summary of the reliability test of entrepreneurship education and training is analyzed. Cronbach's alpha of 0.881 was achieved. Bryman (2011) has indicated 0.7 to be an acceptable reliability coefficient. Thus entrepreneurship education and training had a good internal consistency. --- b) Government policy A summary of the reliability test of government policy is analyzed. The findings indicated a summary of reliability test of metacognitive awareness. Cronbach's alpha of 0.703 was recorded. Bryman (2011) has indicated 0.7 to be an acceptable reliability coefficient. Thus government policy reported a good internal consistency. --- c) Accessibility to microfinance services A summary of the reliability test of accessibility to microfinance services is analyzed. The findings indicated a summary of reliability test of entrepreneurial mindset. Cronbach's alpha of 0.880 was achieved. Bryman (2011) has indicated 0.7 to be an acceptable reliability coefficient. Thus entrepreneurial mindset reported a good internal consistency. Validity test was computed by the use of convergent validity. Average Variance Extracted (AVE) is commonly used to assess convergent validity. The AVE was found to be more than 0.7, and the established criterion is fulfilled in all cases and, therefore, it may be said that convergent validity of those constructs was adequate. --- Validity test --- Demographic information of respondents --- Gender of respondents The study asked the respondent to indicate their gender. The study findings revealed that majority of the respondents (58%) were males, with the other 42% being females. This implied that youth entrepreneurship in Nakuru County involved all genders. --- Age of respondents The study for the purpose of making sure that the respondents were youths as defined by the Kenya's new constitution, sought to establish the ages of the respondents. The findings indicated that all the respondents were in the age bracket of youths of 18-34. Majority of the respondents were in the age group 22-30 years. --- Higher level of education The study sought to ascertain the highest level of education for the respondents. According to the findings most of the respondents 54% had secondary school education with 39.08% stating that the highest level of their education was Secondary school level and 12% had primary school education. Those that had college level education and above represented 31%. Only 4% of the respondents had primary school education. --- Running any other business of your own prior to founding the present business The study sought the respondents to indicate whether they had been operating any other business before the current one. The findings indicated that majority of the respondents (59%) had operated another business with 41% stating that they had not. The findings implied that the youth entrepreneurs in Nakuru County consisted of a mixture of experienced and non-experienced ones in entrepreneurship. --- Duration of operating current business The study sought the respondents to indicate the duration they had operated the current business. The findings indicated that majority of the respondents (66%) had operated their current business for between 1-3 years. This implied that they have had experience on the entrepreneurial skills necessary to run their business for the duaration. Another 22% had operated the businesses for less than one year with 14% operating the business for above 4 years. --- Motivation for starting own business The respondents were required to indicate the source of motivation for starting own business. According to the findings, majority of the respondents (68%) indicated that their motivation to engage in entrepreneurship was driven by financial motives with 13% stating that desire for independence drove them to entrepreneurship. Another 11% were driven by the desire for selffulfilment. This implied that the youth entrepreneurs usually have explicit motivation to entrepreneurship. --- Prior experience of business management task through earlier employment The respondents were requested to indicate whether they had prior experience of business management task through earlier employment. According to the findings, most of the respondents (54%) indicated that they had prior experience of business management task through earlier employment with 46% negating the statement. --- Correlation of study variables This section outlines the correlation of the independent and dependent variables. Government policy was the second with a weak positive correlation (r=0.023) to accessibility to microfinance services. This implied that the current entrepreneurship policies in place in Nakuru County do not have deterrence to youth entrepreneurship. --- Descriptive and qualitative analysis of the study variables The descriptive study was anchored on crossed and open-ended questions as discussed in the following statements. --- a) Entrepreneurship training and education This section made a presentation, discussion, analysis and implications of aspects of entrepreneurship training and education. --- Provision of entrepreneurship training and education prior to starting business The respondents were requested to state when they had received entrepreneurship training and education prior to starting business. The findings showed that most of the respondents strongly agreed (54%) stated that they had received entrepreneurship training and education prior to starting business with 46% negating. The findings supports Vanguard ( 2004) who stated that while entrepreneurship education has continued to thrive in many instances, it has been neglected. The findings implied that entrepreneurship education and training is vital for business survival. --- Entrepreneurship education and training The respondents were requested to indicate their agreement on aspects of entrepreneurship education and training. The findings are shown in table 3. agreed that the role of entrepreneurship education is to build an entrepreneurial culture among young people. 55% agreed that entrepreneurship education should focus on starting and sustaining a business. 40% agreed that entrepreneurship is only suited to those with the necessary skills and acumen. 45% agreed that entrepreneurship education is not yet sufficiently integrated into the curriculum of education institutions in Kenya. 47% agreed that entrepreneurship can unleash the economic potential of young people. 48% agreed that entrepreneurship education seeks to equip young people with entrepreneurial attitude and skills. --- Entrepreneurship skills acquired through training The respondents were probed on the entrepreneurship skills they had acquired through training. The findings indicated that the respondents responses on entrepreneurship skills they had acquired through training. 37% stated they acquired entrepreneurship skills, 33% had business plan writing, 19% characteristics of entrepreneurs while 11% had acquired entrepreneurship interpersonal skills. --- Business development services before starting business The respondents were requested to state whether they had received any business development services before starting their business. Majority of the respondent (70%) agreed with the other 30% disagreeing. --- Business development services after starting business The respondents were requested to state whether they had received any business development services after starting their business. The findings indicated that most of the respondent (55%) agreed with the other 45% disagreeing. --- Organizations providing business development services The respondents were asked to indicate the organizations providing them with business development services. The findings are as shown in table 4. Table 4 shows that 25% stated the government provided them with business development services, 23% NGOs and 16% MFIs and Saccos. --- Areas trained or mentored The respondents were requested to state the areas they were trained on during business development services. The findings are as shown in table 5. Table 5 shows that the respondents were trained/mentored in the following areas, 45% (marketing accountancy), 36% (management) and 14% (financial management). --- Importance of business development services during the start-up phase The respondents were requested to indicate the importance of business development services during the start-up phase. The findings indicated that majority of the respondents 79% stated that business development services during the start-up phase while 17% stating it helped in survival in business industry. --- Importance of business development services to you during the growth phase The respondents were further requested to indicate the importance of business development services during the growth phase. The findings indicated that majority (63%) of the respondents stated that business development services during the growth phase assisted in improving business networks with 22% stating that they enabled formal empowerment. --- b) Government policy Presence of government regulations difficult to cope with at start-up phase The respondents were asked to comment on whether there were government regulations which difficult to cope with when starting own business. The findings indicated that majority of the respondents (88%) agreed that there were government regulations which were difficult to cope with when starting own business while a few 12% were in disagreement. --- Regulatory challenges faced as young entrepreneur The respondents were asked to comment on regulatory challenges they faced as young entrepreneurs. The findings showed that 50% and 46% of the respondents stated that licensing and taxation laws were very serious challenges. Another 46% stated that competition laws and subsidy policy were serious challenges. --- Changes proposed for government policies to look friendly to youth entrepreneurs The respondents were asked to make proposals of changes needed in government policies and regulations to be friendly to youth entrepreneurs. The findings indicated that 65% proposed on favorable tax systems with 29% proposing reduction in cumbersome procedures. --- c) Accessibility of microfinance services --- Benefits of accessibility of MFI services among the youth The study sought to establish the benefits of accessibility of MFI services among the youth. The findings are presented in the table 6. On being requested to state the benefits of accessibility of MFI services among the youth, the respondents agreed on the following. 54% stated that it enhances credit access to the youth which is critical to poverty alleviation, 67% stated that it led to growth of youth enterprises, 55% said it enhances the profitability of youth enterprises 51% stated it enabled access to credit and led to generation of self-employment among the youth. Similarly, 54% stated it enhances the economic value of the youth population in the society with 63% stating it led to financial creativity among the youth. --- Rating performance of business after accessing MFI services The respondent's views were sought on the performance in terms of sales volume after accessing MFI services. The findings indicated that the 48% of the respondents stated that business performance after accessing MFI services, 21% stated it was moderately satisfactory and 19% agreed that it was very satisfactory. --- Have you ever sourced for funding since you started your business The respondents were asked to comment on sourcing for funding since they started their business. The indicated that the majority (85%) respondents stated that they had sourced for funding since they started their business with 15% negating it. --- Institutions that facilitated the funding The respondents who had sourced for funding were asked to comment on institutions they got funding from. The findings are as presented in table 7. --- Accessibility of MFI services factors inhibiting the growth of your enterprises The respondents were asked to state the factors related to accessibility of MFI services inhibiting the growth of youth enterprises. The findings indicated that 36.4% pointed at lack of collateral, 32.7% on lack of business plan with 15% stating that lack of knowledge about lending sources as an inhibitor. --- Solution to overcoming the inhibitors The respondents were asked to state the solutions to inhibiting factors related to accessibility of MFI services that affect growth of youth enterprises. The findings indicated that majority of the respondents (64%) stated that special programs to promote access of credit as a solution. A few (26%) stated that reduction of access barriers as a solution. The findings showed that the youth entrepreneurs should have the ability to access and afford financing and support from these institutions. --- Testing Regression Model Assumption Before regression analysis was done, the assumptions of multivariate analysis were tested to ensure that there was no violation of multivariate analysis assumptions. The data was checked for normality, outliers and multicollinearity. --- Regression analysis The regression analysis of the study variables was, presented, outlined and discussed in this section. The model analysis describes the effect of the three explanatory variables acting jointly on the SME accessibility to microfinance services. The R 2 value is the coefficient of determinant (expressed as a percentage) shows the variability of the dependent variable explained by the variability in independent variable(s). The R 2 value of 0.567 implies that 56.7% of the variations in the dependent variable (accessibility to microfinance) are explained by the variations in independent variables (government policy, entrepreneurship education and training and availability of microfinance services). The adjusted R 2 is an indicator of generalizability as it is used to estimate the expected shrinkage in R 2 that would not generalize to the population because of the solution being over-fitted to the data set by including too many independent variables. In this case, R 2 = 0.567 and Adjusted R 2 = 0.535. These values are very close, anticipating minimal shrinkage based on this indicator. --- Analysis of Variance (ANOVA) Table 9 analysis of variance (ANOVA) very one unit increase in government policy will decrease accessibility to microfinance services by 0.101 holding other variables constant. --- THE SUMMARY OF THE FINDINGS The study was set out to assess the factors affecting accessibility of microfinance services among the youth in Nakuru County. The study employed a survey research design. The sample was picked from 75 registered youth group in Nakuru County. Purposive, stratified and simple random sampling were used to arrive at a sample of 75 registered youth groups. Questionnaire was used as the principle tool for collecting primary data whereas data was analyzed using descriptive statistics and multiple regression approach. From the analysis, the study revealed the following findings. A response rate of 80% was obtained from the study participants. The study findings revealed that majority of the respondents (58%) were males, with the other 42% being females. Majority of the respondents were in the age group 22-30 years with 54% having a secondary school education. Majority of the respondents (59%) also had operated another business with

Financial sector development is recognized as a prerequisite to growth and poverty reduction. The goal of microfinance is to provide "booster shot", and financing that would lead to the following projected outcomes, selfsufficiency for talented youth entrepreneurs, breaking of poverty cycle, facilitating and encouraging entrepreneurial spirit in quest for self-reliance and economic empowerment through business expansion and growth. Microfinance is seen as a solution to include on a large-scale previously excluded poorer groups like the youth without access to capital into the financial system so that they may "rise out of poverty" by on their own. This study was designed to assess the factors influencing accessibility of microfinance services amongst the youth in Nakuru County. The aim of the study was based on three objectives: entrepreneurship education and training and government policies and their influence on accessibility of microfinance services for youth. However, the study intended to answer two research questions based on the two objectives in relationship to accessibility of micro finance services for the youth. The study adopted survey design that was carried out in Nakuru County. The study sample comprised of 75 registered groups in the county. The instruments of data collection were self-administered questionnaires. The study concluded that, potential of entrepreneurship education and training to the overall sharpening of entrepreneurial instincts of youth entrepreneurs cannot be understated. Entrepreneurship education and training can drastically convert a novice youth entrepreneurs into a budding one with the knowledge to adapt, conquer and cope with the challenges in the world of business. Availability of affordable and accessible microfinance services is virtually important in enabling the budding youth entrepreneurs to succeed in business. Government policies on youth entrepreneurship should aim at reducing the bureaucracy in the participation of youth entrepreneurs in business. The current regime of regulatory framework requires an adaptation and inclusiveness to ensure that the youth entrepreneurs are incorporated and accommodated to engage in entrepreneurship. The study recommended that In order to enhance the full participation of youths in entrepreneurship and improve the wellbeing of their survival, the youths should be facilitated to access affordable microfinance credits. Also the government in collaboration with development partners should build capacity for youths to use credit efficiently and enforce laws for defaulters. On areas for further studies, the study on the determinants of entrepreneurial characteristics affecting accessibility of microfinance services among the youth in Nakuru County should be undertaken in other counties in Kenya.

close, anticipating minimal shrinkage based on this indicator. --- Analysis of Variance (ANOVA) Table 9 analysis of variance (ANOVA) very one unit increase in government policy will decrease accessibility to microfinance services by 0.101 holding other variables constant. --- THE SUMMARY OF THE FINDINGS The study was set out to assess the factors affecting accessibility of microfinance services among the youth in Nakuru County. The study employed a survey research design. The sample was picked from 75 registered youth group in Nakuru County. Purposive, stratified and simple random sampling were used to arrive at a sample of 75 registered youth groups. Questionnaire was used as the principle tool for collecting primary data whereas data was analyzed using descriptive statistics and multiple regression approach. From the analysis, the study revealed the following findings. A response rate of 80% was obtained from the study participants. The study findings revealed that majority of the respondents (58%) were males, with the other 42% being females. Majority of the respondents were in the age group 22-30 years with 54% having a secondary school education. Majority of the respondents (59%) also had operated another business with 66% having operated their current business for between 1-3 years. Majority of the respondents (68%) indicated that their motivation to engage in entrepreneurship was driven by financial motives with 13% with another 11% being driven by the desire for self-fulfilment. Most of the respondents (54%) indicated that they had prior experience of business management task through earlier employment. Reliability test was conducted and all factors had cronbach alphas of 0.7 and therefore measures were internally consistent. The study found that overall cronbach's alpha for availability of microfinance services was 0.709, entrepreneurship education and training (0.881), government policy (0.703), and accessibility to microfinance services was 0.870. The questionnaire was validated using convergent validity test. Average Variance Extracted (AVE) which is commonly used to assess convergent validity was found to be more than 0.7, implying that convergent validity of those constructs was adequate. To ensure that there was no violation of the data before analysis test for outliers, normality, multicollinearity were performed. The first objective of this study was to outline the effect of entrepreneurship education and training on accessibility of microfinance services amongst the youth in Nakuru County. Entrepreneurship education and training had the best correlation, a strong positive correlation of r=0.746. Factor loadings on all the items under this factor was 0.881, therefore, the measures used were internally consistent and reliable. Majority of the respondents agreed with questionnaire items. Entrepreneurship education and training had a strong positive correlation with accessibility to microfinance services. This implied that the youth entrepreneurs sought education entrepreneurship and education to acquire entrepreneurship skills to grow their business The second objective sought to find out the effect of government policies on accessibility of microfinance services amongst the youth in Nakuru County. Government policy was the third with a weak positive correlation (r=0.023) to accessibility to microfinance services. Factor loadings on all items under this factor was 0.703, therefore, the measures used were internally consistent and reliable. Majority of the respondents agreed with questionnaire items. This implied that the current entrepreneurship policies in place in Nakuru County do not have deterrence to youth entrepreneurship. --- Conclusions This study investigated the factors affecting accessibility of microfinance services among the youth in Nakuru County. Two predictor variables namely; entrepreneurship education and training, government policies and their effect on accessibility to microfinance services were studied. The study concluded that, entrepreneurship education and training had the best correlation, a strong positive correlation of r=0.746. Factor loadings on all the items under this factor was 0.881, therefore, the measures used were internally consistent and reliable. This implied that the youth entrepreneurs sought education entrepreneurship and education to acquire entrepreneurship skills to grow their business. The conclusion is that the potential of entrepreneurship education and training to the overall sharpening of entrepreneurial instincts of youth entrepreneurs cannot be understated. Entrepreneurship education and training can drastically convert a novice youth entrepreneurs into a budding one with the knowledge to adapt, conquer and cope with the challenges in the world of business. It is therefore of paramount importance to equip and inculcate entrepreneurship skills and training to the youth in Kenya. Government policy was the third with a weak positive correlation (r=0.023) to accessibility to microfinance services. Factor loadings on all items under this factor were 0.703. The findings implied that the current entrepreneurship policies in place in Nakuru County do not have deterrence to youth entrepreneurship. Government policies on youth entrepreneurship should aim at reducing the bureaucracy in the participation of youth entrepreneurs in business. The current regime of regulatory framework requires an adaptation and inclusiveness to ensure that the youth entrepreneurs are incorporated and accommodated to engage in entrepreneurship. If this is done conclusively, the youth entrepreneurs will engage and compete favorably in business engagements. Therefore, it can be concluded that for success to be achieved among the youth in business ventures, entrepreneurship training and education should be inculcated to unleash their potential, microfinance services should be readily available and affordable and there should exist friendly and accommodative government regulations and policies. If this is conclusively undertaken, the potential of youth entrepreneurship in Nakuru County and Kenya in general will be realized, unleashed and utilized. --- Recommendations The study recommends that In order to enhance the full participation of youths in entrepreneurship and improve the wellbeing of their survival, the youths should be facilitated to access affordable microfinance credits. Also the government in collaboration with development partners should build capacity for youths to use credit efficiently and enforce laws for defaulters. --- Area for further studies Since the four variables under this study namely; government policy, entrepreneurship education and training and microfinance services, contributed 56.7% of the variations in the dependent variable (accessibility to microfinance), a study on the other variables that contributes 43.3% should be undertaken. The study on the determinants of entrepreneurial characteristics affecting accessibility of microfinance services among the youth in Nakuru County should be undertaken in other counties in Kenya. --- Dependent variable= accessibility to microfinance services b. independent variable=(constant), government policy and entrepreneurship education and training With a sig=.000 as indicated in table (table no) above, the sig. provides a significance level of over 99%. The model significance implies that the model is acceptable. The total deviation in the dependent variable in the model is 135.219. The model was able to explain 165.219 of the total sum of squares while 47.121 of the total sum of squares were not explained. The F ratio (in the Analysis of Variance table) is 66.285 and significant at sig=.000. This provides evidence of existence of a linear relationship between the response (accessibility to microfinance services) and the three explanatory variables (government policy, entrepreneurship education and training and availability of microfinance services). --- Coefficients a The coefficient of this study is discussed and summarized in this section. (Cherotich, 2013;Mugori, 2012). The findings in this study state that entrepreneurship education and training was the predictor variable that contributes the highest to accessibility to microfinance services. Thus, every unit increase by entrepreneurship education and training will increase a total of 0.434 of accessibility to microfinance services provided other variables remain constant followed by government policy (<unk>, 0.101). This implied that

Financial sector development is recognized as a prerequisite to growth and poverty reduction. The goal of microfinance is to provide "booster shot", and financing that would lead to the following projected outcomes, selfsufficiency for talented youth entrepreneurs, breaking of poverty cycle, facilitating and encouraging entrepreneurial spirit in quest for self-reliance and economic empowerment through business expansion and growth. Microfinance is seen as a solution to include on a large-scale previously excluded poorer groups like the youth without access to capital into the financial system so that they may "rise out of poverty" by on their own. This study was designed to assess the factors influencing accessibility of microfinance services amongst the youth in Nakuru County. The aim of the study was based on three objectives: entrepreneurship education and training and government policies and their influence on accessibility of microfinance services for youth. However, the study intended to answer two research questions based on the two objectives in relationship to accessibility of micro finance services for the youth. The study adopted survey design that was carried out in Nakuru County. The study sample comprised of 75 registered groups in the county. The instruments of data collection were self-administered questionnaires. The study concluded that, potential of entrepreneurship education and training to the overall sharpening of entrepreneurial instincts of youth entrepreneurs cannot be understated. Entrepreneurship education and training can drastically convert a novice youth entrepreneurs into a budding one with the knowledge to adapt, conquer and cope with the challenges in the world of business. Availability of affordable and accessible microfinance services is virtually important in enabling the budding youth entrepreneurs to succeed in business. Government policies on youth entrepreneurship should aim at reducing the bureaucracy in the participation of youth entrepreneurs in business. The current regime of regulatory framework requires an adaptation and inclusiveness to ensure that the youth entrepreneurs are incorporated and accommodated to engage in entrepreneurship. The study recommended that In order to enhance the full participation of youths in entrepreneurship and improve the wellbeing of their survival, the youths should be facilitated to access affordable microfinance credits. Also the government in collaboration with development partners should build capacity for youths to use credit efficiently and enforce laws for defaulters. On areas for further studies, the study on the determinants of entrepreneurial characteristics affecting accessibility of microfinance services among the youth in Nakuru County should be undertaken in other counties in Kenya.

INTRODUCTION What does it mean to teach for Black lives when state governments are passing laws that prevent teachers from discussing race and gender and a vocal minority of parents are attacking school board meetings insisting on a return to book banning and other educational How to cite this article (APA): Jones, D. (2023). Black Lives Matter at School and Social Studies Education: Paying Down the Educational Debt Owed to Black People. Annals of Social Studies Education Research for Teachers, 4(1), 6-14. doi: 10.29173/assert55 gag orders to stop the Critical Race Theory (CRT) boogeyman (Johnson, 2022;Ockerman, 2021)? How can public education pay down the educational debt (Ladson-Billings, 2006) owed to Black, Indigenous, and Children of Color and their families when elected officials are prioritizing protecting whiteness at their expense? What role can social studies educators play in reducing the debt and promoting educational justice for racialized students? Despite the attacks, educators have a responsibility to use their privilege and power to challenge those who use education as a weapon against the marginalized and oppressed (Royal, 2022). The Black Lives Matter at School (BLMAS) movement is offered as a space for public education in general, and social studies educators in particular, to enact what it means to teach for Black lives and pay down the debt. Gloria Ladson-Billings (2006) argued that instead of focusing on a so-called "achievement-gap" we should focus our efforts on the education debt owed to BIPOC children. She compared the obsession with gaps in achievement with only focusing on the nation's deficit, which can disappear during a time of a balanced budget. The national debt is an accumulation of all the previous deficits and will grow even when the budget is balanced. Thus, she asserts that a focus on gaps in achievement is misleading and instead presents the idea of an education debt, constructed from the historical, sociopolitical, economic, and moral policies that produce the racial and class gaps in achievement. A full review of each aspect of the education debt is beyond the scope of this article, so the focus will be on the historical debt and social studies education. --- THE RESEARCH L.G. King (2014) examined the work of Black educators who authored Black history textbooks in the late 19th and early 20th century as an alternative to the social studies textbooks by white educators that denied citizenship to Black people. He notes, "It was common in these textbooks to underscore Black persons as inferior and second-class citizens...The racializations of Blackness were used as justifications for the paternalistic attitudes White citizens had towards African Americans" (L. J. King, 2014, p. 2). As the purveyor of ideologies regarding citizenship, the mainstream social studies textbooks presented whiteness as the standard for citizenship and stripped Blackness of its humanity. Thus, the field of social studies contributed to the historical educational debt extracted from Black lives. And despite the work of Black educators to counter this narrative through the creation of culturally relevant Black history textbooks, the field of social studies education has yet to embrace a pedagogy or curriculum that centers Black lives and fosters Black citizenship. J. E. King (2004) defined cultural knowledge as "the learned behaviors, beliefs, and ways of relating to people and the environment that members of a cultural group acquire through normal processes of enculturation" (p. 356). She notes how the American school curriculum is steeped in European American cultural knowledge that legitimizes white middleclass cultural dominance while fields such as Black history have worked to validate Black cultural knowledge and autonomy. Curriculum is transformed by adherence to culturecentered knowledge, but that transformation depends on where the culture-centered knowl- ASSERT,4(1) | 2023 | 10.29173/assert55 edge is situated on the spectrum. J.E. King (2004) differentiated marginalizing and invisibilizing knowledge on the end connected with sameness and hegemony from expanding and deciphering knowledge on the other end linked to difference and autonomy. Social studies education was traditionally steeped in invisibilizing knowledge, ignoring or downplaying the contributions of African Americans to this country's development, and has gradually moved to marginalizing knowledge through the selective inclusion of Black individuals palatable to the white dominant narrative without challenging it. To pay down the debt, social studies education in general and citizenship education, in particular, must embrace Black cultural expanding knowledge that includes diverse narratives from diverse communities and deciphering knowledge that demands autonomy from the constraints of other socially constructed belief systems. Teaching for Black lives requires a curriculum and pedagogy that humanizes Black people in history and the present. For social studies educators, teaching for Black lives must include teaching history that disrupts the traditional narratives of enslavement, civil rights, and individual Black achievements that often reinforce messages of Black inferiority and respectability politics. A curriculum for Black lives requires contemporary Black cultural knowledge as a form of emancipatory pedagogy (Gordon, 1985) needed to undo the historical indoctrination that contributed to the education debt. A pedagogy for Black lives strives for Black liberation through collective social action with a commitment to centering Black joy. Social studies educators are invited to engage in the BLMAS movement as a pedagogy and curriculum for Black lives. As the #BlackLivesMatter movement grew with national calls for racial justice, BLMAS brought the fight to the schoolhouse and evolved from a day of solidarity to a Week of Action, to a Year of Purpose. The BLMAS movement highlights 13 guiding principles (13Gps) (see Figure 1) from the national #BlackLivesMatter movement, advocates four national demands (see Figure 2) to pay down the education debt and asks "educators to reflect on their own work in relationship, to antiracist pedagogy, and abolitionist practice, persistently challenging themselves to center Black lives in their classrooms" ( (Jones & Hagopian, 2020), p. 209). Each year a national team of volunteers curates K-12 curriculum resources aligned with the 13GPS, and local organizers host curriculum fairs to orient teachers to the materials. The Week of Action, conceived by educators in Philadelphia after hearing about the one-day teach-ins in Seattle, organizes events related to the demands and the various 13GPS spread throughout the week. Beginning in 2020, the BLMAS National Steering Committee enacted the Year of Purpose framework that would begin in September and end in June. This ensured that the work of BLMAS would happen throughout the year, while local organizers could still plan a Week of Action during the first week of February. --- IMPLICATIONS FOR TEACHERS Although the BLMAS curriculum does not belong to any one content area, it has a natural connection to social studies and citizenship education. Mathews and Jones (2022) tural citizenship education. Though most of the research on cultural citizenship focuses on Latinx and Asian Americans, they document how the "BLMAS curriculum provides the opportunity for schools to teach Black cultural knowledge, a Black history that centers resistance as foundational to Black struggle, and a curriculum affirming Black humanity" (Mathews and Jones, 2022, p. 4). Their qualitative narrative inquiry of seven teachers who participated in multiple BLMAS Week of Actions identified the following aspects of Black cultural citizenship education: talking to young children about big ideas so they can see themselves and others as change agents (Jones & Mathews, 2023), supporting student in unlearning and relearning Black history, centering students as active contributors in the current movement for Black liberation, providing opportunities for students to recognize and challenge systems of oppression in the present and the future (Mathews & Jones, 2022); and reframing critical civic praxis centered on Black experiences (Jones & Mathews, in press). Even though none of the teachers in their study taught social studies, their research demonstrates how social studies educators can use the BLMAS curriculum and pedagogy as a tool for teaching for Black lives. Social studies scholars have documented how the field historically added to the education debt (Ladson-Billings, 2003) and kept citizenship separate from Blackness (Busey & Dowie-Chin, 2021;Woodson, 2019). Other scholars have studied the work of contemporary Black social studies educators who confront the education debt by creating "imagined communities in their classrooms as a site of citizenship" (Vickery, 2017, p. 332) or accepting their responsibility as citizens to support their students in resisting white supremacy (Duncan, 2020). Social studies teachers and scholars are invited to embrace the BLMAS movement and accept their responsibility in paying down the debt through a commitment to center Black liberation in their curriculum and pedagogy. Many teachers understand it is necessary to center the Black perspective since the Eurocentric perspective has been privileged in our schools and curriculum. As a White and new teacher, how would you suggest introducing Black knowledge into the classroom in an effective and authentic way? --- Denisha Jones's Response: I would suggest that white teachers, strive to change the narrative of Black knowledge from pain, struggle, and inferiority to joy, resistance, and collective efforts for liberation. Too often, well-meaning white teachers believe that to teach Black history means to teach the Trans-Atlantic Slave Trade, and that is not our history. That is world history. Black history cannot begin with the atrocities committed against Black people. This starting point ensures that Blackness will always be seen as a deficit. I ask my pre-service teachers what does it mean to teach for Black joy, and when most of them can't answer that question, I suggest they investigate what that means. To my knowledge, young Jewish children aren't taught about the Holocaust as an introduction to who they are as people, so why do we think that it is appropriate for children's introduction to Black culture should begin with enslavement? You must unlearn invisibilizing and marginalizing knowledge and replace it with expanding and deciphering knowledge. --- Question #2 --- Teacher's Question: To what extent do you envision BLM at school as a way of paying off the "educational debt" as primarily a pedagogical possibility that happens through curriculum enactment versus a more foundational and fundamental approach to the existential nature of educational spaces? I do not want to misconstrue these questions solely within a binary but as a means of prioritization. --- Denisha Jones's Response: I see BLMAS as a movement that pays down the debt through national demands. As we work to eliminate punitive discipline, hire more Black teachers, mandate Black and Ethnic studies, and ensure every child goes to school with counselors instead of cops, we pay down the debt at the macro level. However, teachers can pay down the debt on a micro level by teaching the 13GPS and enacting the Week of Action and Year of Purpose in their classrooms. Even if our demands are never realized, the debt can be addressed at the individual level, and I believe that both are needed simultaneously. How can teacher education programs do more to support future educators in disrupting the narrative within the curriculum and schools toward paying down the educational debt you describe? --- Denisha Jones's Response: Teacher education programs must accept the responsibility of exposing the relationship between American education and colonization. Since the founding of this country, education has been used to further the American colonization project against Black, Indigenous, and People of Color. In order to pay down the debt, teachers must recognize how the curriculum, pedagogy, and policies work to maintain American colonization. Once they expose their students to this expanding knowledge, teacher education programs can also document how cultural groups have fought against American colonization. Teachers need the historical knowledge of what education has done and the possibilities of what education can be. --- Question #4 Teacher's Question: Altering how we center Black lives is one step individual teachers can take in my classroom. But how can individual teachers effectively identify and address classroom and school-wide policies that hurt or impact our minority students more than they help? --- Denisha Jones's Response: Teachers must speak out about these policies. It's important that they revise their own classroom practices to abandon punitive discipline, but they must also speak to their colleagues and administration about the need to make these changes school-wide. Teachers must also invite parents to understand their approaches to education that seek support from all students and welcome them as partners. Parents might not understand why a teacher is taking a certain approach, but with continued reassurance that the teacher has their child's best interest at heart and believes that a more justice-oriented approach serves all children well, they can model how to live and work their values. --- Question #5 Teacher's Question: How does re-authoring the script on Black Life that is untold in the social studies curriculum serve to repay these historical debts, and how do you envision we would recognize when it had been repaid? --- Denisha Jones's Response: I don't believe the debt can ever be repaid in the sense that we can stop making Black Lives Matter in school. We pay down the debt when we center Black joy, affirm Black life, and provide counternarratives that center the ongoing collective struggle for Black liberation. But this is a debt that must be paid every year. Even if all our demands were met, we would still need to assert that Black lives matter. If Black people were granted reparations today, Black Lives Matter would not disappear. Paying down the debt doesn't take away how the debt was created. Social studies education contributed to this debt, and by embracing the BLMAS pedagogy, it can pay down the debt without expecting that the work will one day end.

My ultimate goal is to devise policies and programs that nurture young children's innate curiosity and drive for learning in a space where they are free to develop and grow, and educators are free to teach. I study how curriculum and pedagogy can promote education as liberation through play and other emancipatory approaches to teaching and learning. I also emphasize the importance of positive racial, ethnic, and cultural identity development in the early years. My personal life recently underwent major changes as I am now parenting two teenagers from Colombia. I love to travel, read, write, and camp with friends. In June of 2023, I plan on visiting France, Scotland, and Amsterdam! Before spending the last 18 years preparing future teachers in different universities, I was a kindergarten teacher in DC, a preschool teacher in Indiana, and a preschool director in California.

The education of English learners (ELs) has attracted national attention recently with the Supreme Court ruling in Horne v. Flores (2009). This case, the first funding case on behalf of ELs to reach the Supreme Court, challenged Arizona's formula for adequately funding programs for ELs. Adequate resources have been identified as key for effective program implementation (Gándara, Rumberger, Maxwell-Jolly, & Callahan, 2003;Reeves, 2004;Williams v. State of California, 2005), and many would argue that the focal resource is the teacher (Darling-Hammond, 2006;Faltis & Coulter, 2007). Research indicates that there is a critical shortage of teachers prepared to respond to the needs of ELs (Wong-Fillmore & Snow, 2002). In this article, we reflect on the preparation of teachers for ELs and articulate the importance of enhancing teacher knowledge through contact and collaboration with diverse ethnolinguistic communities. We build on recent research on the preparation of teachers for cultural responsiveness and linguistic diversity and recommend a situated preparation within EL communities that fosters the development of teacher knowledge of the dynamics of language in children's lives and communities. We begin our review by summarizing recent demographic developments for ELs. This section is followed by a brief review of the context of education for ELs. We summarize the most recent research on culturally and linguistically responsive teacher preparation and focus on a framework that includes developing teacher knowledge through contact, collaboration, and community. How we define ELs and the labels we ascribe to their diversity can be confusing. Who teaches these students can be just as confusing and diverse. And there are often inconsistencies across schools, districts, and states. Therefore, a brief clarification of terms is in order before proceeding. Several terms are used in the literature to describe U.S. schoolchildren whose native language is other than English. A common term is language minority, which is used to describe children whose native language is other than English, the mainstream societal language in the United States. This term is applied to nonnative English speakers regardless of their current level of English proficiency. Other common terms are English language learner (ELL) (or, shorter, English learner [EL]) and limited English proficient (LEP). These two terms are used interchangeably to refer to students whose native language is other than English and whose English proficiency is not yet developed to a point where they can profit fully from English instruction or communication. They have not developed academic English proficiency. In this introduction, the term English learner and its respective abbreviation is used rather than limited English proficient as a way of emphasizing students' learning and progress, rather than what they lack-their limitations. Teachers who are assigned as instructors of these students can have no formal preparation, minimal formal preparation related to workshop training, or substantial coursework and experience that can produce a state-issued credential. They may be labeled English-as-a-second-language teacher (ESL), bilingual teacher (BLE), English language development teacher (ELD), or sheltered English immersion teacher (SEI). These are only representative terms. Yet they all are expected to take the special responsibility of implementing instruction for EL students. Overall, too many EL students are provided instructors who themselves admit they are not prepared for effective instruction of these students (Gándara, Maxwell-Jolly, & Driscoll, 2005). Nonetheless, recognizing, emphasizing, and strategically integrating children's knowledge, skills, and abilities is central to the teaching and teachers needed in schools and classrooms to improve educational opportunities for ELs (Genessee, Lindholm-Leary, Sanders, & Christian, 2006). --- A Demographic Imperative for Enhanced Teacher Development The common phrase "demography is destiny" is applicable to the present teacher development circumstances. Two useful reports outlining the demography of EL students are The New Demography of America's Schools by demographer Randy Capps and colleagues (2005) at the Urban Institute and Children in Immigrant Families by Donald Hernandez and his colleagues (2008) at the University at Albany, State University of New York. These reports use Census 2000 data to describe the ethnic, linguistic, economic, domestic, educational, and geographic (including their origins and destinations) variations among immigrant children and families. Whereas the data authors analyze and interpret in these reports are nearly a decade old, the information provided is useful to project the future demographic characteristics of the U.S. student body. Certainly, Census 2010 will shed further light and, in some cases, correct misguided projections based on 2000 data. Until then, however, these reports continue to be helpful tools in orienting our understanding of the future challenges and opportunities for educators serving children of immigrant origins who learn English as an additional language. Currently, at least one in five children ages 5 to 17 in the United States has a foreign-born parent (Capps et al., 2005), and many of these children learn English as their second language, though not all. It is important to note that EL students and children from immigrant families (i.e., a child with at least one foreign-born parent) are not synonymous populations, but certainly they are closely related. Most children from immigrant households are considered ELs at some point in their lives. Yet a majority (74%) of school-aged children (5 to 17 years) from immigrant families speak English exclusively or very well according to the Census 2000 data. The overall child population speaking a non-English native language in the United States rose from 6% in 1979 to 14% in 1999 (Garc<unk>a & Jensen, 2009), and the number of language minority students in K-12 schools has been recently estimated to be greater than 14 million (August, 2006). The representation of ELs in U.S. schools has its highest concentration in early education. This is because EL children from preschool or kindergarten tend to develop oral and academic English proficiency by 3rd grade. The EL share of students from prekindergarten to Grade 5 rose from 4.7% to 7.4% from 1980 to 2000, whereas the EL share of students in Grades 6 to 12 rose from 3.1% to 5.5% during the same time period (Capps et al., 2005). Young ELs (ages 0 to 8 years) have been the fastest growing student population in the country over the past few decades, due primarily to increased rates in (legal and illegal) immigration as well as high birthrates among immigrant families (Hernandez et al., 2008). Although a majority come from Spanish-speaking immigrant families, ELs represent many national origins and more than 350 languages. In 2000, more than half of ELs came from Latin American immigrant families (Capps et al., 2005). Mexico led the way with nearly 40% of children from immigrant families (Hernandez et al., 2008), and Spanish was the native language of some 77% of ELs nationally during the 2000-2001 school year (Hopstock & Stephenson, 2003). Following Mexico, EL students find their origins around the globe. The Caribbean, East Asia, and Europe (combined with Canada and Australia) each account for 10% to 11% of the overall population of children from immigrant families, whereas Central America, South America, Indochina, and West Asia each account for 5% to 7% of the total; and the former Soviet Union and Africa account for 2% to 3% each. At least 3 in 4 children in immigrant families are born in the United States (Capps, 2001), though U.S. nativity is higher among elementary-age children of immigrant families than those attending secondary schooling (Capps et al., 2005). As immigrant families are settling new destinations in response to labor demands (Z<unk>iga & Hernández-León, 2005), EL students are increasingly attending school in districts and states that served few to no EL children in the 1980s and decades previous. Although immigrant families continue to be concentrated in California, Texas, New York, Florida, Illinois, and New Jersey (Capps et al., 2005), several states witnessed rapid increases in their immigrant populations. Indeed, seven states experienced over 100% increases in the number of children from immigrant families attending pre-Kthrough 5th-grade students from 1990 to 2000 including Nevada, North Carolina, Georgia, Nebraska, Arkansas, Arizona, and South Dakota (from greatest to lesser percentage 134 Journal of Teacher Education 61(1-2) increases) (Capps et al., 2005). This led several school districts and states to frantically search out, identify, and provide educational resources to children learning English as a second language. During the 1990s, Nevada, Nebraska, and South Dakota saw increases of 354%, 350%, and 264% in their EL populations, respectively. In addition to the demographic reality that ELs constitute a growing number of students in the nation's schools and across the country, there are other reasons for their increasing numbers in mainstream classes. Lucas and Grinberg (2008) asserted that due to the diminished number of bilingual programs (which began in the 1980s), classroom teachers are increasingly responsible for providing most of the instruction to ELs. Furthermore, requirements of No Child Left Behind (NCLB) for testing have pushed districts to speed up the process of enrolling ELs in mainstream classes. Cost factors associated with providing special services for ELs fuel the urgency of transitioning them to mainstream classrooms (Cornell, 1995). These factors led Lucas and Grinberg to conclude that regular teachers may spend more time with ELs than teachers who have specialized preparation. --- Educational Context The academic performance patterns of EL students as a whole cannot be adequately understood without considering their social and economic characteristics in comparison with native English speakers, the characteristics of the schools they attend, and the institutional history of U.S. schools (Jensen, 2008;Márquez-López, 2005). Although a great deal of socioeconomic variation exists among ELs, they are more likely than native English-speaking children, on average, to live in poverty and to have parents with limited formal education (Garc<unk>a & Cuéllar, 2006). In addition, EL students are more likely to be an ethnic/racial minority (Capps et al., 2005). Each of these factors-low income, low parent education, and ethnic/racial minority status-decreases group achievement averages across academic areas, leading to the relatively low performance of EL students. In their analyses of a national data set of elementary academic performance in early elementary schools, Reardon and Galindo (2006) found reading and mathematics achievement patterns from kindergarten through third grade to vary by home language environments among Hispanic students. Those living in homes categorized as "primarily Spanish" or "Spanish only" lagged further behind White children than did Hispanics who lived in homes where primarily English or English only was spoken. Given the associations among educational risk factors for EL students, the impact of language background on achievement outcomes should be contextualized. The interrelationship of risk variables has been documented in several reports (Collier, 1987;Jensen, 2007; National Cen ter for Education Statistics [NCES], 1995). Thus, rather than pointing to one or two student background factors that account for the low achievement of EL students, it should be understood that educational risk, in general, is attributable to a myriad of interrelated out-of-school factors. These factors may include parent education levels, family income, parent English language proficiency, mother's marital status at the time of birth, and single-versus dualparent homes (NCES, 1995). The more risk factors the child is subject to, the lower the probability the child will do well in school in terms of learning and attainment in the standard educational environment. Because EL children, on average, exhibit three of the five risk factors at higher rates than native English speakers, they are generally at greater risk for academic underachievement (Hernandez et al., 2008). Capps and colleagues (2005) found that 68% of EL students in pre-K through 5th grade lived in low-income families, compared to 36% of English-proficient children. The percentages changed to 60% and 32%, respectively, for 6th-to 12th-grade students. Moreover, 48% of EL children in pre K through grade and 35% of ELs in the higher grades had a parent with less than a high school education, compared to 11% and 9% of Englishproficient children in the same grades, respectively (Capps et al., 2005). Teachers for EL students must be able to address these challenging educational circumstances. The characteristics of schools ELs attend are cause for concern. ELs do not attend the same schools as other students (Fry, 2008). ELs are concentrated in a subset of low-achieving schools (Cosentino de Cohen, Deterding, & Clewell, 2005) with less experienced principals and teachers located in the urban cores. Most ELs attend linguistically segregated schools and live in linguistically isolated families (Capps et al., 2005). Seven dimensions of inadequate schooling for ELs have recently been documented (Gándara, Maxwell-Jolly, & Rumberger, 2008). These include (a) inadequate access to appropriately trained teachers, (b) inadequate professional development opportunities to help teachers address their instructional needs, (c) inequitable access to appropriate assessment, (d) inadequate instructional time to accomplish learning goals, (e) inequitable access to instructional materials and curriculum, (f) inequitable access to adequate facilities, and (g) intense segregation into schools and classrooms that place them at risk. Throughout the literature on the context of schooling for ELs, the theme of the need for well-prepared teachers resonates. Gándara and her colleagues (2003) concluded that "Students with limited English proficiency are the least likely of all students to have a teacher who is actually prepared to instruct them." --- Developing Teachers for ELs The preceding section highlighted the critical need for enhanced teacher development based on the demographic imperative. This need has been documented for close to 20 years. Eugene Garc<unk>a (1990) reviewed and discussed the research pertaining to educating teachers for language minority students. Garc<unk>a noted the growing presence of students with Spanish language backgrounds and the critical need to prepare teachers for their diverse educational experiences. He emphasized that language minority students can be taught in schools through effective teaching practices characterized by culturally appropriate interactions and instructions. This concern for effectively preparing teachers for language minority learners continues today (Márquez-López, 2005). Teachers who are ready to handle this demographic reality are no longer a luxury but a necessity (Menken & Antunez, 2001). The reality of teacher demographics is that they are very different from the students they serve. As noted earlier, the demographic imperative is reflected not only in the growth and dispersal of ELs across the nation. The other demographic fact is that the teacher corps lacks diversity. According to data gathered by the U.S. Department of Education's NCES ( 2006) on the Schools and Staffing Survey, the public teaching workforce is predominately female (75%), of non-Hispanic White background (83%), and this trend continues. Teachers who were racial and ethnic minorities rose from 13% in 1993-1994 to 17% in 2003-2004. Overall, the demography of the U.S. teaching workforce is rather homogeneous, and students attending schools are growing in their diversity, culturally, racially, and linguistically (Capps et al., 2005;NCES, 2007;Zumwalt & Craig, 2005). Growing racial differences between teachers and students continue, and diversity is viewed as an obstacle to overcome (Ladson-Billings, 1995). Rather than teaching students in the way they were prepared, current and prospective teachers often revert to the traditional ways in which they were taught as students. --- Knowledge for Teachers Effective teachers are key to meeting the needs of diverse learners and critical in preparing these learners for the 21st century. Teacher preparation programs can help prepare prospective teachers to teach these learners successfully. Darling-Hammond (2006) has described seven highly successful teacher education programs that have prepared teachers to teach diverse learners to achieve high levels of performance. These colleges and universities include Alverno College, Bank Street College; Trinity University; University of California, Berkeley; University of Southern Maine; University of Virginia; and Wheelock College. Darling-Hammond summarized common features of exemplary teacher education programs. Four of the seven common features connect specifically to the preparation of teachers working with ELs: • a common, clear vision of good teaching permeating all coursework and clinical experiences; • curriculum is grounded in knowledge of child and adolescent development, learning, social contexts, and subject matter pedagogy, taught in the context of practice; • extended clinical experiences are carefully developed to support the ideas and practices presented in simultaneous, closely interwoven coursework; and • explicit strategies help students confront their own deep-seated beliefs and assumptions about learning and students and learn about the experiences of people different from themselves. Darling-Hammond and Bransford ( 2005) presented a framework for exploring the kinds of knowledge, skills, and commitment that enable teachers to be effective. Specifically, these scholars identified three general areas of knowledge that teachers must acquire: • knowledge of learners and how they learn and develop within social context, • conceptions of curriculum and social purposes of education, and • understanding of teaching. This framework may be used to support teachers in improving their teaching practice. --- Knowledge Related to ELs Research on teacher preparation for ELs includes both prospective and practicing teachers (Lucas & Grinberg, 2008;Wong-Fillmore & Snow, 2002). Data indicate that teachers are not well prepared to meet the needs of ELs (NCES, 2001;Wong-Fillmore & Snow, 2002). A series of conceptual pieces have recently emerged that identify aspects of the knowledge base, skills base, and attitudes and dispositions necessary to effectively work with ELs (Ballantyne, Sanderman & Levy, 2008;Lucas & Grinberg, 2008;Lucas, Villegas, & Freedson-González, 2008;Merino, 2007;Téllez & Waxman, 2006). According to Lucas and Grinberg (2008), teachers should have language-related experience, linguistic knowledge, and opportunities to participate in programs that collaboratively prepare teachers across disciplines to instruct ELs in mainstream classrooms. They argued that effectively prepared teachers of ELs need specialized training within these areas. Current research on teacher preparation for ELs reports inconsistencies in the way teachers are prepared due to state mandates (e.g., Proposition 203 in Arizona, Proposition 227 in California) and other larger policy implications (e.g., NCLB, Reading First). Gándara et al. (2005) reported variations in the preparation of teachers for ELs stemming from the impact of such larger social policies and state initiatives. Nevertheless, common practices necessary for effectively teaching ELs have been identified (Faltis,Arias,136 Journal of Teacher Education 61(1-2) & Ramirez-Marin, 2009). In their synthesis of research on effective practices for ELs, Waxman and Téllez (2002) reported several strategies, which included collaborative learning communities, multiple representations, building on prior knowledge, instructional conversation, culturally responsive instruction, and technology-rich instruction. We argue for situating teacher preparation within ELL communities in school settings linked to university teacher preparation. We support partnerships between universities and school districts, which can foster collaborative efforts in teacher preparation and socialization. We are in concert with the work of Lucas et al. (2008) and Lucas and Grinberg (2008), who argued that teachers need specialized preparation that includes language-related experience and linguistic knowledge. We assert that this specialized preparation should occur, at least in part, in the communities where ELs attend school. In our review of the most recent research on the preparation of teachers for ELs, we find much in common with the factors represented in high-quality teacher preparation as noted by Darling-Hammond (2006) and Darling-Hammond and Bransford (2005). Table 1 illustrates these common factors. Table 1 summarizes main themes of developing teacher knowledge in the broad literature (Darling-Hammond & Bransford, 2005), in the literature on developing culturally responsive teachers (Villegas & Lucas, 2002a, 2002b), and in the literature on preparing teachers for ELs (Lucas & Grinberg, 2008). We highlight the commonalities between the knowledge related to learners, curriculum, and understanding teaching as they are applied to developing knowledge for culturally responsive teachers and knowledge of ELs. The literatures on preparing culturally responsive teachers and knowledge related to ELs focus on contextualizing knowledge of students within their communities, along with understanding the nexus between identity and language and the sociocultural impact of communities on students and classrooms. We recognize that teachers develop this knowledge by guided experience situated in EL communities, and we call for teacher preparation to promote understanding of ELs through field experiences grounded in EL communities. --- Responsive Teacher Preparation We frame this discussion in a broad theoretical continuum. At one end of this continuum, it is argued that addressing linguistically and culturally diverse populations calls for a deeper understanding of the interaction of a student's language and culture and the prevailing school language and culture (Garc<unk>a, 2001). This cultural significance position is supported by a rich body of research, which suggests that the educational failure of "diverse" student populations is related to this culture clash between home and school. These researchers have suggested that without attending to the distinctiveness of the contribution of culture, educational endeavors for culturally distinct students are likely to fail. To facilitate the discussion of how considerations of cultural diversity can be integrated into the development of a pedagogy and practices that improve the educational conditions of diverse students, Table 2 depicts the continuum of approaches suggested by the literature reviewed briefly here. At one end of this continuum is the notion that preparation of teachers is based on specific understandings of what works with diverse populations-one size does not fit all. Teachers must understand diversity and be responsive in the pedagogy that they utilize to serve their students. At the other end of this continuum is the notion that we can prepare a teacher from some generic principles that would serve the teacher no matter the population served-one size fits all. We assert here that teacher development must prepare teachers that are responsive to the diversity of their students. Preservice and practicing teachers must be given opportunities to explore and comprehend their own cultural and personal values, their identities, and their social beliefs. It has been well documented in the literature that teachers' attitudes and beliefs serve as filters for what they learn, what they teach, and how they manage their classroom (Pajares, 1992;Richardson, 1996). In addition, research suggests the influence of teachers' attitudes and beliefs on their expectations of ELs, interactions, and instructional practices (Garcia-Navarez, Stafford, & Arias, 2005;Reeves, 2004). In their study of mainstream teachers' attitudes towards ESL students, Youngs and Youngs (2001) found that teachers who had taken foreign language classes were significantly more positive towards teaching ELs then those teachers who had not taken such courses. Based on the results of their investigation, they suggested that both inservice and preservice teachers would benefit from more opportunities with diverse learners and diverse experiences. Garc<unk>a (2005) referred to a "pedagogy of empowerment" as a responsive pedagogy that expands students' knowledge beyond their own immediate experiences while using those experiences as a sound foundation for appropriating new knowledge (p. 76). He characterized the schoolwide and teacher practices that reflect this pedagogy. Included in the schoolwide practices are a school vision that values diversity and professional collaboration and teacher practices that focus on language development through meaningful interactions and communications and awareness of the role of language and language policy in schools. --- Knowledge Base for Culturally Responsive Pedagogy The work on culturally responsive pedagogy can be divided into two broad categories: beliefs and values of teachers and characteristics of culturally responsive teaching practices. Based on her work with African American students, Ladson-Billings (1995) stated that teachers must "develop a broader sociopolitical consciousness that allows them to critique the cultural norms, values, mores, and institutions that produce and maintain social inequities" (p. 162). Through their review of the research and work with teachers in culturally and linguistically diverse classrooms, to become culturally responsive teachers, Villegas and Lucas (2002a) proposed that teachers develop a "sociocultural consciousness," recognizing that each individual's "perspective reflects his or her location in the social order" (p. 42). They stated that the task of teacher educators is to help prospective teachers move towards a greater consciousness that includes understanding themselves as individuals (race, class, ethnicity, gender) and developing an understanding of the distribution of power in society that causes inequities and oppression. In her review of the research and her work with national projects, Gay (2002) defined culturally responsive teaching as using the cultural characteristics, experiences, and perspectives of ethnically diverse students as conduits for teaching them more effectively. It is based on the assumption that when academic knowledge and skills are situated within the lived experiences and frames of reference of students, they are more personally meaningful, have higher interest appeal, and are learned more easily and thoroughly. (p. 106) Culturally responsive teaching practices must be grounded in an understanding of students' cultural background (Gay, 2000;Ladson-Billings, 1994;Villegas & Lucas, 2002a, 2002b). Villegas andLucas (2002a, 2002b) reported common characteristics of culturally responsive teaching practices that include building on what students already know, understanding how students construct knowledge, demonstrating a socio cultural consciousness, knowing and understanding about the lives of their students, and affirming the views of their students. These practices cannot be conducted in isolation but rather must be supported and situated within specific learning communities. In teacher preparation programs, this speaks to field placements where prospective teachers may actively participate in the community within which they teach and their students live. Research strongly sug gests the benefits of experiencing such culturally diverse field placements (Hollins & Guzman, 2005;Ladson-Billings, 1994, 1995;Zeichner, 1996). These experiences provide opportunities for prospective teachers to change the way they think about their students. --- Situated Learning in EL Communities One route to responsive pedagogy is to propose that teacher preparation needs to include a service-learning component, which situates teaching and learning in the EL community. Boyle-Baise and McIntyre (2008) reviewed the research on preparing teachers in two contexts for teacher education, one professional development schools and the other community settings. Professional development schools focus on student academic achievement, develop teachers' academic expertise, and "aim to be centers of educational excellence" (p. 313). The authors further stated that service learning "eases a community orientation into teacher education," "allows preservice teachers to work with and learn from local youth and adults while doing something worthwhile," and "fosters greater comfort with people unlike oneself" (p. 309). Service learning experiences provide opportunities for prospective teachers to engage in the schools' communities. For example, in the American Indian Reservation Project, Stachowski and Frey (2005) reviewed the service learning activities performed by student teachers placed in the Navajo Nation. Student teachers were immersed into the lives and cultures of the people with whom they lived and worked. Through community involvement, student teachers gained cultural insights, developed a deeper appreciation for other people's lives, experienced the multiple realities of the classroom and community setting, and in turn gained acceptance by community members. Cooper (2007) described ways preservice teachers responded to cultural immersion, communitybased activities located in the home communities of their (Villegas & Lucas, 2002a, 2002b) and cultural sensitivity (Lucas & Grinberg, Bransford, 2005) 2008) learners that challenged their previous beliefs and stereotypes about the students they teach. Results from her study suggest that community experiences incorporated in teacher preparation programs may facilitate new discoveries about the students, their families, and the community's strength. Additionally, Seidl (2007) explained how a group of prospective teachers participating in an African American community began to develop culturally relevant pedagogies. Voluntary internships were arranged at an African American Baptist church where preservice teachers worked with adults from the church in projects for children such as tutoring and other community-sponsored events. Students also completed coursework and readings on African American history, racism, culture, and privilege. Through these guided experiences, preservice teachers were engaged in the community and began to implement culturally responsive approaches in their teaching. These preservice teachers were immersed in the cultural experiences of the community with situated educational opportunities and as a result learned to personalize cultural and political knowledge. Language, culture, and their accompanying values are acquired in the home and community environment. Teachers must be aware that children come to school with some knowledge about what language is, how it works, and what it is used for; that children learn higher level cognitive and communicative skills as they engage in socially meaningful activities; and that children's development and learning is best understood as the interaction of linguistic, sociocultural, and cognitive knowledge and experiences. Garc<unk>a (2005) further emphasized that students learn best and teachers feel most satisfied when both become allies in the learning process and are encouraged to actively cooperate and share. A more appropriate perspective of learning, then, is one that recognizes that learning is enhanced when it occurs in contexts that are both socioculturally and linguistically meaningful for the learner. Such meaningful contexts have been notoriously inaccessible to linguistically and culturally diverse children. On the contrary, schooling practices and teachers, who are the architects and engineers of instruction, often contribute to educational vulnerability. The monolithic culture of U.S. schools, which is a poor fit for culturally diverse students, is reflected in such practices as • the systematic exclusion of the histories, languages, experiences, and values of diverse students from classroom curricula and activities; • "tracking," which limits access to academic courses and justifies learning environments that do not foster academic development and socialization or perception of self as a competent learner and language user; and • a lack of opportunities to engage in developmentally and culturally appropriate learning in ways other than by teacher-led instruction. Practices such as these perpetuate inequitable school experiences and hinder student progress and achievement (Nieto, 2004). --- Teachers Who Construct Responsive Pedagogy and Learning Communities This rethinking of teacher preparation has important implications for the teaching/learning enterprise related to culturally diverse students (Garc<unk>a, 2005). This new pedagogy redefines the classroom as a community of learners in which speakers, readers, and writers come together to define and redefine the meaning of the academic experience. It may be described as a pedagogy of empowerment, as cultural learning, or as a cultural view of providing instructional assistance/ guidance. In any case, it argues for a teacher who respects and integrates students' values, beliefs, and histories; patterns of thoughts and behaviors; and experiences and recognizes the active role that students must play in the learning process. In addition, teachers must also recognize that what each student brings to the classroom is continually influenced by family norms and the larger society (Cloud, 2002). This kind of instruction takes into account what students know and can do. It is therefore a responsive pedagogy, one that encompasses practical, contextual, and empirical knowledge and a worldview of education that evolves through meaningful interactions between teachers, students, and other school community members. Of course, a teaching and learning community that is responsive to the dynamics of social, cultural, and linguistic diversity within the broader concerns for high academic achievement both requires and emerges from a particular schooling environment. Whereas considerable work has been devoted to restructuring schools and changing the fundamental relationships that exist between school personnel, students, families, and community members, seldom have these efforts included attention to the unique influences of the linguistic and sociocultural dimensions of these same --- Responsive Learning Communities The learning environments that we consider essential to the development of a responsive pedagogy are referred to as effective schooling (Garc<unk>a, 1999(Garc<unk>a,, 2001(Garc<unk>a,, 2005)). The focus on the social, cultural, and linguistic diversity represented by students in today's public schools further challenges us to consider the theoretical and practical concerns relative to ensuring educational success for diverse students. That is, responsive learning communities must necessarily address issues of diversity to maximize their potential and to sustain educational improvement over time. Examples of responsive learning communities are found in the work of Michelle Fine and her colleagues (2007), who illustrated successful public school models for working with ELs in New York City. These schools work against the negative effects of high-stakes education policy and "produce strong academic and civic outcomes with English Language Learners." Their schoolwide practices were grounded in understanding the student population and their commitment to maximizing students' potential. At these schools, teachers and staff focus on supporting students in the use of their individual experiences to benefit themselves and their classmates. University-school partnerships are an example of collaboration that supports teacher preparation in communities. One example of such a partnership is provided by the Arizona State University (ASU) Office of the Vice President for Educational Partnerships in eight urban districts. This long-term community collaboration involved various opportunities to support the development and enhancement of early childhood programs; supporting teachers by providing endorsements for SEI and ESL to prepare them for working with ELs; providing scholarship opportunities for student teachers to teach in partnership schools; supporting educational leaders by providing leadership institutes and leader certification; and providing support to students, schools, and families. The goal of the partnership was for all students attending these schools to attain educational success. Specifically, the work conducted in the ASU Educational Partnerships created critical linkages between the university, prospective teachers, and their placement settings: urban schools with high populations of ELs. Preservice teachers were placed in cohort groups. For example, one semester three student teachers were placed in one elementary school in early elementary settings (K-1). Beyond the traditional triad (student teacher, mentor teacher, and university supervisor), student teachers were provided with a district coach. These student teachers often presented questions that went beyond simple management concerns to ones that questioned why (Arias, Harris-Murri, Estrella, & Garc<unk>a, 2007). The role of the district coach was to create a context where questions, as well as district beliefs, state/district/school policies and practices, and community orientations could be shared (Arias et al., 2007). This mediated situation also encouraged student teachers to engage in rethinking their university learning around language issues and rethinking their own teaching in English only. The success of this approach has led to many of these student teachers' remaining within their student teaching placement district. Some have gone on to become mentor teachers and leaders in the school community. Through our research, we began to understand the multiple aspects needed to transition the student teacher from the preservice level to the novice level. To prepare teachers for the growing diversity faced in the classroom's of today, we must consider the support system in place, the changes necessary for programatic improvement, and the fostering of responsive learning communities. --- Conclusion In summary, we suggest that developing responsive teachers requires a setting for developing teacher knowledge that has its roots both the school community and the university setting. A focus on developing responsive teachers encourages teacher educators to support prospective teachers to construct and reconstruct meaning and to seek reinterpretations and augmentations to past knowledge within compatible and nurturing schooling contexts. This mission requires an understanding of how individuals with diverse sets of experiences, packaged individually into cultures, make meaning, communicate that meaning, and extend that meaning, particularly in the social contexts we call schools. Such a mission requires in-depth treatment of the processes associated with producing diversity, issues of socialization in and out of schools, and a clear examination of how such understanding is actually transformed into pedagogy and curriculum that result in high academic performance for all students. Our review of the literature underscores the need to prepare all teachers for culturally and linguistically diverse students. We have presented evidence that there is a demographic and intellectual imperative that motivates teacher preparation to

In this article, the authors reflect on the preparation of teachers for English learners (ELs) and articulate the importance of enhancing teacher knowledge through contact and collaboration with diverse ethnolinguistic communities. The authors build on recent research on the preparation of teachers for cultural responsiveness and linguistic diversity and recommend a situated preparation within EL communities that fosters the development of teacher knowledge of the dynamics of language in children's lives and communities. The authors begin their review by summarizing recent demographic developments for ELs. This section is followed by a brief review of the context of education for ELs. The authors summarize the most recent research on culturally and linguistically responsive teacher preparation and focus on a framework that includes developing teacher knowledge through contact, collaboration, and community.

teachers for the growing diversity faced in the classroom's of today, we must consider the support system in place, the changes necessary for programatic improvement, and the fostering of responsive learning communities. --- Conclusion In summary, we suggest that developing responsive teachers requires a setting for developing teacher knowledge that has its roots both the school community and the university setting. A focus on developing responsive teachers encourages teacher educators to support prospective teachers to construct and reconstruct meaning and to seek reinterpretations and augmentations to past knowledge within compatible and nurturing schooling contexts. This mission requires an understanding of how individuals with diverse sets of experiences, packaged individually into cultures, make meaning, communicate that meaning, and extend that meaning, particularly in the social contexts we call schools. Such a mission requires in-depth treatment of the processes associated with producing diversity, issues of socialization in and out of schools, and a clear examination of how such understanding is actually transformed into pedagogy and curriculum that result in high academic performance for all students. Our review of the literature underscores the need to prepare all teachers for culturally and linguistically diverse students. We have presented evidence that there is a demographic and intellectual imperative that motivates teacher preparation to become more connected to the schools and communities where ELs reside. Concurrently, we are aware that developing teacher knowledge through guided contact in EL communities requires teacher educators who are engaged in reflective practice. We envision EL communities as sites for guided teacher preparation that require collaboration --- Journal of between universities and school districts and look forward to building the knowledge base that supports teacher learning in EL communities. --- Declaration of Conflicting Interest The authors declared no conflicts of interests with respect to the authorship and/or publication of this article. This role was to strengthen K-12 education in the state of Arizona by linking together the university and private sector for distribution of fiscal and human resources. As of July 1, 2006, he stepped down as dean and assumed the new vice presidential role as VP for education partnerships (VPEP). This assignment carries on the goal of the first VP position across college campuses and school districts in Arizona as well as to oversee the implementation of the University Public School Initiative (UPSI) to establish campus schools. He has published extensively in the area of language teaching and bilingual development. He served as a senior officer and director of the Office of Bilingual Education and Minority Languages Affairs in the U.S. Department of Education from 1993 to 1995. He is currently chairing the National Task Force on Early Childhood Education for Hispanics funded by the Foundation for Child Development and the Mailman Family Foundation. He is presently conducting research in the areas of effective schooling for linguistically and culturally diverse student populations funded by the National Science Foundation. His most recent book is Teaching and Learning in Two Languages: Bilingualism and Schooling in the United States (Teachers College Press, 2005). Further information on his interests and research can be found at http://educationpartnerships.asu.edu. --- About the Authors M. Beatriz Arias is an associate professor of education at Arizona State University. Her courses focus on teacher preparation for English learners, language policy, and equity. Her research explores the implications of linguistic isolation and hypersegregation for urban Latino students. Nancy J. Harris Murri is a mentor teacher for the Archuleta School District 50JT in Colorado. She teaches courses preparing teachers to work with English language learners and exceptional students. Her research focuses on teacher learning and mentoring. Carolina Serna is an assistant professor in the Teacher Education Department at California State University, Monterey Bay. She teachers literacy methods and courses addressing cultural and linguistic diversity. Her areas of research include literacy, second language acquisition, and teacher preparation.

In this article, the authors reflect on the preparation of teachers for English learners (ELs) and articulate the importance of enhancing teacher knowledge through contact and collaboration with diverse ethnolinguistic communities. The authors build on recent research on the preparation of teachers for cultural responsiveness and linguistic diversity and recommend a situated preparation within EL communities that fosters the development of teacher knowledge of the dynamics of language in children's lives and communities. The authors begin their review by summarizing recent demographic developments for ELs. This section is followed by a brief review of the context of education for ELs. The authors summarize the most recent research on culturally and linguistically responsive teacher preparation and focus on a framework that includes developing teacher knowledge through contact, collaboration, and community.

INTRODUCTION Many people with intellectual disabilities (ID) present with multiple chronic and complex physical and mental health needs, which may be overlooked and unmet, with significant implications for their health and well-being (Emerson, 2011;Heslop et al., 2014;McCarron et al. 2013). An intellectual disability has be defined by the World Health Organisation (2018) as a significantly reduced ability to understand new or complex information and to learn and apply new skills (impaired intelligence). This results in a reduced ability to cope independently (impaired social functioning) and begins before adulthood, with a lasting effect on development. Due to the complexity of health needs that people with ID experience there is a need for more frequent involvement with health care services when compared with the general population (Hosking et al., 2017). Advances in health care and technology have improved the life expectancy of young people with complex ID (Scottish Government, 2013; --- Background In many countries the physical health needs of children and young people with ID are met through mainstream primary care and paediatric services, while their mental health and behavioural needs are addressed in child and adolescent mental health services (Shooshtari et al., 2017). Once an adult, care provision becomes more disparate and is often managed in a range of specialties reflecting specific body system disorders such as respiratory disorders, gastro-intestinal disorders and neurology (Cooper et al., 2015). Reiss et al. (2005) and Davies et al. (2011) highlight different philosophies between paediatric and adult services; characterising the former as family-focussed, providing developmentally-appropriate care with significant parental involvement in decision-making. In contrast, adult services are described as patient-focussed, often requiring autonomous skills, which have an impact on the decision-making process, consent and family involvement for patients with ID. Transition can be defined as "a purposeful, planned process that addresses the medical, psychosocial and educational/vocational needs of adolescents and young adults with chronic physical and medical conditions as they move from child-centred to adult-oriented health care systems." (Department of Health, 2006: 14). --- Accepted Article This article is protected by copyright. All rights reserved. Effective transition for young people with ID starts early and demands commitment and support from multi-disciplinary team, including health care professionals who are aware of and responsive to the individual's health and emotional needs and deliver services that are developmentally appropriate (Young-Southward et al., 2017a). Failure to ensure smooth transition can lead to poor experience of adult services, including lack of specialty care, inadequate follow-up, limited access to newer therapies and inferior management of co-morbid conditions (Camfield et al. 2011;Young-Southward et al., 2017a). Although the need to support young people transitioning from paediatric to adult health services has been acknowledged, many people with ID continue to experience poor transition management. Nurses have previously been suggested as potentially instrumental to transition management and practice development (Betz, 2007;2013), however research addressing these issues is scarce. --- THE REVIEW --- Aims The aims of this review were to explore issues related to health care transitions for young people with ID and the policy and nursing practice responses necessary to address their individual and distinct needs. The specific questions addressed were: 1. What are the transition experiences of young people with ID and their families? 2. What are the transition experiences of professionals involved in meeting the health needs of young people with ID and their families? 3. What are the policy and nursing practice responses required to address individual care and support needs at the point of transition from child health to adult health services? --- Accepted Article This article is protected by copyright. All rights reserved. --- Design --- Search methods The systematic review included empirical studies that adopted quantitative, qualitative or mixed research methods. A subject librarian was consulted to support the literature search process. The databases used were AMED, ASSIA, CINAHL, MEDLINE, PsycINFO, PubMed and Science Direct Sociological Abstracts. Search terms included: transition* AND "intellectual disab*" or "developmental disab*" or "cognitive disab*" or handicap or "learning disab*" or retardation AND health or healthcare or "health care" or care or "health service*" or paediatrics or "children service*" or "adult service*" or nurs*. The papers were published from January 2007 to December 2017. The inclusion criteria were limited to academic journals, peer reviewed empirical studies written in English and included young adults with ID who had transitioned from child into adult health care services. Papers that addressed health transitions for other patient groups, such as those with diabetes and asthma or young adults with a learning difficulty were excluded. --- Search outcomes The PRISMA process for reporting the results of the searches was used (Moher et al. 2015) (Figure 1). The searches revealed 637 cumulative hits across all the databases. These were screened for relevance and duplicates and 559 were removed. Following review of titles and abstracts, a total of 78 full text articles were assessed against the following eligibility criteria: (i) addressing transition from paediatric to adult health services; and (ii) the sample included individuals with ID. A further 67 papers were excluded and of the excluded papers, the main reasons were that the study sample did not focus exclusively on young people with ID or address transition from child to adult health services. One further paper was identified through hand searching of reference lists, resulting in a total of 12 studies included for full review and synthesis. All included studies were from peer reviewed journals with impact factors ranging from 0.36-5.067 (Table 2). --- Accepted Article This article is protected by copyright. All rights reserved. --- Quality appraisal The Critical Appraisal Skills Programme (CASP) tools were used as an evidence-based framework to review the papers (Critical Appraisal Skills Programme, 2013). A range of questions were systematically applied to each of the studies (Table 1). Individual questions were scored 0, 1 or 2 out of a possible total score of 20 points. A score of 0 was given if the paper contained no information, 1 if there was a limited amount and a score of 2 indicated that the question was fully addressed (Rushbrooke, Murray & Townsend, 2014). Two members of the research team (MB and JM) independently rated each paper and then compared results and a consensus score was agreed for two where there had been a different result. Papers demonstrating high quality, with a score of 17 or more, was achieved by eight of the 12 studies (Davis et al., 2011;Barron et al., 2013;Bindels de Heus et al., 2013;Jensen & Davis 2013;Kuchenbuch et al., 2013;Schultz 2013;Okumura et al., 2015;Young-Southward et al., 2017b). Two studies achieved a moderate score of between 14 and 16 (Woodward et al., 2012;Rehm et al., 2013). Two studies achieved a lower score of 13 or less (Bhaumik et al., 2011;Camfield et al., 2011). The main reasons for these lower quality assessment scores included limited detail regarding the statement of aims, recruitment strategy, ethical considerations, research relationships or the quality of data analysis. Following a rigorous review against the inclusion criteria and the CASP rating by the research team all 12 studies were deemed suitable for inclusion in the final systematic review. --- Data abstraction The 12 studies that addressed the study aims are detailed in Table 2. They were undertaken across a range of countries including France (N=1), Netherlands (N=1), United Kingdom (UK) (N=3), Canada (N=1) and USA (N=6). The sample sizes ranged from 14-214 participants. --- Accepted Article This article is protected by copyright. All rights reserved. A total of 7 studies used quantitative methods: cross-sectional design N= 6 (Camfield et al., 2011;Woodard et al., 2012;Barron et al., 2013;Bindels-de Heus et al., 2013;Kuchenbuch et al., 2013;Young-Southward et al., 2017b) and longitudinal, observational cohort design N=1 (Jensen and Davis, 2013). Four studies employed qualitative methods: interpretative design N=1 (Davies et al., 2011), ethnography N=1 (Rehm et al., 2012) and grounded theory N= 2 (Schultz et al., 2013;Okumura et al., 2015). Mixed methods (cross-sectional and grounded theory approach) were employed in one study (Bhaumik et al., 2011). A range of data collection methods were used including surveys, questionnaires, interviews and validated measures. The latter fell into two main categories; (i) validated measures widely used and recognised in previous research studies; (ii) those developed specifically for use in the particular transitions study. --- Synthesis It was the initial intention to undertake a meta-analysis of the research studies, however following extraction and critical analysis of the findings this approach was not possible. This was due to the range of designs employed and the different sample sizes. Therefore, a narrative review was undertaken using recognized guidelines and involved a detailed systematic review of the individual papers and synthesis of the key findings (Popay et al. 2006). The findings were grouped into concepts to allow for contrasts and comparisons to be made across and between the themes and studies. The emergent themes were systematically identified across all the studies and coded individually and then as a group by the research team (Caldwell et al. 2011). --- RESULTS The purpose of this narrative review is to present an analysis of the findings from the existing studies to highlight the experiences of young people with ID and their carers at the point of transition between child and adult health services and emphasise areas for policy and nursing practice development. It was notable in the studies that the role of nurses was not always explicit; however, from the emergent --- Accepted Article This article is protected by copyright. All rights reserved. themes it has been possible to identify the potential implications for nursing, which are highlighted in the discussion. Four main themes were identified, along with several sub-themes: 1. Becoming an adult: Progression towards self-management, balancing autonomy and parental involvement, changing expectations, capacity and perception of unnatural changes. 2. Fragmented transition process and care: poor preparation and planning, lack of information, lack of lead agency and coordination, unplanned transfer, loss of information, gaps in follow-up, no holistic overview in adult services, falling between the gaps of services, incomplete or delayed transition. 3. Parents as advocates in emotional turmoil: Parents as advocates fighting for services, a maze of information, parents' resourcefulness as the driver for transition, a sense of loss and rejection, fear of the unknown, reluctance to "let go". --- Making transitions happen: Early initiation and preparation for transition, identifying a lead agency, outlining responsibilities, parent-provider relationships, improved joined and multiagency working, effective information sharing, adequate follow-up, transition coordinator, nursing involvement Theme 1: Becoming an adult How young people with ID are supported to start assuming some responsibility and make decisions about their health care as they transition into adult health services was recognised as requiring extensive planning and support (Bhaumik et al., 2011;Rehm et al., 2012;Schultz 2013;Okumura et al., 2015). Progression towards self-management and balancing autonomy and parental involvement were highlighted as challenging in the context of ID (Rehm et al., 2012;Kuchenbuch et al., 2013). This change of expectations can be an anxious time for both young people and parents, who had been used to being at the centre of the decision-making process (Okumura et al., 2015). Furthermore, transition to adult-oriented health care might feel unnatural to parents of young people with complex ID, who will never develop beyond a young child's developmental age and reach autonomy (Bindelsde Heus et al., 2013). In the US, which operates an insurance-based health service, becoming an adult was seen to have important financial implications for the health care provider, with reports of different total annual charges in paediatric and adult-focused care (Jensen and Davis, 2013) and incentives to retain young people in paediatric services for longer (up to mid-20s) where health insurance policies supported this (Rhem et al., 2012). --- Theme 2: Fragmented transition process A general sense of dissatisfaction with the transition process was found across the studies included in this review, with an exception of one. Kuchenbuch et al., 2013 found that families of young adults with Dravet syndrome reported a positive experience of transition from paediatric to adult health service with no reported gap in the process. However, this could be because of the study focusing on a single condition of epilepsy, where a clear transition route to adult neurology existed, without consideration for complex co-morbidities. Families frequently reported poor transition preparation, lack of clear information on the process, its commencement and available support (Camfield et al., 2011;Davies et al., 2011;Bindels-de Heus et al., 2013;Schultz et al., 2013). Difficulties with identifying a lead agency and the absence of coordinated, holistic and life-course planning often resulted in poor assessment processes, unmet needs in many areas as well as difficulties with accessing services (Woodward et al., 2012;Bhaumik et al., 2011, Bindels-de Heus et al., 2013;Barron et al., 2013). There was also little evidence of multiagency and joint working considering a wider spectrum of needs including employment, day activities and social opportunities (Rehm et al., 2012, Bindels-de Heus et al., 2013). In contrast to a planned transition, the 'transfer' to adult health care was often sparked by a crisis or 'ageing out' of the system due to the terms of insurance policies (Schultz, 2013;Camfield et al., 2011). In turn, this carried a risk of essential medical history and information being lost, resulting in --- Accepted Article This article is protected by copyright. All rights reserved. inappropriate management of medical conditions at the point of transition and beyond (Woodard et al., 2013;Young-Southward et al., 2017b). In some cases, significant gaps in ongoing follow-up after the last paediatric appointment did occur (Davies et al., 2011;Kuchenbuch et al. 2013), resulting in young people and their families turning to emergency departments for care (Davies et al., 2011). An incomplete or delayed transition to adult services was also common (Rehm et al., 2012;Bindel-de Heus et al., 2013) and associated with the need for reinstatement of specialist input by paediatric services (Jensen and Davis, 2013) or difficulties in finding equivalent adult physicians willing to care for severely disabled and complex patients (Camfield et al., 2011). Lack of a paediatrician-like, holistic role in adult services and separation of care into individual specialties across hospital sites (Camfield et al., 2011;Bindels-de Heus et al., 2013) often placed the responsibility of co-ordinating assessments, treatments and reviews of the young person's health needs on the general practitioner. As they tend to have limited involvement with the individual during their childhood and adolescence (Schultz et al., 2013) and often lack awareness of the health needs of people with ID (Bhaumik et al., 2011), this resulted in a sense for families of 'falling between the gaps' of services (Davies et al., 2011). In some areas medical care was provided by psychiatrists with a specific focus on mental health, which left some young people without general medical involvement beyond primary care (Young-Southward et al., 2017b). --- Theme 3: Parents as advocates in emotional turmoil The uncoordinated, poorly planned and inconsistent transition process often forced parents to take on a role of advocates and guardians, with a deep sense of having to 'fight' for appropriate care in adult services (Schultz, 2013;Okumura et al., 2015). Parents acted as 'information gatherers' navigating a maze of absent, incorrect or conflicting information, leading to a sense of frustration and confusion created by uncoordinated agencies and lack of transparency regarding available resources (Schultz, 2013;Okumura et al., 2015;Bhaumik et al., 2011). When appropriate processes were not in place, or --- Accepted Article This article is protected by copyright. All rights reserved. discontinuity between services occurred, transition was often facilitated by parents' resourcefulness, family support and ability to establish new relationships in the adult health care setting (Davies et al., 2011). Several studies highlighted the emotional impact of transition, which was often described as a sense of loss, abandonment or rejection by health care professionals and having to 'let go' of trusting relationships with professionals and services (Bhaumik et al., 2011;Davies et al, 2011;Schultz 2013;Young-Sutherland et al., 2017b;Camfield et al., 2011;Bindels de-Heus et al., 2013). Families rarely felt ready to move to adult-oriented health systems and entered the transition period with little or no information, which created uncertainty with regards to the process, future care and source of medical insurance (Camfield et al., 2011;Davies et al., 2011;Rehm et al., 2012;Bhaumik et al., 2011). A fear of the unknown, losing services and having to build a new network of support with professionals was often expressed (Bhaumik et al., 2011;Davies et al., 2011;Schultz, 2013). These feelings were sometimes further reinforced by stories of poor transition experiences of other families and a desire to remain in child service was often expressed to avoid what was viewed as leading to potentially poorer health outcomes and loss of much needed support (Camfield et al., 2011;Davies et al., 2011;Woodward et al., 2012;Bindels-de Heus et al., 2013;Jensen & Davis 2013;Kuchenbach et al., 2013). --- Theme 4: Making transitions happen The reviewed studies highlighted transition as a multidimensional, multiagency process which needs to address all areas of adult functioning and account for interactions between multiple sectors in the environment (Bhaumik et al., 2011;Schultz, 2013). Recommendations for effective transition included early initiation of the process (Davies et al., 2011;Bindels-de Heus et al., 2013;Bhaumik et al., 2011) and identifying a lead agency to ensure that policies, --- Accepted Article This article is protected by copyright. All rights reserved. procedures and care pathways that account for the often-complex health needs of young adults with ID are in place (Camfield et al., 2011;Davies et al., 2011;Barron et al., 2013). Quality of transition preparation was considered paramount to the individual and family's experience (Kuchenbuch et al., 2013) and should include a robust assessment of needs (Barron et al., 2012), including legal requirements such as advance care planning, health care power of attorney and guardianship (Woodward et al., 2012). There were calls for clear definition of responsibilities for each professional, improved provision of written information and education for young people and their families (Camfield et al., 2011) and the identification of a key professional to coordinate the process (Davies et al., Bhaumik et al. 2011). The role of a transition coordinator was seen as beneficial in ensuring that care needs were met, essential information communicated, and a formal handover of care undertaken (Bindels-de Heus et al., 2013). The coordinator often took on an advocacy role and was seen as an important bridge between the young person, their family and all agencies involved (Davies et al., 2011;Rhem et al., 2012;Bhaumik et al., 2011;Okumura et al., 2015). Better working relationships between child and adult health services, for instance through joint transition clinics could aid the development of standards of care or transition care pathways (Camfield et al., 2011), promote effective coordination and information sharing (Bindels-de Heus et al., 2013;Kuchenbuch et al., 2013) as well as help alleviate patient and family anxiety and clinician's concerns about the quality of adult health care (Camfield et al., 2011). --- Accepted Article This article is protected by copyright. All rights reserved. Adequate follow-up and ongoing involvement of paediatricians after transition was considered helpful and influenced overall satisfaction with the transitions process along with the stability of the health conditions experienced by the young adult (Kuchenbuch et al., 2013, Bindels-de Heus et al., 2013). Determining transition outcomes measure was seen as necessary for addressing individual needs and assessing the effectiveness of the process (Bhaumik et al., 2011;Barron et al., 2013). Family and patient-centred approach to transition and service provision, with strong parentprovider relationships and acknowledgement of parental expertise through their involvement in decision-making process were viewed as important for enabling transition for people with ID (Bindels-de Heus et al., 2013;Schultz, 2013). Providing parents access to transparent and accurate information, including the young person's medical records (Schultz, 2013) and assistance to navigate and manage available resources (Okumura et al., 2015) could help use parents' networking and advocacy skills as well as improve their satisfaction with the transition process (Bhaumik et al., 2011;Bindels-de Heus et al., 2013). Nurses were highlighted as having the potential to play an instrumental role in transition planning and implementation due to their holistic, life-course perspective that includes family and wider psychosocial needs of the individual (Schultz, 2013;Rehm et al., 2012). Acting as care providers, coordinators and consultants for young people with chronic health and developmental conditions, they were often seen as best suited to address unmet needs (Rehm et al., 2012;Woodward et al., 2012). Nurses were recognised for their expert knowledge (Davies et al., 2011) and ability to easily adopt new tools and clinical guidelines to assist young people with ID and their families to undertake planning of transition and future care --- Accepted Article This article is protected by copyright. All rights reserved. (Rehm et al., 2012). They were also seen as well situated to develop and implement a transition program that acknowledges the interrelationship between the individual, their family and the environment (Schultz, 2013). 2011) describe children with medical complexities as 'an emerging population' whose needs are not easily met by existing health care models. Advances in health care have significantly improved life expectancy leading to increasing numbers of people with complex intellectual and developmental disabilities moving through childhood, adolescence and into adulthood (Ryan et al., 2014;Jajour 2015). This review reveals that current services are often ill-prepared to respond to these multifaceted health needs of young people with ID at the point of transition from paediatric to adult health care (Hughes-McCormack et al., 2018). The findings are in keeping with wider evidence pointing to poor experience of health transitions for young people with a range of chronic conditions (Heery et al., 2015;Sheehan et al., 2015;Singh and Tuomainen, 2015;Solanke et al., 2018) and a lack of research to evaluate focussed interventions (Campbell et al., 2016). --- DISCUSSION --- Cohen et al. ( The findings of this review can be interpreted within the framework of the middle-range Transition Theory (Meleis et al., 2000), which recognises transitions as complex processes occurring simultaneously in multiple dimensions. It highlights transition as core to nursing practice, with nurses acting as the primary caregivers acting as facilitators at this vulnerable time. Consistent with the Transition Theory framework (Meleis et al., 2000), this review reiterates the importance of awareness, engagement, adapting to change and difference, time span and critical points and events as being core properties of health transitions from paediatric to adult health services. Knowledge of the transition process was seen to influence both the carers' and healthcare professionals' level of engagement and --- Accepted Article This article is protected by copyright. All rights reserved. carers' unmet or divergent expectations towards the adult health system, which had an impact on their ability to adapt to the new environment. Anticipation, distress and confusion are characteristic signs that precede stability and nurses are in a position to provide critical input, knowledge and experience to facilitate the transition milestones. Furthermore, personal, community and societal conditions such as the carers' ability to act as an advocate or access to information and support is seen to further facilitate or inhibit the transition process and health outcomes (Meleis et al., 2000). The implications and relevance of the findings of this review for nursing are considered from policy, practice and educational perspectives along with recommendations for future research. --- Policy The specific needs of young people with an ID and their families and carers during transition must be acknowledged at a strategic level through inter-agency policy development recognising the interrelationships between health, education and social services. Such policy should be informed by existing quality standards and models that focus on processes to embed a co-ordinated approach to planning, centred on clear identification of roles and responsibilities of each agency and key --- Accepted Article This article is protected by copyright. All rights reserved. Both approaches mirror recommendations from this review in relation to early initiation of the transition process (Davies et al., 2011;Bindels-de Heus et al., 2013;Bhaumik et al., 2011), identifying lead professionals (Camfield et al., 2011;Davies et al., 2011;Barron et al., 2013, Bhaumik et al., 2011) and post transition follow-up (Kuchenbuch et al., 2013, Bindels-de Heus et al., 2013) Policy should support efficient, timely, gradual approaches to transition, based on person-centred, needs-led services that promote continuity. The role of family carers during transition planning and processes must also be addressed (Aldiss et al., 2015), including the potential of parent-led peer support groups acting as an information point with regards to options and resources in adult health services (Kingsnorth et al., 2011). This supports the Transition Theory's outcome indicators of "feeling connected" to the community, reliable information and knowledgeable and supportive healthcare professionals (Meleis et al., 2000). --- Nursing Practice The review revealed numerous examples of separate and compartmentalised adult and child services, which hindered the health transitions of young people (Davies et al., 2011). Operating in silos could be counterbalanced by the development and application of shared models of practice and integrated care pathways from paediatric services to adult health care settings (Young-Southward et al., 2017a). Nurses were often identified in the research studies as playing an instrumental role in both the development and implementation of these kinds of approaches (Woodward et al., 2012;Schultz, 2013, Rehm et al, 2012). However, Betz (2013) argues that nurses in paediatric and adult services need to raise their profile and collaborate more fully with interdisciplinary colleagues to help shape the best quality transition practices for people with ID. Joint paediatric and adult transition clinics, involving specialist nurses, could be a way to share skills and information as well as relieve parents' anxieties regarding the move to an adult-oriented health care (Camfield and Camfield, 2011;Crowley et al., 2011). --- Accepted Article This article is protected by copyright. All rights reserved. There is also a need to understand and evaluate the contribution of nursing roles that sit outside mainstream paediatric and adult nursing. School nurses have specialist graduate level education in community health and the health needs of school-aged children and young people (Royal College of Nursing, 2017) and exist in many countries in North America, Europe, Asia and Australasia (Maughan, 2016). They are increasingly recognised as having a crucial role in care co-ordination and planning for children with complex needs (McClanahan and Weismuller, 2015) and should be integral to transition planning. Whilst there have been examples of nurses with specialist qualifications in ID being appointed in the US to transition co-ordinator posts (Betz and Redcay, 2005) such roles often project based and not sustained. Many UK health services are implementing the role of intellectual disability liaison nurses as a way of operationalising person-centred health care in general hospital settings (Castles et al., 2015;MacArthur et al., 2015;). This role is recognised as contributing to family support, more effective communication between services and individual clinicians, proactive care as well as enabling inclusive decision-making and appropriate levels of autonomy (Brown et al., 2016). There are lessons to be learned from this type of liaison role that could be applied more comprehensively where specialist nurses are instrumental to transition planning. --- Nurse Education The recommendations emerging from this review have implications for pre and post registration education of all nurses, both in terms of raising awareness of the unique health needs of young people with ID and the potential for deterioration in some health outcomes and negative experiences at the transitions of health care (Young-Southward et al., 2017a). According to the Transition Theory, raising awareness of transition and associated issues are paramount to healthy transition outcomes (Meleis et al., 2000). There is recognition of the importance of developing meaningful learning approaches for undergraduate nurses (Trollor et al., 2018), particularly where this involves direct contact with people with ID. In the UK the recently published proficiency standards for registered nurses (Nursing and Midwifery Council, 2018) emphasise the leadership role for nurses in coordinating and managing the complex nursing and integrated care needs of people at any stage of --- Accepted Article This article is protected by copyright. All rights reserved. their lives, across a range of organisations and settings. Curriculum planning, teaching and practice competencies based on these standards will need to include the principles of partnership, collaboration and interagency working, all of which have been highlighted in this review as key components of transition planning. Focussing on the health needs of young people with an ID at the time of transition must be central to both theory and practice elements of undergraduate education of all nurses, given their likely involvement in care of such individuals in a wide range of specialties and care settings. In addition to highlighting essential components for undergraduate nursing education, this review identifies important professional and ethical issues for inclusion in continuing professional development programmes for all nurses. These include communication and legal issues related to capacity and consent (Sowney & Barr, 2007), the need for reasonable adjustments to support shared decision-making and meet specific health needs (Tuffrey-Wijney, 2014;MacArthur et al., 2015) and the concept of family-centred care (Coyne, 2015). --- Limitations There are several limitations of this review, reflecting methodological issues and gaps in the existing literature. Due to a wide range of designs and mainly qualitative or mixed-methods employed by the studies, a meta-analysis was not possible; a systematic narrative synthesis was conducted. The full extent of nursing involvement in the transition process was difficult to assess due to the variety of research questions of the individual studies. This review focused primarily on health transitions, however several the studies also explored experiences of other transitions occurring simultaneously, including moving to adult social care services or accommodation and these have not been explicitly integrated in this review. Although the reviewed studies were conducted in several different countries, with divergent health and health insurance systems, the primary findings and recommendations appear to be generalisable and transferable to nursing practice in different healthcare settings in the UK and internationally. --- ccepted Article This article is protected by copyright. All rights reserved. Access to health and social care services 1. Integrated referral systems for health and care services need to be developed. --- 2. Clear pathways of care need to be in place with monitoring of individual and system outcomes. --- 3. There is a need to examine different healthcare access patterns for South Asian populations. --- ccepted Article This article is protected by copyright. All rights reserved. with intellectual disabilities experience significant health problems. --- 2. The transition between child and adult services must ensure that existing health and emerging problems identified and managed. --- Accepted Article This article is protected by copyright. All rights reserved. Schultz, R. J. (2013). Parental experiences transitioning their adolescent with epilepsy and cognitive impairments to adult health care. Journal of Pediatric Health Care, 27(5), 359-366. https://doi.org/10.1016/j.pedhc.2012.03.004 Scottish Government. (2013). The keys to life: improving quality of life for people with learning disabilities. Edinburgh: Scottish Government. Sheehan, A.M., While, A.E., Coyne, I., (2015). The experiences and impact of transition from child to adult healthcare services for young people with Type 1 diabetes: a systematic review. Diabetic Medicine, 32(4), 440-458. https://doi.org/10.1111/dme.12639 Shooshtari, S., Brownell, M., Mills, R.S., Dik, N., Yu, D.C., Chateau, D., Burchill, C.A. &Wetzel, M. (2017). Comparing Health Status, Health Trajectories and Use of Health and Social Services between Children with and without Developmental Disabilities: A Population-based Longitudinal Study in Manitoba. Journal of Applied Research in Intellectual Disabilities, 30(4), 584-601. https://doi.org/10.1111/jar.12253 Singh, S.P. & Tuomainen, H., (2015). Transition from child to adult mental health services: needs, barriers, experiences and new models of care. World Psychiatry, 14(3), 358-361. https://doi.org/10.1002/wps.20266 Solanke, F., Colver, A., McConachie, H. & Transition

To examine the experiences of health transitions for young people with intellectual disabilities and their carers and identify the implications for nursing practice. Design: A systematic review and critical appraisal of qualitative, quantitative and mixed methods studies.

a systematic review. Diabetic Medicine, 32(4), 440-458. https://doi.org/10.1111/dme.12639 Shooshtari, S., Brownell, M., Mills, R.S., Dik, N., Yu, D.C., Chateau, D., Burchill, C.A. &Wetzel, M. (2017). Comparing Health Status, Health Trajectories and Use of Health and Social Services between Children with and without Developmental Disabilities: A Population-based Longitudinal Study in Manitoba. Journal of Applied Research in Intellectual Disabilities, 30(4), 584-601. https://doi.org/10.1111/jar.12253 Singh, S.P. & Tuomainen, H., (2015). Transition from child to adult mental health services: needs, barriers, experiences and new models of care. World Psychiatry, 14(3), 358-361. https://doi.org/10.1002/wps.20266 Solanke, F., Colver, A., McConachie, H. & Transition Collaborative Group (2018). Are the health needs of young people with cerebral palsy met during transition from child to adult health care?. Child: care, health and development, 44(3), 355-363. https://doi.org/10.1111/cch.12549 --- Accepted Article This article is protected by copyright. All rights reserved. Sowney, M., & Barr, O. (2007). The challenges for nurses communicating with and gaining valid consent from adults with intellectual disabilities within the accident and emergency care service. Journal of Clinical Nursing, 16(9), 1678-1686. https://doi.org/10.1111/j.1365-2702.2006.01642.x Trollor, J.N., Eagleson, C., Turner, B., Salomon, C., Cashin, A., Iacono, T., Goddard, L. & Lennox, N., (2018). Intellectual disability content within pre-registration nursing curriculum: How is it taught?. Nurse Education Today. 69, 48-52. https://doi.org/10.1016/j.nedt.2018.07.002 Tuffrey-Wijne, I., Goulding, L., Giatras, N., Abraham, E., Gillard, S., White, S., Edwards, C., Hollins, S., (2014). The barriers to and enablers of providing reasonably adjusted health services to people with intellectual disabilities in acute hospitals: evidence from a mixed-methods study. BMJ open, 4(4), e004606. http://dx.doi.org/10.1136/bmjopen-2013-004606 Woodward, J. F., Swigonski, N. L., & Ciccarelli, M. R. (2012). Assessing the health, functional characteristics and health needs of youth attending a noncategorical transition support program. Journal of adolescent health, 51(3), 272-278. https://doi.org/10.1016/j.jadohealth.2011.12.016 World Health Organisation (2018) Definition: intellectual disability. http://www.euro.who.int/en/health-topics/noncommunicable-diseases/mentalhealth/news/news/2010/15/childrens-right-to-family-life/definition-intellectual-disability [Accessed --- Accepted Article This article is protected by copyright. All rights reserved. --- CONCLUSION The findings of this review highlight that transition from paediatric to adult health services is a vulnerable time for both individuals with ID and their families and carers, who continue to have multiple, complex needs. These are often left unrecognised and unmet by existing services, which are often ill-prepared to respond to the increasing life expectancy and medical complexity of this population of young adults. Parents often take on roles of advocates, while experiencing emotional turmoil and have limited access to reliable information and support. This review reveals that nurses can play a significant role at the time of transition and beyond in ensuring that the transition process is managed in a more person-centred and family-centred manner and thus limit the negative impact on health and wellbeing of people with ID and their carers. Changes at the policy, nursing practice and education levels are needed to ensure an improvement to transition experiences. Further research is required to further identify nursing contributions, best practice and education needs in relation to transition from child to adult health services for young people with ID. Transition intervention and outcome studies, considering experiences, health and wellbeing of both carers and people with ID are also limited and require further research input. --- Conflict of Interest statement No conflict of interest has been declared by the authors. --- Author Contributions: All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE*): 1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; --- Accepted Article This article is protected by copyright. All rights reserved. the care and support provided by paediatricians and wanted it to continue. They were critical of their preparation for the transition. --- 2. The transitioning process should to start at an early stage with provision of information about what is involved. --- 3. Joint consultation clinics between paediatric and adult health services are recommended to improve coordination, communication and information sharing. --- 8. Jensen The transition process needs to include one follow up appointment within paediatric neurology.

To examine the experiences of health transitions for young people with intellectual disabilities and their carers and identify the implications for nursing practice. Design: A systematic review and critical appraisal of qualitative, quantitative and mixed methods studies.

Introduction The growing diversity of the workforce today presents employers with both opportunities and challenges. As a result, the organization is enriched by the diversity of beliefs, opinions, values, and attitudes. Despite this, conflicts will eventually result from these differences. It expresses the struggles between at least two interdependent parties with seemingly incompatible goals, scarce resources, and interference on the other party's part that prevents them from accomplishing what they are trying to accomplish. Katz and Kahn [1] define conflict as a particular type of interaction characterised by obstruction, struggles, constraints, and problems, as well as resistance to these efforts or retaliation against them. Organizational conflict is typically perceived as opposed to cooperation rather than an open dialogue between two or more organizational groups. Negative manifestations prevent communication and break trust, which prevents cooperation [2]. In fact, Rose et al. [3] acknowledged that the conflict continues both in social circles and in professional interactions. Apart from that, Henry [4] and Hotepo et al. [5] also mentioned that workplace conflict is an unpleasant reality for the organization as long as there is competition for jobs, resources, power, recognition, and stability. Several researchers identify that organizational conflict at work can result from various things, such as poor leadership, lack of commitment, personality conflicts, poor coordination, and poor communication [6][7][8]. Researchers have noted that conflict can result in stress, absenteeism, and turnover [9,10]. De Dreu and Weingart [11] has proved empirically that relationship conflict adversely affects work-related and individual outcomes. Conflicts within organizations reduce individuals' ability to work as a team since they spend more energy arguing rather than solving tasks. In a separate study, it was discovered that there was a strong relationship between organizational conflict and lower levels of innovative behavior [12], higher turnover intentions [13], and lower employee trust levels [14]. Although it is always viewed as negative phenomenon, the existence and importance of organizational conflict has been deemed to be inherent and essential for organizational functioning. In fact, not all conflicts are destructive because some constructive and managed conflict increases the understanding and productivity of members of an organization. As Pace [15] asserts, conflict-free organizations are impossible and will never exist as long as men have to live together and work together. Organizational conflict is critical for understanding central phenomena and performing necessary functions [16]. Conflict in the workplace allows managers to reassess their roles and goals. As a result, it promotes healthy conversations among employees and improves an organization's overall productivity and performance. Organizations benefit from cooperative relations because they enable conflict resolution at all levels, primarily through mutual trust between parties [17]. There is evidence that conflict plays a positive role in the continuation of organizations by triggering change [18] and innovation [19]. Conflicts can contribute to long-term organizational development and sustainability [20], challenging conventional wisdom. The impact of diversity on an organization can be either positive or negative [21]. However, the more dissimilar an individual is from other group members on a given demographic characteristic, the more likely there is a conflict in the relationship [22]. As a nation with a multiracial culture, Malaysia can be a powerhouse if it fulfills equal racial rights in every aspect of governance. It will enable it to sustain its stability and progress. There is a possibility that this condition can either be seen as a risk or as an opportunity. Any organization that refuses to recognise both risks and opportunities will probably fail in the future. There is no doubt that corporate culture is considered a very complex issue to discuss in the workplace. It is because of the psychological and social influences that are present in the workplace. Management of organizational conflict in Malaysia is, therefore, a challenging task. In addition to regular organizational conflict, they also experience diverse organizational conflict. It is crucial to determine which conflict management approach is best for the Malaysian context in order to reduce the risk of conflict, address it before it worsens, and spend less time and money doing so [23,24]. So, in order to improve organizational outcomes through effective conflict management approaches, the article seeks to investigate how Malaysia's organization and its employees managed workplace conflict. The research will utilise a systematic literature review technique to assess the most popular conflict management strategies employed by local organizations. --- Literature review --- Organizational conflict Organizational conflict is defined as "organizational rift" (a lack of understanding or common sense or disagreement caused by the perceived and actual conflict between needs, interests, values and personalities of those who work together to achieve success). Organizational conflict is another name for workplace conflict. Conflicts occur when two or more members of an organization engage in a manner that is contrary to each other's views. These opinions may be expressed as regards any specific activity or task carried out by the organization. Essentially, organizational conflict refers to the results of human interaction that starts with a member of an organization identifying its values, attitudes or purposes as incompatible with those set out by it and expects its members to obey them [25]. Conflict is inevitable in an organization because of the extensive social interaction that occurs there, but how it is handled determines whether it will have a positive or negative outcome. Conflicts may be functional, although they're usually deemed dysfunctional; conflict can have both good and bad effects. If it facilitates creative thinking and clarification, this may be beneficial. This also includes the development of people's ability to cope with other people's differences. Conflict within organization is not unusual because they create or provide opportunities for change and resolution between the aggrieved parties for the benefit of employees and the organization [26]. However, some scholars argued that conflict is not necessarily related to the differences in the perception ends. It can also happen when people disagree over means but have similar goals in mind. From an end's perspective, there has been a lot of focus on the theories underlying conflict and how it arises. Jehn [27], this could not have been the case in every situation because it was likely that conflict would occur as a result of disagreement regarding how work should be managed. One commonly used approach to defining this phenomenon is the classification of conflicts on the basis of means and ends, but other causes of conflict should also be taken into account. As a general rule, Putnam and Poole [28] argue that the description of conflict must be considered in relation to interactions with one another. Individuals or groups are not compatible with each other, but the requirements of their work force them to coordinate with each other. In other words, it illustrates the existence of interdependence. However, there is a propensity for recurrent arguments because of incompatibility for factors like personally, emotionally, or socially. Some studies have looked into this idea as well. For instance, Almost et al. [29] identified conflict as being present due to the group members' personal and environmental influences. Therefore, this study adduces that organizational conflict can be inferred as a coherent behavioral and perceptual framework of organizational members driven by a sense of disadvantage or incompatibility with others. --- Conflict management strategy Conflict in the workplace is inevitable; but how conflict is managed may have a bearing on its outcome. How conflicts are handled will determine the scale and intensity of future conflicts. Conflict management effectiveness fosters enthusiasm, boosts morale, and stimulates personal and organizational development. On the other hand, when conflict resolution is ineffective, it can lead to larger conflicts with devastating effects on the entire organization [30]. Effective conflict management requires the use of different styles depending on the conflict situation. For that reason, the biggest step in building a strategy for conflict management is to find out early on which sources of conflict are present and how they affect an organization [31]. The best way to manage conflict within an organization is to focus on strategies which will enhance constructive function in order to increase the efficiency of an organization; therefore, it is essential to identify all levels of conflict at organizational level, e.g., individuals, interpersonal or intergroup conflicts. A few of the early researchers [32] who took intrigued in conflict and conflict management styles include Follet (1926-1940) [33], Blake and Mouton [34] and Thomas [35]. Murewa and Guantai [33] who synthesized the type of conflict management, described that Follet [33] recommended three primary strategies for managing interpersonal conflicts: domination, compromise, and integration. She also suggested that organization could manage conflicts through avoidance and suppression strategies. Blake and Moutton [34] emphasized their conflict style according to the level of concerns for individuals and production. They asserted that interpersonal conflict can be managed based on the five styles, forcing, compromising, withdrawing, problem solving and smoothing. In contrast with Follet's strategy [33], they added forcing, solving and smoothing as part of conflict management resolution. At the same time, they hold compromise as best conflictual resolution. Thomas [35] proposed a two-dimensional framework for conflict management strategies based on the parties' assertiveness (fulfill their own concerns) and willingness to cooperate (more concerns on other's needs). At the same time, the following five conflict handling modes were supported by him; collaborating, accommodating, competing, avoiding and compromising. Aside from them, Rahim [36] proposed that interpersonal conflict could be handled using his five modes: integrating, obliging, dominating, avoiding, and compromising, all of which are based on how much a person cares about themself and the people they are in relationships with. Although Rahim modes included obliging, a style that Follet [33] had not considered, they were an extension of Follet [33]. A comparison of Thomas and Rahim's approaches shows that the two approaches have great similarities and are widely used by modern managers [37,38], the study will elaborate on the Rahim's five styles. The goal of a collaboration strategy is to meet the needs of the parties involved, particularly when the participants have important goals in common. The aim of one person or group to achieve their objectives is known as a competition strategy. In an organization, individuals and groups compete for limited resources, positions, recognition, and power, either fairly or to the detriment of other groups. John-Eke and Akintokunbo [32] claimed that, to prevent a highly competitive individual from exerting too much power, it is necessary to utilize external factors such as legal restrictions or social stigmas whenever they going too far. In cases where a dispute between management and employees regarding responsibilities is resolved before taking legal action, the bargaining process is commonly employed [39]. It gives all parties who have been wronged the opportunity to express themselves on an equal footing, without regard to who is in a higher position in the conflict. There is controversy surrounding the application of avoidance strategy in organizational conflict management. Abdullah [40] has acknowledged that it can have a detrimental effect on organizational effectiveness by creating undisclosed conflicts that may not be resolved promptly, leading to increased conflict and employee disapproval of management decisions. However, Ohbuchi and Atsumi [41] found that avoidance as a great strategy for collectivists, who are concerned with belonging to a group. They valued collectivistic and actively choose avoidance with the expectation that it will contribute to group harmony and relationships. Lastly, compromising style encourages on give and take, or a win-win condition which focuses to address each disputed party concerns. In this style, the concerned parties are willing to settle any differences in peace and harmoniously without furthering any conflict [42]. It entails finding the middle ground amongst individual or groups in the dispute that has common interest [43]. It is the most appropriate and best conflictual style as both parties gain something over the conflict. The style considers appropriate when involved parties are ready for mutual actions and agree to the mutual supremacies. --- Methodology --- Search strategy The RepOrting Standards for Systematic Evidence Syntheses (ROSES) protocol was used in the current study. It was specifically designed for systematic reviews and mapping in the management field [44]. The purpose of ROSES is to make sure that researchers offer the appropriate kind and amount of information. The authors created good research questions for the SLR by adhering to the review protocol. The three main sub-processes of systematic searching strategies are identification, screening (inclusion and exclusion criteria), and eligibility. After outlining the method used to ensure the quality of the articles to be examined, the authors move on to evaluate the chosen articles' quality. --- Formulating research questions This study developed its research question using PICo. It assists authors in identifying appropriate research questions for reviews [45]. PICo is based on population or Problem, Interest, and Context. This review focuses on three main aspects based on these concepts, namely organizational conflict management (population/problem), style/approaches (interest), and Malaysia (context). These concepts enable the authors to formulate their central research question: What are organizational conflict management approaches in Malaysia? --- Identification Identification entails looking for synonyms, related terms, and variations of the study's primary keywords, conflict management approach/style in Malaysia. The aim is to make the selected database searchable for more relevant articles as part of the review. The keywords were developed based on the research question [46], and they were identified using an online thesaurus, keywords suggested by experts, and keywords used in previous studies (Table 1). The authors expanded the existing keywords and developed thorough search strings using Scopus, Web of Science and Google Scholar (Table 1) using Boolean operators, phrase searches, truncation, wild cards, and field codes. These three databases could be the most crucial ones in a thorough literature review because they provide sophisticated search capabilities, comprehensiveness (indexing more than 5000 publishers), article quality control, and a multidisciplinary focus [44,47], including studies on management. Scopus, Web of Science, and Google Scholar databases produced 635 articles. ("organizational* conflict*" OR "organization* dispute*" OR "workplace* conflict*") ("manage*" OR "handle") ("style*" OR "approach*") --- Screening This study screened all 635 selected articles by choosing the criteria for articles selection which is done automatically based on the sorting function available in the database. Brereton et al. [48] suggested that the selection criteria are based on the research question. As it is almost impossible for the researchers to review all the existing published articles, Okoli [46] suggested that researchers determine the range of periods they can review. Therefore, the timeline between 2013 and February 2023 was selected as one of the inclusion criteria. Furthermore, to ensure the quality of the review, only articles published in a journal and credible conference proceedings are included. Moreover, only articles published in English are incorporated in the review to avoid confusion in understanding (Table 3). This process excluded 320 articles as they did not fit the inclusion criteria and removed 47 duplicated articles. The remaining 268 articles were used for the third process: eligibility. --- Eligibility Eligibility is the third process, where the authors manually monitor the retrieved articles to ensure all the remaining articles (after the screening process) align with the criteria. This process was done by reading the title and abstract of the articles. This process excluded 257 articles due to not using proper conflict management style theory, focus cultural factors rather than conflict management style, focusing on employee's perception of organizational conflict rather than conflict management style, focusing on factors of organizational conflict, focusing on the effect of organizational conflict towards the employee, and published in the form of a book chapter. Overall, there were only 11 selected articles. --- Results The three themes of the study emerged from an in-depth analysis of the chosen articles. These themes are integrating, compromising, and avoidance. These studies were conducted in Malaysian organizations, with the vast majority adopting the Rahim Conflict Management Style [49]. Intriguingly employees in Malaysia are less likely to choose an approach that avoids conflict. However, if foreigners from other countries are present (cross cultural) or if sensitive background such as religion, race and culture are involved, participants tend to use an avoidance style [50][51][52]. It can be said that Malaysians are respectful and attempt to avoid potential conflict by employing withdrawal style to maintain harmony and peace within organization. Therefore, it can be concluded from this study that Malaysians seek win-win solutions to ensure their comfort without hurting others. --- Authors Scope of study Findings Asyraf et al. [24] Conflict management style in public universities in Malaysia. Integrating and compromising styles were perceived to have higher value efforts of affective commitment towards the organization. Musah et al. [53] Conflict management style in the east and west petrochemical plants in Malaysia. Integrating and compromising styles augment functional outcomes and positively impact employee performance. Hamid and Bakar [54] Conflict management style in Teacher's Training Institute in Malaysia. The educators at the Teacher's Training Institute demonstrated that they favour the integrating and compromising style to overcome conflict, especially intergroup conflict. Ariffin et al. [55] Conflict handling style among employees at Eversafe Extinguisher Sdn Bhd. The findings reveal that employees in the company are more committed to integrating and compromising styles in resolving conflict. Mohd Kassim et al. [56] Conflict management style among bank employees in Malaysia. Bank employees with higher sensitivity to fairness issues tend to be integrative, obligated and compromising for conflict resolution. Izham et al. [57] Conflict management style and teacher's job satisfaction in Malaysia's Primary School. It was found that the headmaster used all types of conflict management styles (cooperating/integrating, adapting, compromising, bargaining and problem-solving). However, the most favourable is cooperating/integrating, which allows a winwin situation for both parties and makes employees feel appreciated. Johari et al. [58] Workplace conflict management style UiTM, Sawarak, public university in Malaysia. The UiTM lecturers, Sarawak, prefer collaborating's conflict management style to sustain professionalism and preserve harmony and unity in the organization. Sahban and Abbas [51] Conflict management style among Malaysia and Thailand employees in Top Glove Corporation. Malaysia's employees in Top Glove corporation favoured avoiding and compromising conflict style due to the cultural influence. Tabassi et al. [52] Conflict management style in the multicultural working environment in the construction industry in Malaysia. The findings advocate that avoiding conflict management will be adopted to improve team performance and coordination. Jamail et al. [59] The conflict management style of Generation Y Teachers in Malaysia. There is a high correlation between compromising and conflict resolution among Generation Y teachers, where they hope to achieve a mutual resolution that satisfies all parties involved. Ramayan et al. [50] Conflict management among students in Sunway University, Malaysia. Students use the avoiding style to overcome intercultural conflict regarding gender, race, religion and cultural issues. --- Discussion --- Integrating style Integrative style can be defined as a style that stresses high regard for both self and others distinguishes integrating style. It requires transparency, exchanging information, and examining differences to reach a mutually acceptable solution. It is linked to problem-solving, which can lead to innovative solutions. This style has effectively utilised various individuals' skills and knowledge to generate solutions, and it may be suitable for addressing strategic issues on objectives, policies, and long-term planning [60]. In Muhammad Asyraf et al. [24], 1200 questionnaires were distributed to the academic staff of public universities in Malaysia, and the results indicated that integrating style positively affects the respondents' commitment. It demonstrates that using an integrative style reduces the likelihood of negative behaviour and increases employee commitment to the organization. The results are consistent with Izham et al. [57], in that same academic setting, where teachers favour an integrative strategy to resolve conflict. The teaching staff hoped the principal would join them in promoting mutually beneficial interactions and peaceful conflict resolution. The teachers anticipated their principal would collaborate to promote win-win situations and peaceful conflict resolution. In this way, the teacher's job satisfaction can be ensured. The author also discovered that respondents have a high level of job satisfaction. It can be concluded that an integrative style improves task satisfaction, colleague satisfaction, and supervisor (principal) satisfaction. Even though some people may believe that the academic world is full of professionalism, there is a high likelihood that they will use a professional approach to resolve conflicts maturely. Nonetheless, a study by Ariffin et al. [55] in a Malaysian company demonstrated that Malaysians prefer integrative conflict resolution styles over others. Integrating style can strengthen employee commitment and increase employee-employer understanding. According to the analysis, Malaysians most frequently use the integrative conflict resolution style. It indicates that Malaysians probably hold traits of individuals with feminist tendencies, which they prefer modesty, humility, empathy, affection, kindness, and warmth. Such individuals prefer to interact socially, develop close relationships with others, and refrain from affecting them [53]. People will indeed react positively to any conflict if they are satisfied with the resolution of the conflict. It is practical because it focuses on working together to develop the best feasible and appropriate solution, where both sides will own the solution and be committed to it [58]. They will have a sense of ownership over resolving the conflict, resulting in an improved and more harmonious working environment. --- Compromising style Compromising styles prone to have a moderate regard for themselves and others. Managers can benefit from a compromising conflict style, especially when confronting multiple parties with divergent interests. The Latin word "comprmissum" translates to "mutual promise", and the French word "compromis" means agreement. Compromise leads to agreement, but it does not necessarily resolve underlying issues. Commonly, a compromise involves a similar concession: an agreement is reached, and both parties sacrifice something to gain something. It could result in a solution, and everyone could move on for a brief time, but in the long run, those involved may feel dissatisfied. Rahim [61] found in his research that when both parties involved in compromise or sharing solutions agree to give up something to make mutually agreeable decisions. It may mean splitting the difference, exchanging concessions, or seeking a quick middle position. Musah et al. [53] studied thirteen Malaysian petrochemical companies and discovered respondents favoured integrating and compromising conflict management styles. She explained that people are oriented toward compromise because they prefer a less aggressive approach to conflict resolution, mainly if the task is completed by oneself and other group members. The finding backed up by Jamail et al. [59] that generation Y teachers in Malaysia demonstrated a high level of a compromising approach to conflict resolution. They believe a compromise should be reached when a conflict arises between them and the school's principal (manager). This style is frequently used because it involves a give-and-take action between both parties, in which neither party wins nor loses. Conflicting parties would exchange and share ideas, ultimately satisfying all parties involved. It has been agreed upon by Ariffin et al. [55] that the compromising style of conflict management exhibited significant positive relationships and was highly correlated with employees' organizational commitment in a Malaysian company. Malaysians prefer compromising because they value two-way communication to resolve ambiguities and issues, as suggested by Noh et al. [62] in their study of communication patterns in Malaysia. They simultaneously desired two-way communication with the leader regarding a holistic matter to have a dialogue that matched their style of receiving logical responses [63,64]. Their behavior defines Malaysians as having an integrated customs orientation, a strong sense of community, and a respectful attitude toward the elderly. Malaysians value harmony in the community and view disagreement as divisive and harmful. For people who value collectivism over individualism, reaching a middle ground is second nature; a sacrifice of personal gain is often accepted in exchange for the greater good. --- Avoiding style Even though a general analysis of selected articles indicates that avoiding style is the least popular approach by Malaysians, it was preferred in certain instances. Malaysians avoid situations involving multiple cultural backgrounds, including the presence of foreigners and issues on religion and race. For instance, Ariffinl et al. [55] and Mohd Kassim et al. [56] found avoiding style somewhat unfavorable among Malaysian workers. However, in a study encompassing multiple cultural values, such as those of Tabassi et al. [52] and that of Sahban and Abbas [51], avoiding style was discovered to be the preference of Malaysian employees. Rahim [61] claimed that avoiding behavior was related to withholding, shifting blame, and eluding responsibility. Avoidance is a common strategy used by those agitated by the conflicts and dissatisfied with conflict, and it is neither assertive nor cooperative [65]. Avoidance is a sign of suppression, which is handling conflict with little regard for oneself or others. They consequently fall short of addressing their and the other party's concerns. As previously discussed, Malaysians have a femineity trait whereby they demonstrate affection and compassion for conflict resolution. The avoidance style, ironically, contrasts with the feminine personality. However, in an intercultural situation, the avoidance style of organizational conflict may be understood as the best way to protect one's long-term interests and avoid escalation of conflict due to misunderstanding. In Ramayan et al. [50], many respondents identified misunderstanding as the primary source of intercultural conflict and viewed it as something negative that creates a barrier between them and others. Identically, Tabassi et al. [52] discovered that Malaysians use an avoidance approach to improve team coordination and performance. It is a practice for situational management and is regarded as a short-term style when working with people from different cultural backgrounds to achieve common goals. Regarding the adaptability of various conflict management styles, the avoidance style was most prevalent when addressing cultural issues. As every culture is unique, if one side respects the other, there is a chance that they will gain respect and reduce intercultural conflict. Despite this, if members of the organization have divergent viewpoints on a particular project, it may be helpful to note them and then attempt to settle the conflict later. It complements a passive, conflict-avoidance management style, which usually implies ignoring the conflict altogether. Instead, it is refraining from confrontation or disagreement to find an appropriate opportunity or moment for addressing the conflict. Although most of the prior research indicates that avoiding conflict is a lose-lose situation, the purpose of this study is to contend that avoiding is a situation in which neither party wins nor loses. Respect is regarded as the highest standard of professional conduct in employment. Everyone must comprehend the red lines of other cultures and accept them exactly as they are unless other parties are willing to talk. However, if the conflict persists, compromise should be a leading option for conflict remedy. It is the best approach to prevent ill feelings toward each other. --- Discussion's summary The study offers significant novelty in conflict management styles in Malaysia. It has been found from the synthesized literatures that Malaysians preferred to utilize integrative and compromising styles. Thus, its reject [41] statement that avoidance is preferred by Asian to manage organizational conflict. Though, several previous studies claimed that Asian cultures are predominantly collectivistic in nature [66][67][68], Malaysians prefer to compromise to settle any rising dispute, rather than avoiding the issue. Malaysians are known for their --- friendly and well-diverse country, so compromising is not an uncommon handling style for them. The country established and maintained its peace and harmony through musyrawah (discussion) among the majority races in the country, where the ends always seek a win-win solution that gratifies all racial needs. Even at the international diplomacy level, musyawarah (for compromising) always becomes the conflict management style adopted by the country's leader. The musyawarah method of compromising is inherently embedded among Malaysians, who believe that one's must seek their right in harmony and a peaceful way without jeopardizing any group's right. It is a style to ensure one's well-being is respected and promotes fairness and justice in interdependent community. Ironically, Malaysians recognized avoidance strategy as a viable form of conflict management in some cases, especially the conflict is deadlocked and harmful to all parties. However, such a strategy only acts for the short term as Malaysians are not good at hiding their dissatisfaction and they might quit and look for other job employments that compromise with their needs. Malaysians expect the organization to promote employees' mental health and the current generation is not reluctant to be direct to settle conflict but rather hide their feelings or problems. The statement supported by Jamail et al. [59], that Y generation teachers perceived compromise as a better conflict resolution. It indicates the future generation expected that conflict management will be open, transparent, fair and justice to all parties. --- Conclusion The study reflects Malaysia's most preferred organizational conflict management style. It was discovered that Malaysians preferred integrative and compromising conflict resolution styles while avoiding styles were the least preferred. Malaysians, on the other hand, will use an avoiding style when dealing with intercultural issues to avoid any confrontation. It shows that Malaysians are both pacifists and fighters regarding conflicting issues that threaten their well-being. Malaysians are expected to resolve conflicts peacefully, maintain good relationships with all parties involved and care about the organization's health. They tend to safeguard job satisfaction and want to increase organizational commitment. The research has several strengths, including highlighting Malaysia's preferred conflict management style and identifying Malaysians as peacemakers who disregard organizational conflict. Managers and organizational leaders can put the study's findings into practice in their organizations. The study also adds to the body of knowledge by backing prior results and can be applied to other research models or hypothesis testing. Yet, the research paper has some limitations, such as using a limited database (Scopus, WOS, and Google Scholar) and a specific focus on Malaysia. As a result, the number of articles reviewed may be limited, and similar studies should be expanded in other countries. --- Conflict of interest The authors declare no conflict of interest.

Conflict is considered an inevitable aspect of human social relationships and an inevitable and significant occurrence in all organizations. This study will review the literature on preference conflict organizational management style in Malaysia. From 2013 to February 2023, a systematic examination of the three most databases was conducted. Articles from peer-reviewed journals that examine conflict management styles in Malaysia and are consistent with the theory of conflict management style were included to achieve the research goals. The reviewers independently applied the selected criteria, extracted the data, and evaluated the quality of the study. Eleven of the 635 studies discovered met the inclusion requirements. The findings indicate that Malaysia's preferred management style is integrative and compromising. However, if the organization's demographics are multicultural, Malaysians tend to employ a conflict-avoidance style to avoid significant conflicts. Depending on the circumstances, the research indicates that Malaysians are pacifists and fighters in conflicts threatening their well-being. They attempt to become more respectful while maintaining positive relationships with all parties involved. The study provides several significant contributions for practical purposes and knowledge to interested parties, such as managers and organizational leaders, in determining the best practice for conflict resolution. Further research is required to investigate the state of the employee-employer relationship following the implementation of the proposed conflict resolution style.

INTRODUCTION In the last 30 years, community participation interventions with women's groups (WGs) using participatory learning and action (PLA) cycles as an intervention to improve maternal and child health (MCH) have flourished, especially in low-income countries. 1 2 Other types of WGs designed to lead to MCH improvement have also proliferated. In this paper, we use WGs to refer to all groups, whether or not they use PLA approaches. WGs are generally understood in the international MCH literature as community-based organised groups of women who are using PLA cycles, health promotion techniques, peer support, two-way learning or community development, to mobilise individual and/or community action for health or social outcomes. 3 They are used to involve local women in identifying needs and priorities for MCH improvement as well as increasing reach of primary healthcare (PHC), and providing new information or services. The word intervention carries a dual meaning. As a research team, the understanding of WGs as an intervention is in accordance with the WHO definition of a health intervention: A health intervention is an act performed for, with or on behalf of a person or population whose purpose is to assess, improve, maintain, promote or modify health, functioning or health conditions. 4 On the other hand, the use of the word intervention in the Aboriginal and Torres Strait Islander health context carries negative implications of a sociopolitical act of government enacted on Aboriginal and Torres Strait Islander peoples and raises conflicting understandings and emotions for many. The term carries emotionally weighted meanings of an ongoing hegemonic deficit narrative of 'problematising' Aboriginal and Torres Strait Islander peoples. This creates a pall of stigmatisation of communities as places of darkness and violence, and diminishes the inclusion of perspectives of community self-determination and their agency in addressing problematic issues and seeking solutions to community identified issues. 5 As an Indigenous and non-Indigenous research team and authors, we stress the importance of reflecting on the deeper meaning of the word intervention when used in Aboriginal and Torres Strait Islander health. In Aboriginal and Torres Strait Islander health, the term initiative is preferred over intervention. A systematic review and meta-analysis of the outcomes of groups conducted in Nepal, Malawi, Bangladesh and India found improved MCH where there is adequate population coverage and an adequate proportion of pregnant women participate. 3 The Strong Women, Strong Babies, Strong Culture programme in Australian Aboriginal communities is embedded in Aboriginal culture and uses a community development approach with WGs to bring about improvements to MCH. 6 While the results of the WGs in rural, low-income countries in improving MCH indicators appear clear, the group processes through which they exert their influence are less clear. If WGs are to be applied more generally, then analysis is important to identify facilitation styles, leadership, cultural influences and relationships that might best bring about positive outcomes. 7 8 In Australia, in groups involving Aboriginal and Torres Strait Islander women, the wisdom and practical knowledge of Elders is foundational as well as knowledge of the cultural context, community history and the nature of relationships. 9 The challenges in conducting primary research about WGs are accepted. There are numerous variables that may affect functioning including whether groups are newly constructed or existing, the nature and extent of community participation, the type of facilitation and the alignment with the country's health system. In addition, the extent to which contextual factors such as community norms and culture affect the operation of the WGs is important. Further research might consider these variables more systematically in order to uncover aspects that might be associated with MCH improvements. 1 8 In Australia, the setting for this review, Aboriginal and Torres Strait Islander peoples has been working for decades to address the health disparities they experience. 10 The establishment of Aboriginal and Torres Strait Islander community controlled, culturally responsive and comprehensive primary healthcare services in over 150 locations in Australia has been a life-changing achievement for the Aboriginal and Torres Strait Islander community. 11 The research project, WOmen's action for Mums and Bubs (WoMB), was designed to explore the involvement of community women in identifying and implementing strategies to improve MCH outcomes in Aboriginal and Torres Strait Islander communities. A non-randomised step wedge implementation trial was designed using WGs as an initiative. 12 Ideally, WGs are community driven and self-determining; consistent with the principles of Aboriginal and Torres Strait Islander women making decisions about the issues they experience with MCH care and the type of healthcare they want; healthcare that respects culture and relationships. 13 In order to inform the WoMB study, we conducted a systematic review to synthesise and critically analyse the currently available evidence on the characteristics, approaches to community participation, use of theory and group processes associated with the MCH outcomes --- METHODOLOGY The review was conducted between July 2018 and January 2021 by a multidisciplinary team including Aboriginal and Torres Strait Islander and non-Indigenous researchers and practitioners involved in the WoMB project. A published protocol described methods and followed the definition of'systematic review' in the Preferred Reporting Items for Systematic Reviews and Meta-analyses for Protocols (PRISMA-P) guidelines. 14 1516 Patient and public involvement Members of WoMB groups were involved in the reporting and dissemination plans of the systematic review. Catching Mullet (figure 1) provides a community explanation of this systematic review. --- Inclusion criteria The inclusion criteria are outlined in The selection of groups to be included in grey literature searching was based on the researchers' professional 17 All documents that met the inclusion criteria from title and abstract review or those that could not be excluded had the full text retrieved. Full texts were independently reviewed by two team members (SL and RE). Any discrepancies for inclusion were resolved by arbitration by a third team member (MP). Reference lists of included documents were also reviewed for relevant inclusions. --- Open access --- Data extraction Full-text documents were downloaded from Colandr and two reviewers (KCar and JT) extracted information onto a data collection sheet, for each document, covering country, location, cultural lens of researchers, study design, theoretical base, conceptual approach to participation, group length of operation, reason and initiator, membership, decision-making, intragroup relationships and cultural, community, political and institutional contextual factors, study quality and MCH and socioemotional well-being outcomes. Approximately 20% of each reviewer's data extraction were checked by a third reviewer (RP) for consistency. Data were summarised and transferred into two tables (JT, RE and KCar). Online supplemental table 2 included group characteristics, conceptual approach to community participation and theoretical underpinning. Online supplemental table 3 included material about group process including contextual factors influencing group process. Any discrepancies were resolved through consensus-based discussion or a fourth reviewer (SL). --- Quality assessment of studies The Joanna Briggs Institute Critical Appraisal Tools (JBI Tools) for assessing quantitative and qualitative studies were used to assess the quality of included documents, including risk of bias. 18 Documents using multimethods were assessed against relevant approaches. Three authors (KCar, RP and JT) undertook an initial quality review using the JBI tools. One author (SL) then reviewed any discrepancies and categorised/scored the documents based on the tool checklists: low quality (below 5), moderate (6-7) and high (8+). No documents were excluded on quality grounds (online supplemental table 4). --- Data synthesis Qualitative comparative analysis and narrative synthesis was conducted from the extraction tables under three headings; group characteristics, conceptual approach to participation and use of theory and group processes, by a team of researchers (JT, RE, KCar, LY, KCan, MP and JF). Well-recognised frameworks for examining the conceptual approach to participation were examined. 19 20 However, we used an Australian community participation typology derived from research with rural communities, NGOs and health professionals working to plan, identify needs and implement action to improve health. 21 This review was conducted to inform a trial involving an initiative with WGs within Aboriginal and Torres Strait Islander communities-thus our group of investigators felt that the communitarian and collectivist focus was important. A further review by Aboriginal and Torres Strait Islander team members (KCan, LY, NT, CF-B, QT, YCJ and LG) considered concepts for WGs in Aboriginal and Torres Strait Islander WGs, which includes the primacy of culture, relationships and respect. 13 --- RESULTS The database and grey literature searched between August 2019 and January 2021 identified 11 031 unique documents. After initial screening by title, and abstract, 98 papers were included for full-text screening, 35 met the inclusion criteria and have been included in this review (figure 2). Details of the 63 full texts that were excluded are available in online supplemental table 5. --- The scope of the studies The 35 included documents are described in online supplemental tables 2 and 3. The documents were published between 1985 and 2020 about WGs in 19 countries. Twenty-five were conducted in low-income and lowmiddle-income countries using the 2019 World Bank Indicators. 22 Ten were conducted in middle-income and high-income countries including one in Australia with Aboriginal women. 6 In the middle-income and highincome countries, almost all groups were conducted in economically poor communities, some with limited access to MCH services. The primary stated goal for WG activity, reported in all documents, was to improve MCH or women's socioemotional outcomes, increase information about MCH for women or assist in accessing care. Study designs included 13 qualitative studies (evaluations and descriptive studies), 10 mixed-method evaluations, four quasi-experimental designs, six randomised controlled trials and two quantitative cross-sectional studies. The quality of the studies varied, with nine studies classified as high, 16 as moderate and 10 as low quality (online supplemental table 4). --- Open access What are the characteristics, mechanisms and contextual influences associated with the outcomes and effectiveness of WGs? --- Group characteristics The majority of WGs reported on were initiated by NGOs including international aid agencies, 23-33 researchfocussed NGOs 2 31 34-41 or research teams. [42][43][44][45][46] In eight studies the country's government 6 47-53 was responsible for initiating WGs. Information was unavailable for two documents. 54 55 Twenty-two studies reported WGs that were new or remobilised 2 6 23-25 27-34 36 39 40 44 45 50 52 54 55 and the remainder used existing groups. 35 38 41 46 48 49 51 53 All groups included MCH education, two-way learning, awareness raising or information sharing components. Identifying community needs, issues and solutions was a stated activity in 23 groups. A broad range of other activities were covered by WGs. --- Group processes The reporting framework used for the presentation of results is that of Cohen and Uphoff 56 as it includes wellrecognised group process concepts; group membership, group structure, leadership/facilitation, group inter-relationships, cultural/contextual factors affecting process, and decision-making. --- Group membership All groups were comprised local community women. Four documents reported that although primarily aimed at women, some groups also included some men, 45 51 either as expectant fathers 44 or the entire household. 52 In four groups, [43][44][45][46] membership was discussed with village elders some of whom made referrals. --- Group structure and leadership/facilitation The 15 WGs that used a PLA cycle or other methods of identification of local issues, potential solutions and actions were led by local trained facilitators. 2 26 31 33-37 39-43 46 54 The four documents reporting on a community development approach involving autonomous programming and independent decision-making were also usually led by local trained facilitators. 27 44 45 49 Those WGs primarily providing health promotion/education delivered in a group setting were usually led by a health professional. 23 24 28 38 47 48 51-53 55 These groups appeared to involve a didactic educative programme on aspects of MCH. Sometimes education was provided in a group context for reasons of efficiency rather than to benefit from group processes. Three documents used a collective problem solving approach, with peer support and new learning and shared leadership. 29 30 32 Two documents reported on sharing cultural learning with women and health professionals usually without a set programme. Facilitation in these groups involved local women knowledgeable about some aspects of culture. 6 28 Decision-making Thirteen documents reported that decision-making was enacted by WG members 2 25 27 31 33 34 36 38 41 45 49 51 53 or through the combined efforts of WG members, group facilitators, research teams and the wider community. 26 28-30 39 42 46 54 In one document, decision-making was at a level removed from the WG that is, sitting with a research team. 24 For a proportion of documents, it was unclear where decision-making rested. 6 23 32 37 43 47 48 50 52 55 Community/cultural contextual factors affecting group processes Twenty-six documents provided a rich description of community and cultural factors in the background to the study. In 19 documents, contextual factors were linked to group processes although usually this was a passing reference rather than an analysis. Linked factors included gender imbalance affecting women's decision-making and leadership, 26 36 45 46 49 the need to take account of different castes, tribes and languages in group makeup, 37 39 40 43 46 and the presence of deep-rooted cultural and spiritual beliefs that might limit MCH. 2 32 35 44 46 54 55 In considering cultural factors affecting WGs, there was some nuanced discussion. Morrison et al 2 reported on the cultural phenomenon of 'ke garne', a feeling that one has no personal control over one's life circumstances, that might have impacted on women's ability to believe that they could make improvements. 2 A study conducted in Orange County Florida 29 reported that the WGs struggled with envisioning change and discussions often did not move beyond the immediate needs of the participants. There were reports of the presence of valuable cultural factors that enhance MCH. 6 25 Lowell et al 6 reported on the positive influence Aboriginal cultural knowledge about birthing can have in adding to mainstream health knowledge and practice. Seventeen documents described aspects of the sociopolitical context in Nepal, Sri Lanka, Myanmar and India that may have affected WGs. Eight mentioned war or political instability which restricted movement, access to health services and created food insecurity and promoted the emergence of female or child-headed households. 31 36 39 41 47-49 53 A study conducted in Myanmar 47 described political instability, climate change and armed conflict in Kayah State that affected group functioning. --- Reflexivity There was rarely a mention of the impact of the researchers' location, position or culture on their interpretation of aspects of the WGs' functioning. This applied equally to researchers located within or outside the country. The exception was Morrison et al who acknowledged several aspects of Nepal's culture that might have impacted on group processes and the non-Nepali's facilitation role. 54 The use of theory and the conceptual approach to WG participation Use of theory All documents, apart from two 52 53 provided an explicit theoretical approach to WGs. There were a wide range of theories used with 29 Open access development or empowerment. Nine used the theories/ concepts of Alinsky, 27 Freire 29 39 46 and Putnam, 27 or theories of healthcare production and demand, 37 autodiagnosis, 26 gender equity, 51 Bandura's social learning and social cognitive theory 54 and two-way learning. 6 A further four documents used theory of agency, 35 the UK Deptford model, 50 health belief model 25 or a social work practice framework including feminist practice. 30 Conceptual approach to WG participation A typology of the conceptual approach to community participation (table 4) was used to identify conceptual approaches used in the WGs and align these, if possible, with aspects of group process. 21 In most documents, there was evidence of more than one approach, but we classified the group by consensus according to the predominant one (RP, KCar and JT). Twenty-two used predominantly a developmental approach, reflecting an interactive evolutionary process in the groups. 2 6 25 27 30-37 39-46 49 54 Ten documents reported on groups using a predominantly instrumental approach with predetermined goals and outcomes and a set structure. 23 24 28 38 47 48 51-53 55 Two used a predominantly empowerment approach with a focus on enabling women to make decisions, 46 50 with one unable to be classified based on the available information. 26 There was alignment between the overall conceptual approach to community participation and group structure. All of the groups using PLA cycles, except one where we could not classify the conceptual approach, used a developmental approach. In addition to the groups using PLA, those four studies using community development enabling the women to develop autonomous programming and independent decision-making, were also all developmental. 27 44 45 49 The studies reporting using a collective problem-solving approach, with peer support and new learning were also developmental. Two of these used a developmental, 30 32 and one an empowerment approach. 29 Two documents reported on sharing cultural learning with women and health professionals and used a developmental approach. 6 28 The 10 groups reported in studies that used didactic health promotion in a group setting were all classified as having an instrumental approach. 23 24 28 38 47 48 51-53 55 The results likely to inform Aboriginal and Torres Strait Islander WGs The following concepts, from an Aboriginal and Torres Strait Islander lens, were used to examine the studies: the primacy of culture, relationships and respect. 13 Withingroup relationships were one aspect of reporting that had some relevance to Aboriginal and Torres Strait Islander WGs. Just over half of the documents reported on group members supporting each other. From an Aboriginal and Torres Strait Islander perspective, within-groups relationships would be considered fundamental and likely influence all aspects of WGs developed for MCH purposes. In two documents, 6 25 sharing cultural activities and knowledge was described. One of these was reporting the value of Australian Aboriginal knowledge 6 and practice in MCH and another promoting women's use of Ecuadorian Quichua traditional foods to improve nutrition. 25 --- DISCUSSION What are the characteristics, contextual influences and mechanisms that are associated with the outcomes and effectiveness of WGs? The strength of this review is that a wealth of information was compiled from the studies describing the characteristics of WGs, their establishment and the operation of community, cultural, institutional and political contextual factors. The information comes from diverse contexts in different countries, with differently structured groups and alignment to state/country health systems. What was common was an overall aim to progress MCH and/or social well-being through WGs. To understand how the WGs achieved their health or well-being outcomes from the data available was challenging. This is not a new finding, and is consistent with Byass's commentary about the complexity of achieving a link between specific real-life inputs such as WGs and health improvements, and the focus on outcomes rather than the processes that might achieve them. 57 Abimbola suggests that achieving a broad understanding of community participation processes should be a 'holy grail' and he contributes an in-depth study about the group facilitator's role in WGs. 58 More of this type of analysis would be useful in establishing the key factors relevant to successful WGs. The use of WGs to assist women to develop knowledge, plan and make decisions about MCH improvements requires that the groups involve active participation. There is extensive recent commentary on the importance of participation in aspects of health improvement and providing care of high value to participants Open access including MCH. 13 58-65 While health policy-makers adhere to this maxim, the difficulty lies in how 'participatory' components of health system activities should become. Furthermore, the processes to effectively implement this participation should draw on available evidence. The usual role of didactic health information giving must be adjusted if participants are to be actively involved. 50 In the 22 documents classified as developmental, there are references to WG members making decisions necessitating interaction. However, facilitators in these groups would have had to overcome perceptions that receiving health information is a one-way didactic process. In the 10 instrumental WGs, the extent of interaction and decision-making was difficult to determine; for example, whether women's suggestions could influence the topics to be addressed. A step towards achieving a better understanding of how WGs might improve MCH could be the development of a theoretical frame or set of variables that could be used to examine a WG across a life course or timeline. If variables, such as we used in analysing studies about WGs structure and processes, were consistently applied when evaluating WGs, then a conceptual model of the interaction between different aspects of groups could be developed. Morrison et al began this process as they summarised their findings regarding processes through which WGs led to equitable behaviour change including learning and developing knowledge, social support gained through group participation and the process of taking action. 54 The reporting of contextual factors affecting group structure and process remains difficult. Again, a framework to consider community, cultural, institutional and political factors at the micro, meso and macro levels would prove helpful. In these studies, macro (national or state) political factors such as political upheaval and security issues were well documented and the impact clear. 36 41 54 Grouping variables at the meso (community) and micro (WG) levels such as traditional attitudes towards birthing (meso) and membership of WGs being advised by male elders (micro) might clarify the link to group functioning. Regarding the importance of culture, there were documents in which the integration of culture into WGs was strong. For example, traditional Quichua values about participating for the common good and the nutritional value of consuming certain greens (meso level factors) influenced the way WGs were organised in one study. 25 Systematic reviews show that WGs have been applied with the goal of improved MCH and well-being in countries with all income levels. 63 From these reviews, it is the improvements that have occurred in low-income and lowmiddle income settings that appear to justify the scaling up and extension of WGs where facilitators can be drawn from a cadre of local workers/volunteers. 3 8 41 57 66 In highincome settings, the situation is different regarding the role of volunteers in usually strong health systems. To effectively scale up WGs in countries of all income levels, better understanding of the role of facilitation, 58 cultural influences 13 67 and the group's structural arrangements 6 is key. Without this understanding, transferring an initiative to other countries and cultures might amount to transposing programmes from very different contexts and cultures with minimal adaptation. 68 Understanding the sustainability of a community participation initiative beyond a project initiative is also important. Sondaal et al sought to investigate the sustainability of the WGs in Makwanpur established by the NGO Mother and Infant Research Activities, once the research was completed. 69 These authors found that over 80% of the groups continued, especially if they were considered important at the local level and new information was being provided. What are the theoretical and conceptual approaches to WGs? In a systematic review of rural community participation in PHC, Preston et al found limited use of theory (there was not a 'theory' data extraction category) to support initiatives and some conceptual confusion in approaches to community participation. 62 In this review, 10 years later, the predominant conceptual approach to community participation was identifiable, except in one document. Almost all documents referenced a theoretical basis, although there was a wide range of theories and different levels of description. Usually theory about community participation/engagement or capacity building was used and there was evidence of developing theoretical frameworks about WGs, such as Morrison's et al's study described above. 54 The value in theory-driven initiatives, is that theory might provide a foundation for consistent evidence gathering about process and outcomes, which in turn might inform the effectiveness of future initiatives. WG's outcomes have been measured through randomised controlled trials, mixed-method studies and descriptive qualitative research. Mannell and Davis suggest that qualitative methods are necessary to fully understand interventions and their effects. 64 Currently, innovative qualitative methods are being included as part of randomised controlled trials in intervention evaluation, realist evaluation and pragmatic trials in order to answer some of the questions about the processes involved in effecting health improvements. In the future, it is important that there is more theoretical work that accounts for some of the messiness and uncertainty of community participation initiatives. Implementing community participation necessarily engages researchers in understanding complexity as an empirical reality and requires flexibility in approach. 65 Theorising women's participation and action through group work, accommodating this messiness, might assist effective implementation. --- Implications for Aboriginal and Torres Strait Islander WGs As mentioned, this review was performed to inform an ongoing project implementing WGs to strengthen MCH with Aboriginal and Torres Strait Islander women in 10 locations in remote and rural Australia. 12 Yet only one Open access study reporting on the use of WGs in this setting was included in this review. Theory generation applicable to Australian Aboriginal and Torres Strait Islander WGs was difficult given that the studies reported on did not use the concepts of the primacy of culture, relationships, and respect in the same way. Aboriginal and Torres Strait Islander authors reflected on this, concluding that the dearth of documents reporting on WGs in the Australian Indigenous context belies the long history of Aboriginal and Torres Strait Islander women's leadership in our everyday worlds and survival as a peoples, especially in the sphere of family well-being. Although much activity is occurring, little of this is reported in the academic literature, suggesting a need to get better at sharing our story using this medium! Nevertheless, the WoMB project will be informed through this systematic review, and we anticipate that the stories of facilitators and WGs will be told, and the theory will be elicited from the experiences of our women, facilitators and each of us. Using an Indigenist approach, our team proposes to use our new empirical data from Aboriginal and Torres Strait Islander women to generate more much needed theory and voice in a subsequent publication. We also reiterate that researchers reflect on research language and use of terminology that is generally accepted in the research health field but may have negative meanings for Indigenous community partners and may impact on participatory processes. This means reflecting on the use of accepted health and research language that carry different meanings for people who have generational lived experience of government 'punitive intervention' policies and practices enacted on them. We suggest including strengths-based language and approaches when working with Aboriginal and Torres Strait Islander health reform processes. --- Limitations and strengths There were several factors about the methodology of this systematic review that may impact on the findings. These include the difficulty with defining search terms that would ensure incorporation of all studies that used WGs for MCH improvement; the diversity of material retrieved in terms of amount of detail, concerns about the methodological soundness of the included documents and studies and appropriate quality assessment particularly where multiple methods are used. It was not always clear at the initial search whether or not a WG was participatory. In the first screen of documents, a judgement was made to include those where there was mention of a WG's involvement in any of the aspects of planning, identifying needs, decision-making or taking action. The level of participation described varied from women independently making decisions and running groups to women participants giving feedback about how they would use the information given in the groups. In including documents that met the criteria of women's involvement, we may have included reports of WGs that were not participatory. The included documents varied significantly in the level of detail provided about the group, whether they were part of a programme or 'one-off' group, whether there were changes in the groups over time and whether they proceeded as planned. The varying purposes of the studies reported may have accounted for the diverse methodological quality. Because of the need to capture as much information as possible about the functioning of WGs, a decision not to exclude studies of limited methodological quality was taken. Some of the early literature, for example Nishiuchi, 53 provided rich information but had limited description of methodology. There were nine multimethod evaluations included in the studies and the quality assessment tools used did not include an adequate assessment for mixed-method studies. 18 We completed a quality assessment for each of the components (quantitative and qualitative) and produced an overall composite score. This quality assessment did not consider the convergence or integration of data essential in mixed methodologies. Despite this, our systematic review was methodologically robust, adhering to the PRISMA protocol and with a prepublished protocol and registration on PROS-PERO. 15 16 Multiple authors, both Aboriginal and Torres Strait Islander and non-Indigenous were involved in each step of the review, increasing the rigour of our analysis. --- CONCLUSION Our systematic review adds to existing systematic reviews about the functioning of WGs in MCH improvement in that it covers WGs in both high-income and low-income settings, identifies the theory underpinning the WGs and classifies the conceptual approach to participation. It also introduces an Australian Indigenous perspective into analysis of WGs used to improve MCH. This systematic review found that inconsistencies in the reporting of contextual and process issues made it difficult to determine the processes through which WGs achieved their health or well-being outcomes. We propose a framework adapted from that of Cohen and Uphoff 56 of key concepts about group process that may assist in standardising the expectations for reporting. We also propose that contextual factors, including culture, affecting the WGs be discussed at the macro, meso and micro levels in order to assist establishment of links to group functioning. This might assist in addressing the methodological limitations identified in this review. Only one study identified in this review involved Aboriginal and Torres Strait Islander women. 6 This does not reflect a lack of activity of WGs in communities, rather a lack of reporting this activity through the peer-reviewed literature. As we learn from our current implementation of WGs to improve MCH with Aboriginal and Torres Strait Islander women, theory generation by the women in these groups may be advanced. --- Open access Participation is a complex phenomenon; and most studies did not define the processes of participation. The exciting potential of participatory and codesign initiatives is reflected in widespread policy uptake, yet our nuanced and contextually informed understanding of how, in a practical sense, these groups are best introduced and supported still lags behind. Contributors KCan: conceptualised and designed the study, contributed to the conception and design of this research, extracted data from individual studies, assisted with the analysis, critically reviewed the manuscript, provided information on methods design, contributed to the interpretation of the findings, revised the manuscript for important intellectual content, approved the final manuscript as submitted; SR: contributed to the conception and design of this research, performed the literature search and extracted data from individual studies, reviewed and revised the manuscript, provided information on data sources, methods design, revised the manuscript for important intellectual content, approved the final manuscript as submitted; CF-B, LG, NT and QT: reviewed and revised manuscript, gave cultural advice, contributed to interpretation of findings, approved the final manuscript as submitted; LY: contributed to the conception and design of this research, conducted the data analysis and interpreted the data, revised the first and subsequent drafts for important intellectual content, approved the final manuscript as submitted; KCar: contributed to conceptualisation and study design, contributed to methods design, extracted data from the included studies, contributed to data analysis and interpretation, assisted with draft revisions and critically reviewed the manuscript, approved the final manuscript as submitted; MP: contributed to conceptualisation and study design, assisted with data extraction, assisted with data integration and interpretation, critically reviewed the manuscript, approved the final manuscript as submitted; RE and SL: contributed to conceptualisation and study design, assisted in the literature search, screening and extracted data from individual studies, contributed to the interpretation of the findings, reviewed and revised the manuscript, revised the manuscript for important intellectual content, approved the final manuscript as submitted; MR-M: contributed to conceptualisation and study design, critically reviewed and revised the manuscript, contributed to the interpretation of the findings, revised the manuscript for important intellectual content, approved the final manuscript as submitted; JF: assisted with the analysis, reviewed and revised the manuscript, provided information on data sources, methods design, approved the final manuscript as submitted, MM: reviewed and revised manuscript; gave cultural advice, contributed to interpretation of findings, approved the final manuscript as submitted; RP and JT: conceptualised and designed the study, assisted with methods design, performed the literature search and extracted data from individual studies, conducted the data analysis and interpreted the data, wrote the first draft of the paper, revised the first and subsequent drafts for important intellectual content, approved the final manuscript as submitted. RP is guarantor and accepts full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish. --- Competing interests None declared. Patient consent for publication Not required. Ethics approval This study does not involve human participants. Provenance and peer review Not commissioned; externally peer reviewed. --- Data availability statement No data are available. There is no data set as this is a systematic review. Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Background This systematic review was undertaken to assist the implementation of the WOmen's action for Mums and Bubs (WOMB) project which explores Aboriginal and Torres Strait Islander community women's group (WG) action to improve maternal and child health (MCH) outcomes. There is now considerable international evidence that WGs improve MCH outcomes, and we were interested in understanding how and why this occurs. The following questions guided the review: (1) What are the characteristics, contextual influences and group processes associated with the MCH outcomes of WGs? (2) What are the theoretical and conceptual approaches to WGs? (3) What are the implications likely to inform Aboriginal and Torres Strait Islander WGs? Methods We systematically searched electronic databases (MEDLINE (Ovid); CINAHL (Ebsco); Informit health suite, Scopus, Emcare (Ovid) and the Cochrane Library and Informit), online search registers and grey literature using the terms mother, child, group, participatory and community and their variations during all time periods to January 2021. The inclusion criteria were: (1) Population: studies involving community WGs in any country. (2) Intervention: a program/intervention involving any aspect of community WGs planning, acting, learning and reviewing MCH improvements. (3) Outcome: studies with WGs reported a component of: (i) MCH outcomes; or (ii) improvements in the quality of MCH care or (iii) improvements in socioemotional well-being of mothers and/or children. (4) Context: the primary focus of initiatives must be in community-based or primary health care settings. (5) Process: includes some description of the process of WGs or any factors influencing the process. (6) Language: English. (7) Study design: all types of quantitative and qualitative study designs involving primary research and data collection. Data were extracted under 14 headings and a narrative synthesis identified group characteristics and analysed the conceptual approach to community participation, the use of theory and group processes. An Australian typology of community participation, concepts from Aboriginal and Torres Strait Islander group work and an adapted framework of Cohen and Uphoff were used to synthesise results. Risk of bias was assessed using Joanna Briggs Institute Critical Appraisal Tools. Results Thirty-five (35) documents were included with studies conducted in 19 countries. Fifteen WGs used participatory learning and action cycles and the remainder used cultural learning, community development or group health education. Group activities, structure and who facilitated groups was usually identified. Intergroup relationships and decision-making were less often described as were important concepts from an Aboriginal or Torres Strait Islander perspective (the primacy of culture, relationships and respect). All but two documents used an explicit theoretical approach. Using the typology of community participation, WGs were identified as predominantly developmental (22), instrumental (10), empowerment (2) and one was unclear. Strengths and limitations of this study ► Our systematic review was methodologically robust, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses protocol and with a prepublished protocol and registration on PROSPERO. ► Multiple authors, both Aboriginal and Torres Strait Islander and non-Indigenous, were involved in each step of the review, increasing the rigour of our analysis. ► International review including documents from both high-income and low-income countries. ► Limitations include difficulty with defining search terms that would ensure incorporation of all studies that used women's groups for maternal and child health improvement and the diversity of material retrieved in terms of amount of detail. ► Furthermore, there are concerns about the methodological soundness of some of the included documents and studies, and appropriate quality assessment particularly where multiple methods are used.

Background Identifying a problem that you can't do anything about is not necessarily a wonderful thing. <unk>Quote by primary care provider<unk> Around the globe, intimate partner violence (IPV) is one of the most common forms of gender-based violence. Historically, the terms "domestic/family violence" have been used to describe violence between someone and an intimate member or family member; however, IPV is a more nuanced and encompassing term to describe violence between partners who may not be confined to domestic or familial settings. IPV is defined as physical, psychological, emotional, financial, sexual, or spiritual violence experienced in any intimate relationship and is a grave social issue associated with many adverse health outcomes [1][2][3]. Although seen among all socio-economic, religious, ethnic, and cultural groups, Indigenous 1 women in Canada experience elevated rates of IPV, which is best explained within the context of multi-generational trauma experienced by Indigenous communities as a consequence of colonization and forced assimilation [5,6]. The estimates of the prevalence of IPV experienced by Indigenous women in the existing literature vary and depend on factors such as levels of underreporting of IPV, methodology employed by a study, location of study (e.g.: rural vs. urban area), how researchers defined IPV, and willingness to disclose IPV in household surveys and personal interviews [7,8]. Thus, reported estimates of IPV experienced by Indigenous women are variable and difficult to ascertain, with studies reporting rates between 25% and 90-100% in some populations [8,9] 2. Despite this range in estimates, authors agree unanimously that Indigenous women in Canada face elevated rates of IPV victimization relative to non-Indigenous women. For example, Brownridge [10] conducted a study with two nationally representative populations in 1999 and 2004 and found that Indigenous women were four times as likely to experience IPV compared to non-Indigenous women. In addition, the Ontario Native Women's Association reports significant rates of IPV: Indigenous women are eight times more likely to experience abuse compared to non-Indigenous women [7]. Furthermore, Indigenous women living in rural and Northern Canadian communities were found to experience higher rates and more severe cases of IPV than those living in urban communities [8]. An integrated framework to explain the origins of gender-based violence from an individual, familial, community and societal perspective is the Ecological Framework [11]. Some individual risk factors that contribute to gender-based violence include witnessing marital abuse as a child and having an absent father; family risk factors include alcohol abuse and male dominance in the family; community risk factors include low socioeconomic status and isolation; and societal risk factors include rigid gender roles and the acceptance of interpersonal violence. However, to understand IPV experienced by Indigenous women, distal causes of these risk factors should be examined through the lens of colonization and the related historical trauma theory. This theory aims to explain how colonial policies has promoted and propagated the use of violence against the Indigenous Peoples, and caused unmeasurable intergenerational grief. Just some of these colonial policies include the forced removal from ancestral lands, and the practice of government enforced removal of Indigenous children from their families for adoption or to attend residential schooling [12]. Historical trauma response is a term to describe the negative affect and behavior associated with multi-generational trauma, such as depression, self-destructive behavior, low self-esteem, suicidal ideation and acts, and restricted emotional expression [13]. Evans-Campbell [12] built on this response into an elaborate framework including familial and community constituents. Inter-generational family level responses to historical trauma includes damaged family communication and parenting stress, while community level responses include the disintegration of traditional culture, internalized racism, widespread alcoholism, and other physical ailments. She asserted that the historical trauma theory is applicable to all Indigenous Peoples who have experienced the colonization [12]. In a clinical setting, primary care providers3 are in a unique, frontline position to promote the well-being of those affected by IPV and to offer support to prevent future incidents [14]. These providers interact with patients who are experiencing IPV, either through suspected or direct disclosure of violence. One study suggested that women are not likely to disclose violence in a health care setting unless directly asked [15], but even when patients present with symptoms indicative of IPV, providers were often reluctant to ask about abuse and grapple with a variety of barriers that prevent them from addressing the abuse [16]. Among the studies reviewed, health care providers identified the following barriers: time restraints during the clinical encounter; discomfort in asking; fear of offending; lack of training in how to ask and intervene; cultural or language barriers; attitudes and behaviors from the one experiencing IPV; partner presence; lack of resources/referrals; and a lack of disclosure/denial of abuse. Conversely, there are also factors that could enable providers to ask about abuse and help patients who are experiencing IPV more effectively, such as being an older and more experienced provider, attending training to respond to abuse, as well as having a history with abuse themselves [17]. Research investigating the intersection between the health care system and IPV experienced by rural, remote and Northern Indigenous women is scarce [18]. Most recently, Wuerch and colleagues [18] conducted a qualitative study with community and justice service providers in northern Saskatchewan, Canada, a region whose population is predominantly Indigenous. The aim of their study was to investigate challenges providers faced in meeting the needs of women who experience IPV. They reported that providers perceived that community members held stigma towards mental health services. This stigma may stem from personal notions such as trying to put one's best foot forward, and structural factors like high employee turnover and a lack of trust patients may have with their provider, which may in turn hinder strong and trusting patient-provider relationships. Providers also expressed that survivors of IPV may be deterred from reporting abuse because perpetrators of IPV in northern communities are often perceived to not be held accountable to the same degree as they might be in urban communities. Given the many barriers to accessing support services, primary care encounters could represent a lifeline for abused women, especially in low resource environments which are often found in rural Indigenous communities. The partner communities involved in this study identified the lack of a strategic approach to address IPV and the need for a multi-pronged solutions in the services sector (described elsewhere) [19], including practical steps to improve the response to IPV in primary care, especially with First Nations women living on reserve. 4To support this need we researched the barriers that primary care providers encounter to support First Nations women who might experience IPV. --- Methods --- Objective This research was part of a larger initiative conducted by several First Nations communities in collaboration with researchers at the Northern Ontario School of Medicine. The study identified IPV as a significant health and social issue prioritized for community based participatory research. During the planning stage, providers expressed a lack of coordinated approach and an uncertainty in their preparedness to approach this complex phenomenon in the clinical. The overall aim of this research was to identify the perceived barriers and facilitators in the primary care setting to respond to First Nations who experience IPV and to provide recommendations to improve the response to IPV at a clinical and community level. --- Design We employed a community-based participatory research (CBPR) approach to this study, in which we worked closely alongside community members and organizations throughout each stage of the research process from identification of the research question to knowledge translation [20,21]. CBPR was used in such a way that this research would be tailored, beneficial and meaningful to the collaborating First Nations and the Family Health Teams on Manitoulin Island. --- Setting This study took place on Manitoulin Island, in North Eastern Ontario. The Manitoulin District has a population of over 13,000, whereby approximately 5260 are Indigenous. Manitoulin District is comprised of more than 10 villages, seven Anishinabe First Nation communities and many hamlets [22]. The First Nations communities receive health service provision from federally funded health centers on reserve, from one provincially funded Aboriginal Health Access Center as well as from providers working in private practice and Family Health Teams off reserve [23]. In this study, providers participated from two First Nations Health centres in two communities and from two Family Health Teams in two towns (whose staff also work in the Emergency Room), located at two hospital sites. --- Ethics approval This research project obtained ethics approval from the Manitoulin Anishinaabek Research Review Committee and Laurentian University Research Ethics Board. --- Participants For participant selection we contacted health team leads to ask if their team would be interested in contributing to the study. Posters advertising the nature, relevance and expected outcomes for the study were relayed to the health team leads by email. For the purposes of this study, an eligible primary care provider was defined as any professional in the healthcare system who provides direct patient or client services and is accessible through self-referral. In addition, these individuals should have had prior experience with IPV in their practice or find IPV relevant to their practice. Eligible providers included regulated and non-regulated health providers, such as physicians, registered nurses, nurse practitioners, mental health workers, physiotherapists, social workers and community health workers. --- Data collection The participants were invited to share, over lunch, interactions with individuals in clinic, home care, hospital inpatient, emergency room settings and social situations. Before the start of a focus group or interview, an information page of the study was given for review by participants and consent was given to record the session. The lead and senior author collaboratively conducted the facilitation of interviews and focus groups (see Appendix 1). The senior author is a qualitative researcher with more than 20 years of experience in First Nations and rural health research. Each focus group lasted on average 2 h, while semi structured interviews lasted on average 1 h. The participants who were not able to attend a focus group or who had been suggested as a beneficial resource by focus group participants were invited to participate in a semi-structured interview. Consistent with Grounded Theory we applied theoretical sampling to test emergent observations and theories and to better understand nuances and contradictory experiences between the providers. A total of four focus groups and two in-depth semi-structured interviews with healthcare providers were conducted, at which point data saturation was reached. --- Data analysis The analysis of data followed a Grounded Theory approach as outlined by Kathy Charmaz [24], whereby data collection and data analysis were performed concurrently. The Grounded Theory approach to analysis is inductive, in that themes and categories emerge directly from the data and were not pre-determined [25]. The data was transcribed verbatim and the initial coding of the data was done by two researchers (KR, MM) using qualitative software, NVivo 12. Data was scanned line by line, and then the researchers moved on to grouping these words, ideas or phrases into larger categories, or themes [24]. To ensure the validity of emerging themes and categories, coding of the data was performed independently by the coresearchers and then compared, and consensus was reached by involving all researchers in the discussion. Emerging themes were discussed after each data collection session between the primary and senior researcher. A core category that defined the main patterns of concern was established. Member checking was conducted by involving one provider and one community member in the analysis as well as presenting results back to the community for discussion and feedback. --- Results Thirty-one participants contributed in either a focus group or semi-structured interview. Two of the focus groups as well as the semi-structured interviews were held with members of Family Health Teams in mainstream organizations, while the remaining two focus groups were held at First Nations health organizations. Of the 31 participants, six (19.4%) self-identified as physicians, five as social workers/personal social workers (16.1%), two as registered nurses (6.5%), 13 as community health workers 5 (41.9%), and five as other primary care workers (16.1%). "Other" primary care workers can be very specific positions to Family Health Teams or First Nation health teams, therefore the grouping is used to protect participants' identities. Examples of these positions include physiotherapists and administrative workers. The majority of participants were female (90%, n = 28) and the rest were male (10%, n = 3) and approximately half of the participants were Indigenous. --- Grounded theory results A core category of concern held by providers when they respond to women who experience IPV was discovered during Grounded Theory analysis. The core concern was the uncertainty of adequate preparedness to respond to women who experience IPV in the primary care setting, compounded by various barriers (see Fig. 1). In turn, this concern can lead to a suboptimal approach or lack of response to IPV by providers. We identified seven main barriers that contribute to the core phenomenon of the unpreparedness to consistently respond to IPV. --- Recognition of patient under disclosure of IPV due to stigma and shame 2. Lack of formal provider training on appropriate approaches to IPV 3. Lack of understanding of jurisdictional complexity of First Nations and non-First Nations 4. Uncertainty how to negotiate cultural safety & IPV 5. Multiple-role relationship and confidentiality dilemmas characteristic of small communities 6. Fear of jeopardizing patient-provider relationship 7. Lack of referral network due to fragmented services and limited access to these services for IPV Description of Barriers that contribute to lack of preparedness. --- Recognition of patients' under disclosure of IPV due to fear, stigma and shame Many providers felt what hindered them from helping both First Nations patients experiencing IPV was women's reluctance to disclose. Providers saw patient fear, shame or stigma as one element making it difficult to identify and respond effectively to IPV. When you look at intimate partner violence, there's a lot that's not reported in our communities. It's well hidden. --- <unk>Community 2, Participant 5<unk> There's often times reluctance to disclose even if you ask several times. 6<unk>Community 1, Participant 1<unk> Sometimes, even when resources are available, patients will not access the services because of fear, stigma or shame. One reason for not disclosing is the shame over staying in the relationship or fear of being pressured into leaving the relationship by providers. The women's shelter on the island does offer outreach services... it does home visiting as long as it's safe to do home visiting.... All of those things are accessible, but still I find people reluctant to be connected to the women's shelter with the perception that they'd have to leave their relationship. <unk>Community 1, Participant 2<unk> Another fear that especially affects First Nation mothers is rooted in the historic high rates of child apprehensions and while in the child welfare system Indigenous children in Canada have suffered high rates of neglect, abuse and even death [27]. Since disclosing IPV might lead to child apprehension, the mother may feel that it is a greater risk than remaining in a home with violence. I think that there's a reluctance to report to us, because there's an understanding out there of what we need to report to [Children's Aid Societies]. --- <unk>Community 2<unk> Awareness of reporting requirements may cause sufficient fear to prevent any disclosure for First Nations mothers. --- Lack of formal provider training on appropriate approaches to IPV Many providers expressed that a lack of training prevented them from addressing the complex issue of IPV in clinical encounters. --- You can't open a can of worms because you don't have training for that. <unk>Community 1, Participant 1 referring to Participant 2<unk> Moreover, dealing with IPV was described as potentially precarious by many providers. Well we do want to address violence, especially sexual violence, the topic that has been at our table for a year and a half, two years, maybe longer. And then I think part of the challenge is how we're going to do it, because we know once we open it, that the potential for something to just explode out is high. So we want to be sure we're experienced enough to handle it. <unk>Community 3, Participant 9<unk> Coupled with the perception of high risk, there was confusion surrounding protocol or procedures regarding IPV in a clinical setting and perceived differences between professions. Some expressed concern that there was no explicit response to IPV at all within their discipline: There's really no standard in our profession on how you deal with [IPV], it's kind of a personal thing, or you call the practice advisor and hope you get somebody who might give you a different answer than someone else. <unk>Community 1, Participant 2<unk> A physician noted that although they had learned about IPV in postgraduate education, they were not well prepared to deal with it on a practical level: It's addressed in residency, but... at the end,... you are sort of looking out for it, you know how to identify it, but then again, what do you do with it? <unk>Community 1<unk> Non-physician providers discussed not having learned about IPV in their profession and that presented as a barrier to respond properly. One physiotherapist noted: They didn't really touch on this kind of stuff [IPV education] in physio school as much. <unk>Community 1, Participant 2<unk> Furthermore, IPV within a First Nations context represents a particular gap in health care provider curriculum. A social worker spoke about overall gaps in awareness of First Nations culture, history of colonization or ways of knowing within primary care as a further obstacle: [There is] not nearly enough [... ] But bare minimum, I think anybody that wants to work with First Nations populations should at least take that [First Nations cultural competency course], or take something similar to that. So that they have some context, because if you have absolutely no context and you think it's all pow-wows and jingle dresses... --- <unk>Community 1<unk> The reference to pow-wows underscores the understanding by this provider that a simplistic level of cultural understanding can be observed among many providers. The lack of a coordinated application of a valid screening tool in their practice resulted in many providers being unsure how to broach the topic of IPV with patients: I'm not sure what the 2018 best practice is: screen, don't screen? Or secondary screening only for suspicious behavior or something? <unk>Community 1, Participant 3<unk> Providers also wondered whether one screening method was more valid than another, and whether more direct or indirect questions would be more effective in opening up a dialogue on IPV, and if opening dialogue was actually helping patients or not. You don't know how often I ask the wrong question, like... (what) would be THE best question to elicit the highest or to pick up the biggest number of cases? <unk>Community 2, Participant 1<unk> One provider summarized the dilemma for providers due to the lack of good information about IPV: So there's that whole mystery, it would be nice if people found out what they can do and what options are there if they're hearing or witnessing this. So I don't think that's very well known. People are scared to make that call, or people are scared on how to support. So I think learning more of that would be beneficial. <unk>Community 3, Participant 6<unk> One provider reflected how the ambiguity lead to her feeling powerlessness in her role as a primary care provider, especially upon disclosure of intimate partner violence: [Intimate partner violence] is not even reportable. It's not reportable in a nursing home. It's not part of the process... So, you sort of appreciate them for opening up, encouraging them to maybe take it further or get some sort of counselling. But it's sort of an unsatisfying thing, because how many times would you let an abused woman out of your emerg? <unk>Community 1, Participant 1<unk> Lack of understanding of jurisdictional complexity of First nations and non-First nations specific services for IPV A few physicians expressed how the siloed funding imposed on First Nations and the rural health and social services system interfere with the effective delivery of care towards patients who experience IPV, So she was a Wiikwemkoong patient, but I had referred her to M'Chigeeng [services]. And they all have very long names that I can't pronounce yet, so it is a bit overwhelming for me. <unk>Community 2, Participant 3<unk> The comment implies that the patient as a member from one community was ineligible for services provided in another community, however Family Health Team staff often do not understand the First Nations health care system. Regional providers have similar restrictions which fragments care and impedes access. If we're having as health care professionals difficulty navigating the system and figuring out where people get the help, how much more so for actual patients in the community? [... ] I have to admit to not knowing specifically what resources would be available other than the general mental health services in each of the First Nations communities. <unk>Community 2, Participant 1<unk> Uncertainty how to negotiate cultural safety and IPV Another concern that providers voiced about responding to First Nations women who may be experiencing IPV was a fear of being perceived as culturally inappropriate, judgemental or being labeled as an "outsider, interfering in this relationship." <unk>Community 1, Participant 5<unk>. Similarly, First Nations providers also acknowledged cultural safety concerns when it came to connecting with First Nations women who experience IPV with counselling: Counselling, especially if it's non-Indigenous providers coming in, they're very Westernized in terms of, like some of our young people don't want to sit in the office awkwardly with somebody to try and figure out what's going on with them. They don't talk about ever doing other activities, like taking a walk, doing things that way, or any activity on the land. Because once you get to that point with somebody, it's just a conversation, and an entire counselling session can happen right there, doing that activity and getting to know one another. So that's one of the barriers I saw, is that they don't want to come to the health centre to sit in a room, awkwardly sit there with somebody, trying to explore what's going on with me, you know? <unk>Community 3, Participant 3<unk> --- Multiple-role relationship & confidentiality dilemmas characteristic of small community Multi-role relationships in small rural communities posed a dilemma with respect to confidentiality. One health care worker commented that even when IPV is suspected based on her observations in the community when she was off duty, there was still a perception of a duty to maintain confidentiality. This in turn limits what some providers feel they are able to do. We had a client who had been sexually assaulted and had physical injuries as a result of that violence, and came in, would talk to the female staff... about her injuries. She'd never say how she'd got them, although we heard that she got them. You're walking on a tightrope of what you could say and what you couldn't say based on what you knew <unk>through observations in the community<unk>. And for her to finally reveal her story and to finally agree, it was over a month in before she agreed to see a health professional [... ] But that was a real challenge... to manage her confidentiality, but you wanted to help her and allow her to go through that process, and have her process everything. <unk>Community 3, Participant 9<unk> Often providers find it difficult to balance confidentiality and personal relationships in these situations especially when IPV was disclosed to them personally outside of their conventional working hours. What I've noticed or experienced [in terms of patients' IPV], it's always after hours. Or it's just friend to friend. [... ] But where do I draw the line, as a health care professional? I work 8-4. My friendship starts from 4:01 to 7:59 the next day. Am I obligated, because I'm a health care professional, to report this? Or do I do it in confidence as a friend? <unk>Community 4, Participant 2<unk> Patients on the other hand can also struggle with their personal relationships with a primary care provider: And people often times don't want to let anything out because they know that it's gonna be, like, their cousin who works as a nurse in emerg, you know, somebody was passing by because they're here for different reasons and it's gonna be known and it all becomes known. So they wanna hide it. They don't want to disclose it to you, to healthcare professionals. <unk>Community 2, Participant 1<unk> Another provider spoke about that it can be prohibitive to seek support for IPV if a relative is working in the services system. Privacy was seen as a big concern to access services. [It's about] recognizing though that a lot of our people are private, and it comes down to confidentiality. That's why we don't see them in the health system too often. <unk>Community 2, Participant 5<unk> --- Fear of jeopardizing the patient-provider relationship Providers also identified their concerns with legal implications for their patients associated with acting on IPV. It is the provider's duty to report to children's protective services in the case of suspected IPV that involves children under the age of 16 in the home. One physician noted: We always try to tease out whether children are at risk, because children at risk gives you sort of a way to report it, but that might actually ruin your relationship with the patient. <unk>Community 1, Participant 1<unk> In addition, providers may be targeted with criticism for taking action to helping women. Community or family members, who are not yet ready to deal with the issue of IPV especially where physical acts of violence may involve arrests; one family member for example approached a provider asking "why would you criminalize my father's behavior?" <unk>Community 1, Participant 1<unk>. Lack of referral network due to fragmented, scarce services for IPV Some providers mentioned that directing patients who may be experiencing violence in their lives to appropriate agencies in a fragmented rural services landscape is daunting and even overwhelming as described by this participant. Wow, you feel... overwhelmed, and that they will share that with you, so it's kind of this sign of just, respect on their part, and a burden at the same time because now what do you with some of that information? Some of that is difficult to know, you know, whether you need to involve the law. <unk>Community 1, Participant 7<unk> What to do with the information once IPV is disclosed was a major concern for medical staff and for social/ mental health providers. Details about referrals and resources were frequently unclear, especially the availability of shelter and support services, long wait times, and if those services were culturally safe and accessible to both First Nations and non-First Nations women. Many providers struggled with connecting First Nations patients with the complicated assortment of federallyfunded, often community-specific or regional services as well as mainstream provincial services. Some spoke of making inappropriate referrals to First Nations services to First Nations women who were not eligible for these services due to, for example, place of residency. Those who have worked longer in the area helped when possible to connect patients informally: I would case manage the linkage into the appropriate community-based agency, because it is a complex system... <unk>Community 2, Participant 2<unk> One physician noted that a lack of resources or challenge in accessing existing resources for First Nations as well as non-First Nations women may prevent a provider altogether from helping a patient who was experiencing IPV. Where the rural challenge is greater is the lack of resources. <unk>Community 1, Participant 3<unk> Description of Facilitators to care towards Indigenous women who experience violence. After discussing barriers, providers shared what they saw as facilitators for responding to IPV in the PC setting as well as the strengths of their patients in improving their own situation. Perhaps one of the strongest facilitators discussed amongst the sample of providers was the concept of working together as a team across health disciplines. One social worker explains this teamwork well, by saying: We try within our clinic to use the multidisciplinary model and to say 'okay well, [medical doctors] may not have time to ask more about this, on this day, but would you be willing to talk to this person or this person or this person?' <unk>Community 2, Participant 7<unk> Having a social worker embedded in the family health team opens up new opportunity for more comprehensive services as physician appointments may be too short to address many social issues. I struggle with how short a doctor's appointment is. I mean doctors are good people, they would like to ask all the questions, but they're not in the position to be able to ask all of the questions that would be helpful sometimes. And so I think that pressure to see this many patients... I don't even think that's within OUR service delivery kind of training. <unk>Community 2, Participant 7<unk> Sometimes, a team member who has seemingly little impact on helping a patient with IPV may have great insight into the lives of exactly those patients as this physician explained: But they're the eyes of the community, right? We don't go in the houses, they do! They can come in the house and they sort of -they provide very interesting insights on our rounds because he's the one who actually goes in the house... <unk>Community 1, Participant 1<unk> --- Culturally safe care Several providers mentioned understanding Indigenous culture and values was an enabler to care involving sensitive issues within a clinical setting and that there were some services that are culturally safe. I think knowing a bit about the culture and knowing how the interconnectedness of the First Nations value system, plays a key role in how far you're going to be able to get. [... ] When... Betty is telling you that Charlie is abusing her, it's not just Betty in the room. Betty brings all of her [family] and ancestors with her as well, and being cognisant of that, being understanding of that, being aware of it, being respectful and mindful of that to allow her to talk about how this is impacting her in this holistic way, in this bigger way. <unk>Community 1, Participant 8<unk> On the other hand, Indigenous providers found that culturally sensitive care also entailed giving patients the option to choose cultural options that fit their life path and again this awareness was often present. We do have people that practice different cultural traditions and religion. Like we have people who still have very strong ties to our church and then we have people who do ceremonies, but we have different types of ceremonies in our communities too, so when you're bringing one culture in too, it might not resonate with everyone in our community. <unk>Community 4, Participant 3<unk> Some providers offered what has worked for them practically in terms of screening, which includes using progressive screening, a customized script and other means of flagging IPV. I think everyone that works in the health profession should have a script that they feel comfortable with. And to me, it doesn't matter to me who you are. [... ] So it may be a combination of both being direct, and also being gentle. So how does that feel for you? Because for me, being authentic, being present, with you right now, is the primary goal. <unk>Community 1, Participant 8<unk> Others mentioned that they were actively trying to identify screening that would work in their practice. --- Discussion --- Barriers In general, barriers to support women who experience IPV were discussed by providers much more frequently relative to facilitators. This is a result of the complex factors that lead this pervasive level of uncertainty related to responding to IPV, which the providers saw at a survivor, systemic, and provider level. With respect to survivor barriers, the colonial systems and policies that have resulted in historical trauma such as the high rates of violence perpetrated against Indigenous women still operates and creates fear in Indigenous women from further structural violence such as removal of children, due to the violence they are experiencing at home. This creates a dilemma for the women of fear of losing children and shame of their living situation while primary care providers are in a dilemma of addressing the issue and being bound by mandatory reporting that will lead to losing trust. With respect to provider barriers, challenges regarding confidentiality and reluctance to go to their service provider who may also happen to be a family member compound this dilemma. Some of the barriers to address IPV in primary care were similar to those experienced in the justice sector in other rural and Northern communities in Canada and are connected to limited resources or access to resources in rural areas. However, the First Nations health care systems presents with unique barriers given the jurisdictional gaps between First Nations and mainstream health care. With respect to systemic barriers, some primary care providers may experience confusion when faced with the complex health and social services system, especially if they are not knowledgeable about the to the jurisdictional divides that cause gaps in First Nations health and social services. In addition, a clear presenting barrier is a lack in coordinated protocols or procedures regarding intimate partner violence across the health care systems. Currently there is no universal screening; some using screening only once a strong trusting relationship between the patient and provider is established. Clearly, provider training and more supportive services are needed to allow women more choices for safety are urgently needed. --- Facilitators Previous literature has demonstrated that adequate time to build a relationship with the patient may help providers identify and support patients who are experiencing IPV. This was validated in our study, in which inadequate time was relevant to physicians more so than other disciplines. Social workers, who are often much less restricted in time, acknowledged that a lack of time was a limiting factor for physicians in potentially helping an abused patient. The social workers in this study recommended interdisciplinary collaboration as a way to address this. This teamwork may help to better identify IPV by providing more opportunities to screen for IPV or for case-finding IPV in patients who may not have regular appointments with a physician. Analysis showed that providers valued knowledge of Indigenous values and the ability to offer safe spaces for traditional practices, in order to provide culturally sensitive care. Providers should understand that Indigenous Peoples are diverse and have unique needs. In this sense, culturally sensitive care entails a patient-centered approach, wherein the patient chooses what approach best suits them. --- Recommendations Our analysis provides the basis for the following recommendations to improve the ability of providers to respond to women who experience IPV in rural and First Nations communities. --- Continuing to address stigma through community awareness Providers felt that empowering the patients directly through ongoing public health campaigns is a helpful strategy. Ongoing funding for these campaigns helps patients to better understand the various dimensions of IPV, what acceptable behaviour in an intimate relationship looks like, to reflect upon their experiences and eventually to be able to seek out and access services they need directly. Information pamphlets, educational videos to play in waiting areas and culturally specific posters, particularly if trying to address Indigenous health, are recommended awareness strategies. --- Create effective referral pathways A local task force to create appropriate referral pathways should be formed. These pathways could be promoted through information sessions on the locally available services and resources, including access to workshops, counselling and shelter services for rural and First Nations women. All women's and children's services and agencies in the area as well as the process for accessing these services or for referring clients should be detailed in writing. This should include criteria who can access services due to catchment area, First Nations status, geographic location as well as cultural safety. This list of resources should also be accessible by patients, especially in the emergency room. --- Improve cultural safety within the referral network The idea of cultural safety refers ultimately to supportive, non-judgemental care that suits a patient's specific needs and is not assumed. It may include offering a First Nation person access to traditional healing such as smudging, sweat lodges and other ceremonies, while understanding that some may select mainstream services. Cultural safety training will be beneficial to increase providers' ability to approach care and referrals for Indigenous women [28]. --- Develop services for perpetrators Numerous providers mentioned that many perpetrators were struggling with mental wellness, anxiety and control issues and did not have the skills to change their attitude or behaviours towards women. While providers did not deny that there may be need for involving the justice system in some cases, it was felt that restorative justice and rehabilitative programs were seen as key to reducing IPV. Some of the providers from counselling professions explained that the perpetrator have themselves abuse histories. Cultural programs for Indigenous men were suggested, for example "I am a Kind Man" offered in some of the local First Nations health organizations [29]. --- Engage natural helpers in the community Engaging the natural helpers, knowledge holders, grandmothers, grandfather

Background: Some legacies of colonialism are that Indigenous women living in Canada experience higher rates of intimate partner violence (IPV) and that violence is often more severe relative to non-Indigenous women. This results in avoidable physical, psychological, emotional, financial, sexual and spiritual harm in the lives of Indigenous women, families, and communities. Trusted primary care providers are well positioned to provide brief interventions and referrals to treatment and services, but little is known about the providers' preparedness to support Indigenous women. Information on what enables or prevents providers to respond to Indigenous patients who experience IPV is needed in order to ensure this potential lifeline for support is realized. Methods: The purpose of this community-based participatory study was to elucidate the barriers and facilitators to care for rural Indigenous women who experience IPV from the perspectives of primary care providers and to recommend strategies to improve their preparedness. Using a Grounded Theory approach, we conducted qualitative research with 31 providers to discuss their experiences with patients affected by IPV. Results: The results showed providers often feel a degree of unpreparedness to deal with IPV in a clinical setting. Underlying the feelings of unpreparedness were: Recognition of patients' under disclosure of IPV due to stigma, shame and fear Lack of formal provider training on appropriate approaches to IPV Lack of referral network due to fragmented, scarce services for IPV Lack of understanding of jurisdictional complexity of First Nations and non-First Nations specific services for IPV Uncertainty how to negotiate cultural safety around IPV Multiple-role relationship & confidentiality dilemmas characteristic of small communities Risk of jeopardizing patient-provider relationship

safety within the referral network The idea of cultural safety refers ultimately to supportive, non-judgemental care that suits a patient's specific needs and is not assumed. It may include offering a First Nation person access to traditional healing such as smudging, sweat lodges and other ceremonies, while understanding that some may select mainstream services. Cultural safety training will be beneficial to increase providers' ability to approach care and referrals for Indigenous women [28]. --- Develop services for perpetrators Numerous providers mentioned that many perpetrators were struggling with mental wellness, anxiety and control issues and did not have the skills to change their attitude or behaviours towards women. While providers did not deny that there may be need for involving the justice system in some cases, it was felt that restorative justice and rehabilitative programs were seen as key to reducing IPV. Some of the providers from counselling professions explained that the perpetrator have themselves abuse histories. Cultural programs for Indigenous men were suggested, for example "I am a Kind Man" offered in some of the local First Nations health organizations [29]. --- Engage natural helpers in the community Engaging the natural helpers, knowledge holders, grandmothers, grandfathers, and elders within the communities with provider teams and other service organizations to help survivors and abusers was also seen as long-term strategy to address IPV. Several providers mentioned the resilience demonstrated by the First Nations communities on Manitoulin Island, namely around the fact that there are strong ties within small communities. Therefore, implementing concepts into First Nation programming such as individual and community resilience as well as the seven grandfather teachings were recommended by some First Nation providers. Ungar's [30] international study explains how resilience is inextricably related to context and culture and delineates three protective processes for resilience: how environmental level variables can be more influential than individual level variables; how facilitative environments can positively impact how individuals, families and communities perceive, navigate and access resources; and how a greater exposure to risk can be mitigated when there are resources that target those specific risks. Develop policies, procedures and continuing education related to patients who experience IPV Finally, while education and training may differ based on the discipline of a provider, this study has implications for policies, procedures and the education of providers. For example, web-based training on how to speak to patients in a clinical setting may be beneficial in creating a safe and non-judgemental environment for a patient to disclose and seek help for intimate partner violence [31]. To continue, there appears to be a lack of coordinated approach to screening in the health care system on Manitoulin Island, which does not seem unusual given the debate as to whether universal screening (screening regardless of perceived risk) or non-universal screening is most effective [32]. Moreover, the screening protocols as they stand also appear to undermine provider confidence, as they may not be aware of which questions to ask or how to proceed upon disclosure of IPV [33]. To overcome these challenges, a universal and routine screening protocols with clear guidelines ought to be considered. Successful programs were shown to have standardized and direct screening IPV questions, as well as provide protocols on how to assess patient safety, and refer to appropriate services. These guidelines should be disseminated to staff through initial and ongoing mandatory training sessions to increase provider comfort and self-efficacy. Finally, as this study highlighted the importance of cultural sensitivity in delivery of care, this study may lead to reforms to provider undergraduate training or continuing professional development by educating on First Nations ways of life. --- Strengths & limitations of study The participants included in this study are from a single district, therefore the results may not be generalizable to other rural, remote or northern districts of Canada. In addition, 90% of the providers involved in this study were women and the perspectives of male providers were not explored in as much detail. One notable strength of this study was the variety of First Nations community staff and conventional health providers and disciplines involved. Based on this broad spectrum of perspectives, we believe our results will resonate with providers who care for Indigenous women elsewhere. Further studies should build on this with direct research with Indigenous women who have experienced IPV. --- Conclusion Intimate partner violence is an extremely serious health and social issue that affects Indigenous women at elevated rates [5]. This study identified barriers that need to be overcome to alleviate feelings of unpreparedness experienced by primary care providers in supporting Indigenous women who experience IPV. In addition, this study identified facilitators that may help mitigate feelings of unpreparedness. Strategies to ameliorate current conditions should go beyond provider training and include community wide interventions to address stigma, cultural safety and community awareness of healthy relationships. Services for perpetrators are also urgently needed. This study can serve as a starting point to more effectively address IPV in rural and First Nations health care systems and inform future programming in the health care system, as well as inform clinical approaches to intimate partner violence. Appendix 1 --- Availability of data and materials The datasets used and analyzed during this current study are not publicly available due to sensitive nature of the data and for the potential for identifying research participants but are available from the corresponding author on reasonable request. --- Abbreviations --- IPV: Intimate partner violence; CBPR: Community based participatory research Authors' contributions KR is the primary author for this article. As part of her master's work (M.Sc.) in Interdisciplinary Health at Laurentian University, she contributed to each step of this research project, including literature review, data collection, data analysis and development of this research paper. As corresponding author, she will respond promptly to the International Journal of Indigenous Health correspondence regarding reviewer comments, copyeditor revisions and publishing agreements. MM is the supervisor of this project as well as her much larger scale community based participatory study. She was heavily involved in every aspect of this project, including the research design, data collection and analysis. Dr. Maar provided ongoing feedback and revisions for this document. MR, RP and LM have each individually provided feedback on research methods, analysis and earlier versions of this paper and have granted permission to be co-authors. All authors read and approved the final manuscript. --- Funding We would like to thank the Women's College Hospital's Women's Xchange $15 K Challenge and Canadian Institutes for Health Research (FNR 151698) for the funding to carry out this project. The funding bodies were not involved in the study design, data collection, analysis, interpretation, writing or revisions of this manuscript. --- Ethics approval and consent to participate This research project obtained ethics approval from Indigenous and non-Indigenous review boards, the Manitoulin Anishinaabek Research Review Committee and Laurentian University Research Ethics Board (REB # 6009722). The two participating communities, Wikwemikong Unceded Reserve and White Fish River First Nation, granted band council resolutions approving this research. Furthermore, this study abided by the Tri-Council Policy Statement 2nd Edition -Chapter 9 [34] and respected Ownership, Control, Access and Possession (OCAP) principles [34]. Finally, the participants provided their written consent to participate in this study. --- Consent for publication Not applicable. --- Competing interests The authors declare that they have no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Some legacies of colonialism are that Indigenous women living in Canada experience higher rates of intimate partner violence (IPV) and that violence is often more severe relative to non-Indigenous women. This results in avoidable physical, psychological, emotional, financial, sexual and spiritual harm in the lives of Indigenous women, families, and communities. Trusted primary care providers are well positioned to provide brief interventions and referrals to treatment and services, but little is known about the providers' preparedness to support Indigenous women. Information on what enables or prevents providers to respond to Indigenous patients who experience IPV is needed in order to ensure this potential lifeline for support is realized. Methods: The purpose of this community-based participatory study was to elucidate the barriers and facilitators to care for rural Indigenous women who experience IPV from the perspectives of primary care providers and to recommend strategies to improve their preparedness. Using a Grounded Theory approach, we conducted qualitative research with 31 providers to discuss their experiences with patients affected by IPV. Results: The results showed providers often feel a degree of unpreparedness to deal with IPV in a clinical setting. Underlying the feelings of unpreparedness were: Recognition of patients' under disclosure of IPV due to stigma, shame and fear Lack of formal provider training on appropriate approaches to IPV Lack of referral network due to fragmented, scarce services for IPV Lack of understanding of jurisdictional complexity of First Nations and non-First Nations specific services for IPV Uncertainty how to negotiate cultural safety around IPV Multiple-role relationship & confidentiality dilemmas characteristic of small communities Risk of jeopardizing patient-provider relationship

Introduction There were 82.4 million forcibly displaced persons at the end of 2020 [1], and 70% live in urban regions [2]. With 1.4 million refugees, Uganda is the fourth largest refugee hosting nation in the world and the largest in Sub-Saharan Africa [1]. More than 90,000 of Uganda's forcibly displaced persons live in the capital city of Kampala, and of these, one-quarter are youth aged 15-24 [3]. Most of Kampala's refugees live in slums [4][5][6], environments characterized by poverty, precarious housing, overcrowding, violence, and elevated HIV and sexually transmitted infections (STI) prevalence [7][8][9][10][11][12][13][14]. Forcibly displaced persons may have elevated HIV exposure due to the convergence of social and structural drivers of HIV, including sexual and gender-based violence (SGBV), poverty, and constrained access to sexual and reproductive health (SRH) services [15][16][17][18]. Yet systematic reviews note how the needs of refugee youth have been overlooked in SRH programs, as have the needs of urban refugees [15][16][17][18]. There is a dearth of HIV testing programs tailored for urban refugee youth. Notable gaps in HIV testing-a key entry point to HIV prevention and care cascades [19]-exist for urban refugee youth in Kampala. For instance, cross-sectional studies have noted testing uptake of 56% among urban refugee youth living in slums in Kampala [20], far from the UNAIDS goal of 95% of people knowing their status to achieve an AIDS Free Generation [21]. While three-quarters of a sample (n = 445) of urban refugee youth in Kampala knew about HIV testing availability in their community, far less (56%) reported having ever been tested for HIV in their lifetime [20]. In this study, the stigma youth experienced for being sexually active and engaging in SRH care was associated with reduced odds of ever having tested for HIV [20]. Qualitative findings have also pointed to the important role of intersecting forms of stigma, including HIV, adolescent SRH, refugee, and sex work stigma, as well as cost and transportation challenges, in producing HIV testing barriers for urban refugee youth in Kampala [22,23]. Less is known about relational contexts of HIV testing decision-making among urban refugee youth. Relational contexts include the larger power structures that shape interactions, as well as the ways that relationships can reproduce or challenge power inequities [24]. Relationality, the interconnectedness between people and places, includes expressive domains (e.g. working on goals and priorities with other persons) as well as instrumental domains (e.g. sharing resources and skills) [24]. Relational transactions and processes shape identities, wellbeing, and knowledge production. Shifting the focus of behavior change from individual agents to their wider environment can bring into focus the socio-environmental situations that shape daily interactions that enable or constrain decision making [25]. Relational contexts that produce HIV enabling environments have been conceptualized as including social support, social capital, and recognition of rights [26]. Social support is multifaceted and includes different sources (e.g. family, friends, significant others), quality, and quantity [27]. Most social support is generated from informal sources, such as family and friends, and can be supplemented by formal sources of support offered through organizations [28]. Support is also multi-dimensional, comprised of emotional (e.g., caring, empathy), instrumental (e.g., tangible aid), appraisal (e.g., help with self-evaluation), and informational (e.g., advice, information) dimensions [29]. Social capital can include relationships that foster bonding, such as between persons from a shared social identity group (e.g. between refugee young women) and/or bridging, whereby persons build connections with those with increased access to power (e.g. between refugee young women and government stakeholders) [30,31]. Persons may participate in both formal social networks, such as religious institutions and HIV support groups, as well as informal social networks in families and neighborhoods, in order to build community connections and enact personal and social change goals [32]. Taken together, these social relations can nurture HIV competent communities [30], whereby persons share information about HIV and support one another to overcome barriers to engaging in HIV prevention and care. This approach moves beyond simply providing information to facilitating discussion of how this information can be applied to real life practices [30]. Health promoting HIV enabling environments can nurture solidarity and resilience, as well as reduce power inequities [26,33]. Yet challenges for creating HIV competent communities include inequitable social norms and social networks that share misinformation. Relational contexts thus have the potential to shape both HIV risks and protective factors in the structuring of social networks, social interactions, and daily lived experiences. There are knowledge gaps regarding characteristics of HIV competent communities from the perspective of urban refugee youth. A broader scan of HIV research literature with non-refugee populations identified relational influences on HIV testing practices. For instance, relationship dynamics with family, peers, and partners may have both negative or positive influences on youth HIV testing practices [34,35]. For instance, among youth aged 14-24 in Kenya, 22% reported that their decision to test was influenced by a peer, 20% by a partner, and 12% by a parent [36]. Family, peers, and partners might offer support, positively influencing HIV testing among youth [34]. Among orphaned youth in Ethiopia, Kenya, and Tanzania, increased perceived social support was associated with pastyear HIV testing [37]. Conversely, fear of family, friends, peers, or partners discovering one's HIV positive serostatus as well as a perceived lack of support are reported testing barriers among young people in South Africa [38]. Peerled approaches to increase HIV testing were associated with increased HIV testing among men who have sex with men in a systematic review [39]. Micro-social environments comprise social and physical environments that have the potential to exacerbate or reduce harm through shaping perceptions of health risks and practices, community values and norms, social relationships and networks, and neighborhood cohesion [25]. Urban refugee youth in Kampala's slums experience micro-social environments of poverty and elevated SGBV exposure [40], and macro-social contexts of intersecting stigma toward refugees, HIV, sexually active adolescents, and gender inequities that may converge to reduce HIV testing uptake [22,41,42]. It is thus particularly important to understand relational contexts of HIV testing among this population, as refugees may experience disruptions to social and community networks and family dynamics due to the effects of conflict and displacement [43][44][45][46]. O'Laughlin et al.'s thoughtful social ecological framework conceptualizes barriers to HIV clinic attendance among refugee adults living with HIV in Nakivale settlement in Uganda [47]. They found that social support from family and friends helped persons to overcome barriers to HIV care engagement; for instance, material (transport funds, childcare) and emotional (hope, 1 3 moral) support facilitated care engagement. Yet HIV positive serostatus disclosure was selective, and fear of stigma and discrimination presented disclosure barriers that resulted in social isolation [47]. Their work on HIV testing with refugee adults in Nakivale signals the importance of community sensitization, stigma reduction, and engaging with peer educators in HIV testing interventions [48]. Better understanding the social environments of HIV testing decision-making among urban refugee youth in Kampala can inform tailored testing initiatives that employ a strengths-based focus and leverage urban refugee community solidarity and networks [49]. In response, this manuscript aims to address knowledge gaps regarding the relational factors that shape HIV testing practices with urban refugee youth in Kampala. We explore urban refugee youth perspectives, experiences, and preferences for social support in HIV testing. --- Methods --- Study Design and Data Collection This qualitative study of refugee youth ages 16 to 24 (n = 44) living in five informal settlements (Nsamyba, Katwe, Rubaga, Kansanga, Kabalagala) in Kampala, Uganda was conducted from February-April 2019. This communitybased study was a collaboration with refugee youth serving agencies, Ugandan researchers, the Ugandan Ministry of Health, and academics. Five focus groups, approximately 45-min in duration, were conducted with refugee youth: two with young men (one aged 16-19, one aged 20-24), two with young women (one aged 16-19, one aged 20-24), and one with young women sex workers (aged [16][17][18][19][20][21][22][23][24]. Additionally, we conducted five key informant (KI) interviews, approximately 30 min in duration. The KI interviews were conducted at the KI's workplaces or at community-based agencies in the settlements, and focus groups were conducted a community-based youth refugee agency and at a humanitarian agency. Peer navigators (PN) (n = 12), six men and six women, were hired to recruit focus group participants through a combination of snowball sampling methods [50], whereby we invited participants and PN to invite others in their social networks to take part in the study, and targeted sampling [50] in order to reach a predetermined number of participants by age and gender (e.g., 6-10 young women aged [16][17][18][19]. To participate in the focus groups, participants had to be 16-24 years old, able to provide informed consent, and identify as a refugee, displaced, or asylum-seeking person, or have a parent who identified as refugee or displaced. Peer navigators were refugee youth between the ages of 18 and 24 who lived in the target communities; they supported recruitment through the sharing of study information with their peers and helped to pilot the interview guide that was created in collaboration with community partners. KI were purposively sampled by collaborators due to their experience working with refugee youth through community-based agencies, humanitarian agencies, or government and non-government clinics providing HIV/STI services. KI interviews and focus groups were facilitated by trained local researchers in English, French, Swahili, Kinyarwanda, or Kirundi languages, with the support of a translator, audio recorded, and translated and transcribed verbatim into English. Participants provided verbal informed consent prior to participation, and all participants (focus groups, key informant interviews) received the equivalent to $15 CAD reimbursement for time and travel. Research ethics board approval was obtained from: University of Toronto, Mildmay Uganda, and the Uganda National Council for Science & Technology. We applied thematic analysis, which is theoretically flexible and includes both inductive and deductive analyses conducted concurrently [51,52]. We followed thematic analysis steps, including having three authors read and become familiar with the transcripts, code the transcripts (CHL, ML, SP), engage in discussions about codes, produce preliminary themes, and review and reassemble themes [53]. This analysis focused on participant narratives that discussed sources and dimensions of social support important to HIV testing engagement. Interview/focus group guides inquired about the role of peer support, family support, and intimate partner support in HIV testing. As this study was theoretically informed by conceptualizations of HIV enabling environments [26] and HIV competent communities [30], we hypothesized that intimate partners, family, and peer support would be important resources for testing, and these were explored using deductive coding approaches [53]. Inductive coding, exploring data driven codes, identified another source of support (health professionals) salient to participants' HIV testing decision-making. We produced a thematic map of the findings from both inductive and deductive analyses that together identify varying perspectives on social support sources, and dimensions of social support. Member checking was conducted with collaborators at refugee community agencies and HIV service providers in Kampala, including study co-authors. --- Results The 44 focus group participants (mean age: 20.3, range: 16-24, standard deviation: 2.2) included men (n = 17, 38.6%) and women (n = 27, 61.4%). Countries of origin included the Democratic Republic of Congo (DRC) (n = 29, 65.9%), Rwanda (n = 11, 25.0%), Burundi (n = 3, 6.8%) and Sudan (n = 1, 2.3%). Most were refugees (42/44, 95.5%), one person was undocumented, and one was seeking asylum. Less than three-quarters (n = 31.44, 70.5%) had ever received an HIV test, and the majority (n = 35/44, 79.5%) were unemployed. The key informants (mean age: 32.9, standard deviation: 4.2) included men (n = 3, 60.0%) and women (n = 2, 40.0%) from Uganda (n = 2, 40.0%), Rwanda (n = 2, 40.0%), and the DRC (n = 1, 20.0%). Participant narratives identified informal (intimate partner, family) and formal (peer educator, health professional) sources of social support as salient to HIV testing decisionmaking. The facets of support that emerged as relevant for testing are presented in Fig. 1. --- Informal Sources of Social Support --- Intimate Partners The effects that HIV testing practices could have on relationships with intimate partners was a frequently raised topic amongst participants when making decisions regarding engaging partners in testing. Participant responses were heterogenous and reflected diverse concerns and perspectives on both positive and negative outcomes that testing engagement, and test results, could have on intimate partnerships. Participants described how supportive relationships could encourage HIV testing, discussing how open communication and sharing personal information had the potential to facilitate conditions where both parties could feel secure. "Since you share with your partner everything, deep things," one young man put forth, "there's no secrets, and we know that we are safe." (focus group [FG], young men, aged [20][21][22][23][24]. Women also described how getting tested themselves could help them to feel more confident discussing and enforcing HIV testing with male partners. As one young woman elaborated: For me it would be very simple. If I have been through counseling and they give it [a test] to me, I would tell my boyfriend that, you know, nowadays things have improved, instead of going to the hospital we can do these things [get tested] together, you can even do it on yourself so that you can know your status whether you are negative or positive. If he refuses it would be up to him, but for me I would have done my job. (FG, young women, aged [16][17][18][19] Another participant similarly reflected on the importance of knowing one's status and the growing empowerment of women: It is difficult for them to share with you their status because they have very many partners, but once you know about your own status first of all, and you have that confidence, [then] knowing about your partner's status will be a must. Because yourself you're okay, then how come you accept to die just for free?... You have to know also, so women are becoming more powerful. (FG, young women, aged [16][17][18][19] Conversely, many participants felt that engaging intimate partners in HIV testing practices was a more The potential empowerment that testing could provide for women as described above was understood as conditional, as it was also dependent on receiving negative test results. Participants described fears that they would be rejected or left by their partner should they test positive for HIV. This was also illustrated by a key informant: If the girl is already infected, or if she suspects that she has HIV, she will be afraid of being asked for her results. There is also denial, the fear of being neglected, the fear of losing the boyfriend. She may not be willing to disclose her status immediately. However, if she is negative, it will be very, very easy to give it to the boyfriend. She might even force him to take it. (key informant, AIDS service organization) Another key informant working with sex workers reinforced this concern: It is hard, and of course you know that once this partner gets to find out if I test positive of course this partner is going to run away and maybe you need that partner around, so it is always more comfortable if you do it [HIV testing] alone but not with your partner. (key informant, sex worker) Taken together, participant responses signal how supportive intimate partner relationships can encourage and even be further strengthened by HIV testing. However, this outcome was contingent on the stability of relationship, and on the results of the test. When intimate relationships were already precarious, positive HIV test results were understood to have the potential to end relationships. --- Family Perspectives on engaging family members in HIV testing decision-making reflected a high degree of ambivalence. Many participants viewed family engagement as important in HIV self-testing, as family members were trusted, understood them, and could care for youth with an HIV-positive diagnosis. The strength of kinship ties emerged as important in HIV testing decisions, evidenced when participants described a family member would be the preferred person to provide them with an HIV self-test. For instance, when asked who they would prefer receiving an HIV self-test kit from-a friend, a peer, or a family member-one young man responded: "the family member, because you won't neglect blood. The brother, what he's telling you...you will take it with value." (FG, young men, aged 20-24) This sentiment was corroborated by another participant, framing support from families as long-term: "A family member, because, if you get any problem, they won't give up on you so quickly." (FG, young men, aged [20][21][22][23][24]. In addition to offering stability, family members were perceived to have increased access to other family members compared to outsiders. As a participant explained, they preferred HIV testing with "the member of the family because where the leader or peer educator can't reach, the member of the family may take charge." (FG, young man, aged [20][21][22][23][24] The family was further understood as a network for sharing HIV knowledge. Another young man added how family members could support others with less education or information: "some people didn't go to school, but in the family we understand each other. So, when you have a family member, [they] will explain to you how to use it [HIV self-test kit]." (FG, young man, aged 20-24) Kinship bonds were thus understood as having the potential to facilitate HIV testing in situations of social and educational marginalization. In contrast, other participants discussed wariness engaging with family members in HIV testing decision-making due to fears of judgment and even potential coercion. To illustrate, a key informant discussed concerns of coercion by family members for HIV self-testing and other prevention techniques: If you give it [HIV self-test kit] to a family member, they will say,'my son, you didn't spend the night here, come and test because I am your mother, so I force you to test.' Yet testing for HIV is not a must, it should be voluntary. This can cause problems in the family. That is the same issue that happened with condom distribution, when we were taking them to people's homes and they were saying that we are promoting adultery. (key informant, humanitarian agency) Participants feared judgment for being sexually active if family members knew they were testing for HIV. As a participant described, testing with "the family member it is a big problem because if I tell my auntie to give me [an HIV self-test] and I test myself, that auntie of mine will start asking why this girl is asking for the test kit to test herself, meaning she is suspecting herself." (FG, young women, aged 20-24) Similarly, another participant noted that "for the family member there is a challenge because it may cause some misunderstanding, and for parents they might think the child is spoilt." (FG, young women, aged [20][21][22][23][24]. Additionally, concerns were raised that sometimes family members did not disclose their child's HIV positive serostatus to them due to HIV stigma and/or misinformation. As one key informant related: You have to engage the parents to understand the benefits of using the HIV self-test. Why? We have had scenarios where an adolescent turns (HIV) positive and the parents say, 'don't start ARVs [antiretroviral therapy], because those drugs will just weaken you.' Of course, this is not right but you can't handle this young refugee alone leaving the parents or caretaker out of the picture." (key informant, AIDS service organization) These concerns were further corroborated by a service provider who reported: I do home-based testing where we go to homes and we identify those in care, call them and go and test the family members. That is a bit complicated because most of them don't want us to go and test the family members. There are those who refuse us to test the children and even that age is very tricky. If they test themselves and can't read, they will end up asking someone else. There are clients at that age 15-25 years who are taking ARVs every day and they are not aware that these are ARVs. The parents have failed to tell them that they are HIV positive. They tell them the medicine is for liver problems and things like that. You find parents who don't want their children to know that they are HIV positive. (key informant, hospital-based HIV care) Thus, although some families were understood as being able to support HIV testing and engage other family members, there were also circumstances where family members could hinder those same efforts and HIV treatment engagement due to larger contexts of stigma and misinformation. --- Formal Sources of Social Support --- Peer Educators Where participants were largely unified was in expressing the desire to receive HIV testing information and support from peers, understood as other refugee youth who were trained in HIV prevention. Participants discussed that the benefits of engaging such peers, as distinct from friends, in HIV testing included less judgment, increased confidentiality, and they understood peers to be more knowledgeable. As one young woman told us: "I would go with the peer educator mostly because they have experience, they are more mature than you, there is that comfort they can give to you, the direction, the instructions. Even when you find yourself positive you may not worry so much." (FG, young women, aged 20-24) Others described the benefit of engaging with trained peer educators who could also support engagement with other sexual and reproductive healthcare needs: "The peer educator is educated about confidentiality [and about] counselling for both (HIV) positive and negative. If we test and we are negative the next thing is, remember we are fighting against HIV but we also can look at issues like unwanted pregnancies, STIs." (key informant, humanitarian agency). Women engaged in sex work also reported preferences for peer engagement with HIV testing. As one key informant working at a sex worker agency described: We have peers operating at different [sex worker] hotspots, so these peers one of their responsibilities is ensuring that they mobilize our members, so when we take out the HIV counselling and testing, the outreaches and all that, it is the peers that are responsible to do the mobilization and communication. I think a peer would be the best option because as you know when it comes to us, sometimes our families have abandoned us because of the work we do, so it will not be comfortable for me to confide in my family or a friend because it is hard for one to disclose even when they find out that you are [HIV] positive. You know a friend would judge you and your family would say that you see now you had to acquire this because you are a sex worker, we have been telling you this and that, however we feel more comfortable being with a fellow sex worker because we are in the same industry and we understand our issues and we will not be judged. (key informant, sex worker agency). Peer support in this narrative was understood as a way to circumnavigate HIV stigma as well as other forms of intersecting stigma, such as sex work stigma. --- Health Professionals Finally, many participants suggested accessing professional health worker support in HIV testing. This was particularly pronounced for wanting counselling alongside HIV testing: "The health workers and the counsellors before they test you, they first take you through some counselling," one young man noted. (FG, young men, aged [16][17][18][19] As another young man told us, "It's better to go directly to the doctor because you will receive counselling from the doctor regardless of your (HIV) status results." (FG, young men, aged [20][21][22][23][24]. A young woman highlighted that the advantages of talking to a professional healthcare provider could extend beyond the biomedical realm, commenting on how counselling can help to reduce HIV stigma: "say the result is (HIV) positive, there is a way the doctor engages with you into a counselling session in order not to feel stigmatized or feel undermined in the society, you start a new process." (FG, young women, aged [16][17][18][19] Counselling can also promote living positively with HIV: "It's very important because it makes the person aware that there's life after being sick," another participant told us, "you find that [you] can live for some time knowing that there's still hope. Therefore, your mind changes after meeting with a doctor, takes you through counselling, so that way, you can have life." (FG, young men, aged [16][17][18][19] These mental health benefits of being supported by a professional when testing were memorably summed up by one young man who, when discussing the idea of HIV self-testing, told us he preferred to access HIV testing at a local hospital: Going to hospital direct is still better because [if you are] alone, maybe you are in your room alone, and see that you're positive, you might get a heart attack and die direct because you never had someone to prepare you like the doctor could. (FG, young men, aged [20][21][22][23][24] These concerns reflect fears surrounding a lack of support and understanding when receiving an HIV positive diagnosis that could be addressed by professional healthcare workers. The importance of engaging with health professionals was also commonly articulated as a need for mental health support at large rather than for HIV care alone. A number of participants mentioned the risk of suicide after receiving an HIV positive diagnosis, underscoring the stress involved in testing decisions. As one woman told us, "you might kill yourself so you need someone to keep on counseling you on how to conduct yourself, how to take drugs such that you don't infect others." (FG, young women, aged [16][17][18][19]) "There might be a possibility of suicidal tendencies," a young man similarly related, "but if you have someone checking on you, guiding and encouraging you every week, you can easily regain your courage." (FG, young men, aged [16][17][18][19]. Pre-existing mental health challenges among refugees intersects with these considerations for professional support during HIV testing. As one service provider told us about their experiences working at an AIDS service organization: "Most refugees have mental health issues so when handling them you have to be extra careful. They expect health workers to give them special attention. As a service provider, you have to keep the waiting time very short." (key informant, AIDS service organization) Others noted that refugee youth often experience persistent mental health challenges due to trauma related to war, violence, and forced displacement. For instance, a key informant at a humanitarian organization described the lasting effects of experiences of sexual violence during migration, telling us that: In that rape you will find that SGBV (sexual and gender-based violence) is there, then psychosocial and mental problems also arise from that SGBV, that rape. So, we also have a mental health desk and that is comprised of a psychiatric doctor, a clinical psychologist, we have a psychiatric nurse, we have a psychosocial counsellor." (KI, humanitarian agency) Thus, the provision of counselling for HIV testing could help to mitigate barriers of fear and stigma by providing social support and information on living positively, as well as serving an important gateway for accessing other mental health support for pre-existing trauma. --- Discussion Participant narratives reflect multi-dimensional relational contexts that shape HIV testing decision-making among urban refugee youth in Kampala (see Fig. 1). Findings aligned with our hypothesis that informal (intimate partners, family) and formal (peer educators) support sources play important roles in shaping HIV testing practices. Narratives also identified another formal source of support-health professionals-that can facilitate HIV testing, and wellbeing more generally, with urban refugee youth. Our study contributes to the nascent knowledge base on HIV testing with urban refugees to reveal the ways that collectively these formal and informal sources hold the possibility to provide three key dimensions of support [27,29]: emotional (managing stress in testing processes), appraisal (better understanding the need for HIV testing), and informational (providing HIV information, treatment literacy) support. Our findings also reveal important complexity within informal support sources regarding HIV testing. While testing could occur within strong intimate partnerships, it could also negatively impact tenuous partnerships and these harms could be amplified with HIV positive test results. Family contexts could provide stable support and knowledge of how to access marginalized family members, including those with low literacy or language barriers, yet simultaneously, family members could re/produce stigma regarding adolescent sexual practices and HIV. Formal support sources were more commonly discussed as beneficial, signaling their potential in offering bonding (peer educators) and bridging (health professionals) social capital that encourages HIV testing engagement. Findings can inform HIV testing and disclosure interventions that span formal and informal support sources and share both the positive and potentially negative implications of engaging a diversity of support networks. Findings corroborate prior research on the complexity of HIV testing with intimate partners conducted among non-refugee populations. For instance, a body of research shows that fear of negative repercussions including stigma, violence, and rejection from testing positive present barriers for HIV testing uptake among women [54], including pregnant women [55], and couples [56,57] in Eastern and Southern African contexts. Yet in supportive relationship contexts, HIV testing and disclosure may facilitate care engagement and strengthen relationships [56]. Findings from life history interviews with non-refugee young adults matched by HIV positive and HIV negative serostatus in Rakai, Uganda demonstrated that the nature and quality of sexual relationships were key factors that differed by HIV serostatus [58]. Increased HIV-related communication, trust, and smaller sexual networks were more likely to be reported among HIV negative participants, emphasizing the need for relational and dyadic approaches to understanding the micro-social contexts of HIV risk perception and testing decision-making [58]. Our findings indicate the need to assess sexual relationship power dynamics [59] among urban refugee youth in decision-making regarding HIV testing and disclosure with intimate partners. Our finding of diverging perspectives toward family involvement in HIV testing decision-making is congruent with prior research with non-refugee youth. For instance, a study with adolescents in Zambia found that: youth commonly sought advice from family members before testing; conceptions of family broadened beyond parents to include siblings and extended family members; and when a family member was unsupportive of HIV testing, this could discourage engagement in testing and result in seeking support from other sources [60]. The quality of kinship relationships -similar to couple-based HIV prevention [61] -was a key consideration that influenced participant perspectives on engaging family. Families have also been conceptualized as a source of hope for people with HIV, both at diagnosis and over the long-term, suggesting the social environment, and families in particular, are "a regulator of hope" [62](p. 18,802). Among adolescents and young adults in Kenya, parents were the most common support person to influence testing decision-making and to accompany a youth to testing for those aged 14-19 [36]. Our findings suggest the importance of family stability to urban refugee youth in accessing testing support-possibly more important for refugee youth who often experience breakdown of family and community networks in conflict-as well as the reciprocal nature of family support, where youth described providing HIV information to marginalized family members. Participant narratives overwhelmingly supported engaging peers in HIV testing processes, corroborating a robust evidence base on the importance of peer engagement in youth HIV prevention and care cascades [63,64]. Systematic reviews report that peer education programs in low and middle-income countries [65] and Sub-Saharan Africa [66] were associated with increased HIV knowledge and condom use, yet did not examine HIV testing. In a study with adolescents and young adults in Kenya, those aged 20-24 were most likely to identify being influenced to engage in HIV testing by partners or peers and to go for testing with peers [36]. O'Laughlin et al. identified the importance of engaging peer educators living with HIV in Nakivale refugee settlement in HIV testing educational campaigns [48]. Future implementation science research can explore successful approaches for engaging peer supporters in HIV testing processes with youth in Sub-Saharan Africa [67], particularly among urban refugee youth. The present study's finding that some urban refugee youth wanted professional support and pre-test counselling aligns with prior research with youth in Lesotho [68] and South Africa [38] who reported wanting pre-test counselling, information, and support in case of an HIV positive diagnosis. In another study with youth in Nigeria, most participants preferred testing in a health facility with physician-administered tests, although there was heterogeneity in testing preferences [69]. While limited research has explored preferences for professional support with HIV testing among urban refugees, O'Laughlin et al. explored home-based and clinicbased testing in Nakivale settlement in Uganda [70]. They found that home-based testing participants were more likely to be refugees than clinic-based testers, suggesting that this could be due to language barriers at clinics or due to living further from the clinic and experiencing transit barriers [70]. Building on this, our findings suggest the importance of offering a range of accessible testing options for urban refugee youth and ensuring that counselling services are offered in languages spoken by refugees. Further research can explore the ways that HIV counselling can screen for mental health issues and facilitate linkage to mental health support with urban refugee youth. There were several study limitations. The focus group study design did not include the opportunity for individual interviews with youth, thus some youth may have not felt as comfortable sharing about HIV testing in group setting. We did not explore experiences of sexually or gender diverse youth, or of transgender women or cisgender men sex workers. The prior linkages to a youth refugee agency among most participants could result in them having increased access to social support and HIV knowledge. As this study focused on urban refugee youth, we did not collect information about youth testing experiences in a refugee settlement, and this would give us insight into what is unique and different based on the social context young refugees live in. We also were unable to differentiate experiences based on country of origin or length of time in Uganda, and those could be linked with access to social support. Finally, we did not explore religious support and other formalized social support networks, and these could be important to HIV testing engagement [71]. Notwithstanding these limitations, our study offers a unique contribution to understanding the emotional, appraisal, and informational support domains offered across varying sources (peer, family, intimate partner, professional). These findings can inform tailored HIV testing interventions that leverage these multi-dimensional forms and sources of support to create enabling environments that include both technical (e.g., information, such as treatment literacy) and transformative communication (e.g., awareness of and confidence to address power inequities, such as young women's awareness of gendered power inequities and confidence to insist on partner testing) [26]. Places as a concept, comprising social processes and practices in a particular location [72,73], are relationalboth shaped by and shaping social networks and interactions across the life-course [24]. The quality of places is formed not only by the people inhabiting

Despite the global phenomenon of refugee urbanization, little is known of relational contexts that shape HIV testing among urban refugee youth. We explored perspectives, experiences, and preferences for social support in HIV testing among refugee youth aged 16-24 in Kampala, Uganda. We conducted five focus groups with refugee youth (n = 44) and five in-depth key informant interviews. Participant narratives signaled relational contexts shaping HIV testing included informal sources (intimate partners and family members) and formal sources (peer educators and professionals). There was heterogeneity in perspectives based on relationship dynamics. While some felt empowered to test with partners, others feared negative relationship consequences. Participant narratives reflected kinship ties that could facilitate testing with family, while others feared coercion and judgment. Peer support was widely accepted. Professional support was key for HIV testing as well as conflict-related trauma. Findings emphasize bonding and bridging social capital as salient components of enabling HIV testing environments.

the social context young refugees live in. We also were unable to differentiate experiences based on country of origin or length of time in Uganda, and those could be linked with access to social support. Finally, we did not explore religious support and other formalized social support networks, and these could be important to HIV testing engagement [71]. Notwithstanding these limitations, our study offers a unique contribution to understanding the emotional, appraisal, and informational support domains offered across varying sources (peer, family, intimate partner, professional). These findings can inform tailored HIV testing interventions that leverage these multi-dimensional forms and sources of support to create enabling environments that include both technical (e.g., information, such as treatment literacy) and transformative communication (e.g., awareness of and confidence to address power inequities, such as young women's awareness of gendered power inequities and confidence to insist on partner testing) [26]. Places as a concept, comprising social processes and practices in a particular location [72,73], are relationalboth shaped by and shaping social networks and interactions across the life-course [24]. The quality of places is formed not only by the people inhabiting them, but also by the nature of their interactions [74]. Among refugee youth participants living in Kampala's slums, social relationships varied in ways that facilitated or inhibited HIV testing engagement. Slums are spatial entities with shared social and physical environments characterized by poverty and inadequate housing and social services [75]. Contextual characteristics of slums that may influence HIV testing include dense, crowded living spaces that afford limited privacy for self-testing, and access barriers, including a lack of health facilities, poverty, and transport costs [23,76]. Aligned with discourse on place [24,72], participant narratives reminded us that places such as slums in Kampala are fluid, shifting, and dynamic, and residents can have distinct experiences. Our findings point to the heterogeneity within a particular place-in this example, among urban refugee youth in Kampala-that can inform diverse approaches to HIV testing to create enabling environments [26]. These shared social entities hold the potential for 'neighborhood effects' whereby intervention benefits can be widely dispersed in the community [75,76]-thus HIV testing interventions focused on refugee youth in slums could potentially benefit others (adults, non-refugees) in these communities. Our findings offer insight into the importance of offering urban refugee youth professional support for both HIV and mental health needs, signaling the importance of applying a syndemics approach to investigate social contexts that shape co-occurring sexual and mental health disparities among slum-dwelling refugees [18,77]. Refugee youth narratives also shed light into the potential beneficial and harmful outcomes of engaging informal supports (intimate partners, family) in HIV testing decision-making. We apply the Disclosure Process Model [78,79] to conceptualize the antecedent goals for engaging these support sources (Fig. 2), with attention to both the approach goals for positive outcomes and avoidance goals for negative outcomes identified in participant narratives. As refugee youth have unique experiences of conflict-related SGBV and family breakdown [80][81][82], it is particularly important to identify the range of potential outcomes for accessing support in HIV testing to inform decision-making among this population. Attention to gender dynamics as complex and dynamic is key in HIV testing programs-young refugee women in our study discussed increased women's empowerment alongside persisting inequitable sexual relationship power. Refugee young women sex workers noted the particular importance of peer support in light of family rejection, signaling the salience of an intersectional approach to gender [83]. Young refugee men appeared to be more in favor of family engagement-they possibly experience less judgment for being sexually active than young women due to inequitable gender norms [84]. Mannell et al. explain that programs need to focus on agency and pleasure rather than risk, and recognize evolving gender norms and relationship dynamics, in order to effectively prevent HIV and intimate partner violence with young women in Southern Africa [85]. Our findings align with the call for HIV testing campaigns to consider HIV status disclosure concerns, risk of partner violence, and social support [54] a risk framework toward a strengths-based approach that leverages community strengths, resilience, and resources [49]. Building on the concept of HIV competent communities that help persons to acquire information, support and skills to overcome barriers [30], HIV testing interventions with urban refugee youth can facilitate access to bonding (peers, partners) and bridging (family, professionals) social capital. With this approach, HIV testing interventions hold the potential to advance sexual justice-sexual health experiences that are person-centred and advance sexual rights and sex positive practices [86]. --- Declarations Conflict of interest The authors have no conflicts of interest to declare. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Despite the global phenomenon of refugee urbanization, little is known of relational contexts that shape HIV testing among urban refugee youth. We explored perspectives, experiences, and preferences for social support in HIV testing among refugee youth aged 16-24 in Kampala, Uganda. We conducted five focus groups with refugee youth (n = 44) and five in-depth key informant interviews. Participant narratives signaled relational contexts shaping HIV testing included informal sources (intimate partners and family members) and formal sources (peer educators and professionals). There was heterogeneity in perspectives based on relationship dynamics. While some felt empowered to test with partners, others feared negative relationship consequences. Participant narratives reflected kinship ties that could facilitate testing with family, while others feared coercion and judgment. Peer support was widely accepted. Professional support was key for HIV testing as well as conflict-related trauma. Findings emphasize bonding and bridging social capital as salient components of enabling HIV testing environments.

Background The first visible outcome of the fertility process is the birth of the first child. The first birth marks a woman's transition into motherhood. It plays a significant role in the future life of each individual woman and has a direct relationship with fertility [1]. The timing of the first birth influences the number of children a woman bears throughout her reproductive period in the absence of any active fertility control, and woman who starts giving the first birth very early in life tends to have a large number of children than those who starts late [2]. Fertility patterns in the world have changed dramatically over the last two decades since the international conference on population and development (ICPD) in 1994, producing a world with very diverse child bearing patterns [3]. Many countries in Asia were able to reduce their fertility through government policies. For instance, China and Vietnam have witnessed declines in their total fertility rate (TFR) due to stringent government policies that discourage early and arranged marriage [4]. However, the delayed fertility transition has been observed to be underway in the region with remarkable progress in African countries like South Africa, Botswana, and Zimbabwe [5], fertility remains high in Africa by the standards of the rest of the world. Fertility rates in sub Saharan Africa have been identified to exhibit a very unique demographic scenario in the world that sets it apart from other regions in the world. Contrary to the case of most regions like Europe, South America and Asia that have for long entered the fertility transition marked by a declined in their fertility rates in the 1950s and 1960s, sub-Saharan Africa is the only region in the world, where fertility decline has been rather slow and late [6]. Fertility rates in the subcontinent stand at the same level as that of Asia and South America towards the end of the 1970s. Most countries in Sub Saharan Africa are still experiencing relatively higher fertility rates. What can be discern from the information so far provided, is that sub-Saharan Africa is the sole region in the world that has not so far experienced any significant decline in its fertility rates [7]. According to United Nations 2014 report, 45 out of 66 high fertility countries (more than 3.2 children per woman) are increasingly concentrated in sub-Saharan Africa [3]. Ethiopia is the second most populous countries in sub-Saharan Africa next to Nigeria with 94,351,001 population size and 29 years of doubling time along with the scarcity of resources [8]. Uncontrolled fertility has adversely influenced the socio-economic, demographic and environmental development of the country. Poverty, war and famine, associated with low levels of education and health, a weak infrastructure, and low agricultural and industrial production have aggravated the problem of overpopulation [9]. When we look back at the history of Ethiopia population growth rate, there has been a steady increase since 1960. Based on 1984 census information, population growth rate was estimated at about 2.3% for the 1960-70 period, 2.5% for the 1970-80 period, and 2.8% for the 1980-85 period. Population projections compiled in 1988 by the CSA projected a 2.83% growth rate for 1985-90 and a 2.96%t growth rate for 1990-95. According to the 2007 Ethiopia population census, the annual population growth rate within 1994-2007 was estimated as 2.6%. Age at the start of marriage is one of determinant factors. Early childbearing can interrupt a young women's education and other activities which women need to accomplish [3]. Other major social, economic and cultural factors which are related to family and reproduction status, as well as personal values and practices, are shown to influence fertility and thus time to first birth [4,5]. But the fertility rate is quite different across different customs, culture and practice of people living in different regions of Ethiopia. This implied that the existence of heterogeneity in the survival of time-to-first birth between different regions. For the formulation of effective policy to motivate people for longer first birth interval after marriage, it is crucial to study the effect of various socio-economic and demographic factors which affect time-to-first birth. Having these, this research aimed to examine factors associated to time-to-first birth interval after marriage using parametric shared frailty survival models. --- Methods --- Study population and sampling design The data was obtained from 2011 EDHS, which was taken from Central Statistical Agency (CSA). Each region of Ethiopia was stratified into urban and rural areas resulting 21 sampling strata. Enumeration Areas (EAs) were selected independently in each stratum in two stages. In the first stage, a total of 645 EAs (202 EAs in urban areas and 443 EAs in rural areas) were selected with probability proportional to the EA size (based on the 2007 Population and House Census) and with independent selection in each sampling stratum. The resulting lists of households served as a sampling frame for the selection of households in the second stage. In the second stage of selection, a fixed number of 28 households per cluster were selected with an equal probability systematic selection from the newly created household listing. The questionnaires for data collection were adapted from model survey instruments developed for the measure DHS project to reflect the population and health issues relevant to Ethiopia. The questionnaires were developed in English and translated into three major local languages-Amharic, Oromiffa, and Tigrigna. A representative sample of 17,817 households were selected, of these, 16,702 were successfully interviewed. In the interviewed households 17,385 eligible women were identified for individual interview; complete interviews were conducted for 16,515. After excluding missing values, a total of 7925 with women were included [10]. --- Variables and statistical analysis Response variable The response variable is time-to-first birth among woman in Ethiopia, which is measured in months. For women who did not give birth (censored) the time was measured till the date of the interview. Independent Variables: Independent variables included in the analysis are described in Table 1 as follows. --- Statistical analysis Descriptive analysis was performed using frequency and percentage for both dependent and independent variables. Parametric Shared Frailty survival model was used to identify significant factors of FBI by considering region of women as clustering variable because fertility rate is different due to the presence of different custom; culture and practice of people across regions of the country. The shared frailty approach assumes that all FBI in a cluster are conditionally independent given the frailties. The value of the frailty term is constant over time and common to all individuals in the cluster, and thus it is responsible for creating dependence between event times in a cluster [11,12]. Akaike's information criterion (AIC) was used for model comparison. Data cleaning, management and analysis were carried out using STATA, Version 12. All hypotheses testing to determine differences, associations and relationships were judged significant at p <unk> 0.05. --- Inclusion exclusion criteria Women who went into marriage for the first time without a child or no pregnancy and with complete records were considered. Thus, women having less than nine months of waiting time for first birth after marriage and having negative birth interval were excluded. --- Limitation of study This research excluded Somali region because the data cannot be considered as representatives of the region since some EAs are not interviewed due to drought and security problems. And also some factors which may have significant contribution to FBI such as age at menarche and menstrual status were not considered. Investigating the influence of these factors may be appropriate to understand further dynamics of time to first birth after marriage in the country. In addition to this, further studies should be warranted in each region of Ethiopia and explore other factors that are not addressed in this study. --- Results A total of 7925 women who got first marriage from eight regional states and two administrative cities of Ethiopia were included. Of the total women, 5966 (75.3%) of them gave first birth while 1959 (24.7%) of them did not give birth until the end of the interview (Table 2). The median time of FBI and age of women at first marriage were estimated to be 30 months and 16 years respectively. The median survival time to first birth with the corresponding 95% confidence interval for all region of the country was presented in Table 3. The maximum and minimum median time to first birth for women was from Amhara (51 months) and SNNP (23 months) region respectively. The result of log-normal gamma shared frailty model was presented in Table 4. The age of women at marriage was statistically significant to determine time-to-first birth after marriage, the acceleration factor (<unk> = 0.927, 95% CI: 0.922-0.932). Accordingly, as age of women at first marriage increases, the time-to-first birth becomes shorter by a factor of <unk> =0.927. Urban women have prolonged time-to-first birth than women from rural by a factor of <unk> =1.292. Employed women prolonged time-to-first birth than unemployed women by a factor of <unk> = 1.080 with 95% CI: 1.042-1.120. Mothers who used contraceptive methods prolonged time-to-first birth by a factor of <unk> = 1.116 (95% CI: 1.072-1.162) as compared to non-users. Women who attended secondary education and above had shorten time-to-first birth by a factor of <unk> = 0.828 with 95% confidence interval (0.796, 0.862) as compared to the uneducated women. The variance of the frailty distribution (<unk> = 0.78) had significant contribution to the model that indicates the presence of heterogeneity among timing of first birth among the regions. --- Discussion This study applied parametric survival frailty models in order to investigate the determinant factors of time-tofirst birth after marriage among Ethiopian women, based EDHS 2011 data set. 7925 Ethiopian women who got an official marriage were included in the study. The prevalence of having the first child after marriage was 75.3%. Graphically it could be observed that high rate of first birth within the first three years following the marriage. This finding similar to the previous community based cross-sectional study in Lemo district, Ethiopia [1]. Previous study in Sub-Saharan level was established that 57% of women of child bearing age in 2002 practiced time to first birth less than 3 years [6]. This may be due to the reason that many women in developing countries do not use contraception after birth and therefore are likely to become pregnant once fecundity achieved [13]. The estimated median age of women at marriage was 16 years. This result is consistent withstudy conducted in the county where 60.6% of Ethiopian women were married before the ageof 18 years [14]. --- Table 1 Description of independent variables used in the analysis The estimated median survival time of first birth after marriage of Ethiopian women is found to be 30 months. This finding is almost similar with the finding for the same country using 2005 EDHS [15] and result revealed that the median time of FBI was 29 months. This estimate is also exactly identical to Ghanaian women [16]. However, the median time of FBI is a bit lower than women in Bangladesh where it was estimated to be 25 months [17]. This difference may be due to the practice of early marriage in Ethiopia which had potential to prolong timing of first birth [15]. Marriage at older age significantly associated with shorter time interval for the first birth. This result is consistent with the study in the country and abroad [18,19]. The reason may be older women need to give birth soon after marriage to have the desired number of children before the end of their reproductive life. And, woman who gets early marriage use contraceptive to elongate time-to-first birth until it becomes physically mentally matured [17]. However, some contradictory results were also observed such as in Pakistan, younger women at marriage had shorter FBI [20]. The results of this study suggested that women who lived in urban areas had longer first birth interval than women who lived in rural areas. Rural inhabitants have usually no access for maternal health and family planning programs as compared to urban residents [15] which may results in short birth interval. This finding is supported by a study in Bangladeshi study and a longitudinal data based study in Nigeria [16,17]. Another important finding of this study was that employment status of the women had a significant association to time-to-first birth. Time-to-first birth interval following marriage for employed women was longer than unemployed women. This is consistent with studies which were done abroad [21,22]. Women those used contraceptive had long time-to-first birth than the non-users. This is due to contraceptive service which helped them to protect early and unwanted pregnancy in marriage life of the couples [17]. A similar study in India reported that contraceptive use did not emerge as a significant associated factor at any birth interval [23]. A significant association was found between women education and time-to-first birth. Women with secondary and above education have significant shorter first birth interval as compared to women who were not educated. This may be due to the reason that at the time of entry to marriage life, educated women can be emotionally prepared, biologically matured, and financially secured to have a child. A study in India established that education of women was significantly associated with first birth interval only while husband's education was significantly associated with first and second birth interval [23]. In another study on timeto-age at first birth in Ethiopia, they established that educated women have longer waiting time to time-tofirst birth after marriage. When women spend a longer time at school, this is likely to significantly affect both age at marriage and the duration between marriage and the first birth [24]. --- Conclusions The study aimed to examine time-to-first birth interval after marriage and its associated factors among Ethiopian women using Parametric Shared Frailty Model. A total of 7925 woman who got involved in first marriage from the nine region of the country included in this study. The median survival time of FBI was estimated to be 30 months. Younger age, residence area, employment status, contraceptive use and education status of woman associated significantly to time to FBI. There is a need of teaching family for contraceptive use and improving woman education to increase the length of FBI along with not encouraging early marriage to get control a rapid population growth in Ethiopia. --- Availability of data and materials The dataset was demanded and retrieved from CSA website after formal online registration and submission of the project title and description. The data can be accessed through http://www.statsethiopia.gov.et/. --- Abbreviations ANC: Antenatal Care; CSA: Central Statistical Agency; EAs: Enumeration Areas; EDHS: Ethiopian Demographic and Health Survey; FBI: First Birth Interval; HH: Household; SE: Standard Error; WHO: World Health Organization Authors' contributions AG wrote the proposal collects data from CSA and analysed the data in consultation with the DS and AB. DS and AB edited the document and gave critical comments. All authors read and approved the final manuscript. --- Ethics approval and consent to participate Ethics approval and participant consent were not necessary as this study used previously-published database by CSA of Ethiopia. --- Competing interests The authors declare that they have no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Time-to-first birth after marriage has a significant role in the future life of each individual woman and has a direct relationship with fertility. This study aimed to see the determinant of time-to-first birth interval after marriage among Ethiopian women. Methods: The data was obtained from 2011 Ethiopia Demographic and Health Survey which is the third survey. The sample was selected using a stratified; two-stage cluster sampling design and the data was analysed using parametric shared frailty model. Results: A total of 7925 ever married women from the nine region of the country were included in this study. Of the total women, 5966 (75.3%) of them gave firstbirth. Age, residence area, employment status, contraceptive use and education of women were associated significantly to time-to-first birth. Conclusions: Women having younger age at first marriage, urban women, contraceptive users had prolonged time to first birth interval. There is a need of teaching family for contraceptive use and improving women education to increase the length of first birth interval in Ethiopia.

INTRODUCTION Since the 2000s, China has witnessed a rapid growth in the number of non-governmental organizations (NGOs), including social work organizations. In 2020, over 669 thousand qualified social workers in China played a vital role in social service and local governance (1). However, social workers have a high risk of burnout, which is considered a worldwide issue (2)(3)(4)(5) and concerns the social work industry in China (6,7). Existing literature associated social workers' burnout with their mental and physical health problems, such as depression (8,9), sickleave absences (10), and self-reported health problems (11). The burnout also increased social workers' intentional (12) and actual turnover (13). Furthermore, when they localize Western social work theories and practices, Chinese social workers find they work in a considerably different environment from their western counterparts as they are highly involved in the local governance (14,15). To be more specific, compared with the mature social work industry in the west, the professionalism of social work in China is still under development after being abandoned by the revolutionary regime in the 1950s and re-introduced in the late 1980s (16). In addition, Chinese social work tends to be embedded into the existing executive-led and unprofessional social service system (16,17). The westernized social work ideologies of "individualism, democracy, and Christianity" do not sit comfortably in China's unique social and political backgrounds (18). Therefore, it is crucial to further explore social worker burnout in China's social and political context. Burnout is characterized as a crisis in one's relationship with work (19). In the condition of burnout, workers become worn out or exhausted as their energy, strength, and resources encounter excessive demands (4). Maslach and Jackson generated a threedimension definition of burnout, the Maslach Burnout Inventory (MBI), including emotional exhaustion, depersonalization of clients, and reduced personal accomplishment (RPA) (20). These three dimensions were considered to be psychologically discrete (21). Due to the Chinese government's strong promotion, social work organizations have been playing an important role in social governance in both urban and rural areas (17,22,23), but the strong government involvement could be a macro factor causing role stress on social workers (7), which could, in turn, increase their burnout. Role stress is a response that occurs when workers face job requirements that do not match their knowledge and skills, thus challenging their coping ability (24). Role stressor includes two dimensions, i.e., role conflict and role ambiguity (25,26). Role conflict refers to the feeling of conflicting requirements or competing values at work or requiring the realization of multiple roles in a task (27,28). Role ambiguity refers to the uncertainty in the definition, expectation, responsibility, and task of one's role, and workers thus do not know what kind of behavior they are expected to do when encountering a specific situation (29). Amplified existing research confirmed the role stress-burnout model that role stress and its two dimensions had a positive direct effect on burnout (30)(31)(32)(33)(34)(35), and so had they among social workers (36,37) and social workers in China (7,38). Since the governments contract out massive social services to social work organizations in China, social work organizations' legitimacy and financial resources largely depend on local governments (39,40). Social workers are thus often in a weaker position when they work with local governments. Therefore, under the contracting-out social services arrangement, they usually have to conduct the additional workload imposed by local governments besides helping their clients with professional skills (41). That administrative workload includes two types: one could be potentially relevant to their professional work, such as assisting government departments with interviewing and investigating, organizing contemporary events, and conducting telephone follow-ups for social service recipients, while the other one is just daily chores utterly irrelevant to their professionalism, such as assisting government departments with sending, receiving or copying documents, drafting unimportant reports, and carrying out reception work (42). If social workers have to deal with local governments too often, they may not have enough time to provide professional services for their clients, and thus the deviation in the time-allocating priority may stress social workers. For example, this additional workload from dealing with governments could cause role ambiguity among social workers as it deviated from their professionalism of focusing on helping clients, especially the underprivileged ones (43,44). On the other hand, some local governments' demands in China, such as unjustly allocating social welfare resources, emphasizing social control rather than professional caring, and FIGURE 1 | Hypothesized model. ignoring the underprivileged clients' willingness, conflicted with social work professionalism, and this anti-social-work thus could cause role conflict among social workers (45,46). However, the above viewpoints and findings on the effects of the tension between working with governments and clients on social workers' role stress in China were based on theoretical discussion or qualitative exploration, which few studies have investigated with quantitative methods. Furthermore, the tension between working with governments and clients reflects the long-standing debate on the contradictory understandings of social work ethics between the conventional western social work view focusing on helping people to help themselves and Chinese social work's local knowledge of participating in social governance and conducting administrative affairs (18,47). The ethics tension could cause burnout among workers (48,49), and so did the two role stressors through the role stress-burnout model reviewed in the above paragraphs. Therefore, it is necessary to investigate whether the tension between working with governments and clients could impact social workers' burnout through the mediating effects of role ambiguity and conflict, which has not been researched in China. Existing research indicated that burnout was higher among front-line health care workers than the second-line ones (50,51). In terms of the social work vocation, the front-line social workers in China could feel the obvious tension between working with governments and clients since they found it was difficult to reconcile the role assigned by local governments with their professional role (45,52,53). However, the primary role responsibility of the management of a social work organization was to respond to the funding bodies, usually the local governments in China (54,55). Therefore, the front-line social workers may experience different role stress caused by the tension between working with governments and clients from the nonfront-line ones in China, and such a difference may result in different burnout between those two groups, which little research has investigated. Based on the Role Stress-burnout Model and the previous theoretical and field-work investigations on the tension caused by social workers working with local governments in China, this study examines the effects of the tension between working with governments and clients indicated by the deviation in the social worker's time-allocating priority from their professionalism, which is measured the by the government-client work interaction frequency gap (Interaction gap), on social workers' burnout as well as the mediating effects of role stress (role ambiguity and conflict) and the moderating effects of the non-front-line work (manager and/or supervisor). Understanding how the tension affects social workers' burnout is meaningful, a research gap identified by our literature review. Figure 1 depicts the hypothesized model. For simplicity of the model, this figure only displays the associated paths for the independent, mediating, moderating, and dependent variables, while the path diagram of control variables is omitted. --- METHOD Sample --- Ethical Approval Participants of CSWLS were informed about the aims, objectives, and framework of the survey and assured that their responses would be kept strictly anonymous and confidential. Written informed consent was collected from each participant confidentially. The research ethics committee of ECUST granted the ethical approval for the CSWLS (57). Furthermore, the ethics committee of the first author's university approved the research protocol of this article. --- Measures --- Dependent Variables Work burnout was measured by the Chinese version (58) of Maslach's Burnout Inventory-Human Service Survey (MBI-HSS) developed by Maslach et al. (21). The 22-item selfreported MBI-HSS consisted of emotional exhaustion (nine items), depersonalization (five items), and reduced personal accomplishment (RPA, eight items), which three subscales evaluated the emotional reactions caused by excessive work stress, the stress-induced attitudes and feelings toward the service recipient, and the feelings of competence and achievement in one's work separately. The MBI-HSS uses a seven-point Likerttype scale (0 = never and 6 = once every day). Cronbach's alpha for the above three subscales were 0.918, 0.816, and 0.921, respectively. --- Independent Variable This study focused on the tension between working with governments and clients indicated by the deviation in the social worker's time-allocating priority from their professionalism. Therefore, we constructed the government-client work interaction frequency gap (Interaction gap) as the independent variable, which was measured by the difference between the self-reported frequency level of work interaction with contractissuing government departments minus the one with clients. That self-reported work interaction frequency level is a five-point ordinal variable based on the item "How often do you deal with the following types of people (e.g., clients and government departments) at work respectively?" and its responses range from 1 = never to 5 = always. Although the evaluation criteria of interaction frequency level are subjective, the criteria for the governments and the clients are the same for the same person. Therefore, measuring the gap can help reduce the impact of different evaluation criteria between respondents on the estimation. --- Mediators The role stress was measured by the Chinese version [as cited in Liao's article (59)] of the shortened form of the Role Conflict and Ambiguity Scales developed by Rizzo et al. (60). The 14item self-reported scale consists of the nine-item role conflict (RC) and the five-item role ambiguity (RA) sub-scales. The respondents were invited to indicate the degree to which the condition described in the items applied to them on a five-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Cronbach's alpha for the above two subscales were 0.855 and 0.827, respectively. --- Moderator We used the variable Non-front-line as the moderator, which was measured as follows: whether the respondent focused on the front-line social work (Non-front-line = 0, front-line social worker, N = 2,643) or undertook both front-line social work and supervision or management work (Non-front-line = 1, nonfront-line social worker, N = 2,599). --- Controls This study's controls included three categories of variables: (a) demographic variables of a respondent, including age, gender, and educational attainment, (b) job-related characteristics of a respondent, including monthly income (natural logarithm), length of work experience at the current organization, length of work experience in the social work profession, hours of work per week, and (c) variables of the organization where a respondent worked, including organization age, size of the management board, number of full-time employees, numbers of full-time employees with at least the bachelor's degree, with the social work degree, and with the social work vocational qualification certificate respectively, level of the registered district (province, municipality or district/county), political connection, and the autonomy of expansion (registering a similar organization outside the registered district), service district (providing services outside the registered district), and service content (not undertaking other work arranged by the government outside the contract). We referred to the research of Ye and Sun (40) and Su et al. (57) to design the framework of control variables, and the measurement of those variables can be found in those two articles. We excluded the social support variables and the organization's annual revenue variable due to massive missing values in those variables. Descriptive characteristics of the variables for the front-line and the nonfront-line social worker groups are reported separately in Table 1. --- Data Analysis This study adopted structural equation modeling (SEM) to analyze the data and test the model using Stata 16.0 (Stata Corporation, College Station, TX, USA). Since this study has a large sample size, it would not be easy to test the degree of modeling fitness by the <unk> 2 (61,62). We thus used the following three indices that are widely applied to evaluate the model fit: --- RESULTS Pearson's correlation was used to analyze the correlations between the government-client work interaction frequency gap, two role stress variables (i.e., role conflict and role ambiguity), and three burnout variables (i.e., emotional exhaustion, depersonalization, and reduced personal accomplishment) in this study. The means, standard deviations, and correlations for each variable are presented in Table 2 for the sample of front-line social workers and in Table 3 for the sample of non-front-line social workers. --- Test of Measurement Model The measurement model of five latent variables, including two role stress subscales and three burnout subscales, should be verified before the structural model validation. Results show that the measurement model has a good fit index for the full sample and both the samples of front-line social workers and non-frontline social workers. In terms of the full sample, although <unk> 2 (7,275.955, df = 545, N = 5,242, p <unk> 0.001) is significant, the other three indicators show that the model fits well: RMSEA (0.049) is less than the cutoff value of 0.05 while CFI (0.926) and TLI (0.920) are greater than the cutoff value of 0.9. Therefore, RMSEA, CFI, and TLI results show that the measurement model fits well. In addition, the model analysis results show that the selected observation variables effectively reflect the intrinsic structure of the latent variable, as all the variables that make up the latent variable in this model have significant loadings on the latent variable. The standard factor loadings of all the variables that make up the latent variable are between 0.356 and 0.868 (shown in Table 4), and the acceptable factor loading is above 0.3 (68,69). Therefore, the measurement model confirms the reliability and validity of the latent variables. We also checked the fit index of the measurement model for the front-line sample (RMSEA = 0.049, CFI = 0.925, and TLI = 0.918) and the non-front-line sample (RMSEA = 0.050, CFI=0.924, and TLI = 0.917) separately, and the measurement model fits well with the data of both samples. According to the model analyses for both samples, all the variables' standard factor loadings are above 0.3. --- Test of Structural Model We used SEM to test the fitness of the hypothesized model in the correlation between the Interaction gap and role conflict is only significant for the front-line social worker sample (<unk> = 0.076, p <unk> 0.001). The result indicates that the mediation effects of role conflict are likely to be moderated by the variable of Non-front-line. Before testing the hypothesized moderation part of the model in Figure 1 by treating the variable of Non-front-line as the moderator, we separately tested the mediation model with the data of the front-line and the non-front-line social worker samples to reveal the direct, indirect and total effects for them. Results shows that the mediation models for both the front-line (RMSEA = 0.036 <unk> 0.05, CFI = 0.917 > 0.9, and TLI = 0.909 > 0.9) and the non-front-line (RMSEA = 0.038 <unk> 0.05, CFI = 0.911 > 0.9, and TLI = 0.903 > 0.9) social worker samples are well fitted. Tables 5,6 illustrates those two sets of path analysis results respectively. Table 5 shows that the government-client work interaction frequency gap directly affects two of the three indicators of front-line social workers' burnout. First, it has a significant direct negative influence on the emotional exhaustion of front-line social workers (<unk> = -0.031, p <unk> 0.05), indicating that those social workers involved in more work interaction with governments while less with clients have a lower level of emotional exhaustion after controlling for other factors. Meanwhile, the Interaction gap has a distinguished impact on the RPA of front-line social workers (<unk> = 0.048, p <unk> 0.01), suggesting that those social workers involved in more work interaction with governments while less with clients have a higher level of reduced personal accomplishment (i.e., lower level of personal accomplishment) after controlling for other factors. However, the effects of Interaction gap on depersonalization are not statistically significant (<unk> = 0.016, p > 0.05). In terms of the indirect influence, the path analysis in Table 5 presents that the Interaction gap has indirect effects on all the three burnout indicators of front-line social workers, whose coefficients are 0.019 (p <unk> 0.01) on emotional exhaustion, 0.011 (p <unk> 0.01) on depersonalization, and 0.016 (p <unk> 0.05) on RPA. The indirect influence mainly takes effect through the mediator, role conflict, rather than role ambiguity. Results suggest that the Interaction gap is significantly associated with higher levels of role conflict (<unk> = 0.024, p <unk> 0.01), which, in turn, predicates higher levels of emotional exhaustion, depersonalization, and RPA. However, role ambiguity is not a significant mediator between the Interaction gap and the frontline social workers' burnout. It should be noted that the directions of the direct and the indirect effects of the interaction gap on emotional exhaustion are opposite, which results in its weak and insignificant total effects (<unk> = -0.012, p > 0.05). Table 6 shows that only the direct and total effects of the Interaction gap on the RPA of non-front-line social workers are statistically significant, while the direct and total effects of the Interaction gap on the other two burnout indicators are not significant. The results in Table 6 are different from those for the frontline social workers, and especially all the three indirect effects are not significant for the non-front-line social workers. Comparing the results between Tables 5,6, we found that the association between the Interaction gap and the mediator Role conflict is only significant for the front-line sample (<unk> = 0.024, p <unk> 0.01) but not for the non-front-line sample (<unk> = 0.006, p > 0.05). Therefore, we further tested whether the mediation effects of the Interaction gap have been moderated by the variable of Non-front-line (vs. Front-line as the reference). According to the above results based on the data of two separate samples, we revised the moderated mediation model by treating the role ambiguity as one control variable rather than one of the mediators. Figure 3 displays the standardized results of the revised model with the data of the full sample. This structural model has an adequate fit (RMSEA = 0.037 <unk> 0.05, CFI = 0.909 > 0.9, and TLI = 0.901 > 0.9). The effects of the interaction item between the Interaction gap and Non-front-line on the association between the Interaction gap and the mediator Role conflict is significant (<unk> = -0.030, p <unk> 0.01), which suggests that Non-front-line has moderated the above association. In terms of the effects of control variables on the three burnout dimensions, the results suggest that: 1) the emotional exhaustion level of social wokers will be higher if they have a higher level of educational attainment (<unk> = 0.039, p <unk> 0.05) or more work hours per day (<unk> = 0.046, p <unk> 0.001), or work in a older organization (<unk> = 0.010, p <unk> 0.024), but be lower if they are older (<unk> = -0.020, p <unk> 0.001) or male (<unk> = -0.120, p <unk> 0.001); 2) their depersonalization level will be higher if they are male (<unk> = 0.104, p <unk> 0.001) but be lower if they are older (<unk> = -0.020, p <unk> 0.001); and 3) their RPA level will be lower if they have a higher level of educational attainment (<unk> = -0.065, p <unk> 0.01) or work in a organization with the autonomy of providing services outside the registered area (<unk> = -0.130, p <unk> 0.001). --- DISCUSSION This study investigated the effects of the gap between social workers' interaction frequency with governments and clients on their burnout by using the data collected from the CSWLS 2019, the first national survey for the social work profession in China. We also evaluated the mediating effects of role conflict and ambiguity and the moderating effects of non-frontline work. For the non-front-line social workers with extra management or supervision workload, the gap caused by more work interaction with governments and less with clients could only directly reduce social workers' personal accomplishments. However, for the front-line social workers, besides directly reducing personal accomplishment, the government-client work interaction frequency gap could indirectly neutralize its alleviating effects on emotional exhaustion, make its total effects on depersonalization significant, and reduce personal accomplishment further through increasing social workers' role conflict. That is to say, the mediating effects of role conflict are only significant for the front-line social workers but not for social workers with extra management or supervision workload, which reveals the moderating effects of non-front-line work. The findings of this study have implications for social policies and administration guidelines to form a healthy relationship between local governments and social work organizations. They are also an initial basis for psychological intervention and relevant course designs to get social work students and newly graduated social workers well prepared for the workplace. First, this study establishes that only role conflict mediates the effects of social workers' government-client work interaction frequency gap on their burnout, while role ambiguity does not take effect as a mediator. Consistent with previous studies (32,33,(35)(36)(37), role conflict and ambiguity significantly impact three dimensions of burnout. In addition, this study demonstrates that more work interaction with governments and less with clients is associated with a higher level of role conflict, which quantitative finding is consistent with the theoretical and qualitative investigations of previous research (45,46). However, the association between the government-client work interaction frequency gap and the social worker's role ambiguity is insignificant. Further study on such a difference is necessary. One possible explanation could be as follows: after more than a decade of vigorous promotion by the government, social workers' participation in local government administrative and other work has been normalized or even standardized. Although the role conflict caused by different work ethics could still be deep-rooted, social workers could have been certain about the definition, expectation, responsibility, and task of working with local governments and clients simultaneously. Second, this study demonstrates the significant moderating effects of non-front-line work on the association between the social workers' government-client work interaction frequency gap and the mediator of role conflict. Only the front-line social workers' role conflict has indirect positive effects on their burnout. Although the above finding is new and quantitative, it is consistent with previous qualitative findings on the different roles in working with local governments played by the non-frontline social workers from the front-line ones in China (45,(52)(53)(54)(55). Since social work supervisors and managers usually have the role of responding to the local governments as the primary funding body in China (55), they could get used to facing conflicting requirements or competing values at work. Thus, the government-client work interaction frequency gap would not significantly result in role conflict among them. However, this explanation requires further empirical investigation. Third, although front-line social workers' role conflict facilitates the government-client work interaction frequency gap to increase all the three dimensions of their burnout indirectly, we find the Interaction gap is different in its direct effects on those dimensions as follows: 1) significant negative on emotional exhaustion, 2) not significant on depersonalization, and 3) significant positive on reduced personal accomplishment, which results in its different total effects on those three dimensions. Such a difference is consistent with previous academic research on the components of the Maslach Burnout Inventory, whose three dimensions were psychologically discrete and represented different aspects of burnout (21,38). However, regarding the specific effects of the Interaction gap, it is difficult to compare our results to previous research because there are few quantitative studies on the tension between working with governments and clients on social workers' burnout. Based on the definition of those three dimensions of burnout (20,70) and the observations of social workers' work in China (18,43,44,47), we propose possible explanations for its significant adverse effects on emotional exhaustion, which is different from our hypothesis and has a different effect direction from RPA. Previous research observed that social workers often conducted assistant administrative work for local governments (including quasi-government neighborhood committees) besides the professional social work for clients in China (43,44). Regarding the administrative work commissioned by the government in China, it may have much less emotional demand (e.g., sympathy) from social workers than the "typical" social work services for the clients, most of whom are underprivileged. Thus, the social worker who has more work interaction with governments and less with clients could feel less overextended and depleted of one's emotional resources. However, compared to the typical social work services, which usually help underprivileged children, seniors, and disabled people directly, the administrative work commissioned by governments may give the social workers much less immediate positive feedback. Therefore, the social worker who has more work interaction with governments and less with clients may be more likely to negatively evaluate the achievements at work and feel reduced personal accomplishment. Regarding the insignificant effects of the Interaction gap on depersonalization, we could consider that longterm administrative work may make those social workers actively ignore the qualities that make the service recipients unique-for example, regarding the recipients as a number in statistics. Such an effect on depersonalization may be no different from the effects of highly stressed professional social work. Further research should investigate the above assumptions. Several limitations should be acknowledged. First, as only the first wave of the CSWLS was conducted, this study was based on cross-sectional data, which limited our ability to determine causal relationships between independent and dependent variables. The present study's findings should be tested further using the data from the future waves of the CSWLS. Second, the tension between working with governments and clients was not measured directly, and it should include more dimensions related to social workers' investment in work, such as energy and brainpower, besides time. However, due to the data limitation, this paper only investigated the deviation in the time-allocation priority measured by asking social workers' frequency level of work interaction with contractissuing government departments and the one with clients separately and then calculating the gap between the two levels. More specific direct and multi-dimensional measures of the above tension should be implemented in future research. Third, in order to provide more feasible practical implications, further investigations should be focused on finding some protective factors (e.g., personal resilience, work conditions, and organizational cultures) to mitigate (negative moderate) the effects of the tension between working with governments and clients on role conflict and in turn reduce social worker's burnout. We hope the following waves of the CSWLS or other similar projects can provide relevant data for those studies. Nevertheless, our study provides preliminary but significant evidence to show the vital role of the tension between working with governments and clients in increasing social workers' burnout. --- CONCLUSION This study reveals that front-line social workers in China who have more work interaction with contract-issuing government departments and less with clients could have a higher level of role conflict, and the role conflict then could increase their vocational burnout. However, such an association does not apply to social workers with extra management or supervision workload. In order to reduce burnout in social workers, social work educational programs should include adequate mental adjustment courses and practical emplacement to prepare students for the potential role conflict in the workplace. As Chinese social work organizations' reliance on governments will not be significantly changed soon, social work education should prepare students to understand the local knowledge of Chinese social work, which could be different from the knowledge they learned from western textbooks. In addition, front-line social workers should be involved in the management and supervision work as least as an assistant in their early career as soon as possible, which could help them understand the organization's relationship with governments better and thus reduce their role conflict. At the policy level, the professionalization of social work has been promoted significantly in China but still requires more policy support. Local governments should treat social workers as partners rather than clerks, which would benefit social workers' mental health and the government's social governance. Therefore, higher-level governments should issue relevant regulations and administration guidelines on contracting out social services to form a collaborative rather than an employment relationship between local governments and social worker organizations. --- DATA AVAILABILITY STATEMENT The datasets China Social Work Longitudinal Study 2019 for this study can be acquired by sending the application to the email address of the study's organizer, the East China University of Science and Technology (ECUST): [email protected]. --- ETHICS STATEMENT The studies (CSWLS) involving human participants were reviewed and approved by the research Ethics Committee of the East China University of Science and Technology that the corresponding author is affiliated with the Ethics Committee of the first author's university Sun Yat-sen University approved the research protocol of this article. The participants provided their written informed consent to participate in this study. --- AUTHOR CONTRIBUTIONS JW designed this study and was responsible for data analysis and writing. ZT guided the study design and interpretations, was responsible for data access, and supported the writing. JL supported the data analysis. QW assisted in writing the literature review. All authors approved the final paper. --- FUNDING This research was supported by Shanghai Philosophy and Social Science Youth Project (grant no. 2020ESH004). --- Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Publisher's Note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Interaction Gap on Burnout significant for social workers with extra management or supervision workload, revealing the moderating effects of non-front-line work. Conclusions: This study revealed that front-line social workers in China who had more work interaction with governments and less with clients could have higher role conflict, increasing their burnout further. Therefore, social work educational programs should include adequate mental adjustment courses and practical emplacement to prepare students for the potential role conflict. Furthermore, higher-level governments should issue relevant regulations to form a collaborative rather than an employment relationship between local governments and social worker organizations.

INTRODUCTION The uptake and adoption of preventative interventions by mothers of young children is a key component of public health policy to reduce child health inequalities in the UK. [1,2] Immunisation and breastfeeding provide children with a healthy start in life, not least by protecting against infectious diseases; [3, 4] increasing rates of breastfeeding in disadvantaged groups is identified as an important step in actions to reduce inequalities in infant mortality. [5] Key social and demographic indicators of disadvantage that are associated with lower uptake of immunisation and/or breastfeeding include lower socioeconomic status, lower level of education, teenage motherhood, single parenthood and multi parity. [6][7][8] Delivering interventions that have an impact on inequalities in practices that are protective of child health is a particular challenge in inner city areas of the UK with ethnically diverse populations, since Black and Ethnic Minority (BME) groups tend to be clustered in the most deprived neighbourhoods. [9] The extent to which ethnic group determines inequalities over and above those associated with poverty is thus fundamental to the equitable provision of preventative services in infancy and early childhood. Influential evidence on the determinants of inequalities in health by ethnic group in adulthood has, in general, shown that the relationship between poorer health and membership of a BME group is explained by relative deprivation, given the concentration of BME groups in deprived areas and thus the effects of poverty and social disadvantage on their health. [10,11] Infant mortality rates (IMR) are currently used as the headline indicator to measure child health inequality in the UK and these suggest some degree of health disadvantage in infancy associated with BME status. [12] In 2005 IMRs in both Pakistani and Caribbean ethnic groups were twice that of the White British group. However the extent to which IMR constitutes a reliable marker of child health inequality in this context is questionable for two reasons. Firstly evidence suggests that high rates of infant mortality for women of Pakistani origin are associated with congenital anomalies and those for Caribbean women with very preterm births. These conditions are unlikely to be related to deprivation. [13] Secondly there are a relatively small number of infant deaths in this country. The rate of infant deaths was 5.00 per 1000 population in England in 2002-4 [5] ranging from 1.6 per 1000 live births to 11.9 per 1000 live births in the 354 local authority areas. Measurement problems with using small numbers are compounded when breakdown of the figures by ethnicity are considered, since BME groups constitute a relatively small proportion of the UK population (8% according to the 2001 Census). In this paper we examine the extent to which deprivation is the common factor that explains inequalities both between and within ethnic groups across three contrasting preventative practices in childhood, uptake of Measles, Mumps and Rubella (MMR) vaccine, uptake of the Triple vaccine (Diptheria, Pertussis and Tetanus) and breast feeding. In this endeavour we are focusing not directly on health itself, but on maternal behaviours that are health promoting. The relation between deprivation and adoption of such behaviours is likely to be mediated by factors as various as access to health care, beliefs about the efficacy of an intervention, cultural /social group norms and support networks. Interestingly, recent studies that focus on only one of these three preventative practices, demonstrate higher rates of immunisation and breastfeeding for South Asian when compared with White infants, even when the confounding effect of relative deprivation has been taken into account, although there is less consistency for Black or Black British infants; some studies have found lower rates of immunisation for this group, compared with South Asian and White infants, although these have not consistently controlled for relative deprivation. [7,8,[14][15][16][17][18] The study presented here builds on this evidence by comparing immunisation and breast feeding practice between White, Mixed, South Asian and Black or Black British ethnic groups for infants born in the city of Manchester, the 4 th most deprived local authority in the UK, where in some areas BME groups constitute over one third of the population. In addition we examine the socioeconomic and demographic factors that are associated with variations in these practices within the three largest ethnic groups in this area -Black or Black British, Pakistani and White. No previous research has undertaken such a comparative analysis for a community based population. --- METHODOLOGY Data were drawn from the Child Health System database for the city of Manchester UK. These data were collected from two sources: 1. The formal notification of birth which contains mandatory information collected by the midwife immediately after the birth of all babies and includes basic demographic details of mother and child, previous obstetric history and birth details. 2. A Personal Child Health Record that is issued on the birth of every child by all the Manchester Primary Care Trusts. This document is the main record of the child's health, growth and development and is used by everyone involved in the care of the child from birth to school entry and contains information about feeding practice and child immunisations from 8 weeks to 3-5 years. Each section of the Child Health Record is produced in triplicate with the top copy remaining in the Child Health Record and on completion, one copy is retained by the Health Visitor and the third copy returned to The Child Health Department for entry onto the database. This study covers the period from 1/4/2002 and 31/3/2007 during which a total of 31521 births were recorded. However, this analysis is limited to 20,203 children born during the study period coded as being of White, Mixed, Indian, Pakistani, Bangladeshi and Black or Black British ethnicity in the Child Health System database. Together, these ethnic groupings make up approximately 97% of the city of Manchester population. The following variables were extracted from this database:- --- Maternal Characteristics Self report of ethnicity has been collected on this database since 2002, using a categorisation based on the 2001 Census. The following are the ethnic group categories that were used as the basis for analysis by ethnic group in this study: • White: this category includes White British, White Irish and any other White background. • Mixed: this category includes White and Black Caribbean, White and Black African, White and Asian and any other Mixed background (e.g. Black and Asian, Black and Chinese, Black and White, Chinese and White, Asian and Chinese). • Asian and Asian British. Data for Indian, Pakistani and Bangladeshi (South Asian ethnic groups) have been included from this category. • Black or Black British. This category includes Black Caribbean, Black African, and any other Black background. Other maternal characteristics that have been used in this analysis are age (<unk>17, 17-18, 19-25, 26-29 30-34, 35+) parenthood status (one parent family or not) and parity (no previous births, 1 previous birth, 2 previous births, 3 or more previous births). --- The measurement of breastfeeding and immunisation Breastfeeding at two weeks postpartum is recorded as 'fully breastfed', 'partially breastfed' or 'not breastfed'. For this analysis the first two categories have been combined to produce the dichotomous variable 'breastfed : yes/no', since the intention of the analysis was to establish the uptake of breastfeeding as a health promoting behaviour and its variation by ethnic group. The Triple Vaccine immunisation against Diptheria, Pertussis and Tetanus is offered to children 8, 12 and 16 weeks after birth. The Child Health System database records information on the children who have received all three inoculations as a single variable and this has been used to measure uptake ('yes/no'). The Measles, Mumps and Rubella vaccine (MMR) is offered to children at 13 months, but can be administered up to the age of 2; this was the cut-off point for measurement of uptake. Using IDAC scores for the constituent Lower Super Output Areas, the mean level of area deprivation for each of the 32 wards in Manchester was calculated and divided into quartiles. The most affluent wards in Manchester had a range of IDAC scores between 0.12 and <unk>0.37; the 2nd quartile between >0.37 and <unk>0.47 the 3rd quartile between >0.47 and <unk> 0.54 and the least affluent quartile between >0.54 and 0.73. In the statistical analysis the 2 nd and 3 rd quartiles have been merged. --- The measurement of deprivation --- Area level of deprivation was measured using the Income Deprivation Affecting Data were anonymised at source. The Local Ethnics Committee agreed that in this circumstance ethics approval was not required for the study. --- ANALYSIS We first calculated the distribution of our sample by maternal age, parity, parenthood status, ethnic group and area level of deprivation using descriptive statistics. Logistic regression models were then used to examine the independent association of ethnic group with MMR uptake by 2yrs, Triple vaccine uptake by 16 weeks postpartum and breastfeeding at 2 weeks postpartum. The final analysis examined predictors of immunisation and breastfeeding within the main ethnic groups in Manchester -White, Pakistani and Black or Black British ethnic groups. The independent variables entered into logistic regression models were maternal age, parenthood status, parity and area deprivation level. Each of these variables was controlled for the others in the logistic regression models. --- RESULTS Table 1 shows that just under half of the sample lived in the most deprived areas of Manchester (43%). In addition 13% of the population were single parents, 1% were aged under 17 and 5% were aged between 17 and 18 years at the time of birth. The largest ethnic minority groups were Pakistani (15%) and Black or Black British (15%), with Whites constituting 51% of the sample. Socioeconomic and demographic characteristics were differentially distributed across ethnic groups. 43% of White mothers and 51% of mothers with Mixed ethnicity lived in areas of high deprivation. But those most likely to live in these areas were of Black or Black British ethnicity (68%). In contrast, members of South Asian ethnic groups were more likely to live in more affluent areas. For example only 19% of Pakistanis lived in deprived areas. Single parenthood and teenage motherhood were most commonly characteristic of mothers of White (17%, 9% respectively), Mixed (18%,9%) and Black or Black British ethnicity (14%,5%), but were uncommon in South Asian ethnic minority groups. In terms of parity, members of Black or Black British, Pakistani and Bangladeshi ethnic groups were more likely to have larger families with two or more previous births (38%, 35%, 41% respectively) compared to White mothers (25%). --- 11 For health promoting behaviours, in the sample as a whole 90% of children had been MMR vaccinated, 93% had received all three courses of the Triple vaccine and 58% were breastfed at 2 weeks postpartum. Table 2 shows that there were distinct patterns of MMR/Triple uptake and breastfeeding for the largest ethnic groups. White babies were least likely to have had the MMR vaccine (88%) and infants from Indian, Pakistani and Bangladeshi ethnic groups were most likely to have been vaccinated (96%, 95%, 95%). The lowest uptake rate for the Triple vaccine was observed for White (92%) and Mixed ethnicity (91%) and highest for Indian (94%), Pakistani (95%) and Bangladeshi (96%) ethnic groups. Breastfeeding was most common amongst Black or Black British mothers (89%). Over two thirds of women in South Asian ethnic groups were breastfeeding at two weeks postpartum; the highest percentage was for Indians (85%). In contrast only 36% of White mothers were breastfeeding at this time, although this figure was higher for women of Mixed ethnicity (58%). Table 3 shows that for White mothers, living in a deprived area was significantly associated with lower uptake of the MMR and Triple vaccines and breastfeeding at two weeks postpartum. There were no significant relationships between these outcome measures and area level of deprivation for Pakistani mothers. Black or Black British mothers were significantly more likely to be breastfeeding at two weeks postpartum, if they lived in a deprived area (OR=2.41, 95% CIs= 1.51-3.86, p<unk>0.001). Multiparity was also a strong independent predictor of lower uptake across all three measures for White women only, with the likelihood of MMR and Triple vaccination and breastfeeding decreasing with increasing parity. White women who were single parents were significantly less likely to breast feed than those with partners (OR=0.58, 95% CIs=0.46-0.74, p<unk>0.001). The latter was also the case for Black or Black British mothers (OR=0.58, 95% CIs=0.35-0.89, p<unk>0.02). Younger White mothers, particularly those aged 25 or under, were significantly less likely to take up the Triple vaccine and to breastfeed at two weeks post partum when compared with older mothers (>35yrs). There was no similarly consistent relationship between age and uptake of vaccination for Pakistani and Black or Black British mothers. --- DISCUSSION --- Principal Findings The health disadvantage of White infants living in deprived areas This research shows that ethnicity is associated with important variations in the practice of health promoting behaviours in infancy and that differences between ethnic groups remain after area level of deprivation has been taken into account. In this study Black or Black British infants were most likely to be breastfed and Pakistani and Bangladeshi infants most likely to be vaccinated with both MMR and Triple vaccines. Immunisation and breastfeeding were lowest for White infants. This study exposes the unique disadvantage of children born to White mothers living in deprived areas. These mothers were more likely to be single parents or teenage mothers -both of which are indicators of social exclusion -but infants were also less likely to be breastfed and to be vaccinated. Typically uptake of immunisation and breastfeeding initiation became less likely with each new child that was born into a family. The health impact of socioeconomic disadvantage is thus compounded for White infants by lower adherence to practices conferring a health advantage. Most notably, this is not the case for Black or Black British infants whose chance of being brought up in a deprived area was even greater than that of the White infants in this sample. Within this ethnic group there were no significant associations between lower rates of breastfeeding and immunisation and area level of deprivation; this was also the case for Pakistanis, although these mothers were less likely to live in deprived areas. --- Strengths and Weaknesses of Study Design One of the main strengths of the study is its location in an inner city area with an ethnically diverse population. This enabled a breakdown of the BME sample into subgroups with substantial numbers that allowed for the analysis of inequalities within -as well as between ethnic groups. In order to maximise numbers for within group analyses, Black or Black British ethnicity was not disaggregated into its constituent ethnic groups. In this sample the majority of people in this category were Black African (64%), 19% were Black Caribbean and the remaining 17% were from 'any other Black background'. There were no significant differences in immunisation uptake between these groups although Black African women were significantly more likely to breastfeed (92% breastfeeding at two weeks postpartum) compared with Black Caribbean women (79% breastfeeding at two weeks postpartum). The location also enabled a test for the confounding effect of deprivation in an area which is the 4 th most deprived local authority in England. Access to routinely collected statistics on immunisation and breastfeeding enabled a comparison of patterns of uptake by ethnic group across three outcome measures. Previous studies have focused on single outcomes only. The poor coding of ethnic group in routinely collected data sources is a common problem for research in the UK. [20,16,15] In the time period covered by this study (2002 -2007) almost a third of entries on the Child Health System database were incomplete for ethnicity (9846/31521). Analyses of possible bias indicated that a large proportion of the missing values emanated from an area of Manchester with a predominantly White population and with no significant movement of BME groups into the area between the 1991 and 2001 Census. When the investigators compared the distribution of the sample by ethnicity with 2001 Census data for Manchester for children aged 0-4 it was clear that the missing values led to an under estimation of White ethnicity as a percentage of the total population and an overestimation of BME groups, particularly Black or Black British infants (Supplementary Table 1), although it is also a possibility that the sample in the Child Health System database is indicative of a trend towards the decline of the White population in ethnically diverse inner city areas and the increase of ethnic minority populations. [21] Following the assumption that the missing values were predominantly of White ethnicity did not significantly alter the demographic profile of the sample White population in terms of gender, age or parity (Supplementary Table 2). However it did indicate that those with missing ethnicity codes were less likely to be deprived and more likely to breastfeed than the White study sample. Including these values as 'White' would decrease the % living in deprived areas from 43% to 39% and increase those breastfeeding by 5%. Entry of breastfeeding data onto the Child Health System database was also poor, with only 8946/20203 records for breastfeeding at 2 weeks postpartum. However the reliability of the findings are enhanced by replicating the results at another time point, for breastfeeding at initiation ( Supplementary Table 3). Tests for representativeness revealed that there were no significant differences by ethnic group or by area of deprivation between the characteristics of the whole sample and the missing values sample for breastfeeding at two weeks postpartum. It is therefore unlikely that missing values were a source of bias in the study. Moreover the numbers available for analyses of breastfeeding by ethnic group are more substantial than those of comparable studies based on the UK populations, in which breastfeeding data are based on retrospective self report. [8,22] A further limitation of this study is that deprivation was measured at the area level rather than using individual level measures of socio economic or educational statuses, which were not available on the Child Health System database. Some proxies of social disadvantage at the individual level such as teenage motherhood and single parenthood were however available and these display similar trends to findings based on area level of deprivation. --- Interpretation of results --- Socioeconomic and cultural context of health promoting behaviours in infancy The fact that patterns of association between immunisation and breastfeeding and relative deprivation within the White ethnic group do not generalise to Black or Black British and Pakistani ethnic groups suggests that the role of relative deprivation as a determinant of such behaviours is dependent on the extent to which other possible explanatory factors such as access to health care, beliefs about the efficacy of immunisation and breastfeeding, cultural/social norms and support networks vary according to socioeconomic status. For example a qualitative study that explored decisions about infant feeding method for mothers living in deprived areas in the UK found a characteristic set of norms and values associated with breastfeeding that were embedded in support networks. [23] Mothers were prepared to give breastfeeding a 'go', but there was a strong expectation of difficulties and even failure. Expertise and confidence with bottle feeding was more widespread amongst support networks of family and friends and women relied strongly on this advice in the transition from hospital to home. A recent cross -cultural study of breastfeeding initiation comparing ethnic groups in the UK and the USA also concluded that the relationship between socioeconomic status and infant feeding practice is strongly influenced by the cultural/social context. Kelly et al [22] found that the advantage shared by black and other ethnic minority groups in the UK with regard to breastfeeding was not observed in the US, where the lowest rate of breastfeeding was found amongst disadvantaged non-Hispanic Black mothers. Similar conclusions can be drawn from the higher immunisation rates for South Asian infants. [16,24] For example the higher uptake of MMR vaccine for mothers of South Asian ethnicity has been attributed to trust in the judgment of health professionals, a tradition of belief within communities in the protective effect of child immunisation and language barriers leading to a lack of awareness of the debate about the safety of MMR. [16] The health advantage for infants from South Asian ethnic groups could also relate to the selective migration of healthier women of childbearing age whose positive attitudes towards child protection are drawn from practices in their country of origin.[13] South Asian communities in Manchester increased by half from the 1991-2001 Censuses, with the largest increase in the Pakistani ethnic group. [21] --- Policy Implications The advent of the NHS was marked by improvements in maternal and child health that were the consequence of preventative services that reached the poorest people in the UK population. The problem identified in this study is that, particularly for White infants living in deprived inner city areas in the UK, the health effects of socioeconomic disadvantage are compounded by less than optimum adherence to practices that are protective of child health. Reliance on methods of health education and service delivery that are designed for the general population are unlikely to be successful in this context, but the evidence base of interventions developed specifically for disadvantaged populations is sparse and characterised by small scale studies. [25] In general the evidence that does exist suggests that methods of service delivery that take into account the social and cultural context of mothers living in deprived areas are more effective in increasing preventative practice. For example peer support in the community has been found to increase breastfeeding for low income women and adolescent mothers and non -professional voluntary support to improve immunization uptake in deprived communities. [26][27][28], [25,[29][30][31][32] This study identified ethnic inequalities in uptake of immunisation and breastfeeding initiation that favoured BME groups and that were independent of relative deprivation; this has implications for the targets set by the Department of Health for monitoring change in child health inequalities. The findings of our study suggest that figures for breastfeeding initiation and immunisation are likely to be inflated in deprived areas by the presence of South Asian and Black or Black British ethnic minority groups and changes over time could reflect the mobility of these populations rather than the impact of policy interventions. A similar picture would emerge for rates of immunisation. Coding for ethnic group membership is not as yet common practice in routinely collected Child Health data and the poor quality of record completion has been noted elsewhere. [16] And yet these data are essential for monitoring inequalities in uptake of preventative interventions in infancy and early childhood. In the UK change in child health inequalities is currently monitored using the headline indicator of 'a reduction of at least 10% in the gap in infant mortality between manual groups and the population as a whole by 2010'. [5] The extent to which this constitutes a marker of child health advantage and disadvantage that is useful for locality based policies is questionable, particularly in deprived inner city areas with ethnically diverse populations. --- COMPETING INTERESTS: "All authors declare that the answer to the questions on your competing interest form (http://bmj.com/cgi/content/full/317/7154/291/DC1) are all No and therefore have nothing to declare". --- WHAT THIS PAPER ADDS --- What is already known on the subject • There is acceptance that inequalities in health by ethnic group are, in general, explained by relative deprivation. • A review of the evidence focusing on interventions that are protective of health in early childhood suggests the independent effect of ethnicity as a source of inequality. --- What this study adds • This study compares three interventions -uptake of MMR, Triple Vaccine and breastfeeding -across ethnic groups taking into account the potential confounding effect of relative deprivation. • It demonstrates that only for the White ethnic group is lower uptake of immunisation and breastfeeding consistently associated with deprivation and that for this group the likelihood of uptake of all three interventions decreases with increasing parity. • Equitable provision of preventative services in early childhood needs to take account of both ethnicity and deprivation as sources of inequality.

Objectives. To examine inequalities in immunisation and breastfeeding by ethnic group and their relation to relative deprivation. Design. Cross -sectional study. Setting. Manchester, UK Participants. 20,203 children born in Manchester (2002-7), who had been coded as of White, Mixed, Indian, Pakistani, Bangladeshi and Black or Black British ethnicity in the Child Health System database. Main Outcome Measures. Breastfeeding at 2 weeks postpartum; uptake of Triple Vaccine (Diptheria, Pertussis and Tetanus) at 16 weeks postpartum; uptake of the Measles, Mumps and Rubella Vaccine (MMR) by the age of 2. Results. Black or Black British infants had the highest rates of breastfeeding at 2 weeks postpartum (89%), and South Asian infants had highest Triple and MMR vaccination rates (Indian, 95%, 96%; Pakistani 95%, 95%; Bangladeshi 96.%, 95%) after controlling for area level of deprivation, parity, parenthood status and age. White infants were least likely to be breastfed at 2 weeks postpartum (36%), and to be vaccinated with Triple (92%) and MMR vaccines (88%). Within the White ethnic group lower percentages of immunisation and breastfeeding were significantly associated with living in a deprived area and with increasing parity. This was not found within Black or Black British and Pakistani ethnic groups. Discussion Practices that are protective of child health were consistently less likely to be adopted by White mothers living in deprived areas. Methods of health education and service delivery that are designed for the general population are unlikely to be

Background Countries around the globe are experiencing an increase in the proportion of their citizens that are aged 60 and over [1]. Economically, an ageing population is associated with decreasing productivity and higher government spending [2,3]. Part of this increased spending by governments relates to the provision of institutional aged care and other health services [4]. us, sustaining living at home for older people has become high on the agenda of governments in countries such as Australia and the UK [5,6]. Home relates to both the spatial location in which one resides and to social and psychological constructs [7,8]. One review of 49 articles found that the concept of home encompassed descriptions of the house itself along with discussions about family, the self, gender, the home as a haven, and the idea of journeying [9]. Another study of the meaning of home in palliative care situations from the nursing literature similarly found that the concept involved attributes related to the physical location, as well as to an emotional environment [10]. In the current study, although we focus on defining the concept of home from the perspectives of the older adults who participated in our study, we follow Kontos' definition [11] and use the term "home" in a broad sense to refer to a physical location in which the individual lives, "a space that is controlled by and is uniquely the domain of the individual" (p. 179). Individuals report a preference for staying in their own homes rather than relocating to care accommodation as they age [12]. In Australia, 99% of people between the ages of 65 and 74 and 75% of people over the age of 85 were living in private dwellings in 2006 [13]. Older people tend to spend up to 72% of their time inside their homes [14], making the decision about where to live a crucial one. Being able to continue living at home assists the older person by providing a familiar environment within which to contend with the challenges and changes to lifestyle that occur due to the ageing process. Home also often remains the one stable entity in the lives of the older person when everything else is changing. Living at home thus assists older people to retain some control over their daily lives and to maintain some independence and autonomy [15]. Given the importance of the home environment to an older adult's capacity to sustain independent living, much research has explored the concept of home in terms of questions relating to the home's usability, or safety [16], or in adapting to the need for relocation. Johnson and Bibbo [17], for example, used a phenomenological approach to examine the meaning of home in a group of eight older adults shortly after their relocation to nursing homes in the Midwest U.S. ey reported that autonomy of decision-making about where to live as well as actively changing their attitudes strongly influenced the capacity for the participants to adapt to their new environment. e concept of home for older adults has also been explored from gerontological, environmental, and psychological viewpoints [18]. Oswald and Wahl [19], for example, took an environmental psychology perspective and focused on concepts related to attachment to place in 126 older persons living at home in Germany. ey found five global meaning categories relating to the concept of attachment to home: physical, behavioural, cognitive, emotional, and social. Another study focused on home as a "space" among widows, showing that emotional attachments to "home" are multifaceted and are strongly influenced by personal connection to place and relationships [20]. Barry and colleagues [21] performed a concept analysis of 49 published articles to define a concept of home from older women living alone in the community. ey found that to older women home was a resource and an attachment that took an increasing effort to sustain, but that maintaining one's capacity to stay living at home was a cultural expectation. In other research, the concept of home has been explored with a view to understand the housing needs of older individuals. Bigonnesse and colleagues [22], for example, found that personal belongings that hold memories and bring comfort connect older persons to the physical space of home. For some, a house itself can be a place of familial heritage and allows the individual to remain connected to the generations of family members who once lived within the walls [23]. Relationships and roles in the community are also an integral part of the meaning of home and can provide security and comfort [24]. A sense of identity in the community can result from friendly neighbours, nearby friends, and family and participation in volunteer roles or special interest groups [20]. Being forced to leave one's home can sever important community connections and remove the intergenerational aspect of community living. Understanding individual experiences of remaining at home offers important perspectives that can inform ageing policy and practice in residential and community aged care to support ongoing independence in older adults. Furthermore, to understand the issues older people face when considering their housing options, it is vital to explore the feelings and beliefs of older people about the meaning home has for them. However, as conditions relating to ageing at home are experienced in highly individual ways and older persons in the community include individuals with more than 40 years of collective generational experience, it can be difficult to address the phenomenon of sustaining living at home comprehensively and holistically. Older persons are not a homogeneous group. e way a person adjusts and adapts to ageing is influenced by individual, biological, psychological, and social factors within the economic and political context in which they live, as well as lifestyle, educational, and environmental factors [25]. us, the experience of ageing and adapting to the changes with which ageing is associated is highly individual. Despite this, the subjective experience of older persons who remain in their homes during the ageing process has received comparatively little attention in the literature. Few studies have compared the meaning of home between people who are able to remain in the family home and those who must adjust to new locations. Nevertheless, to gain an accurate understanding of the issues older people face when considering their living options, it is vital to explore the perspectives of older persons themselves on the concept of home. is study, therefore, aims to understand the phenomenon of older people living at home in Australia at a personal level, from the perspective both of those living in their long-term family home and those who have adjusted to newer living conditions in older age. e study aims to clarify how older adults conceptualise home and provide a perspective that can inform policy and practice to support continued living at home or successful transitions to care accommodation in older adults. --- Method is study used focus groups and interviews conducted with 21 older adults, drawing on principles of grounded theory [26] in its approach to data collection and analysis. Grounded theory is a qualitative method often used to investigate an individual's experience of a phenomenon and was followed in the current study in that we took an inductive approach to exploring the research question, without prior hypotheses [27]. is approach has been widely used across nursing and midwifery disciplines from pregnancy to end of life care and has been successful in gaining knowledge about areas of limited understanding [28][29][30]. --- Participants and Recruitment. Both focus groups and interviews were used to collect data, following the model of Lambert and Loiselle [31]. Purposive sampling was used to recruit participants for the focus groups, and theoretical sampling (with the researcher using data previously collected to determine where to next collect data) was used to recruit interview participants, as is common in the practice of grounded theory and will be described in more detail below [32]. Participants were recruited from a local government Seniors Centre in Western Sydney, Australia. Inclusion criteria were as follows: (i) aged 65 or over; (ii) a resident of Western Sydney NSW, Australia, (iii) currently living in their home for at least 12 months before the study, (iv) English speaking, and (v) consented to participate in the study. Of the 21 participants in total, seven were married, 12 widowed, one never married, and one divorced. Twelve participants lived in a house, six in a unit and the other three in a town house, retirement village, and a duplex. e length of time participants had lived in their current dwelling ranged from 2.5-74 years. Almost all participants had lived in their current homes for at least 10 years, and some had lived there for more than 40 years. e household composition included 12 living alone, five living with a partner, two with their children, and two with a partner and children. According to local census information, demographics were relatively reflective of the population of older people living in the study's geographical area [33]. --- Focus Groups. Purposive sampling was first used to develop focus groups which provided a broad collective perspective of the topic. ree focus groups were conducted, and participants were invited to participate following their attendance at regular classes at the Seniors Centre, including line dancing, exercise, and indoor bowls classes. Group 1 consisted of three males and seven females, group 2 consisted of six females, and group 3 consisted of four males. Same gender groups such as those in groups 2 and 3 were used to account for gender-based differences in interaction styles [34]. 2.1.2. Interviews. Following the three focus groups, interviews were conducted to provide an opportunity for exploration of topics that were difficult to cover in a group setting such as personal finances and health and to explore individual perspectives in more depth. Recruitment for the interviews occurred at the conclusion of each focus group. In total, 17 out of 20 focus group participants accepted the invitation to participate in the individual interviews. Based on the preliminary concepts that emerged from the analysis of focus group data, nine older persons were recruited to be interviewed using theoretical sampling. ese nine participants were selected because they reflected a range of personal circumstances and variability in the strategies they used to sustain their capacity to continue living at home. ey also had various levels of good health and support, which allowed for a wide exploration of circumstances. One other older person who was unable to attend a focus group also accepted the invitation to be interviewed (n 10). Pseudonyms were used, and personally identifying information was removed from transcriptions to ensure participant confidentiality. Sampling was determined by the need to recruit a participant who could provide the information necessary to further develop the theory. In the first five interviews, four females over the age of 75 years living alone and one male living with a family member were chosen as data showed these participants had already put in place a number of processes to enable continued living at home. In the second group of five interviews, the older persons selected for interview were chosen because their individual circumstances had changed significantly and become more complex due to deteriorating health. ese five participants had either moved out of their home into alternative accommodation or were now living at home with higher levels of support. One female participant was interviewed in each group due to changing circumstances over time. --- Data Collection. After obtaining ethics approval from the Western Sydney University Human Research Ethics Committee and meeting with the Senior Centre's coordinator, the researcher attended a forum for centre members to explain details of the study. Potential participants were told that the study related to exploring the concept of ageing and remaining living at home with a positive ageing focus. Participants were given both verbal and written information about the study and were given a chance to ask questions about the study. ey were told that they could take the information sheet and consent form away and think about participation. However, all those who volunteered wanted to sign up immediately. Older persons who accepted the invitation to participate were personally contacted via telephone within two days of the study to ascertain that they met the inclusion criteria. All volunteers met the inclusion criteria. Written informed consent was obtained from all participants prior to commencing the focus groups. Consistent with grounded theory, data collection and analysis proceeded in an iterative fashion that moved backwards and forwards from one level of analysis to another. Data collection commenced with a general approach through focus group discussions. As the study progressed, data collection and analysis became more focused through the individual interviews. e concepts generated from this analysis were then used as the basis for questions for the individual interviews. Data collection ceased when theoretical saturation was reached, i.e., when no additional data could be used to further develop the properties of a category [26]. --- Focus Groups. Focus groups were conducted in a small quiet room that was free from visual and outside distractions with participants seated in a circular fashion behind tables. Discussions were audio recorded using a digital recorder. Biographical data were collected from each person by means of a Participant Personal Profile form, which collected information about personal characteristics, education, occupation, retirement, income, housing, living arrangement, and support. Participants in each focus group were then welcomed and an introduction about the purpose of the focus group given. A topic guide that had been developed based on the literature was used to prompt the discussions following Krueger and Casey's [35] recommendation (see Appendix A). Concept checking was performed by reading the main points to participants for confirmation both during and after data collection [36]. --- Interviews. e interviews were conducted using a focused, open-ended, and semistructured interview guide to prompt conversation [37]. is approach enabled the researcher to ensure coverage of essential topics while still allowing the interview to be largely directed by the participant (see Appendix B). Each interview gathered more data on the developing categories, and the questions became more focused as the interviews progressed in order to obtain saturation of the developing categories. Data were collected, coded, and analysed to determine where to next collect data, as described below. Of the nine participants (one interviewed twice), two chose to be interviewed in their own homes and one in a hostel. Another chose to be interviewed over the telephone at the retirement village. e remaining interviews were conducted at the Seniors Centre. All interviews were audiorecorded using a digital recorder. --- Data Analysis. Data collection and analysis informed each other throughout the progress of the study [32]. Open coding was first conducted line by line on printed transcripts using a process that Strauss and Corbin described as microanalysis. Initial codes were in vivo, that is, in the words of the older persons. Later in analysis, axial coding was used in which codes were conceptualised and initial in vivo codes were further developed into categories by grouping of similar concepts and exploration of relationships between the codes. Constant comparison was used, with all new data coded and compared with previously collected data for similarities and differences. During this process, questions were continually asked of the data, diagrams were constructed and memos were written to assist with theoretical conception. In a third level of analysis, selective coding was used to integrate data categories in formation and refinement of an overarching theory [38]. Guided by the Strauss and Corbin [32] approach, a storyline was written to define and explain the central category and the relationship of all categories. --- Results e study revealed four major categories in the data that related to the perspectives of home of the older adults in this study: anchoring self, enabling freedom, being comfortable, and staying in touch. ese categories along with their subcategories will be discussed in more detail below (see Table 1). --- Anchoring Self. e determination to remain living at home was evident for all older persons in this study. Home represented their past, present, and future and gave the notion of "anchoring self," as Jane described: "But one's life gets locked into an area... your life gets locked up in the things you create." Within this concept of anchoring self, four factors appeared to increase the sense of connection that individuals felt with their home: (i) longevity of domicile, (ii) personal investment in the home, (iii) the sense of identity and place in the world that the home instilled, (iv) and the facilitation of self-expression that having one's own home provided. --- Longevity of Domicile. Most of the older persons had lived in the same home for a significant time such as John, "I have lived in the same place for 32 years," and Sarah, "I have lived there for 74 years." is longevity of domicile created strong and deep connections, resulting in a reluctance to leave. Sarah described how she felt firmly anchored at home and had "never ever thought about" living elsewhere. Rose similarly said: I couldn't imagine being anywhere else.... I love my home and I lived there when I was married and I've never had another home on my own.... I don't want to leave it and I can't imagine going into a nursing home or a retirement village or anything like that because it's just, I suppose, just home to me. --- Personal Investment. e investment of personal and financial resources in obtaining one's home further strengthened this sense of attachment to their home. As Irene stated: Well, why give up a home when I've fought so hard to get it? I had to pay for the place myself.... I have lived in the house for 40 years and I don't want to shift... I've got no intentions unless I have to of leaving. Maybe I'm too determined. I think I'd die before leaving. Others described how a part of them had gone into building and creating their home. As Peggy said: "We built our house." Kathy further spoke about how she built a new home to facilitate self-management of her chronic illness, taking responsibility for creating her own living circumstances as her needs changed. --- Sense of Identity and Place in the World. For many, a major reason that home provided a sense of anchorage for the self related to self-identity. is concept was illustrated by the way older persons consistently made reference to their home as my home, implying a sense of identity through ownership. A sense of the status and a place in the world that is achieved by home ownership was also described. Sally said: "It is my home because I own it." Living in one's home over a significant period of time also facilitated close connections with the local community, which further strengthened this sense of self-identity as being attached to the location of the physical place of residence. Living at home enabled the older persons to maintain this sense of identity within their community as it conveyed messages about them to others. ese community connections became even more evident when significant life changes occurred, such as the death of a spouse. Jane described this when she said: " ose people [neighbours] had known him [her husband] and that is very important to me, that I am not just me but that I was part of a double, part of somebody else." 3.1.4. Facilitation of Self-Expression. For others, creating a home was as simple as keeping mementos around the home as a reflection and expression of self. is aspect was illustrated when Ellen made reference to moving from house to house throughout her adult years and creating a new home through decorating each new house with personal mementos. She expressed this as: "I can make a home anywhere... Everybody has a few personal things that they dearly love... I put up two paintings. at was home." In summary, to the older persons in this study, home represented a place where they felt anchored and where they were able to create and maintain their self-identity despite the changes and challenges that occur with ageing. is sense of connection with their home made it difficult for many of these older people to envisage living in alternative accommodation. Home was presented as an extension of the person and extraction from their entrenched lives at home would mean leaving behind a part of themselves, losing their sense of self. --- Enabling Freedom. e meaning of home also encompassed being free of constraints. To many participants, home symbolised freedom as highlighted by Dan, "Because I am sure that living in my home, definitely, [means] more freedom." is freedom included (i) the ability to personalize activities and self-manage time, (ii) having a purpose and reasons to keep busy, (iii) performing the tasks of everyday living independently, and (iv) not having to contend with interference from others. --- Personalize Activities and Self-Manage Time. Home offered the older persons a known territory and a familiar environment in which they retained self-determination in deciding how they would go about their everyday living. us, living at home afforded people the freedom to personalize their daily activities and self-manage their time. Rose expressed this freedom saying: "Because it is home and I can do what I like." Irene similarly identified the control she maintains: "Come and go when you wish... without someone wanting you to do this or that." --- Purpose and Reason to Keep Busy. Living independently in one's own home necessitates a certain amount of work in order to care for oneself and the home. us, living at home gave individuals a degree of purpose in life and a reason to keep busy. Irene expressed this as: "I feed my cat and look after that, keep the house tidy in general and I see that the raking up's done out in the garden." Sarah said: "I do my own cooking and things like that... I do all my housework myself." e participants recognised that keeping busy and active would help them to maintain good health. --- Independence in Everyday Tasks. Although the participants varied in their ability to perform the tasks of everyday living themselves, a range of benefits ensued from being independent, including a sense of self-pride and personal satisfaction through feelings of accomplishment. Many expressed pride at their ability to live independently. Anne and Rose both proudly stated, "I do all my own work." Home gave them the freedom to do this, which might not be possible if they relocated. --- Lack of Interference from Others. Independent living enabled the freedom of not having to consider anyone else or contend with interference from others. is freedom facilitated autonomy and control in their planning of everyday living. Rose described her experience as: It was felt that the sense of freedom and independence gained from living at home would be lost with moving out of home. Irene revealed this concern when she said, "I'm too attached to my home... I'm used to being independent and I don't think I could confine down to regulations and rules." Tim, who was interviewed both before and after moving to a hostel commented on the loss to his freedom and independence after the move, saying: ey have fixed meal times here, so you can't wander down any old time... On your own you might say, "Oh, I'll have something early," or "I'll have it later"... I'm used to sort of going out to the shops and doing a little bit of shopping and now that's a problem. In summary, home as a place for freedom was one of the most important meanings of home emerging from the data. Older persons described having a choice in making decisions about everyday activities, as well as the capacity to live independently and to keep busy with the tasks of everyday living. is not only resulted in great pride and personal satisfaction but also enabled them to live without the interference of others. --- Being Comfortable. A third subcategory emerging from the responses of the older persons as they described the meaning of home was that home was a source of emotional and physical comfort. Comfort was derived from (i) having things one needs, (ii) the good memories associated with home, (iii) the familiar territory providing peace of mind and stability, and (iv) having a space for relaxation and restoration. --- Having ings One Needs. Ellen spoke of the contentment derived from living at home when she said, "It's very comfortable. We're here together... Our home is very important to us... I think we've got everything we want in this house." Marjorie echoed Ellen's comments when she said, "I've got everything there that I want." Tim similarly stated, I had all my stuff there, and it's organised comfortably with comfortable chairs and a good bed and everything... you've got everything, when I'd arranged everything the way I wanted. Interestingly, "comfort" was one of the meanings of home that older persons were able to renegotiate after relocation. Although only a few older persons had moved out of their homes by the conclusion of the study, all had managed to find comfort through having familiar things around them. After relocating to a hostel, Tim was able to state, " is is my home... I'm comfortable here." Referring to her relocation to a retirement village, Maree similarly said: "It's very comfortable... happy to be here and it is, with all my things around me, it's just like my own home." --- Good Memories. Older persons also found comfort from the many good memories their home generated. Home was a place where they could reflect on happy times. Dan spoke of these pleasant memories when he said, "You cannot deny at our age, our memories, still there is a lot [of memories at] home... and everyone enjoys to see or to live or to tell about his memories." Some described home as a place where memories of their childhood, adulthood, and parenthood are held and embodied. Irene stated, "I have a lot of memories... when no one's here... I have a lot of thinking to do." Sarah also described feeling comfort through reliving fond childhood memories of the home where she still resides. A few older persons also revealed that living at home gave comfort to their adult children who now resided in their own homes. Rose, for example, described the happy memories her home continues to give them. She stated that home was "your comfort and your memories... memories of the children when they were small... When they [children] all married and had their own homes, they call my place home." --- Familiarity, Peace of Mind, and Stability. e idea of familiarity also seems to underpin the concept of comfort in the older persons in this study. Having comfort at home was also expressed as having peace of mind and a sense of competence through living in a familiar environment. Ellen illustrated this when she said, "I know where things are so that's a big plus... It's familiar." Rose similarly said, "I'm comfortable... I know where everything is that I need... even if I didn't have my fairly good eyesight I would still be able to get around." is familiarity evidently added to a sense of happiness and wellbeing in participants. As Peggy stated, "I have been there [home] for about 50 years now and I enjoy it." 3.3.4. Space for Relaxation and Restoration. Living at home and having access to their own garden also provided participants with a comfortable place for relaxation. Sally said, "It's a sort of relaxation to go down there [garden]." For some, their garden had become a haven to unwind and a place to take things easy. Irene described her experience as: "You forget your worries I reckon when you go outside." She also stated, "I like space... would hate to live in a room. I like my backyard." Being able to use home as a place for revival and restoration when returning home after engaging with others in the community was also a way of being comfortable. Ellen described being at home between activities and social outings as: "You stay at home to catch your breath." In summary, being comfortable was an important subcategory describing the meaning of home emerging from the responses of older persons in this study. Living at home provided emotional and physical comfort as home afforded the physical comforts of having the things one needs organized as one pleased, connection with good memories, a peaceful space for relaxation and restoration, and peace of mind and stability through familiarity. --- Staying in Touch. e final subcategory which emerged from the data was "staying in touch." e older persons agreed that living at home (i) positioned them close to their family, friends, and neighbours and (ii) provided a base for participation in community activities and making new friends. --- Positioning Close to Family and Friends. e consensus among the older persons in this study was that living at home positioned them close to their family, friends, and neighbours. In this way, home provided a support network and prevented isolation, allowing them to keep in contact with others. When describing her available support network Sarah stated, "My sister lives next door," and Ellen referred to her support as: "We have got our family around there. We got our interests all round this area.... It's just in a good position.... We've got a daughter down at (-)." 6 Journal of Aging Research e older persons in this study all agreed that living at home enabled them to maintain ties with people with whom they had longstanding relationships. Living at home was seen to facilitate staying in touch with others, as home and its community is known territory, and people get to know each other over time. Marjorie explained the meaning attached to these relationships with others over time when she said: e people around here, the neighbours around me, we've all been together there... since 1950... e majority of them are the same but we've got some new neighbours and they're up the top end of the street and you wouldn't even know their name... but the ones down where we are, there's only about six or eight houses, they all pitch in and help one another. --- A Base for Community Participation. As home was known territory, it provided a base, a way to get out into the wider community and return. When using home as a base to go out and participate in activities in the community, home also became a link to making friends. e importance of this characteristic was reinforced by Maree when she said, "As you get older it is harder to make new friends." For those who were still living in their long-term home, they saw their established relationships as important to their wellbeing and were reluctant to move away for fear of losing them. However, those who had moved to new homes had made efforts to stay socially connected by establishing new social contacts. Much of the way living at home facilitated community participation had to do with the familiarity and confidence participants expressed in local options for transport and mobility. Mary and Kathy described how they were able to stay in touch with their communities as their homes enabled access to familiar services which provided them with daily options. Kathy said: "I like this area because I can go on my $1 ticket everywhere and there is so much to do." Sally described her home as enabling her to stay in touch with others because, "it is convenient to everything." e location of their home to enable convenience to facilities and services close to their home or located within the local community, including interests, activities, shops, and their GP, was noted as important. Alice described having the accessibility of these services from her home enabled her to stay in touch when she said, "It is very convenient where I live to the shops, the buses and the trains." Sarah similarly commented, "It is very convenient where I live, the shops, a doctor and a chemist and other supermarkets." In summary, one of the four meanings of home formed from the responses of the older persons in this study was that living at home enabled them to stay in touch with their community. rough living at home, participants were able to maintain stable relationships and remain socially connected to familiar support networks and services. Living in a familiar environment promoted an awareness of access to transport and other facilities, which provided a means to get out into the community to engage in social or other activities. --- Discussion is study explored the experiences and perspectives of older people living at home in Western Sydney, Australia. Drawing on principles of grounded theory, focus groups and in-depth interviews were conducted with 21 different participants about the concept of home and what it means to them. e study was able to gain the perspective both of those who were living in their long-term family home, and those who had adjusted to newer living environments in later life. e data revealed that for the older persons in this study, home was the centre of their everyday living and was critical to maintaining independence, comfort, and freedom. Home was pivotal to the older persons self-identity and as such reflected their sense of self. Continued living in a place to which they had long-term connections and had invested considerable resources to attain, added to a sense of being "anchored" to their living environment and having a place in the world. Living in one's own home also enabled individuals a sense of self-expression in that they were able to style and decorate their homes in their own personal way. is is similar to the findings of Cristoforetti and colleagues [20] who highlighted the importance of showcasing belongings in the home as an extension of the self. Other research has similarly shown the relevance of objects of sentimental value in maintaining a connection with memories of family, friends, and life events [18,24]. e concept of home was also closely associated with having a sense of freedom for the older people in this study. ey described the sense of pride and competence that being able to remain independent gave them, as well as the satisfaction of being able to self-manage their time and organize their days to suit themselves without outside interference. ese findings are supported by Sixsmith and colleagues [39] who similarly found that everyday life at home enabled adults over the age of 75 to continue to be engaged in purposeful meaningful action. In addition, the older persons in this study expressed that the concept of home represented comfort for them in that they were able to have the things they needed for daily comfort around them arranged in ways that suited them. ey also derived emotional comfort from the familiarity and stability of remaining in their own home as well as from the connection to happy memories that being in the home gave them. In addition, being at home enabled them to access the outdoors and to have greater space than they would have in institutionalized living arrangements. Furthermore, participants in the current study reported that home was associated with the capacity to stay in touch with family and friends as well as local services and activities. Living at home facilitated this ongoing connection both by its physical proximity to people with whom the older persons had long-term relationships and by its familiarity, which enhanced confidence in being able to access transport and local services. Bigonesse and colleagues [22] similarly found that social contacts among neighbours reinforced social ties among older adults and helped them to feel socially supported. It may be that this aspect of familiarity with the local environment is particularly of importance as the driving capacity of older adults diminishes, reducing their capacity to engage with the local community. Studies have found that driving cessation is associated with almost doubled risk of depression in older adults [40]. Overall, the current study supported Oswald and Wahls' [19] framework in which they argued that concepts of home fell into five broad meaning categories: physical, behavioural, cognitive, emotional, and social. "Anchoring self" in the current study largely related to emotional and cognitive aspects of the meaning of home, in that it was closely connected with self-identity and a sense of stability. e second meaning in the current study, "Freedom" related to behavioural and cognitive aspects in that it concerned the ability of individuals to stay independent and busy, although this was also associated with emotional aspects in that it facilitated a sense of pride and self-competence. Similarly, "Comfort" also described the emotional comfort in that living at home provided the opportunity to be surrounded by happy memories. is aspect, however, also related strongly to the physical comforts of home. "Staying in touch" concerned both social and behavioural aspects, in that remaining at home enabled people to stay connected with family and friends through physical proximity while also maintaining confidence in the ability to negotiate mobility. us, concepts of home in older adults are multifaceted, strongly connected to the physical location and surroundings, but having a deep impact on both emotions and the activities of daily life. ese findings have relevance to policy development both for supporting those who remain living at home and to those who choose to relocate to care accommodation. Nevertheless, it is not always possible or even advantageous for all older adults to remain living at home. For example, some older adults living alone can be at risk of social isolation and difficulty coping with the physical demands of caring for one's self [41]. Individuals with dementia who are living at home can also experience social disconnection and a lack

Objectives. Continuing to live at home is arguably one of the most important challenges older persons face as they age. e aim of this study was to clarify how older adults conceptualise home through age-related lifestyle changes. Methods. Principles from grounded theory were used to examine the perspectives of 21 older adults obtained from three focus group discussions and 10 indepth semistructured interviews. Results. Four major categories were developed: "anchoring self," "enabling freedom," "being comfortable," and "staying in touch." Discussion. For the participants in this study remaining at home enabled a sense of independence and freedom, self-worth and identity, comfort, and an ongoing active role in the community. However, some aspects of home could be renegotiated despite changes to living location, with new social connections able to be forged and personal comforts being transferrable. is holds important implications for supporting older persons to both sustain living at home and to adjust to changing circumstances, suggesting the importance of drawing on the experiences of older persons themselves in developing strategies to promote successful aging.

and busy, although this was also associated with emotional aspects in that it facilitated a sense of pride and self-competence. Similarly, "Comfort" also described the emotional comfort in that living at home provided the opportunity to be surrounded by happy memories. is aspect, however, also related strongly to the physical comforts of home. "Staying in touch" concerned both social and behavioural aspects, in that remaining at home enabled people to stay connected with family and friends through physical proximity while also maintaining confidence in the ability to negotiate mobility. us, concepts of home in older adults are multifaceted, strongly connected to the physical location and surroundings, but having a deep impact on both emotions and the activities of daily life. ese findings have relevance to policy development both for supporting those who remain living at home and to those who choose to relocate to care accommodation. Nevertheless, it is not always possible or even advantageous for all older adults to remain living at home. For example, some older adults living alone can be at risk of social isolation and difficulty coping with the physical demands of caring for one's self [41]. Individuals with dementia who are living at home can also experience social disconnection and a lack of professional care to cope with psychological symptoms [42]. Despite the appeal to many of continuing to live in their own homes and "ageing in place," the current study was also able to demonstrate that some aspects of home can be renegotiated despite a change in physical location. Participants who had relocated from their long-term home had been able to successfully adjust, reporting that their new environment now felt like home. ey seemed able to do this because of the ability to retain some of the comforts of home and personal possessions and the capacity to make new social connections, despite having to make some concessions to change. However, the ability to renegotiate a new environment may be highly dependent upon the flexibility of the systems present in the new living environment in addition to the older person's ability to adjust. e current study is limited by its geographical focus on Western Sydney in Australia, the perspectives of which may not always be applicable to other cultural groups or socioeconomic demographics. Furthermore, participants in the current study may have been biased towards considering the concept of home from a positive perspective both by cultural rhetoric and by the way questions were framed. Since the participants in this study were relatively active, having been recruited from a sample who had been participating in physical activity sessions at the Seniors Centre, it should also be noted that the perspectives of home discussed in this article may not represent the points of view of less active older persons. Nevertheless, this study thus has important implications for the development of policy and practice around both supporting healthy ageing and in facilitating adjustment to new environments where unavoidable. By furthering the understanding of what home means to older adults, strategies can be developed for reinforcing the essential meaning components of home throughout the changes associated with ageing, ensuring that programs are in place to support ongoing independence, self-management, and social connection. Similarly, having a broad knowledge of the meaning of home to older adults can inform the implementation of programs to smooth transitions to new living environments in older adults by reinforcing elements of care that support independence and personalisation. Future research could also benefit from looking more closely at the strategies and personal qualities that older people draw on in both sustaining living at home and in adjusting to changed living circumstances. --- Interviews 6-10 (i) What is it about your home that makes you want to stay living there? (ii) What are the things that have helped you to stay living there? (iii) What are the things that sometimes make it difficult for you to live there? (iv) What are some of the negative things about living at home for you? (v) What are some of the positive things about living at home for you? --- Data Availability Permission was not sought from participants at the time of consent to archive data, so this is not publicly available. --- Appendix --- A. Topic Guide

Objectives. Continuing to live at home is arguably one of the most important challenges older persons face as they age. e aim of this study was to clarify how older adults conceptualise home through age-related lifestyle changes. Methods. Principles from grounded theory were used to examine the perspectives of 21 older adults obtained from three focus group discussions and 10 indepth semistructured interviews. Results. Four major categories were developed: "anchoring self," "enabling freedom," "being comfortable," and "staying in touch." Discussion. For the participants in this study remaining at home enabled a sense of independence and freedom, self-worth and identity, comfort, and an ongoing active role in the community. However, some aspects of home could be renegotiated despite changes to living location, with new social connections able to be forged and personal comforts being transferrable. is holds important implications for supporting older persons to both sustain living at home and to adjust to changing circumstances, suggesting the importance of drawing on the experiences of older persons themselves in developing strategies to promote successful aging.

Background Low back pain (LBP) is a common and disabling disorder, ranked as the leading cause of Years Lived with Disability (YLDs) worldwide [1,2]. In China, a country with a population of 1.4 billion people [3], LBP was estimated to impact 67.3 million people in 2016 with an increase of 19% since 1990 [4], and is ranked as the second highest reason for health burden [4]. The annual prevalence of LBP varies between different occupations [5][6][7][8] ranging from 40% in teachers [5] to 74% in garment workers [5]. Considering that the working population reported 2.5 times higher persistent LBP than nonworking population in low and middle-income regions [9], China, the biggest labour force country [10], suffers high economic and societal burden of LBP. The medical service system in China consists of primary medical services (e.g., community healthcare centres and clinics) and secondary/tertiary hospitals [11]. Western medicine oriented hospitals are dominant in China but many of them have a traditional Chinese medicine department [11]. Each city or county has at least one traditional Chinese medicine hospital [11]. Referrals are not required [12], which means that all patients have direct access to healthcare. Diagnostic imaging is prescribed on a self-service basis or by various healthcare professionals. The excessive diagnostic imaging for LBP in China adds considerable burden on healthcare in China but is also associated with assumptions that diagnostic imaging could identify the causes of LBP [13]. For nearly all people with LBP, it is currently not possible to identify the specific nociceptive source [14]. Intervertebral discs, facet joints and vertebral endplate abnormalities are considered as potential nociceptive contributors to LBP [15][16][17]. There is now considerable research, predominantly conducted in the West, that suggests that attributing LBP to an anatomical basis has an important influence on patients' beliefs. These pain related beliefs are considered to be formed by an individual's past experience of pain and healthcare [18] as well as cultural influences [19]. There is also a large body of research which suggests that there are psychological effects of such biological pain beliefs such as fear avoidance, low self-efficacy and pain catastrophizing beliefs which are related to delayed recovery, poor clinical outcome and chronicity of LBP [20][21][22][23]. Associations between anatomical/ biomechanical pain beliefs and greater fear avoidance beliefs and correspondingly poor clinical outcomes have been found [24]. However, again, the current knowledge about these LBP beliefs [20][21][22][23] or beliefs about causes of pain [25][26][27][28][29][30] mainly comes from high-income countries, most with Westernmedical belief systems. Whether this knowledge would also be applicable to low and middle-income countries such as China [31], and those with different systems of belief requires study [32]. A small amount of research has already suggested that pain beliefs are likely to vary between cultures, races, ethnicities, healthcare and countries [33][34][35][36]. A recent study reported four discourses (patterns of ideas) underlying beliefs of Australians about the causes of persistent or recurrent LBP [30]. The discourses were predominantly biomechanical or anatomical, which is in line with the traditional western biomedical view of health [30]. Comparable biomedical beliefs about the cause of LBP were found in another study attributing pain to anatomical vulnerability of the spine [35]. As Chinese philosophies underpin people's daily life in China, it is likely that these philosophies would influence thinking about health for people living in China [37]. For instance, Yin-Yang posits that the development of a disease is caused by the imbalance of equilibrium in the body [37][38][39]. This ideology suggests that equilibrium can be disrupted by various factors, such as an excess of particular emotions (e.g., anger, happiness), overload (e.g., mental and physical), dietary imbalance and also by climate/weather (e.g., wind, cold weather) [40]. Although Western medicine is commonly practiced in China, it is plausible that Chinese philosophies also underpin beliefs about pain and persistence of pain. The discourses underpinning peoples' beliefs about the causes persistent or recurrent LBP for people living in China have not yet been investigated and are important for improving clinical pain management. Understanding patients' beliefs helps us to develop interventions addressing unhelpful beliefs in patients with LBP, and to target those interventions to patients who are most likely to benefit [26]. Successfully modifying patients' pain beliefs might prevent delayed recovery and poor outcome [26]. Therefore, it is important to understand the discourses underlying how people with LBP in China explain the causes of their persistent or recurrent pain. An in depth understanding of the beliefs about causes of persistent or recurrent LBP is argued to be helpful to tailor pain management [23,41], and may be a critical element to reduce the burden of LBP. The primary aim of this study was to explore the discourses underlying the beliefs of people in China about what causes their persistent or recurrent LBP. The secondary aim was to investigate the individual's perception of the information sources of these discourses. --- Methods --- Study design This study used a cross-sectional online survey which was based on an earlier Australian survey exploring LBP beliefs [30]. The study was approved by the scientific and ethical review board of Vrije Universiteit Amsterdam (VCWE, number 2019-065R1). All participants provided online informed consent. --- Survey The survey (see Additional file 1) was designed in collaboration with the researchers who conducted the Australian survey [30]. The survey was translated into Chinese by one of the researchers (YJL) who is a native speaker in Chinese and fluent in English. The translation involved direct translation of most of the words, but cultural adaptation where necessary. The appropriateness of the translation was verified and confirmed by a second Chinese native speaker fluent in English. The Chinese survey was pilot tested with four Chinese people (n = 2 with a history of LBP and n = 2 who studied linguistics), which resulted in slight modifications of the original translation. The survey had three sections: 1) Background information: Participants were asked demographic questions and questions about their LBP characteristics (e.g., duration of LBP, intensity of LBP on 10-point numeric rating scale, usage of pain medication (Yes/No), presence of comorbidities (Yes/No -if the answer was Yes, participants were asked to list their comorbidities), absenteeism due to LBP (Yes/No -if the answer was Yes, participants were requested to describe the duration of their absenteeism), and impact of LBP on daily life (Yes/No)). The Chinese language online survey was uploaded to a professional online questionnaire platform (WenJuanXing (<unk>)), and released through WeChat (<unk>) in Mainland, China. WeChat is the equivalent to the combination of WhatsApp and Twitter. The link to the survey was first shared in WeChat via researcher YJL' s personal contacts with lay people and health care providers (physicians, physiotherapists) working in primary medical services and hospitals in China. Subsequently, the survey was further spread through these connections. Responses were translated back into English by a Chinese researcher (YJL) and checked for accuracy by a second Chinese reviewer. Discussion to consensus was used to resolve translation discrepancies. --- Participants Participants were invited through WeChat (<unk>), the most popular Chinese social media platform. Inclusion criteria were: 1) aged between 18 and 65 years; 2) persistent or recurrent LBP within the last 6 months; and 3) proficiency in Chinese language. Participants were able to access the survey only if they responded affirmatively that, within the last 6 months, they were experiencing or had experienced LBP for more than 3 months. --- Sample size Based on previous study experiences with satisfying the principal of theoretical saturation [30], we predicted that approximately 130 participant responses were needed to identify the range of discourses underlying pain beliefs in a Chinese population with persistent or recurrent LBP. --- Data analysis The survey data in response to the question about causes of LBP were analysed using discourse analysis. Both the discourse and conventional content analysis (below) were inductive which means that no pre-existing theory was imposed on the analysis. Discourse analysis is a qualitative research methodology which considers that language constructs social and psychological reality [42]. This means that the language people use provides insights into how people view and act in the world [42]. For instance, people with LBP who claim that a herniated disc is the cause of their back pain, are considered to have a biomedical discourse underpinning their beliefs about the cause of their LBP. Drawing on these concepts, discourse analysis was used in this study to interrogate the underlying discourses behind the responses given by Chinese LBP population. Three researchers (JS, GGMSP and YJL) reviewed the entire dataset independently and proposed potential discourses underpinning the data during a meeting. Subsequently, two researchers (YJL, GGMSP) formulated five tentative discourses in a consensus meeting. The five tentative discourses were reappraised by one researcher (JS). During a second consensus meeting, the five discourses were refined, and consensus was reached between the three researchers (JS, GGMSP and YJL). Subsequently, YJL and GGMSP independently reviewed the full dataset again and coded each participant's response into one or more of the five discourses. Initial agreement about the coding was calculated between YJL and GGMSP. Discrepancies were discussed until consensus was reached between the two researchers. Finally, the complete dataset, the coding and the findings of the discourse analysis were reviewed by JS who agreed with the discourses and coding. The data from the final question about where participants' beliefs came from was analysed using descriptive statistics on the quantitative data (option 1 to 5) and conventional content analysis [43] on the qualitative data from option 6 'Other'. In cases where there were overlaps of the answers, the two types of data were compared. This type of analysis was able to provide a descriptive overview of where participants believed the discourses came from. Conventional content analysis was performed by two independent researchers (YJL and GGMSP) and discussion was used to reach consensus. Sociodemographic and clinical information was analysed using descriptive statistics in SPSS version 24 (IBM Corp, Armonk, New York, USA). Normality of continuous variables was visually inspected by histograms, Q-Q plots and box plots. Also, Z-values of skewness and kurtosis, and the Kolmogorov-Smirnov tests (n > 50) or Shapiro-Wilk tests (n <unk> 50) were performed. If the data were normally distributed, means and standard deviations were reported. Otherwise, medians and interquartile range were presented. To observe whether there were any differences between participants with and without missing data, the main baseline characteristics were statistically tested with independent sample t-tests or Mann-Whitney U tests. --- Results There were no differences in sociodemographic and clinical data between participants with and without missing values. In total, 171 participants agreed to participate in the study. Nineteen participants were excluded as they did not fulfil the selection criteria or had missing values for question 17 (Fig. 1). A total of 152 responses were included for data analysis. Seventy-three percent (73%) of the study population was female, 98.7% were Chinese nationals and most came from South Central China (51.3%), which is also the second most populated region [44]. Fifteen percent indicated that they experienced LBP every day and the mean (SD) pain intensity was 3.9 (1.5) on a 10-point numeric rating scale. Additional participant characteristics are presented in Table 1. --- What is your perception of why your low back pain is persistent or recurrent? Five discourses were identified. Most participants answered this question with one or two sentences, and their responses were assigned into one or more of the identified discourses. The initial agreement between YJL and WSP was 90%, and all discrepancies were resolved through discussion. An overview of the five discourses is presented in Table 2 and below. --- Discourse 1: LBP as a biomedical problem 'LBP as a biomedical problem' was the most prevalent discourse. Two-thirds of the responses were underpinned by this discourse. Participants explained their persistent or recurrent LBP by physical damages, incorrect posture, muscle imbalance and congenital issues. Their responses indicated that they considered their body in an anatomical, biomechanical and/or physiological way. Their underlying belief seemed to be that if there was something wrong biomedically in their back (body) that this would produce or provoke pain. For instance, some discussed physical damages as the cause of their ongoing LBP, such as Participant 16, who wrote: "I Fig. 1 Flowchart of the study had an injury during long jump in secondary school and I didn't pay attention to it. So, I probably got LaoSun (muscle strain) for a prolonged period". 'LaoSun' is a common Chinese term which means overuse of muscles that can lead to muscle strain and injury [45]. Participant 72 wrote: Probably because of continuous stimuli, and I didn't get the right diagnosis and treatment for my low back injury. In the beginning, I had an injury in another part of the body which caused poor posture during running. Later on, this led to unequal left and right muscle strength which compressed and pushed out my vertebra. Like a number of other participants, Participant 106 also discussed posture, attributing their LBP persistence or recurrence to "Lower-crossed syndrome, anterior tilt of my pelvic causes incorrect posture during standing". And participant 157 wrote: "... Working posture is not correct". Also underpinned by biomedical discourses, one participant indicated congenital issues as the source of their LBP. Participant 98 wrote: "I had an X-ray, the doctor said there is a deformation in my bone, my family members also have hereditary low back problems". Discourse 2: LBP as unbalanced lifestyle 'LBP as unbalanced lifestyle' was the second most commonly reported discourse. Around half of participants' answers were identified to fit within this discourse. LBP was described as a warning symptom or the result of an unbalanced lifestyle. A figurative individualised 'balance scale' that considers exercise, sitting, standing, walking time or load, could be identified from the responses. For instance, Participant 5 wrote: "I don't perform enough exercise and physical activities, I sit for a long time" and Participant 21 thought the cause could be "Doing too much or too little exercise?" Often, 'LBP as unbalanced lifestyle' seemed to be related to the first discourse 'LBP as a biomedical problem'. For example, a quote selected from the response of Participant 59: I think it's because I'm not exercising regularly. When I do go to gym, I will definitely train my lower back muscles with the back-extension equipment. The problem is, I should have gone more frequently than I usually do. First, this participant pointed out the importance of balanced lifestyle (exercising regularly). They then related the lack of exercise to the idea that back muscles should be trained specifically (indicating a biomechanical view of LBP). The participant then reinforced the importance of a balanced lifestyle by adding "I should have gone more frequently (to the gym) than I usually do". One response related to unbalanced lifestyle based on traditional Chinese beliefs regarding pregnancy: "I didn't take care of my low back during ZuoYueZi (postpartum care)" (Participant 143). This answer related to traditional Chinese health beliefs. ZuoYueZi is a part of Chinese custom that intends to improve health after pregnancy [46]. After delivery, it is strongly recommended that the mother takes particular actions such limiting movement, eating special food and not washing her hair [46]. Also, family members are an important part of ZouYueZi, providing social support to the mother, such as doing housework and taking care of the baby [46]. Discourse 3: LBP is about menstruation and 'kidney' status 'LBP is about menstruation and kidney status' was the third identified discourse. Approximately, 9% of the responses appeared from this discourse. In Chinese culture, menstruation is important to women while 'kidney function' is vital to men. To a certain extent, menstrual function and 'kidney function' reflect reproductive health. The understanding of 'kidney function' in Chinese medicine is fundamentally different to Western medicine [47]. In traditional Chinese medicine, the kidney is not be considered as a real organ but as a symbol that controls reproductive health [40] and causes LBP when the kidney is deficient [40]. As is evident in this quote from Participant 50, "Because of menstruation, I have LBP 2 days before menstruation, but I don't know the reasons behind it", several participants considered menstruation to be the cause (or one of the causes) of their LBP. Further, Participant 28 wrote, "LBP appears before menstruation" and Participant 37 responded, "Because of menstruation". One male participant indicated "ShenKui" was a reason for his LBP. 'Shen' means Kidney while 'Kui' means deficiency [48]. In China, women are generally believed vulnerable and emotionally unstable during menstruation [49], whereas men who have ShenKui are believed to have low sexual performance [48]. Psychosocial stresses in this discourse may be relevant to the LBP reported by participants. --- Discourse 4: LBP is about the 'five elements' imbalance The discourse 'LBP is about Five Elements imbalance' was only occasionally mentioned (7.9%) but was identifiable from the responses. Related to the balance of Yin and Yang, there are 'Five Elements' in Chinese medicine: Water, Fire, Wood, Metal and Earth [40]. There is a selfregulating balance within the five elements. For example, Water balances Fire, but Fire produces Earth that balances Water in return. In traditional Chinese medicine it is considered important to encourage this self-regulating balance to maintain good health. Water is considered to be the foundation of the other Elements [40]. This appears to be the discourse underpinning Participant 114's response "Drinking too little water will cause it (LBP) to recur". The Five Elements can represent different seasons, directions, colours, tastes and climates [40]. For example, spring, summer, autumn and winter are represented by Participant 10: "JingShen status is not optimal" 'Jing' means essence while 'Shen' means 'Mind'. 'JingShen' status can be understood as mental energy status. Participant 70: "... also because of life stress and fatigue caused by work" Participant's response can be coded into one or more of the five discourses wood, fire, metal and water, respectively [40]. Climates such as wind, heat, dampness, dryness and cold are represented separately by wood, fire, earth, metal and water, respectively. The self-regulating balance can be disturbed by exterior invasion of cold, wind and dampness which is believed to cause LBP [40]. Also, external cold can affect 'kidney function' when it invades the low back region, which often happens to modern women due to exposure of lower abdominals and loins in modern fashion [40]. Thus, participant's answers related to climates (e.g., "Probably suffer from cold" -Participant 9), and seasonal change (e.g., "... Pain will certainly occur during autumn-winter seasonal rotation and spring-autumn seasonal rotation, mainly because of climates..." -Participant 41) were considered to be underpinned by this 'Five Elements' discourse. --- Discourse 5: LBP is about energy status The least common discourse (5.9%) was based on 'LBP is about energy status'. In traditional Chinese medicine, 'Qi', understood as a'matter-energy' or 'vital force', connects physical and mental energies in individuals [40]. Qi should circulate freely inside the body and also flow in and out the body in a healthy situation [40]. A low (disturbed) energy status can be caused by, or causes, 'Qi' stagnation, resulting in muscle pain [40]. Answers related to low energy status were considered to draw from this discourse. For example, Participant 10 responded, "... JingShen status is not optimal". 'Jing' means 'essence' while 'Shen' means'mind'. 'JingShen' status can be understood as energy status. Also, answers indicating a disturbed energy status, caused by stress or mental fatigue, were underpinned by this discourse. For example, Participant 70 wrote, "... also because of life stress and fatigue caused by work". Where does the perception come from? Most participants selected only one of the five options and did not provide additional sources as 'other' options. Almost two thirds indicated that their perception of what causes their LBP to become persistent or recurrent came from healthcare professionals (n = 90, 59.2%). The options 'internet' (n = 37; 24.3%), 'family' (n = 35; 23.0%) and 'friends' (n = 25; 16.4%)) were also frequently listed. 'Religion' 0 (0%) was not indicated as an information source. Originally, the option 'other' was selected by 30 participants. However, two answers overlapped with the option 'healthcare professionals', and were moved from the option 'other' and into the option 'healthcare professionals'. In total, 28 participants (18.4%) selected the option 'other'. One of these reported two information sources and another reported three. Under the option 'other', most reported some sort of self-reflection (n = 24, 15.8%) as information source. Others indicated previous medical related education (n = 2, 13.2%), scientific literature (n = 1, 0.7%), and TV programmes (n = 1, 0.7%) as information sources. Three participants (2.0%) provided unclear answers. For example, Participant 19 answered "my personal experience" and Participant 37 wrote "daily observation". An overview of responses for this question are provided in Table 3. --- Discussion This study identified five key discourses underlying the beliefs of people living in China about what causes their persistent or recurrent LBP. The most predominant discourse was that LBP persisted or recurred due to biomedical problems, followed by the discourses influenced by traditional Chinese medicine related beliefs: unbalanced lifestyle, menstruation and 'kidney' status, the 'Five Elements' imbalance, and mental energy status. Most participants responded that their pain beliefs were based on information derived from healthcare professionals followed by the internet and family. A similar study assessed discourses underpinning beliefs about the causes of the persistence of LBP in participants living in Australia [30]. Four discourses were identified in that study: 1) Body as a machine; 2) LBP as permanent/immutable; 3) LBP is complex; 4) LBP is very negative. 'Body as a machine' is comparable with the discourse 'LBP as biomedical problem' and was also the most common discourse in the Australian study. The assumed biomedical causes to explain the ongoing nature of LBP was thus a common trend in both the Chinese and Australian study populations. This comparable understanding of the body between Chinese people and Western people is not surprising. Since 1978 the 'Reform and Opening' policy has been embraced in China, and this has included an increasing uptake of Western Under the option 'Other', one participant reported two information sources and another one reported three medical methods and interventions [50]. Currently, the principal medical practice in China is Western medicine [50][51][52]. However, even in the two-thirds of participants living in China who explained the causes of their pain with biomedical discourse, almost half of them related the causes to other traditional Chinese medicine related discourses. Unlike the previous studies which reported the homogenous usage of biomedical model to explain chronic LBP in Western society [27,28,30] and potentially across cultures [35], in our study, at least in the case of LBP, people in China often think about their health beyond the biomedical paradigm, combining traditional Chinese medicine related beliefs to the aforementioned paradigm. From the answers underpinned by the discourse LBP as unbalanced lifestyle, a metaphorical personalised 'balance scale' about time or load of exercise, sitting, standing or walking could be identified. The language the participants used to describe time or load, was 'too much', 'too little' and 'too long'. However, there was no specific duration, number or load mentioned by the participants. This 'balance scale' seems personal. Although lifestyle causes of ill-health are also found in Western medicine, considerations of balance can be found in traditional Chinese medicine which has long discussed balance as a key to health [40,53]. Any imbalance, e.g., the imbalance between rest and exercise, unbalanced emotion or diet, too much and too little work or sex, can become a cause of disease based on traditional Chinese medicine [40,53]. The idea of an individualised balance scale is part of the Chinese culture. LBP as unbalance lifestyle from a Chinese perspective was at times entangled with the common discourse LBP as a biomedical problem as many participants related the time or load with certain positions or postures to explain their ongoing LBP. To a certain degree, the discourse LBP as unbalanced lifestyle may show how Chinese philosophy merges with a Western biomedical view. The other three discourses regarding LBP as menstruation and 'kidney' status, the 'Five Elements' imbalance, and energy status were less common but unique. These three discourses appear to interconnect with one another. For instance, an explanation that the external invasion of cold can cause LBP from the discourse 'the 'Five Elements' imbalance', can be related to the discourse'menstruation and 'kidney' status', because the invasion of cold is believed to be harmful to 'kidney' in traditional Chinese medicine [40]. Another example of interconnections is the idea that Qi stagnation can cause LBP from the discourse 'energy status'. This concept might be related to the discourse'menstruation and 'kidney' status', because Qi stagnation is also thought to result in irregular menstrual status and 'kidney' deficiency, which ultimately provokes LBP [40]. Importantly, these three discourses together with the previous discourse 'unbalanced lifestyle', eventually seem to be related to the overarching theme of 'balance' -the key concern of health discussed in traditional Chinese medicine [40,53]. These four discourses likely demonstrate the ongoing impact of traditional Chinese medicine on contemporary Chinese society and represent the complexity of the population's understandings of what causes their LBP to be persistent. The four discourses underlying Chinese people's pain beliefs might indicate high thoughtfulness to the body, mind and environment which may generate related neural networks that collaborate to evoke pain [54] and increase susceptibility to pain. However, these discourses might guide people in China to improve self-management (e.g. adjusting unbalanced lifestyle or simply waiting menstrual cycle to pass), unlike Western chronic LBP patients often searching for specific medical diagnosis under the biomedical paradigm [28]. Reported by the earlier study [30], the Australian group also frequently indicated their LBP as permanent/immutable and very negative. The Chinese group seemed more positive about their persistent LBP. This Chinese group seemed more positive about their persistent LBP, compared to an earlier similar study [30] that Australian chronic LBP patients frequently indicated their pain as permanent/immutable and very negative. We reanalysed of the present data by reallocating Chinese participants' responses into the discourses LBP as permanent/immutable and LBP is very negative. Only two Chinese participants indicated their LBP as permanent/immutable with possible negative emotions, by complaining about no useful LBP medical interventions available or saying LBP is inevitable and impacts one's study and life. Although the reasons for these differences across the populations are not known, two possible explanations are that; 1) the study may represent a population with less severe symptoms than the Australian study; and 2) stoicism (meaning showing no emotions when encountering pleasure or pain) is considered as a positive trait in Chinese culture [55]. In contrast to our findings about patients living in China, other research suggests that Chinese healthcare professionals [56,57] show higher levels of fear avoidance beliefs related to physical activities than Western physicians [58] and medical specialists [59], and Chinese nurses have pessimistic views about LBP as many nurses experiencing LBP planned to quit their job due to their back pain [56]. However, we suggest that these comparisons [56][57][58][59] should be viewed with caution as those other studies used variables developed from Western ways of thinking to quantify pain-related beliefs [34]. Moreover, the overuse of MRI in diagnosing LBP in Chinese hospitals may imply that Chinese care providers are grounded in biomedical causes for LBP [13]. Our study found that healthcare professionals were the main (59%) information source of beliefs about causes of persistent or recurrent LBP in Chinese group. This finding was much lower than the previous Australian study where 89% of participants attributed "healthcare professionals" as information source [30]. Information sources 'Family' and 'Friends' were higher (23.0 and 16.4%) in the Chinese sample, compared with 9.0 and 5.0% respectively in the Australian sample [30]. These differences might be explained by a less severe LBP population in our study. Only 15.1% of Chinese versus 82.0% of Australian participants reported having daily LBP. Due to the less severe level of LBP, we assume that less participants needed to seek medical professionals' help. A re-analysis including only the participants who reported LBP every day (n = 23), revealed that 52.2% of Chinese people with LBP every day, selected 'healthcare professionals' as information source. This percentage is still lower than in the Australian study [30]. However, these comparisons should be interpreted with caution due to the small sample size. The lower percentage of 'healthcare professionals' information source, might also be explained by Chinese people's historical grounding in Confucianism, which emphasises family and community needs over those of an individual. As health concerns are viewed as family problems rather than personal ones, seeking help from healthcare professionals may be considered a shameful revelation of private family matters to outsiders [55]. This might be one reason why less Chinese participant chose to seek medical help, even if they had LBP every day. Confucianism has been identified as a cultural barrier to the Chinese population receiving pain interventions [55]. However, Chinese healthcare professionals have been held negative beliefs about LBP [56,57] and could negatively influence pain related beliefs of patients. Confucianism might be considered positive for people in China with LBP by avoiding unhelpful medical help. It is important to consider the representativeness of this study population. Notably, half of the participants were from South Central China and most other participants were from either East China or North China. This can be explained by the way the data were collected by WeChat as most connections were with South Central, East and North region. Due to the lack of data from less-developed China, the study findings may not be as representative of those parts of China. Moreover, pain beliefs influenced by culture are hard to separate from socioeconomic factors [34,60]. As we did not gather participants' socioeconomic status or educational level in this study, our study findings should be interpreted with caution with respect to representativeness. Considering also to the demographics of this study population with 73% females and generally mild LBP, the results may not be as applicable to populations with predominantly males and people with more severe conditions. Additionally, due to our data collection methods, the representativeness of the current study might also be focussed towards younger and richer people with LBP, as they are more likely to have access to mobile phones, internet and social media. Although we have compared some of our results to an Australian study [30] upon which we based our survey questions, these comparisons need to be interpreted with caution as there were some necessary changes to the wording in line with the cultural translation approach that we used. We did not translate the survey according to the recommended guidelines for translating questionnaires [61]. As the questions were very straightforward, there was little room for misunderstanding, but translational errors cannot be ruled out. We have also attempted to address any potential issues by not overstating the comparisons between the findings of the two studies. The different belief system of LBP population in China found in our study, supports research that suggests that cultural factors influence pain-related factors [19,33,34,60,62]. For example, in contrast with the overwhelming LBP medical care in the West [14,25,32], a Nepalese study showed that people who suffered from LBP continued with their daily activities without seeking medical help as they consider LBP to be a normal aging process [60]. Insights from different cultural perspectives can provide useful information to understand patients' beliefs about the causes of pain and can therefore assist with tailoring treatments and addressing beliefs. Our study is the first study that examined the discourses underpinning pain beliefs in a Chinese population with persistent or recurrent LBP. It demonstrates the complexity of the Chinese population's pain beliefs which are beyond the biomedical paradigm. The complexity of this way of thinking about pain is largely influenced by the concept of 'balance' from traditional Chinese medicine. This study also provides a starting point for future research in pain management. It is recommended for future research that customised interventions to explain LBP appropriately, should contain biomedical and thinking of psychosocial causes with integration of Chinese culture related thoughts concerning causes of LBP. Integrating the concept of 'balance' into modern neuroscience pain education could be helpful for the future management of LBP in China. --- Conclusions The findings of this study support those from previous studies in other cultural groups that suggest that people frequently use biomedical viewpoints to explain the persistence or recurrence of their LBP. This perspective appears to be in Chinese populations as well. However, it also establishes the persistent impact of traditional Chinese medicine on contemporary Chinese society's understandings of LBP mainly related to the concept of 'balance'. Findings suggest that comprehensive LBP management for Chinese people should be culturally relevant, multifaceted and involve healthcare professionals, family and the patient. --- Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. --- Supplementary information Supplementary information accompanies this paper at https://doi.org/10. 1186/s12891-020-03500-1. Additional file 1. The survey. The English and Chinese version of the survey. Abbreviations LBP: Low back pain; YLDs: Years lived with disability Authors' contributions YJL, GGMSP, MWC and JS participated in study conception and design. YJL, GGMSP and JS performed the data collection and data analyses. All authors interpreted the data, wrote the manuscript, read and approved the final manuscript. --- Ethics approval and consent to participate The study was approved by The Scientific and Ethical Review Board (VCWE) of the Faculty of Behaviour and Movement Sciences, Vrije Universiteit Amsterdam (VCWE-2019-065R1). All participants gave digital informed consent before completing the survey. --- Consent for publication Not applicable. --- Competing interests The authors declare that they have no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdiction

Background: Low back pain (LBP) is the second highest cause of health burden in China. Delayed recovery, poor clinical outcomes and persistence of LBP are associated with negative pain beliefs about LBP. Chinese philosophies are nested into the daily life of people in China, which is likely to influence pain beliefs. However, there is lack of knowledge about people's discourses regarding their LBP in China. The primary aim of this study was to explore the discourses underlying the beliefs of people in China about what causes their persistent or recurrent LBP. The secondary aim was to investigate the sources of these pain beliefs. Methods: People (n = 152) from South Central, East and North Mainland China with LBP completed an online survey about what they believed caused their persistent or recurrent LBP and where these understandings came from. Potential causes of persistent or recurrent LBP were explored qualitatively using discourse analysis. The sources of these discourses were assessed by descriptive statistics with conventional content analysis. Results: Five discourses were identified to underpin participants' beliefs about what caused their persistent or recurrent LBP, namely: (1) biomedical problems (66.4%), (2) unbalanced lifestyle (48.7%), (3) menstruation and 'kidney' status (9.2%), (4) the 'Five Elements' imbalance (7.9%), and (5) energy status (5.9%). Most participants responded that their pain beliefs were based on information derived from healthcare professionals (59.2%), followed by the internet (24.3%) and family (23.0%). Conclusions: People from moderately and well-developed parts of Mainland China think predominantly in line with a Western biomedical viewpoint about their LBP. Traditional Chinese medicine related pain beliefs mainly to the concept of 'balance' were evident on contemporary Chinese society's understandings of LBP. These cultural beliefs could be relevant to consider in LBP management and involve healthcare professionals, family and patient in this process.

d during the current study are available from the corresponding author on reasonable request. --- Supplementary information Supplementary information accompanies this paper at https://doi.org/10. 1186/s12891-020-03500-1. Additional file 1. The survey. The English and Chinese version of the survey. Abbreviations LBP: Low back pain; YLDs: Years lived with disability Authors' contributions YJL, GGMSP, MWC and JS participated in study conception and design. YJL, GGMSP and JS performed the data collection and data analyses. All authors interpreted the data, wrote the manuscript, read and approved the final manuscript. --- Ethics approval and consent to participate The study was approved by The Scientific and Ethical Review Board (VCWE) of the Faculty of Behaviour and Movement Sciences, Vrije Universiteit Amsterdam (VCWE-2019-065R1). All participants gave digital informed consent before completing the survey. --- Consent for publication Not applicable. --- Competing interests The authors declare that they have no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Low back pain (LBP) is the second highest cause of health burden in China. Delayed recovery, poor clinical outcomes and persistence of LBP are associated with negative pain beliefs about LBP. Chinese philosophies are nested into the daily life of people in China, which is likely to influence pain beliefs. However, there is lack of knowledge about people's discourses regarding their LBP in China. The primary aim of this study was to explore the discourses underlying the beliefs of people in China about what causes their persistent or recurrent LBP. The secondary aim was to investigate the sources of these pain beliefs. Methods: People (n = 152) from South Central, East and North Mainland China with LBP completed an online survey about what they believed caused their persistent or recurrent LBP and where these understandings came from. Potential causes of persistent or recurrent LBP were explored qualitatively using discourse analysis. The sources of these discourses were assessed by descriptive statistics with conventional content analysis. Results: Five discourses were identified to underpin participants' beliefs about what caused their persistent or recurrent LBP, namely: (1) biomedical problems (66.4%), (2) unbalanced lifestyle (48.7%), (3) menstruation and 'kidney' status (9.2%), (4) the 'Five Elements' imbalance (7.9%), and (5) energy status (5.9%). Most participants responded that their pain beliefs were based on information derived from healthcare professionals (59.2%), followed by the internet (24.3%) and family (23.0%). Conclusions: People from moderately and well-developed parts of Mainland China think predominantly in line with a Western biomedical viewpoint about their LBP. Traditional Chinese medicine related pain beliefs mainly to the concept of 'balance' were evident on contemporary Chinese society's understandings of LBP. These cultural beliefs could be relevant to consider in LBP management and involve healthcare professionals, family and patient in this process.

Introduction The diversity of definitions of "consent" in social and humanitarian knowledge is reflected in the polymorphism of interpretations of different aspects of this phenomenon. "Consent" is resolution, unanimity, solidarity, and unanimity harmony. L. Wittgenstein, in Philosophical Studies, noted an important feature of this phenomenon: the consent of people refers to language. It is a consensus not of opinions but of forms of life. Hence, for there to be similarity and agreement in opinions, it is first necessary to agree about the language used, thus presupposing agreement in the way and forms of life." Consent is considered today as a universal value and a philosophical category. For example, in the "New Philosophical Encyclopedia" the following definition is given: Consent is a specific form of interaction of objects and processes, reflecting the spontaneous and conscious connection of opposites, their correlation with each other, the achievement of harmony, symmetry and proportionality of the parts of the whole in certain ratios. In a narrower sense, consent is the acceptance by opposites of each other in certain properties and interactions" (Stepin et al., 2010). Consent is a form of interaction between different parties, assuming their unity and integrity based on equal value and equality of the parties before each other, even though they may have different statuses, thereby ensuring the possibility of conflictfree coexistence. In human relations, consent is important, especially when struggles, conflicts, and contradictions exist. In the interaction of various parties, their similarities are revealed, identities that allow us to form unity and conflict-free integrity. Similarities set up a mutual understanding of the opposing, conflicting parties, smooth out contradictions and bring polarities closer. Since agreement presupposes similarity, it is unnecessary for agreement to be preceded by a struggle, contradiction, or conflict, i.e., disagreement. Consent is possible initially, i.e. not as a result, but as a starting point. Consent can be considered as a phenomenon of human relationships, interactions that are carried out at different levels (from interpersonal to interstate). At the level of social life, when talking about consent, the term consent is not always used. "There are a number of terms that correspond to certain types of relations that arise on the basis of the principle of consent: brotherhood, friendship of peoples, civil peace, social unity, solidarity. While the understanding of dissent, social contradictions occurs using the terms non-fraternal relations, enmity, war, class struggle, discord. The contradictions that arise in the social world are different from natural ones, since in nature changes occur evolutionarily, and in society, in addition, revolutionarily or with the help of reforms (Nikovskaya, Yakimets, 2019). --- Reaching agreement Problems of reaching agreement are the subject of research in political science, sociology, philosophy, psychology, management, management theory, and a number of other social sciences and humanities. Most interpretations of the concept under consideration focus on its result, which is evaluated as a compromise and the result of interaction between subjects. Of course, consent in any sphere is an act resulting from the activities of individuals, social groups or States. The process of reconciling interests and finding their resultant is influenced by many factors, for example, agreement in politics is always determined by time and situational factors. A low level of consent or lack of it can lead to a decrease in confidence in the authorities and, consequently, to a decrease in their legitimacy, or in difficult situations -to social tension and destabilization of society (Grinberg, 2012). Thus, consent acts as a certain arithmetic mean, a certain resultant (in terms of mathematics in relation to politics) of various factors. The basis of consent in modern society: democracy, stable social development and political order. The concept of consent in a broad sense is one of the possible emerging models of relations between political institutions and subjects in the political sphere and allowing them to interact. However, it can also be considered as a result of the interaction of political factors, which is expressed in the coordination of the positions of the parties on topical issues of development. It is possible to distinguish several subject fields in the analysis of the concept of consent: -mechanisms of its achievement (technological component); -forms of interaction between social communities and groups; -the value aspect of the "concept of consent" category (the moral component); -socio-psychological factors that affect the process of achieving consent in society in general and political consent in particular; -socio-cultural aspects that have a significant impact on the worldview and behavior of people, as well as on the process of socialization in general; -the impact of the crisis state of society on the process of reaching agreement; -the phenomenon of the "concept of consent" is interesting for the researcher, first of all, in the context of social changes (RANEPA, 2014). We would like to note the universality of the meanings of the concept of "consent"the multiplicity of ways to achieve it and ideas about consent implies its multi-aspect and multi-faceted vision. An indispensable condition for raising the question of consent is the understanding of the factors of the need to change the political landscape, change, change the vector of development. There is no doubt that consent is necessary at every stage of the progressive movement of society, because it is its presence and meanings that determine the future of society, in fact, it formulates the program of"self-development of society". The political reality of the modern world is characterized by a change in the political landscape under the influence of new trends, one of the manifestations of which is the changing model of modern democracy in developed countries. Despite the abundance of theoretical concepts of democracy proposed by political scientists in the twentieth century, a number of modern scientists express ideas about the transition of modern democracy to a new quality, or a new stage of development, which Professor of sociology at the University of Warwick (UK) Colin Crouch describes as "postdemocracy" (Wittgenstein, 1998). In modern Western political science, attempts are made to rethink the existing models and concepts of democracy, while one of the areas of active theoretical research is the study of the possibilities of their integration. For example, the Belgian political philosopher Chantal Mouffe, author of the theory of Post-Politics, writes in the article "Towards an Agonistic Model of Democracy" about "a new paradigm of democracy, a model of 'democracy of discussion', which is now becoming the most rapidly developing direction". The researcher focuses on the characterization of the views of scientists who are followers of this approach: "supporters of the democracy of discussion argue that it is still possible to reach a consensus that was deeper than "simple agreement on procedures", a consensus that could be called "moral"... The peculiarity of their approach is to support a certain kind of normative rationality, as well as to try to provide a solid foundation of loyalty to liberal democracy by reconciling the idea of democratic sovereignty with the protection of liberal institutions." According to Chantal Mouffe, the" democracy of discussion " has formed two main schools, influenced by John Rawls and Jurgen Habermas. She characterizes them as follows: "the point of contact between these two types of democracy of discussion is the assertion of the possibility of relying on power and legality on certain forms of public justification, as well as the belief in the existence of rationality, which would have not only an instrumental, but also a normative dimension: "reasonable" according to Rawls, "communicative rationality" according to Habermas. In both cases, a sharp distinction is drawn between "simple consent" and "rational consensus", and the field of politics in the proper sense of the word is identified with a discussion between reasonable people guided by the principle of impartiality (Muff, 2014). The methodological basis for studying the concept of consent can be both general scientific methods and private methods of political science, sociology, cultural studies, philosophy and a number of other political sciences. According to Professor A. I. Solovyov, " the political space creates its own theoretical aura, suggesting a special form of application of various methodological approaches to all parameters and aspects of the political." The use of an integrated approach allows us to qualitatively analyze complex social processes. The institutional approach to the problem of political consent offers an examination of the role and functions of political institutions in the process of ensuring procedures for achieving political consent. The activity approach to political consent consists in the fact that consent is considered as the final result of activities aimed at coordinating the interests of social groups and the authorities (Mikhailova, 2016). When analyzing the stages of achieving political agreement, it seems appropriate to use a number of methodological approaches proposed by political science. These include, first of all, behaviorism (Merriam, 1993;Lasswell, 1965) and incrementalism (Taylor, Lindblom, Dahl, 1953), which identify various key variables in assessing the political behavior of subjects, which together have a significant impact on the coordination of the political positions of subjects. The concept of consent is also a state of "balance" in the political sphere, achieved as a result of mutual concessions and on the basis of agreements between the parties. Political actors, as a rule, have divergent interests, often offer opposite methods of achieving socially significant goals, and most often are not interested in reaching agreement and do not even strive for it (Weber, 2021). The phenomenon of the concept of consent includes variables of different order and level. The structural elements of political consent are the subject and object of consent in politics. The subjects of the concept of consent in the political field are the bodies of legislative and executive power, officials (who have authority), political parties and socio-political movements and organizations, interest groups, pressure groups, public figures, journalists, social groups, ordinary citizens. In the context of the transition to the information society, the mass media and communications are playing an increasingly important role. The concept of consent will almost always be associated with the management activities of the subjects. A compromise reached in the process of discussing, preparing and implementing a political solution will also be a real form of agreement in politics. Agreement in politics, as a kind of consensus, involves the convergence of the positions of the participants on the basis of possible benefits and preferences that the contracting parties will ultimately receive. However, hierarchical relationships between subjects largely determine the "vector of consent". In our opinion, it is necessary to rethink the concept of "consent" in relation to the political sphere and other areas. In the context of globalization and informatization, meanings, symbols, and mechanisms of consent are changing. For example," a sign of the moral health of society " is a value agreement, which is practically absent today in the conditions of mass culture, a large-scale spiritual civilizational crisis. It seems that it will take quite a long time to form new conditions for a new state of value agreement (World Economic Forum: Network Readiness Index, 2014). An important condition for humanity's survival and continued existence will be an ever-expanding dialogue between countries, peoples, and cultures. It presupposes the achievement of a certain consensus on the main problems, including in terms of coordinating efforts to solve global problems, which can be a confirmation of the understanding of unity while at the same time preserving the diversity of the modern world. Despite the significant gaps in the level of development of the world's countries, future politicians will inevitably have to agree. It seems that globalization puts on the world agenda, along with the need to solve many global problems, the development and implementation of the "global theory of consent" in practice. In our opinion, one of the most promising technologies of the future will be the "technology of consent", considered as a technologically and socially mediated process of coordinating positions on topical issues of human development in the context of globalization (Crouch, 2010). Is the "Consent Concept" project possible for Kazakhstan today? Of course, it cannot be comprehensive and complete, but pursuing it by all the factors of the political process ensures stability and social development. According to the Doctor of Sociological Sciences L. I. Nikovskaya: "The emerging trends in the development of the country's socio-political system, the activation of civil society, and the increased demands for improving the efficiency of the functioning of the public administration system have significantly increased the social demand for the scale and quality of civil participation, the system of interaction between government and civil society. An important task of such interaction is to establish a meaningful dialogue between civil society institutions, on the one hand, and state power and management structures, on the other, and to overcome mutual distrust among civil servants in civil society initiatives, mechanisms of public control and independent expertise." There is no doubt about the relevance of the problem under consideration for the Russian political elite, which formulates the country's development goals, methods and means of achieving them (Report on the methodological seminar of the Research Committee on Political Communication Studies of the Russian Academy of Sciences "Communicative Audit of the political sphere", 2014). In modern Kazakhstan, there is virtually no discourse about the concept of consent in society, the need to achieve it, or, in extreme cases, putting this problem on the political "agenda". However, the search for a national idea in post-Soviet Kazakhstan, an appeal to the origins-the past, an attempt to rethink the complex, controversial periods of national history, the increasing attention of the state and government to the issues of patriotism, the understanding of the need to educate the younger generation of civil identity-all this indicates the awareness of the importance and significance of these issues and problems. Kazakhstan's model of consent, based on the traditions of domestic political history and political ideas of the past (in our opinion, political scientists and politicians still have to rethink the history of political thought in Kazakhstan in the context of modern realities), will allow us to find the best ways to develop the country. Its use concerning Kazakhstan's practices will prevent social conflicts or minimize their negative consequences (Stepin et al., 2010). Public problems are usually the" agenda " of the administration, but the task of the authorities is, to a certain extent, to structure it, to formulate problems that require urgent solutions and proposals for the implementation of political solutions. Coordination of interests at the stage of preparation and adoption of political decisions will be a form of political agreement. Reaching an agreement is difficult in conditions of social division in times of" turmoil " or destabilization of the political situation. At the same time, in fairly "quiet" periods of history, political consent serves as a factor and a condition for dynamic social development. One of the socially significant results of achieving the concept of consent will be the value agreement in society, but this is more a symbolic result than a real one. But the implementation of socially significant projects is already a real result of the agreement (Neveleva, 2002). Consent acts as an idea in the context of social solidarity and partnership teachings. More effective are the transformations made by joint efforts, i.e., without violence against each other. They allow us to achieve harmonious integrity and optimal order in society. In solidarity, mutual assistance, mutual support, fraternity between people, partnership, and cooperation (all of them exclude mechanical communication), the attitude of consent is manifested, the significance of which is to ensure not only survival but stability and security of human existence, as well as to preserve the integrity of the world in all its diversity, thereby sustainable development. At a time of danger that threatens the existence of not only an individual but also the whole of humanity, the importance of the principle of consent, which fixes the necessary basis for the relationship of people in the world, is growing. Its essence is not only to act in consent but initially to predict the possible struggle when achieving an agreement. This is the key for a confident existence and development in the present and future. --- Conclusion Thus, consent acts as a leading idea in the context of social solidarity and partnership teachings. The relations of consent in society are extremely important, as they contribute to the resolution of social contradictions, and not in a revolutionary XLinguae, Volume 16 Issue 3, June 2023, ISSN 1337-8384, eISSN 2453-711X (violent) way, but peacefully, thereby ensuring the stability of social development. Solidarity, mutual assistance, mutual support, cooperation, and cooperation partnership, which are forms of relations of consent, are creative in nature since they imply mutual communication on the basis of common interests, goals, norms, etc., respect for equal rights, which contributes to the formation of unity not mechanical, but organic and conflict-free integrity, thereby stability. Without a relationship of consent, the existence of society and the individual in it is impossible, so they can be considered a principle-a guide to act together. Joint actions and activities of people in society ensure their social life. The connection of people on the basis of equal rights in public life is the basis of their solidarity and partnership as a conscious, voluntary desire to stay together based on trust in each other. Consent, being social and dialogical, is a generic principle in human nature, without which it is impossible to coexist peacefully and develop steadily (Malyshevsky, 2004). Consent is an objective phenomenon, and not only socio-political but also sociocultural. Without it, it is impossible to sustain the existence of society and the entire human world, designated as a whole by culture. Since there are inevitable contradictions, disagreements caused by differences, diversity, and agreementan important and necessary phenomenon of human existence. The consent of a person with himself and with others allows you to feel the integrity of the external and internal world. Although consent exists intermittently, not always, it acts as a way to resolve contradictions, resolve conflicts, and solve problems at different levels (from interpersonal to international and global) and can be a starting point, a paradigm in relations between people, peoples and states The article was prepared within the framework of financing scientific-targeted projects by the Science Committee of the Ministry of Education and Science of the Republic of Kazakhstan, in the context of sustainable development strategy of Kazakhstan.

The article provides a socio-philosophical analysis of approaches to defining the essence and content of the concept of consent as an idea, problem and principle. It applies a phenomenological methodology that allows us to record the phenomenon of consent and how it takes place. The concept of harmony in Kazakhstan's cultural and civilizational development is an important aspect in overcoming economic, socio-cultural and political crises, gaining socio-political and economic stability by the state. Only a public system based on the consent of citizens can effectively use the opportunities, resources and mechanisms for further development and qualitative transformation of all spheres of public life. Achieving social harmony is necessary since the main goal of social modernization is to enter the orbit of sustainable development. A multi-ethnic and multi-religious Kazakhstan can achieve this goal only by gaining civil peace and democratic consensus. Therefore, efforts should be made to organize and implement a discourse on a wide range of socially significant topics to achieve constructive social agreement.

Introduction Access to safe, clean water and sanitation is globally recognized as essential for public health [1][2][3]. In the United States (US) and beyond, readily accessible public toilets are considered modern necessities (even if often ill-provided [4]), important for accommodating an extremely mobile population, and particularly critical for those with greater needs such as children, the elderly, those with medical conditions requiring increased toilet use, people who are menstruating, and those experiencing homelessness [5]. Fundamental components of a public toilet include its design, its maintenance, and its accessibility; meaning, for example, a toilet should be accessible to members of the public, without social or physical barriers preventing usage, its design should provide privacy and safety, and its upkeep should ensure cleanliness [6,7]. Additional modifications may be mandated, such as handrails for those with special needs, or as will be discussed in this paper, aspects that enable comfortable and safe management of menstruation. Menstrual hygiene management (MHM) refers to the need to ensure that girls, women, and all people who menstruate have access to clean menstrual products, privacy to change the materials as often as needed, facilities for disposing of used materials, and soap and water for washing bodies as required [8]. There is a growing global recognition that public toilets and bathing facilities should provide these fundamentals of MHM [9,10]. Other aspects, such as hooks to hang a bag, adequate lighting, a mirror to check for leaks, and toilet paper or paper towels can further improve these experiences [10]. Absence of adequate enabling factors for MHM contributes to anxiety, embarrassment, and shame for those who menstruate, especially given ongoing menstrual stigma and taboos [11,12]. This hinders the ability to participate successfully in school, work, and other aspects of daily life, and contributes to perpetuating a gender inequitable society [13][14][15]. As more than a quarter of the US population is estimated to currently menstruate [16], access to clean, safe toilets with water, soap, and disposal mechanisms, is essential for ensuring dignified, safe, comfortable MHM for all. Although the US-based literature remains scarce on how people with limited resources manage their menstruation, evidence from a few studies suggests that the cost of menstrual products presents particular challenges [17][18][19]. One survey conducted with low-income women in St. Louis, Missouri, including some experiencing homelessness, found that nearly 50% had been forced to choose between buying food and menstrual products in the last year. Many of the women, especially those experiencing homelessness, had no place to change their menstrual products, particularly at night when they felt that public toilets were not safe [18]. While documentation of the challenges around menstruation faced by people experiencing homelessness are more prevalent in the US media than in the peer reviewed literature, there is an emerging evidence base describing inadequate toilet and bathing facilities for those who live on the street and in shelters, affordability issues around menstrual products, and experienced menstrual stigma [17,19,20]. Homelessness represents a long-standing public health crisis in the US in general, and New York City (NYC) specifically. In September 2019, there were over 62,000 people in NYC's shelter system each night; a number that does not account for the many additional unhoused people living with friends, family, or on the street [21]. A point-in-time count assessment estimated that there were over 3,500 individuals living on the street in January 2019, a number likely to be an underestimation [22]. In addition, the shelter system served over 133,000 separate individuals in 2018, a 59% increase over the prior decade [21]. Access to basic resources is among the many challenges facing this population, including safe and stable shelter, proper nutrition, health care, and toilet facilities. The COVID-19 pandemic has only served to exacerbate these challenges. Public toilets, or restrooms as they are frequently called, are a vital, but often overlooked, resource for MHM, particularly for vulnerable populations such as those experiencing homelessness who may lack reliable access to private, safe, and clean spaces or menstrual products. Of importance to note, this includes access to public versus private toilets, particularly in large urban environments [6]. Public toilets are facilities funded by federal, state or local dollars, technically open to anyone. They range from stand-alone restrooms, such as those in parks or on street corners, to those tied to publicly accessible institutions, such as free museums, transportation systems, or libraries. Although in theory open to the public, access to such toilets may be uneven, and limited in practice by the operating hours of the institution or park in which they are located, the "informal gatekeeping" by the staff, and may range in quality (e.g., cleanliness, stocking of toilet paper) depending on how well resourced and maintained such facilities are by the responsible government entity. Private toilets in this paper refer to those owned and maintained by private sector or commercial entities such as restaurants, coffee shops, and other stores. Access to such toilets is often limited to the paying clientele of the institution, or to those who are able to "pass" as paying customers. The passing requirement frequently translates into denial of access to populations experiencing homelessness, including those who are menstruating and in need of more frequent access [23]. Access and accessibility, as will be applied in this paper to public toilets and related resources for MHM, are concepts that are often constructed from a number of related dimensions. For instance, in health care, the dimensions can be defined as: 1) affordability (e.g., does utilization of the resource result in financial burden); 2) availability (e.g. is there enough of the resource for the demand of the population); 3) accessibility (is the resource geographically accessible and is its distribution equitable); 4) accommodation (e.g., does the resource meet the constraints and preferences of the population); and 5) acceptability (e.g., is the resource appropriate and relevant to the population's needs and cultural setting) [24,25]. As this relates to public toilets and MHM for people experiencing homelessness, this can be thought of as "are there enough public toilets in high-needs areas?"; "do the existing public toilets supply the requisite resources?" (e.g. stocked supply of soap; menstrual product vending machines; menstrual product disposal bins or trash cans); "are there barriers to utilization of the toilets?" (e.g., security guards screening entry into institution; expectation of payment such as a subway fare; requirement to request a code or key to restroom); and "are the characteristics (e.g., cleanliness and safety) of the toilet facilities appropriate for MHM for this population and on terms acceptable to them?" An important feature of resource access, be it to toilets or menstrual products, is equity in the spatial distribution of resources. These "spatial justice" issues can be seen in a wide range of phenomena. For instance, the environmental justice literature has exposed many instances where exposures to environmental insults (e.g., air pollution, toxic exposures) [26][27][28][29] and more general environmental "bads" (e.g., fast food outlets, vacant and derelict land) [30][31][32][33][34][35] are increased in communities with higher proportions of people of color, foreign born residents, or lower household incomes or educational attainment. Similar findings have been reported around access to environmental "goods" such as parks and open space [34][35][36][37], healthy foods [38,39], and health services [40][41][42]. However, it is unclear how or if neighborhood-level demographics associate with qualities and characteristics of public toilets. For our purposes, this is particularly important in considering how public toilet access may impact those experiencing homelessness in relation to managing menstruation. The media has showcased how many large urban areas of the US (e.g., Los Angeles, Seattle), lack adequate public toilets and are grappling with the related implications for populations living on the street [43,44]. In NYC, a recent media inquiry explored the inadequacy of public toilets in the city's vast subway system (some 420 stations). The reporting described toilets turned into storage closets, variable hours of service, and major challenges in maintenance and cleanliness [45]. The public at large would likely benefit from improved, safe, clean public toilets. For those living on the street or in shelters-routinely denied access to the numerous private sector toilets in restaurants, cultural institutions, cafes, and shops-the lack of clean, accessible public toilets presents distinct challenges. However, to date, little research has systematically explored access to public toilets in the US for people experiencing homelessness, especially with respect to managing their menstruation. This study sought to: 1) better understand the lived experiences of menstrual management or MHM among people experiencing homelessness in NYC with respect to public toilets; 2) describe general and MHM-related characteristics of public toilets in high need areas of Manhattan and analyze their interrelationships; and 3) examine the associations among neighborhood-level demographics and the public toilet characteristics in those areas. --- Methods We conducted a mixed-methods study that sought to capture, at individual, institutional, and ecological levels, the nature of menstrual management on the part of those experiencing homelessness, and how the local context may shape those experiences. This included: 1) key informant interviews with staff of government agencies and homeless service organizations; 2) indepth interviews with people experiencing homelessness who menstruate; and 3) audits of public toilet facilities in a select number of sites across the borough of Manhattan in NYC. This paper will focus on select findings from the qualitative data, and quantitative insights gained from public toilet audit data. The qualitative information served to enhance and guide our understanding and interpretation of the toilet audit data. --- Qualitative methods Our sample for the key informant interviews (n = 15) included staff of government agencies and organizations providing services to people experiencing homelessness, including shelters. Our sample for the in-depth interviews (n = 22) included street and sheltered individuals experiencing homelessness who were ages 18 years and older and who menstruate. We sought to identify 4-5 individuals in each of the following age groups: 18-25; 26-35; 36-45; and 46 and above in order to capture a range of menstruation-related experiences (more in-depth methods described in Sommer et.al. 2020 [23]). The participants all presented as female, although we did not ask for gender identification. Similarly, we did not probe on exact age beyond confirming they were above 18 years of age, given the sensitivity of the population. However, a number of participants offered their age during the interviews, and the researchers estimated the age of the others based on appearance and life story. Based on these methods, we can approximate that the participants ranged from ages 18-62, including 8 in the 18-25 category, 5 in the 26-35 category, 4 in the 36-45 category, and 5 in the 46 and above category. All participants provided oral consent prior to participating. Participants were recruited during the months of June-August 2019, with recruitment ending when we reached data saturation. Key Informants were recruited through electronic outreach to organizations known to be relevant to homeless services and/or public toilets provision in NYC. The majority of key informant interviews were conducted online using free conference call, with a small number conducted in the offices of those being interviewed, depending on the preference of the key informant. Recruitment for those experiencing homelessness occurred through the Coalition for the Homeless as well as from an organization specifically serving homeless youth. Both organizations placed a flier in their lobby and made announcements about the study including an incentive ($10 or $15 metro card) to the population who they serve. Clients who expressed interest in participating in the study were introduced to the research team by the Coalition or service provider. All of the interviews conducted with the homeless population occurred in private rooms (e.g. empty offices) at the Coalition or other service provider. Our decision to focus on Manhattan was both pragmatic and strategic. Although the shelter system is scattered throughout NYC's five boroughs, annual street counts routinely find many more street-dwelling homeless in Manhattan than in the other boroughs of NYC (excluding subways) [46]. The study received Internal Review Board (IRB) approval from the Columbia University Medical Center (CUMC) Institutional Review Board. A waiver of written consent was requested and approved by the CUMC IRB on the basis that the only record linking the subject and the research would be the consent document and the principal risk of the study was the potential harm resulting from a breach of confidentiality. In consultation with the Coalition for the Homeless, we concluded that a written consent form may also be an issue due to varying literacy of those experiencing homelessness. A consent tracking sheet was maintained to ensure all participants' consenting was documented. --- Public restroom audit In order to quantify differences in public toilets, an audit instrument was created by combining and adapting existing instruments used to assess the accessibility and acceptability of toilets in global development programs in both humanitarian and development contexts [47]. These tools assess multiple elements of the toilet design including structure and hardware, availability of basic supplies, and safety and privacy features. Data collected by our customized audit instrument included basic information (e.g., location, number of toilets), cleanliness (e.g., floors, toilets, sinks), data on availability of general resources (e.g., soap, toilet paper, trash cans, hooks on the back of stall doors for hanging clothing or bags, locks on stall doors), permission and economic-based accessibility (e.g., permission needed to use toilets, purchase required, codes or keys needed, access to the establishment needed), other accessibility characteristics (e.g., hours of operation, signage, gender neutral restrooms), and availability of MHM-specific resources. The latter included availability of menstrual products such as freely accessible or vending machine-provided menstrual pads or tampons, and disposal bins, which are refuse receptacles near the toilet (e.g. trash can) or within the toilet stall (e.g. small unit on the stall wall). Such internal stall bins eliminate the need to carry a used product to a garbage receptacle situated in a public space (e.g., the shared larger restroom). It is important to note that all of the variables collected, such as hooks on doors and privacy assured by locks on stall doors, are relevant to enabling comfortable, safe and dignified MHM, even if they are not MHM-specific. The majority of variables are binary (yes/no), simply indicating the presence, or lack, of a certain feature or characteristic (e.g., a disposal bin). However, the cleanliness variables were coded on a 5-class Likert scale. Prior to data collection, the full research team met to discuss the tool and reach consensus about the categories included. After the tool was developed, it was field tested, and upgrades were made to improve usability and functionality. This involved discussing the general process for auditing a public toilet facility, including minimizing disruption of usual practice, making careful observations, and performing functionality tests on the hardware (e.g., locks, sinks, hand dryers). In addition, researchers discussed the definition of each variable to ensure common understanding and consistency in utilizing the audit tool. Particular emphasis was placed on the cleanliness variables (Likert scales) as they are the most open to subjectivity. Between July 12 and September 3, 2019, researchers performed the audits in teams of two or more, with one of the researchers participating in every audit to ensure consistency in coding. Spatial methods-Identifying high-needs areas of people experiencing street homelessness. Various data sources were reviewed to identify places within Manhattan which may have a higher need for public toilet facilities. These included various homelessness counts and censuses, shelter locations and capacity, and others. Ultimately, locations of "hot spots," identified with the assistance of the Manhattan Outreach Consortium (MOC) as of April 2019, were used as they proved to be more stable and spatially discrete than other options explored (Fig 1). These are not geographic statistical hot spots (e.g., as calculated by spatial distribution statistics), but rather places where people are known to congregate or "bed down." They are identified mainly through ongoing outreach efforts and updated monthly. It is important to note that locations may change over time due to relocation of the individuals (e.g., some people may get sheltered, accept outreach offers, be asked to disperse by the police, or move to another neighborhood). Gender breakdowns, although important, were more difficult to estimate due to a lack of reliable or complete data and thus are not included in the analysis. This "hot spot" information is used to identify potentially high-needs locations (i.e. locations with greater numbers of people experiencing homelessness) to perform the public toilet audits (see below). Public toilet audit areas were defined by creating 1<unk>2 mile (<unk>805 meters) radius buffers from selected hot spot / encampment locations. As many of these locations are spatially clustered, some audit areas included multiple encampments of individuals who are living on the street or "sleeping rough." The team walked all streets and accessible park and open spaces intersecting the buffer areas and identified all publicly accessible toilets (e.g., within parks, subways, libraries, commuter train stations, public museums). It is important to note that the researchers only audited public restrooms, and did not assess private businesses (e.g., coffee shops, restaurants, bars) or those found in shelters or other facilities. This was because shelter facilities may be unavailable during the daytime for those staying there, and because those sleeping on the street tend not to access shelter facilities if they are not sleeping there. The data collection resulted in the identification of 31 publicly accessible toilet facilities. However, six were out of order, closed, or otherwise inaccessible resulting in 25 fully audited facilities (Fig 2). --- Analysis Qualitative analysis. All of the qualitative data (KIIs and IDIs) was transcribed and analyzed by two of the researchers using Malterud's'systematic text condensation' for thematic cross-case analysis [23]. This included the following steps: (1) identification of preliminary themes; (2) creative development of qualitative codes; (3) condensation of coded text; (4) synthesis and reconceptualization. The PI reviewed and helped to revise the final codebook, and the analysis team used Dedoose analytic software to code the data. The key themes were shared with the full research team for discussion, refinement and validation. The section below presents the key analytical themes and supporting textual passages of relevance to the public toilet audit data insights. Quantitative (audit data) analysis. Statistical analyses were performed in SPSS (IBM Corp., Armonk, NY) and spatial analyses in ArcMap 10.7 (ESRI, Redlands, CA). Collected data from the audits were explored in a number of ways. First, simple indices were created to capture broad domains of public toilet-level characteristics. Second, descriptive statistics of the indices were calculated to show the overall characteristics of the public toilets in these highneeds areas. Third, the indices were compared to one another using Spearman's correlations. And finally, bivariate associations among public toilet characteristics and contextual neighborhood-level socioeconomic data were explored. Simple indices were created to represent major domains of public toilet facility characteristics. These include (1) cleanliness, (2) general resource availability (availability 1-general), (3) MHM-specific resource availability (availability 2-MHM), (4) accessibility with respect to permissions or purchases (access 1-permissions), and (5) accessibility with respect to hours of operation, visibility, and inclusiveness (access 2-other). Raw data were converted into index values by summing the individual variables and then using linear transformations, so that all the resulting index scores were between 0-1. For the cleanliness index, scores were not impacted by missing features (e.g., if there was no trash can or disposal bin present the cleanliness score was not affected; however, it would be reflected in the availability score). A simple additive index was then created (full index) which represents the sum of the individual domain indices, resulting in possible values ranging from zero to five. In order to compare public toilet facility characteristics to the broader social contexts in which they are situated, "neighborhoods" had to be defined and operationalized. Locations of audited public toilets were geocoded using ArcGIS World Geocoding Service and manually checked for accuracy. American Community Survey (ACS) 5-year estimates (2014-18) at the Census Block Group (CBG) level were acquired via IPUMS / National Historical GIS [48] and mapped to represent sociodemographic characteristics of the residential population. ACS data include total population, poverty status, per capita income, median rent, non-Hispanic (NH) White residents, NH Black residents, Latinx/Hispanic residents, and adult population who did not graduate from high school (Fig 3). As the public toilet point locations served as the unit of analysis, pedestrian-accessible network distance buffers of 0.25 miles (<unk>0.40 km) were created (Fig 4). These network buffers differ from fixed-distance ("as-the-crow-flies") buffers as they reflect areas within a walkable distance along the network (pedestrian-accessible streets and paths). Because the buffer boundaries do not conflate with CBG boundaries, the ACS data were attributed to each public toilet by using areal weighting. This method of data disaggregation is a type of dasymetric approach, where a second dataset (in this case area), is used to reapportion the variable of interest (in this case ACS data). Areal weighting assumes a homogeneously distributed population, which although committing ecological fallacy, has been shown to provide more meaningful estimates than other, non-dasymetric, neighborhood estimation techniques (e.g., centroid containment, intersection) [49][50][51][52]. In the case of this study, CBGs intersected by the network buffer are split, creating "child" polygons. The area of each child polygon is calculated and the variable of interest (e.g., total population) is disaggregated to the new polygons by multiplying the CBG value by the ratio of the child polygon area divided by the original CBG area. For instance, if there were 1000 residents in a CBG, and the network buffer included 50% of the CBG area, it would be assumed that 500 residents (50%) lived in within the buffer area. Public toilet-specific demographic and socioeconomic contexts ("neighborhoods") were then calculated by summing count variables in all child polygons within the public toilet's network buffer. Non-count variables (e.g., median rent) were calculated using population-weighted means. --- Results --- Qualitative The qualitative findings served to reveal the human experience behind the toilet audit findings, enriching and guiding our interpretation of the audit data. As reported elsewhere [23], the most prevalent challenges that emerged from the interviews pertained to accessibility, resource, cleanliness, and safety issues. This proved to be the case both for those living on the street and those living in shelters, the latter of whom also need facilities as they move around the city when seeking out services or employment. Inadequate maintenance of public toilets. Specific challenges included significant concerns around the cleanliness of many public toilets; a common refrain was wondering whether public toilets were ever used, particularly in the subway system, combined with comments about the challenges their lack of upkeep posed: I think I've used the subway bathroom like twice in my life...And it was disgusting...The smell. Mostly the smell...you notice little things in there, like the sink might be a little dirty, the tissue might be all over the floor, so, mm, it's just nasty. I wouldn't, if I could avoid it, I would... -IDI017 Many informants also expressed concerns about their lack of maintenance, with recommendations emerging from the respondents that corresponded to the types of cleanliness challenges observed during the toilet audits: Clean the bathrooms enough to where someone can go in and make sure we have the necessities, soap, napkins, the dryer, even if there's no dryer.. ---.Maintain [them] that way. -IDI14 For their part, key informants based in service organizations or local government, described challenges related to the provision and maintenance of public toilets, such as resource limitations that constrain hours of operation. Parks department informants, for example, bemoaned the lack of staff needed to ensure that public toilets could be adequately cleaned in order to open on time at 8am (especially if they had been "trashed" the night before). Given the centrality of park-based toilet facilities (referred to as "comfort stations") as a daytime resource for those needing a public toilet, uncertainty with respect to hours of operation, cleanliness and adequate supplies is a routine worry. When special effort is made to address MHM, other city employees report, vandalism can make short work of, say, menstrual product vending machines in public facilities: We did try sanitary napkins and tampons [in dispensers] at one point, but, people broke in and just...This was quite a while ago, but, people would, you know, try and either take the products, light 'em on fire, have fun with them, whatever it is that they do, because that is the reality.-KII 03 The latter example highlights the challenge facing city government in the provision of more accessible and MHM-friendly public toilet facilities, particularly if there are insufficient resources for monitoring their usage and/or maintenance. However as with the maintenance issue, the homeless respondents had suggestions in relation to improving the accessibility and MHM-friendliness of facilities: If, you know, it were up to me, I would have bathrooms, just, a lot of bathrooms...bathrooms with locks, one stall, privacy, um. I honestly wouldn't even mind if the, I don't know what it's called but there were machines, you paid a quarter, I wouldn't mind if we went back to the twenty-five cent tampons, just I wish there were access, cause I don't carry pads if I don't expect my period....but I feel like just the event of getting your period is such a mission, to like put on a pad, it's like, there should be a bathroom 5, 10 minutes away, with access to stuff like that for free, hopefully one day.-IDI13 Inadequate hours of operation. Informants also complained about the limited numbers of public toilets throughout the city, and their restricted hours of operation, such as those located in the city's parks. As one respondent shared: --- So, you have to, like, go to the subway to use the bathroom, and those are closed from midnight to 5am. They're, um, they don't even always open them at 5am.-IP2 As many noted, periods do not stop flowing at nighttime, yet public toilets become almost inaccessible. As another informant suggested, the restriction of hours-similarly found in the toilet audit data-was potentially purposeful: They just don't want people in it, because they know that that's the place where homeless people go...like, you know, um, so they know that at a certain time at night, if they close it, that this is only when homeless people are going to be in there. _IDI003 --- Toilet audits Such cautionary statements provide a sound prelude to our own inspections. In reviewing the basic descriptive information about the audited public toilets (n = 25) and their respective neighborhoods, there emerged a fair amount of variation in most of the variables (Table 1). For instance, although all of the audited public toilets had running water and adequate lighting available, not all had functioning stall doors and locks (96% and 92%, respectively). Additionally, only 60% (n = 15) provided hooks or shelves for bags, clothing or belongings (a component of the general resource availability index, and useful for those carrying menstrual products with them). Cleanliness scores also demonstrated a wide range of values with all variables ranging between 1 (least clean) to 5 (most clean). With respect to MHM-specific resources, only 24% of restrooms (n = 6) had disposal bins within stalls, 12% (n = 3) had menstrual product vending machines, and none provided free products. Overall, 17 of the 25 (68%) restrooms had no MHM-specific resources at all. Of the three MHM-specific resources (disposal bins, free products, vending machines), only one public toilet had both disposal bins and a vending machine. Of the eight which had any sort of resource, two were in parks (vending machines), two in transit stations, and the remainder were housed within various institutions (e.g., museum, department of motor vehicles, NYC job center). Access data shows that most of the public toilets themselves did not require specific permissions or purchases, with 92% not requiring permission to use the toilet (e.g., asking an officer in the police station to use the restroom) and 96% did not require a purchase to access the toilets (e.g., needing special access to enter the establishment such as a subway station where the fare must first be paid to get to the area where the toilet is located). None required a key or electronic access code, in contrast to what individuals may encounter in some commercial establishments. However, over 75% of the restrooms required researchers to first enter or gain access to the establishment (e.g. museum, library, some park facilities or transit stationswhich may not require payment but may be experienced differently based on one's ability to "pass"). Additionally, only four (16%) were open continuously (24 hours per day, 7 days per week), all of which were either inside a police station or major transit hub. Note that even continuously open restrooms may not, in practice, be continuously available (e.g., long periods of closure for cleaning or maintenance). Characteristics of the residential populations living around the audited public toilets ("neighborhood" variables) showed wide variation. There were large differences in all measured indicators for income (e.g., population-weighted mean per capita income ranged from approximately $17,500 to over $182,000; poverty rates from 6% to 41%), educational attainment (e.g., rates of adults without a high school degree from less than 1% to nearly 45%), and race/ethnicity (e.g., proportion of NH white populations from under 5% to over 80%). Bivariate two-tailed Spearman's correlations show the associations among restroom indices (Table 2). These data suggest that permissions and purchase-related accessibility (Access-1) is inversely related to the availability of MHM-specific resources (Availability-2; -0.588, p = 0.002)-meaning the more accessible a restroom is, the less likely it is to have these resources. Other associations show that cleanliness is positively associated with the availability of general resources (0.685, p <unk>.001). This suggests that cleaner restrooms tend to have more general resources, which may be a function of more frequent maintenance and upkeep. Two-tailed Spearman's correlations were also calculated to assess the associations among restroom index values and neighborhood demographics (Table 3). Higher indicators for income and wealth tended to correspond with more availability of resources as well as overall public toilet facility quality. For instance, higher median rents were positively correlated with a "Criteria Met" represent the proportion of restrooms which meet the variable criteria (e.g., presence of a disposal bin) is only presented for dichotomous variables. "True" is coded as 1 and "false" is coded as 0. b Mean and standard deviations are only presented for ordinal or continuous variables. c Cleanliness variables were collected as Likert scales (1)(2)(3)(4)(5) where "1" is least clean and "5" is most clean. d Index values are continuous and have possible ranges from 0-1 other than the Full Index which has a possible range from 0-5. https://doi.org/10.1371/journal.pone.0252946.t001 more availability of general resources (0.372, p =.067), MHM resources (0.506, p = 0.010), "other" access (0.367, p = 0.071), and the full index (0.445, p = 0.026). Per capita income showed a similar trend; however, only availability of MHM resources had a meaningfully low p-value (0.408, p =.043). The proportion of the population below the federal poverty level and adults without high school degrees both showed negative correlations with MHM resource availability (-0.408, p =.043 and 0.397, p = 0.050, respectively) and the full index (-0.432, p = 0.031 and -0.381, p = 0.061, respectively). With respect to race and ethnicity, higher proportions of NH White populations were associated with greater general availability (0.349, p = 0.087) and NH Black populations with fewer permission or purchase-related access obstacles (0.360, p =.077). However, higher proportions of NH Black populations were also negatively associated with restroom cleanliness (-0.396, p =.050), general resource availability (-0.596, p =.002), and the full index (-0.538, p =.006). The only racial/ethnic variable which showed an association with MHM resource availability was a negative correlation with proportion of the population who are Latinx (-0.362, p = 0.075). --- Discussion This study offers independent support of MHM difficulties previously reported for New Yorkers experiencing homelessness. Specifically, it shows that likely high need areas of Manhattan, those hosting concentrations of people experiencing homelessness, are also wanting in resources for adequate MHM. Qualitative interviews suggest that public toilet-based access to MHM products and resources (e.g. products, disposal bins) is a pressing concern for people experiencing homelessness. Our quantitative results support such worries; none of the toilets audited in our sample provided free products, and nearly 70% had no MHM-specific resources at all. Given the likely higher reliance on public toilet facilities by people experiencing homelessness, this paucity of resources, described as basic and fundamental needs for people who menstruate, almost certainly has a differential effect based on socio-economic status and unequal access to non-public alternatives. The above inequity is further exacerbated by the quantitative findings which suggest that public toilets with more MHM-related resource availability tended to be more difficult to access with respect to needed permissions or purchases, which is in turn compounded by the fact that the vast majority (84%) of audited public toilets are not open overnight. The qualitative interviews revealed the latter to be an important barrier to menstrual management. Pointedly, too, access to public toilets may include hidden costs or location-specific permissions-whether economic (e.g., pay for subway access) or social (e.g., ask an attendant at a museum). Negotiating these is often further complicated for people experiencing homelessness by the need to present themselves convincingly as otherwise: to "pass" as not homeless. Elsewhere, we have shown how access to private toilets, those located within private sector or commercial entities, is encumbered by this symbolic requirement [23]; public toilets, too, often come laden with their own de facto gatekeepers. There were also detectable differences in neighborhood-level characteristics based on public toilet qualities. For instance, the public toilet facilities which provided any sort of MHM resources were positively associated with higher income and higher rent areas-and negatively associated with higher proportions of Latinx residents, lower educational attainment, and people living in poverty. Put simply, MHM resources in public toilet facilities were more prevalent in areas

Access to safe, clean water and sanitation is globally recognized as essential for public health. Public toilets should be accessible to all members of a society, without social or physical barriers preventing usage. A public toilet facility's design and upkeep should offer privacy and safety, ensure cleanliness, provide required sanitation-related resources, and be gender equitable, including enabling comfortable and safe management of menstruation. Menstrual hygiene management (MHM) refers to the need to ensure that girls, women and all people who menstruate have access to clean menstrual products, privacy to change the materials as often as needed, soap and water for washing the body as required, and access to facilities to dispose of used materials. Challenges around menstruation faced by people experiencing homelessness, which tend to be greater than those facing the general population, include inadequate toilet and bathing facilities, affordability issues around menstrual products, and menstrual stigma. Public toilets are a vital resource for managing menstruation, particularly for vulnerable populations without reliable access to private, safe, and clean spaces and menstrual products. This mixed-methods study sought to: 1) understand the lived experiences of MHM among people experiencing homelessness in New York City with respect to public toilets; 2) describe general and MHM-related characteristics of public toilets in high need areas of Manhattan and analyze their interrelationships; and 3) examine the associations among neighborhood-level demographics and the public toilet characteristics in those areas. Qualitative methods included key informant interviews (n = 15) and indepth interviews (n = 22) with people with experience living on the street or in shelters, which were analyzed using Malterud's 'systematic text condensation' for thematic cross-case analysis. Quantitative methods included audits and analyses of public toilet facilities (n = 25) using traditional statistics (e.g., Spearman's correlations) and spatial analyses (e.g., proximity buffers). Qualitative findings suggest cleanliness, access to restrooms, and availability of resources are critical issues for the participants or prospective users. Quantitative analyses revealed insufficiently provided, maintained, and resourced public toilets for managing

(84%) of audited public toilets are not open overnight. The qualitative interviews revealed the latter to be an important barrier to menstrual management. Pointedly, too, access to public toilets may include hidden costs or location-specific permissions-whether economic (e.g., pay for subway access) or social (e.g., ask an attendant at a museum). Negotiating these is often further complicated for people experiencing homelessness by the need to present themselves convincingly as otherwise: to "pass" as not homeless. Elsewhere, we have shown how access to private toilets, those located within private sector or commercial entities, is encumbered by this symbolic requirement [23]; public toilets, too, often come laden with their own de facto gatekeepers. There were also detectable differences in neighborhood-level characteristics based on public toilet qualities. For instance, the public toilet facilities which provided any sort of MHM resources were positively associated with higher income and higher rent areas-and negatively associated with higher proportions of Latinx residents, lower educational attainment, and people living in poverty. Put simply, MHM resources in public toilet facilities were more prevalent in areas characterized by high socioeconomic status, as opposed to areas which may already be under-resourced or marginalized, and as such benefit more from their availability and accessibility. Overall public toilet quality followed the same trend, indicating that neighborhoods which have higher shares of vulnerable residents tend to have lower quality public toilet facilities with fewer MHM resources. This is particularly true for neighborhoods with high proportions of NH Black residents, where the toilets tended to be less clean, have less availability of general resources, and have lower overall quality. These issues may be associated with maintenance and upkeep and were revealed as important aspects of MHM based on qualitative interviews. It is important to be reminded that the overall quality of the public toilet facilities (which included variables describing cleanliness, privacy, safety, and accessibility), are essential for, even if not specific to, MHM. This suggests an environmental injustice, where neighborhoods have differential access to "environmental goods" based on the sociodemographic nature of the residents. As the public toilet facilities that were audited were associated with clusters of people experiencing homelessness who may be menstruating, this has significant implications for their access to private, hygienic spaces for managing their menstruation safely and comfortably as needed. Although a preferential solution would be housing for all, and so reduce the unmet need that public toilet facilities in urban areas are expected to address, the exigency of menstrual management is one that lasts day and all night during a given menstrual period. Hence, safe access to clean public toilets is essential for anyone, housed or otherwise, moving about the streets of Manhattan. If anything, the COVID-19 pandemic has intensified such concerns, and made contagion the metric of solidarity. It is important to note the limitations of this study. First, there were a small number of samples (25 audited public toilets, only audited once each) which may result in unstable statistical findings and would benefit from a more complete (e.g., 100%) sample of the borough. Second, the areas of Manhattan selected for auditing were based on data which are not necessarily representative of the true distribution of people experiencing homelessness, but rather rely on locations identified by homelessness outreach workers as "hot spots" at a specific point in time. Nor were we able to identify any potential bias in the spatial distribution of women or other people who menstruate who would benefit most from MHM resources. Third, this data uncertainty is linked to the inability to perform a true supply-and-demand type of analysis. As such, this study does not examine a central aspect of accessibility or availability in terms of "amount per person," but rather just the qualities of the amenities that exist. It may be argued that any public toilet is better than no public toilets; however, based on the interviews, many women that are experiencing homelessness avoid public toilets specifically because they are not seen as clean, safe, or hygienic. Although the study design and data did not allow for a supply-demand analysis, there was large variability in the number of public toilets, and more so in the number of individual toilets/stalls within those facilities, in any given audited area. For instance, some downtown locations (e.g., near Stuyvesant Town and parts of the East Village) had no nearby public toilet facilities. Conversely, audited locations near major transit hubs or regional attractions often had over 20 individual toilets/stalls in nearby public toilet facilities. --- Conclusion Overall, interviews suggest that public toilet facilities in Manhattan simply do not meet the menstrual hygiene management needs of women experiencing homelessness in terms of accessibility, cleanliness, privacy, or resource provision. The spatial distribution of higher and lower quality public toilet facilities, reinforced by, and interpreted through, the findings from qualitative interviews, may be an example of an environmental or spatial injustice in neighborhoods proximal to "hot spots" of people experiencing homelessness in Manhattan. Such mixed-methodological approaches are a useful way to identify and highlight such inequities; insights that may have been incomplete without the convergence of findings. The overall lack of menstrual hygiene resources in all public toilets is further exacerbated by the findings that these resources tend to be found more often in public toilet facilities which are difficult to access. Ultimately, we believe that if these spatial biases, accessibility and resource issues, and overall paucity and poor quality of supply are addressed in Manhattan, it would not only contribute to meeting the needs of the most marginalized or vulnerable populations (e.g., people experiencing homelessness), but provide substantial benefits for the public good. That such needs are exacerbated during the global COVID-19 pandemic adds ever more urgency. --- All American Community Survey data used in this study is available from the US Census Bureau https://www. census.gov/programs-surveys/acs or NHGIS --- Author Contributions Conceptualization: Andrew R. Maroko, Kim Hopper, Marni Sommer. Data curation: Andrew R. Maroko, Caitlin Gruer, Maayan Jaffe, Erica Zhen.

Access to safe, clean water and sanitation is globally recognized as essential for public health. Public toilets should be accessible to all members of a society, without social or physical barriers preventing usage. A public toilet facility's design and upkeep should offer privacy and safety, ensure cleanliness, provide required sanitation-related resources, and be gender equitable, including enabling comfortable and safe management of menstruation. Menstrual hygiene management (MHM) refers to the need to ensure that girls, women and all people who menstruate have access to clean menstrual products, privacy to change the materials as often as needed, soap and water for washing the body as required, and access to facilities to dispose of used materials. Challenges around menstruation faced by people experiencing homelessness, which tend to be greater than those facing the general population, include inadequate toilet and bathing facilities, affordability issues around menstrual products, and menstrual stigma. Public toilets are a vital resource for managing menstruation, particularly for vulnerable populations without reliable access to private, safe, and clean spaces and menstrual products. This mixed-methods study sought to: 1) understand the lived experiences of MHM among people experiencing homelessness in New York City with respect to public toilets; 2) describe general and MHM-related characteristics of public toilets in high need areas of Manhattan and analyze their interrelationships; and 3) examine the associations among neighborhood-level demographics and the public toilet characteristics in those areas. Qualitative methods included key informant interviews (n = 15) and indepth interviews (n = 22) with people with experience living on the street or in shelters, which were analyzed using Malterud's 'systematic text condensation' for thematic cross-case analysis. Quantitative methods included audits and analyses of public toilet facilities (n = 25) using traditional statistics (e.g., Spearman's correlations) and spatial analyses (e.g., proximity buffers). Qualitative findings suggest cleanliness, access to restrooms, and availability of resources are critical issues for the participants or prospective users. Quantitative analyses revealed insufficiently provided, maintained, and resourced public toilets for managing

Introduction Globally, the phenomenon of declining birth rates has emerged as a matter that cannot be disregarded. This trend, characterized by a diminishing fertility rate which subsequently results in a gradual decrease in the proportion of young population, is closely affiliated with various factors including economic development, governmental policies, and the dwindling desire for childbearing amongst the reproductive age groups. The repercussions of declining birth rates exert profound influences on the socio-economic landscapes of numerous nations and regions. In this context, the declining birth rates witnessed in China and Japan constitute a significant segment of the global discourse on this topic. Since 2018, China has experienced a rapid decline in its fertility rate, marking its entrance into a phase where the issues stemming from a declining birth rate have become pronounced. Conversely, Japan has endured the predicaments associated with a consistently low birth rate for many years. Historically, China witnessed a period of rapid population growth over several decades, which brought an influx of inexpensive labor force, thereby fueling a substantial demographic dividend that propelled immense economic growth. Therefore, the sharp population decrease in recent years necessitates an urgent discussion on its implications for the employment prospects of Chinese university graduates and its subsequent impact on socio-economic development. On the other hand, Japan, a nation perennially grappling with declining birth rates, has encountered significant impacts on its socio-economic fabric. Notwithstanding, Japan has managed to stabilize university graduate employment and sustain positive economic growth, fostering an economic model that coexists with a declining birth rate. The employment scenario for the youth in Japan has undergone a significant transformation from the early 2000s to the present, with various similarities and disparities evident in the circumstances of China and Japan across different time periods. Regarding the literary discourse on declining birth rates, Brinton et al. attribute the cause to a myriad of factors including the educational and employment opportunities for women, the distribution of familial and childcare responsibilities, shifts in the social and political milieu, amongst others. Additionally, the discrepancy between the desire and actual practice of childbearing stands as a crucial factor exacerbating this trend [1]. Many scholars have analyzed the implications of declining birth rates. For instance, Chen posits that it harbors negative repercussions, restraining consumption growth through avenues like population totals and income distribution, consequently affecting the healthy and sustainable development of the economy [2]. Conversely, Liu perceives positive societal influences stemming from declining birth rates, including heightened savings substituting expenditures on education and healthcare, fostering a high savings rate occurrence [3]. In addressing this issue, several scholars have proposed pertinent strategies. For example, Tanasa and Serban suggest that labor market regulations and governmental policy adjustments could to some extent foster fertility rates, although various political, economic, and cultural factors might impede such adjustments [4]. On the basis of the previous research, this paper aims to scrutinize the current status of declining birth rates in China and Japan, and its repercussions on university graduate employment, while dissecting the similarities and discrepancies observed between the two nations in this regard. Integrating the experiences of Japan with the prevailing circumstances in China, this study endeavors to proffer recommendations to the Chinese government and university students grappling with the declining birth rates, thereby holding intrinsic research value in fostering strategies to enhance university graduate employment amidst this trend. --- 2. Background and Causes of the Low Birth Rate in China and Japan In 2020, the birth rate in China had already dropped to an ultra-low fertility rate standard of 1.3 [5]. Since the mid-20th century, China's population had maintained a trend of rapid growth. However, starting in 2018, China's birth rate experienced a sharp decline, interrupting the previously sustained high-speed population growth trend (see Figure 1). Although the population was growing during this period, the growth rate was slowing down, and the negative population growth phenomenon in 2022 was a general trend [5]. Figure 1: China's Birth Rate Statistics. --- Reasons for the Low Birth Rate in China Due to high child-rearing costs, among other factors, the childbearing willingness of couples of childbearing ages has decreased, leading to a year-by-year decline in the birth rate. The primary reason for the contemporary low birth rate phenomenon in China is the continuously escalating cost of raising a child. The steep child-rearing costs have led to a collapse in the willingness to bear children for many individuals [6]. Such ideas are disseminated among the population of childbearing age through various channels, including the internet, fostering a greater sense of identification with the concept of giving birth to fewer but higher quality offspring. Combined with the young people in China continually seeking higher standards of living, has culminated in an ideology that is acknowledged by many. Consequently, there has been a larger scale decline in the willingness to have children. The sharp decrease in the birth rate in recent years is the result of the combined effects of changing perceptions and the realities of the current situation. --- Background and Causes of the Low Birth Rate in Japan --- Background of the Low Birth Rate in Japan In the post-war period, Japan experienced a surge in population due to the repatriation of soldiers and individuals from its colonies, and the government's intention was to support birth rate control. However, population control in Japan was not implemented through compulsory measures, but stemmed from the unwillingness of couples of childbearing age to have children due to high childrearing costs [7]. In 1989, Japan faced a significant shock with a birth rate of 1.57. It was not an isolated incident. In 1995, the birth rate plummeted to a historic low of 1.42. In 2005 and 2006, the birth rates in Japan were 1.26 and 1.32, respectively. Although fluctuations in the birth rate have been observed, the general trend is a decline (see Figure 2). The consequence of the low birth rate is that Japan, having experienced negative population growth starting in 2009, continues to progress further down the path of population decline. --- Reasons for the Low Birth Rate in Japan The reason behind Japan's low birth rate is the expensive costs associated with raising children. In an effort to maintain their current standard of living without a decline, families with couples of childbearing age are unable to accommodate higher child-rearing costs, thus are unwilling to raise more children [7]. Furthermore, the influence of the economic bubble has deeply ingrained a lower willingness to have children within the populace. --- Comparative Analysis of the Low Birth Rate in Both Countries --- Analysis of Time Lag Patterns One pattern can be observed in the low birth rate processes of the two countries: the significant years in which both countries entered a deep phase of low birth rate, namely 2005 and 2018, and the years of negative population growth, 2009 and 2022. Both sets of years have a gap of about 15 years, and the gap between the two respective years within each country is approximately 4 years. This pattern also indicates certain similarities in the low birth rate trends between China and Japan. --- Differences and Similarities One of the differences between the two countries is the period when they entered the deep phase of low birth rate. Taking the point of negative population growth as a benchmark, China achieved negative population growth in 2022, while Japan reached this point in 2009. China faced a slump in birth rates in 2018, while Japan encountered a nadir in birth rates around 2005. These are both significant markers indicating the onset of a deep phase of low birth rate, but they occurred at different times. In the process of entering this deep phase, China demonstrated a more abrupt transition, while Japan started experiencing a gradual decline in birth rates from the 1980s, indicating a slower process. The biggest commonality between the two nations is the reason behind the low birth rate. Although the causes leading to a low birth rate are complex and multifaceted, a central similarity between China and Japan is that the primary cause in both countries is the continuous rise in child-rearing costs, which has resulted in a decline in the willingness to have children among the population of childbearing age. --- Comparison of Employment Conditions of University Students in --- Employment Situation of University Students in Japan During the Deep Phase of Low Birth Rate During 1975-1985, the birth rate in Japan was between 1.76 and 1.91, a period when the birth rate in Japan was relatively high, approximately 0.5 higher than 20 years later. By the late 1990s in Japan, university graduates faced increasingly difficult to secure employment, and the unemployment rate was high. The skills and attributes necessary for employment were relatively insufficient [8]. Companies preferred innovative talents with capabilities over mechanical and submissive workers. During this period, the young people, facing a high-threshold employment environment, began to lower their expectations for life and accept the reality of unemployment [9]. During this period, Japan's unemployment rate surged from the usual 1%-2% before the 90s to 5%-6% around the millennium [10]. --- Employment Situation of University Students in China During the Deep Phase of Low Birth Rate From 1993 to 2003, China's birth rate ranged between 1.57 and 1.69. Although the one-child policy suppressed the growth of the birth rate, it remained relatively high, sustaining a rapid population growth. When the population born during this period reached employment age between 2013 and 2023, a situation similar to Japan's emerged. With the yearly increase in graduates, more individuals flooded the labor market, intensifying competition for jobs and exacerbating employment difficulties for graduates [11]. Due to increased competition, the phenomenon of "lying flat" emerged among Chinese youth, characterized by lowered aspirations for real life, and downgraded consumption and desires [12]. --- Comparison Between the Two Countries From the analysis above, it can be seen that there are many similarities in the employment situation of university students in both countries when entering the deep phase of low birth rates. Both exhibited increased difficulties for university graduates in finding employment and lowered life expectations. Despite a 15-year gap, the manifestations in China and Japan are highly similar during this period. --- Comparison of Current Employment Situations for University Graduates --- Current Employment Situation for University Graduates in Japan In Japan, the deepening of the declining birth rate trend has led to a continuous decrease in the number of graduates. The job market generally exhibits a state of supply exceeding demand. Currently, the employment rate for university graduates in Japan is high, making it easier for them to find jobs. --- Current Employment Situation for University Graduates in China The present employment and labor supply situation in China is in a phase where demand exceeds supply, with the overall scenario being that it is challenging for university graduates to find jobs, and companies have more leeway to suppress wages. --- Comparison Between the Two Countries Compared to China, Japanese graduates nowadays find it easier to secure jobs with decent incomes and benefits than their Chinese counterparts of the same age and individual conditions. In contrast, Japanese companies need to incur higher costs than Chinese companies to hire graduates of the same caliber. --- The Impact of Low Fertility Rates on University Graduates' Employment Opportunities A standard university student takes approximately 20 years from birth to join the workforce. This implies that the changes in the societal birth rates that can influence university students' employment would be seen about 20 years later. 3 and4. The data exhibits a general decline in birth rates in Japan between 1993 and 2003. Conversely, the employment rates for university graduates twenty years later, from 2013 to 2023, display an overall increasing trend. The noticeable dip in the employment rates in 2021 and 2022 is primarily attributed to the global prevalence of COVID-19, an external factor. Nevertheless, the overarching trend is an increase. This suggests that the decreased birth rates in Japan would lead to a rise in university graduates' employment rates as this cohort enters the working age group. Figure 3: Japanese Birth Rate Curve. Figure 4: Japanese University Graduates Employment Rate Curve. --- Positive Effects: Causes The positive impact of declining birth rates on the employment rate of university graduates can be attributed to several factors. The primary reason is the reduction in the number of births, which results in a decreased supply of labor in the job market. With fewer individuals entering the workforce to meet a constant or even increasing demand for labor, competition among university graduates (the suppliers of labor) decreases, potentially driving up the price of labor (i.e., wages). Consequently, university graduates are more likely to secure jobs with satisfactory remuneration. Moreover, there are various other factors contributing to the rise in the employment rate of university graduates, including government initiatives to boost employment and the emphasis by universities on career-oriented education. These aspects will be analyzed in greater detail in the subsequent sections of the paper. --- Negative Impacts of Declining Birth Rates on University Graduate Employment While the deepening trend of declining birth rates generally appears to promote the employment prospects of university graduates, there are also negative repercussions that may not be directly reflected in employment rates. --- Decline in Innovation Potential Young individuals are often regarded as the primary drivers of innovation. A reduced youth presence in the job market, resulting from declining birth rates, could weaken the overall innovative capabilities of corporations and society at large. This could diminish the pursuit of novel technologies, business ventures, or strategic initiatives, thereby affecting the employment opportunities and growth prospects for university graduates. --- Stagnation or Decline in Wages Though a labor shortage theoretically leads to wage increases, the actual outcome may vary. If companies decide to cut costs in response to economic slowdowns, or if they pivot towards automation to reduce their reliance on human labor, wage growth for university graduates could be curtailed. --- Limited Career Progression The aging population brought about by declining birth rates can result in many senior positions being held by middle-aged or elderly individuals for extended periods. This scenario can limit the promotion opportunities and overall career advancement for younger university graduates. --- Countermeasures, Experiences, and Insights While a declining birthrate may alleviate the difficulty of university graduates finding employment, it will ultimately have a general negative impact on the socio-economic fabric, along with a host of other issues [13]. Consequently, there will naturally be factors that are detrimental to the employment prospects of university graduates. However, the reality is that Japan has indeed achieved a year-onyear increase in the employment rate of university graduates under the context of a declining birthrate, with the satisfaction levels of employed graduates also showing a rising trend. On the other hand, China is a country on the brink of facing the repercussions of a declining birthrate on the employment of university graduates. Hence, it is imperative to analyze the strategies and experiences in Japan, identify the current shortcomings in China, and propose recommendations for the Chinese government, universities, and students. --- Japan's Experience in Strategies for University Graduate Employment Japan's university employment guidance is targeted, offering specialized employment guidance tailored to students with diverse characteristics. Japan boasts a unique "experiential employment" system, enabling students to precisely identify roles they are both interested in and competent for. Concurrently, numerous policies and laws have been implemented to facilitate effective employment for university graduates [14]. Japan has a comprehensive employment service system that thrives on the trilateral interaction between the government, higher education institutions, and the broader society [15]. --- Current Shortcomings in China --- Shortcomings at the Government and Societal Levels In China, the efficiency of employment agencies is sub-optimal, with ambiguous delineations of authority and responsibility. The employment promotion policies and regulations are not well developed. The social employment service system lacks robustness, and the related departments are not standardized in their management [14]. China's relatively closed internet environment and limited press freedom impede the dissemination of diverse information. This results in a significant information gap between university students and the real world, further complicating their employment prospects. --- Shortcomings at the University Level Chinese universities are often deprived of academic independence, with ideological content exerting considerable influence on higher education. This interference is detrimental to cultivating the critical thinking skills essential for employment. The feasibility of employment guidance provided by Chinese universities to students is low, limiting its practical application in facilitating student employment. --- Recommendations for the Chinese Government, Universities, and University Students --- Suggestions for the Government and Universities (1) Strengthen Cross-Border and International Exchanges: Encourage universities to collaborate with enterprises from various industries, establishing "experiential employment" to allow students to immerse in real work environments. It is also recommended to moderately ease internet restrictions to open more platforms for international exchanges, helping university students bridge the information gap between domestic and international arenas and foster a global perspective. (2) Promote Academic Independence in Universities: Transform universities into hubs for flourishing academic research. Reduce the interference of ideology in university education and encourage intellectual exchanges of diverse viewpoints. This would foster students' abilities in independent thinking and problem-solving. (3) Enhance Policy Support and Efficiency of Employment Agencies: providing more policies to support for university student employment. Learn from the efficient management models of Japan to ensure that domestic employment agencies can provide quick and accurate services for university students and enterprises. --- Suggestions for University Students (1) Focus on Skills Development: In addition to academic and professional skills, it is vital to cultivate soft skills like communication, teamwork, and critical thinking. Develop the ability to critically assimilate diverse viewpoints, aligning professional knowledge with practical work experiences. (2) Build a Global Perspective: Utilize more online resources both domestically and internationally, participate in foreign courses, or collaborate with student teams abroad to complete projects, thereby cultivating a global viewpoint. (3) Enrich Social Practices: Establish interpersonal exchanges with people from diverse backgrounds outside of the university setting, facilitating interpersonal interactions in the workplace. Strive to secure more internship opportunities during university years to accumulate experience. With the deepening of the low birth rate trend, coupled with the continuous advancement of globalization and technological progress, the future job market for university graduates will face even more challenges and opportunities. In this scenario, the government, universities, and university students need to constantly adapt and innovate to address these challenges and opportunities. Future studies can further explore how to utilize advanced technologies such as big data and artificial intelligence to enhance the matching and accuracy of employment information; how to effectively implement employment-oriented reforms in education; and how to effectively promote the development of employment capabilities among university students. --- Conclusion This paper analyzes and compares the impact of the declining birth rate in China and Japan on college graduates' employment, reaching several conclusions. Firstly, the positive impact mainly manifests in the increase of employment rate among college graduates. Secondly, the negative impacts include a decrease in innovative capability, reduction in wages, and limitations on promotions. The differences between China and Japan are primarily reflected in the time span and speed of the declining birth rate, as well as the relative time differences. A commonality between China and Japan is that the fundamental cause of the declining birth rate in both countries is the high cost of childrearing. On the basis, this paper proposes relevant suggestions for the Chinese government, universities, and college students. It holds research value in terms of how to promote the employment of college students in the wave of declining birth rate. However, this paper only conducts research from the perspectives of fertility rate and college graduate employment rate statistical analysis and qualitative analysis. In the future, empirical tests can be carried out on a more sufficient data foundation to validate the conclusions more effectively.

The low birth rate is a global phenomenon that cannot be overlooked, having profound implications for the socio-economic conditions of many nations and regions. The declining birth rates in China and Japan have been a significant part of the global discourse on this topic. This paper analyzes the impact of low birth rates on the employment of university graduates, encompassing both positive effects such as an increase in employment rates, and negative effects including a decrease in innovation and increased difficulties in promotions. The study observes that there is a roughly 15-year gap in the shifts in the low birth rate phenomenon and the employment conditions of university graduates between China and Japan. The differences between the two nations mainly manifest in the timeframe and pace of the declining birth rates and the associated time lags. A commonality is that the fundamental cause for the low birth rate in both countries is the high cost of child-rearing. Lastly, the paper proposes suggestions for the Chinese government and university graduates, drawing upon the countermeasures and experiences of Japan. These suggestions helps enhance the employment competitiveness of university graduates and promote sustainable economic and social development, offering valuable references for both governments and university students.

compared to those who engaged in mobility for longer periods. 30 The researchers hypothesized that a lack of control over working conditions in destination settings, the absence of peer social networks, and social/cultural isolation increased health and safety risks, including violence and HIV/STI infection, among sex workers. In South Africa, cross-border migration facilitated increased social and economic opportunities (e.g., higher income) for sex workers as well as reduced contact with health providers and lower condom use as compared to internal migration. 23 In the European Union, where movement between countries is relatively easy, mobility and migration are common and may facilitate enhanced income as well as health risks and barriers to care. For example, a study in the UK found that migrant FSWs from Eastern Europe were younger and had a greater number of clients, but at the same time were less likely to use contraception than non-migrants, although this study did not examine recent or internal mobility patterns. 49 Ultimately, evidence suggests that the health and safety of migrant and mobile sex workers are influenced by factors at multiple levels of causation, including structural factors such as safety and exposure to violence (e.g., from clients and other sex partners), health care access, stigma and discrimination, and the enforcement of policies governing sex work and immigration; 2,5,6,10,13,16,21,30,46 interpersonal factors such as barriers to gendered condom negotiation and risk patterns (e.g., substance use and sexual practices) of sex partners, including both clients as well as intimate partners; 4,22,23,30,44,49 and individual influences such as substance use and sociodemographic factors (e.g., age). 5,44,46,49 In Canada, while there is substantial variation by work environments, sex workers often experience heightened vulnerabilities to HIV and STIs, drug use, and violence as well as barriers to accessing care, which have been largely attributed to structural conditions. 32,[50][51][52][53] However, these structural vulnerabilities (e.g., client and intimate partner violence) have not been previously examined in relation to recent mobility patterns despite evidence from other settings suggesting that changes in safety and social networks could result in enhanced violence for mobile FSWs. As in most settings globally, virtually all aspects of sex work (e.g., solicitation, living off the avails of prostitution) in Canada are criminalized. Recent studies from Canada and other international settings have highlighted the importance of structural factors shaping sex workers' health, including violence and criminalization. 2,32,[53][54][55][56] Yet, epidemiological evidence regarding the health and working conditions of mobile sex workers is lacking, with limited evidence on structural factors such as work environments, violence, and health risks within the context of recent migration and mobility. Moreover, whereas the vast majority of prior studies pertaining to migrant and mobile sex workers have been cross-sectional, 49 longitudinal data remain limited, which are needed to better elucidate recent and ongoing mobility patterns and their impacts on health and safety over time. Therefore, we undertook this study to longitudinally investigate structural, interpersonal and behavioral, and individual factors linked to short-term mobility and migration (i.e., engaged in sex work or lived in another city, province, or country in the past 6 months) and to investigate factors linked to short-term mobility for sex work among a cohort of female sex workers in the city of Vancouver, Canada. --- METHODS --- Data Collection Data were drawn from an open prospective cohort study, An Evaluation of Sex Workers Health Access (AESHA). Between January 2010 and August 2012, 646 sex workers completed surveys and biological testing for HIV and STIs at enrolment and on a bi-annual basis. The AESHA study was based on collaborations with sex work agencies and other community partners which have existed since 2005 57 and is monitored by a Community Advisory Board of 915 organizations. All study procedures were approved by the Providence Health Care/University of British Columbia Research Ethics Board. Participants As previously described, 62 eligibility criteria included self-identifying as female (including male-to-female transgender), being 14 years of age or older, having exchanged sex for money within the last 30 days, and providing written informed consent. Time-location sampling was used to recruit FSWs through outreach to street (e.g., streets, alleys) and off-street settings (e.g., online, newspaper, massage parlors, micro-brothels, other in-call locations) across Metro Vancouver. Sex work venues (strolls) were identified through community mapping 57 and updated regularly. Study participants completed questionnaires at study offices in Metro Vancouver or at their work or home location. Participants received $40 CAD at each visit for their time, expertise, and travel. --- Measures Dependent Variable. The dependent variable, short-term mobility or migration, was defined as having engaged in sex work or lived in another city, province, or country outside of Metro Vancouver in the past 6 months. Short-term migration outside of Metro Vancouver was assessed by asking participants to list the places outside of Metro Vancouver where they had lived during the last 6 months, whereas short-term mobility for sex work was based on asking about places that participants had worked in the sex industry during the last 6 months. For both questions, all locations listed outside of Metro Vancouver (e.g., another BC city, province, or country) were coded as "yes." Independent Variables of Interest. Participants completed interviewer-administered questionnaires in English or Mandarin by trained interviewers and received HIV/STI testing from a project nurse. The baseline questionnaire covered sociodemographic characteristics such as age, education, birthplace, ethnicity, languages spoken, and income. Sexual risks (e.g., condom negotiation, client volume) and drug use (e.g., non-injection and injection drug use) were also measured. Inconsistent condom use was defined as responding that they "usually," "sometimes," "occasionally," or "never" used a condom for vaginal or anal sex with clients (including one-time or regular clients) or non-commercial partners (vs. "always" used condoms). Client condom refusal was defined as responding that they were "always," "usually," "sometimes," or "occasionally" coerced into vaginal, anal, or oral sex without a condom by clients (including one-time or regular clients) (vs. "never" coerced into unprotected sex). Condom refusal by intimate partners was defined as a "yes" response to the question, "In the last 6 months, has your intimate partner coerced you into having sex (vaginal/anal) without a condom?" Questions on structural factors included homelessness and housing instability, health care access, and work environment in the past 6 months. Work environment covered primary places of solicitation and servicing clients, physical conditions of street and indoor venues, establishment policies, interactions with third parties (e.g., managers), police, security, city licensing, and workplace violence. Primary place of solicitation was based on the question, "In which of the following ways have solicited/hooked up with your clients?" in the last 6 months, and coded as street/ public (e.g., street/outdoor public space), indoor establishment (e.g., massage/beauty parlor, micro-brothel, bar/nightclub, crack/drug house), and independent (e.g., escort agency, newspaper ads, online). Primary place of servicing clients was based on the question, "In which of the following types of places have you ever serviced/ taken clients?" in the last 6 months, and coded as outdoor/public (e.g., street, vehicle, other public areas), informal indoor (e.g., crack/drug house, bar, nightclub, hotel, client's place, your place, supportive housing), and formal indoor establishment/brothel (e.g., massage parlor, health/beauty enhancement center, micro-brothel). Violence was assessed by asking if participants experienced physical and/or sexual violence in the last 6 months by either clients or intimate partners, including abducted/kidnapped, forced unprotected sex, raped, strangled, physical assault, or assaulted with a weapon. Paid a manager was based on asking if participants had shared or had to pay a third party (e.g., manager or administrator) a percentage of their income from clients. Trafficking was defined as reporting having been trafficked/sold into sex work or traded/sold from one pimp to another in the prior 6 months. Experienced any barrier to health care access was based on the question, "In the last 6 months, what barriers to receiving health care have you experienced?" Response options indicating barriers to health care included limited hours of operation, wait times, don't know where to go, language barrier, couldn't get doctor of preferred gender, difficulty keeping appointments, jail/detention/ prison, poor treatment by health care professionals (vs. no barriers). HIV/STI Measures. Following pre-test counseling, a rapid point-of-care HIV bloodbased test [INSTI test, Biolytical Laboratories Inc, Richmond, BC] was done, and reactive tests were confirmed by Western blot. Urine samples were collected for gonorrhea and chlamydia, and blood was drawn for syphilis testing. All participants received post-test counseling. STI treatment was provided by a project nurse onsite, and free serology and Papanicolaou testing were made available, regardless of study enrolment. STI/HIV infection was defined as positive for any STI (i.e., syphilis, gonorrhea, or Chlamydia) or HIV in the past 6 months. --- Data Analysis As the first step of the analysis, descriptive statistics were calculated for individual, interpersonal and structural factors, as well as HIV/STIs at baseline and were stratified by whether participants had been mobile/migrated (i.e., did sex work or lived outside of Metro Vancouver) in the past 6 months. The differences in these characteristics between those who reported any recent mobility and those who did not at baseline were assessed using the Mann-Whitney test for continuous variables and Pearson's chi-squared test (or Fisher's exact test for small cell counts) for categorical variables. Then, using generalized estimating equations (GEE) and an exchangeable correlation structure, 58,59 we longitudinally examined correlates of short-term mobility/migration (i.e., lived or engaged in sex work outside Metro Vancouver in the past 6 months). Sensitivity analyses were also conducted to separately examine the relationship between mobility for sex work and covariates of interest (e.g., physical/sexual violence). Bivariate and multivariate GEE analyses included data from each participant's baseline and follow-up visits and were conducted with a logit link function for our binary outcome to account for repeated measures among the same individuals. Sociodemographic characteristics were treated as fixed covariates, and all other variables (e.g., homelessness, condom use, drug use, physical/sexual violence, barriers to health care) were treated as time-updated covariates of occurrences within the past 6 months. Variables that were a priori hypothesized to be related to short-term mobility or migration and with a significance level of pG10 % in bivariate analyses were considered for inclusion in the multivariate model. The backward model selection process was used to identify the model with the best overall fit, as indicated by the lowest quasi-likelihood under the independence model criterion (QIC) value. 60 Analyses were performed using the SAS version 9.3 (SAS, Cary, NC). All p values are two-sided. --- RESULTS The median follow-up duration was 17.7 months (interquartile range (IQR) 11.66-23.89). Of 646 FSWs, 10.84 % (n=70) reported short-term mobility or migration (i.e., within the last 6 months) during the study, whereas 89.16 % (n=576) did not. Of mobile/migrant women, 7.12 % (n=46) engaged in short-term mobility for sex work (i.e., engaged in sex work in another city, province, or country), and 6.66 % (n=43) reported short-term migration (i.e., lived in another city, province, or country) during the study period. Primary mobility/migration destinations included other BC cities (n=30, 4.64 %), other Canadian provinces (n=33, 5.11 %) and the USA or China (n=17, 2.63 %). One quarter of participants had moved to Vancouver from another city, province, or country in the last 5 years. At baseline (Table 1), the median age was 34 years (IQR 28-42), and those reporting short-term mobility or migration were younger (median 29.5 vs. 34.5 years, p=0.002) and earned a higher monthly income (median $3,720 vs. $2,500 CAD, p=0.012) than their non-mobile counterparts. Combined prevalence of HIV and STIs was high (21.05 %), but there was no significant difference between women reporting short-term mobility or migration and their non-mobile counterparts at baseline (16.67 % vs. 21.36 %, p=0.473). In bivariate GEE analysis (Table 2), women who engaged in short-term mobility or migration were more likely to experience health and structural vulnerabilities such as condom refusal by clients (odds ratio (OR) 1.76, 95 % confidence interval (CI) 1.00-3.10) and intimate non-commercial partners (OR 4.33, 95 % CI 1.54-12.13); physical/sexual violence by clients (OR 1.92, 95 % CI 1.14-3.23); homelessness (OR 2.31, 95 % CI 1.49-3.57); and experiencing barriers to health care (OR 1.79, 95 % CI 1.12-2.86). In multivariate GEE analysis (Table 2), older age (adjusted odds ratio (AOR) 0.95, 95 % CI 0.92-0.98), soliciting clients in indoor establishments (AOR 2.25, 95 % CI 1.27-3.96), intimate partner condom refusal (AOR 3.00, 1.02-8.84), and barriers to health care access (AOR 1.77, 95 % CI 1.08-2.89) remained independently correlated with short-term mobility and migration. In a separate model examining factors associated with short-term mobility for sex work (Table 3), the same variables were significantly associated, with the exception of soliciting clients in indoor establishments and the addition of physical/sexual violence by clients (AOR 1.92, 95 % CI 1.02-3.61). --- DISCUSSION Over the course of this 2.5-year study, a substantial proportion (10.84 %) of sex workers in an urban Canadian setting had worked or lived in another city, province, or country. Mobile/migrant workers were less likely to be HIV/STI positive and were All variables refer to the last 6 months, except for age, which was treated as a time-fixed covariate negotiation with intimate partners; mobility for sex work was also associated with enhanced workplace violence, which may be related to reduced control over one's work environment in destination settings. These findings are supported by a systematic review documenting that migration to higher-income European countries conferred protection against HIV among sex workers, 6 although the timing of migration and internal mobility were not assessed within this review. These results are also supported by research with indoor sex industry workers in British Columbia and Alberta, which has found that although exotic dancers who work as independent contractors are often younger and have increased earning potential as a result of flexibility in working in different venues, 61 they are often exposed to poorly maintained workplaces and receive inadequate security or support from management and booking agents. 61 Women in this study reported high levels of workplace violence and barriers to condom negotiation, with migrant/mobile women experiencing threefold higher odds of intimate partner condom refusal. Whereas previous studies have documented enhanced vulnerabilities of mobile sex workers to unprotected sex with clients, 8,30,45 our findings provide unique evidence regarding the crucial role of intimate partners in shaping HIV/STI risks for this population. Although further research is needed to ascertain why mobile sex workers were more likely to experience intimate partner violence and barriers to condom negotiation with these partners, this may be explained by reduced access to social support in mobility/ migration destinations, or it may be that mobility itself could be influenced by intimate partners themselves (e.g., mobility to flee intimate partner violence). Future mixed methods research is needed to understand and develop interventions to address condom refusal and violence by intimate partners and clients among mobile FSWs. This study also found that mobility for sex work related to an increased risk of client violence, which is supported by a research from India where a greater degree of mobility was associated with physical violence by clients, 8 and mobility and violence interacted to increase the risk of HIV infection. 30 To the best of our knowledge, this study provides the first longitudinal evidence regarding patterns of violence and mobility among sex workers in higher-income settings. Further research is needed to understand the broader structural factors that place mobile women at elevated risk of violence and health risks, such as limited social networks or poor access to information regarding working conditions in new settings. 61 In Canada 31,32,[50][51][52][53]62 and elsewhere, 2,29,56,[63][64][65] the criminalization of sex work has been linked to HIV/STI risk and violence-for example, police arrest and harassment of sex workers have been found to displace women to isolated settings where they are vulnerable to client condom refusal and violence, and are less likely to access healthcare and social supports. 51,66 However, the extent to which law enforcement practices may be driving mobility and related impacts on the health and safety of mobile/migrant sex workers remains poorly understood and requires further research in light of additional concerns for migrant workers around immigration status, cultural norms, and language barriers to accessing police protections. In light of upcoming legislative changes to Canada's sex work laws (e.g., potential criminalization of clients), further evaluation of the impacts of shifting legal environments surrounding sex work for mobile women in the sex industry remains critical to inform safer workplace policies and practices. Lastly, short-term mobility/migration was linked to reduced health care access. Previous studies from Canada, Mexico, and the USA have found that mobile populations frequently experience difficulty accessing conventional health and social services, both during mobility as well as in migrants' destination settings. 1,[67][68][69] This may be due to limited familiarity with local health systems and services, stigma and discrimination, inconvenient or limited hours of operation, and language and insurance-related barriers. 1,[67][68][69] To inform ongoing public health programs to improve access to care for marginalized populations in Canada and internationally, including support for violence and efforts to scale-up the "cascade of care" for HIV and STIs for sex workers, further research to reduce the gap in access for mobile and migrant populations remains critically needed. --- Strengths and Limitations As the study from which these findings were generated was not designed to investigate the health consequences of migration and mobility, future research is needed to understand the complexities of migration and mobility-related risks and protective factors, particularly as they relate to violence and sexual risk. Studies that gather detailed information regarding the diverse contexts surrounding recent migration and mobility (e.g., drivers of mobility for sex work, mobility patterns, and duration over time) as well as the timing and nature of health-related risks are needed to explore pathways and contexts of risk and risk mitigation. As this study is focused on a transient and largely "hidden" population, it is possible that more vulnerable populations of migrant sex workers and those who are more highly mobile may be under-represented. Future longitudinal and mixed methods studies with larger populations of migrant and mobile sex workers are recommended to better elucidate the context of risk and risk mitigation within the context of mobility and migration. --- Implications for Interventions In conjunction with biomedical and behavioral approaches (e.g., condom promotion), community empowerment (e.g., sex worker collectivization, peer-based delivery of services, and sharing of information) has been key for achieving reductions in sexual risk and improved working conditions in many settings, notably India and the Dominican Republic. 27,[70][71][72][73][74] Tailored interventions for mobile/migrant sex workers that incorporate community organizing and sex workled strategies are recommended to reduce isolation; improve control over working conditions; and link women to health, HIV/STI prevention, and social supports. This could include peer-based outreach to link migrant/mobile FSWs to low-barrier health and social services in mobility destinations and facilitate the sharing of health and safety information (e.g., regarding the structure of sex work and safety risks in mobility destinations). Such interventions are promising for migrant/mobile sex workers due to their ability to reduce social isolation, which is a critical determinant of health for mobile populations. 11,13,75 Critical to supporting access to safer workplace standards, both for the general population of sex workers as well as for migrant/mobile women, is the ability of sex workers to more formally collectivize and share information. Supporting this process will continue to be critical for violence and HIV/STI prevention for sex workers in Canada, as it has been in low-and middle-income countries. 27,76 By facilitating changes in policy and working conditions, such collectivization would enhance opportunities to access safe and healthy work environments for all women in the sex industry, including highly mobile and migrant populations. --- CONCLUSIONS In this cohort study, short-term mobility/migration related to enhanced sexual and safety risks as well as increased social and economic opportunities. There is a need for future migrant health and sex work research to be guided by a broader conceptualization of the diverse (i.e., protective as well as risky) and often complex impacts of migration and mobility on health, safety, and working conditions. The sexual and safety vulnerabilities identified suggest the critical need to develop and evaluate interventions to reduce violence and sexual risks and improve access to healthcare for mobile and migrant women in the sex industry. Tailored, peer-based interventions to reduce isolation and improve mobile/migrant sex workers' control over their working conditions are needed, alongside efforts to link women to health and social supports.

Despite research on the health and safety of mobile and migrant populations in the formal and informal sectors globally, limited information is available regarding the working conditions, health, and safety of sex workers who engage in short-term mobility and migration. The objective of this study was to longitudinally examine work environment, health, and safety experiences linked to short-term mobility/migration (i.e., worked or lived in another city, province, or country) among sex workers in Vancouver, Canada, over a 2.5-year study period (2010-2012). We examined longitudinal correlates of short-term mobility/migration (i.e., worked or lived in another city, province, or country over the 3-year follow-up period) among 646 street and off-street sex workers in a longitudinal community-based study (AESHA). Of 646 sex workers, 10.84 % (n=70) worked or lived in another city, province, or country during the study. In a multivariate generalized estimating equations (GEE) model, short-term mobility/migration was independently correlated with older age (adjusted odds ratio (AOR) 0.95, 95 % confidence interval (CI) 0.92-0.98), soliciting clients in indoor (in-call) establishments (AOR 2.25, 95 % CI 1.27-3.96), intimate partner condom refusal (AOR 3.00, 1.02-8.84), and barriers to health care (AOR 1.77, 95 % CI 1.08-2.89). In a second multivariate GEE model, short-term mobility for sex work (i.e., worked in another city, province, or country) was correlated with client physical/ sexual violence (AOR 1.92, 95 % CI 1.02-3.61). In this study, mobile/migrant sex workers were more likely to be younger, work in indoor sex work establishments, and earn higher income, suggesting that short-term mobility for sex work and migration increase social and economic opportunities. However, mobility and migration also correlated with reduced control over sexual negotiation with intimate partners and reduced health care access, and mobility for sex work was associated with enhanced workplace sexual/physical violence, suggesting that mobility/migration may confer risks through less control over work environment and isolation from health services. Structural and community-led interventions, including policy support to allow for more formal organizing of sex work collectives and access to workplace safety standards, remain critical to supporting health, safety, and access to care for mobile and migrant sex workers.

IntrOductIOn Since the early 1980s, China has been experiencing a historically unprecedented level of domestic migration. According to the 2010 China Population Census, there were over 221 million internal migrants, which accounted for about 17% of the national population. 1 In China's specific context, domestic migrants refer to individuals who move to other areas of the country but do not possess the 'Hukou' (residence registration certificates) of where they live. Since many public policies and social welfare programmes were implemented based on the long-established 'Hukou' system, those rural-to-urban migrants often faced obstacles to accessing local healthcare services. 2 3 In China, public health services are mainly delivered by community health facilities. To strengthen preventive care in the healthcare system, the Chinese central government launched a national programme in 2009, Equalisation of Essential Public Health Services, to provide free essential public health services to all Chinese people. 4 The benefit package of this programme included establishment of health records, health education, and chronic disease management. To implement this programme, the government provided a subsidy of 15 Renminbi (RMB, US$2.14 according to the exchange rate in 2009) per capita for community health --- Social capital, neighbourhood characteristics and utilisation of local public health services among domestic migrants in China: a crosssectional study Zhiyuan Hou, 1 Senlin Lin, 1 Open Access facilities to deliver the defined package. The subsidy was further increased to 35 RMB in 2014 ($5.73 per capita according to the exchange rate in 2014). Despite the fact that many cities have issued policies aimed at equalising essential public health services between migrants and local residents with 'Hukou', previous studies have shown that migrants were less likely to receive public health services than local residents. 5 For example, although establishing health records was necessary for disease prevention and treatment, only 23.8% of migrants had their health records established in 2013, which fell below the national recommendation of 75%. In addition, more than half of the domestic migrants did not receive any health education on occupational safety and injury protection. 6 Among various factors that may prevent migrants from receiving basic public health services, lack of social capital might be one that has been previously overlooked. Social capital is defined as the network resources through which individuals are able to access links to social culture, socioeconomic factors, politics and social changes for a common good. 7 Structural social capital, measured by participation in social organisations and social activities, can potentially strengthen relationships among individuals and enhance cognitive social capital such as trust and a shared social norm in a society. 8 However, a study on migrant workers from seven cities has shown that, in 2006, only 25% of migrants had any contact with the community organisations in their residential areas, and more than 80% never sought help from the community organisations. 9 Social capital may affect an individual's utilisation of public health services through two main pathways: the information pathway, and the norm or peer effect pathway. [10][11][12] (1) The information pathway means that enhanced social capital can facilitate information sharing such as the information on availability of public health services in the neighbourhood. 12 Information then becomes an enabling factor that affects healthcare use. (2) The norm pathway indicates both the shared belief and enforcement mechanism from peers. 13 Through the norm pathway, enhanced social capital can transmit attitudes, values and norms within a group of individuals, and enhance the peer effects on healthcare use. In China, many public health services, especially health education, are often delivered within the communities, and community organisations such as the community committee play an important role in information exchange. Participation in organisations may help migrants obtain and share health information, and may reciprocally affect migrants' health-seeking behaviours through communication with peers within the organisations. In addition, the relationship between social capital and utilisation of public health services may be modified by community characteristics. Migrants often live in rental housing where migrants congregate, and residential segregation is common between migrants and local residents in Chinese cities. 14 Neighbourhood composition affects the quantity and quality of information that migrants can obtain. 12 Living with local residents may help migrants get more information about local resources. Neighbourhood urban status is also linked with access to health services, 11 since more healthcare resources are available in the urban than in the suburban communities. Although ample literature has shown that lack of social capital may negatively impact health, 15 16 few studies have examined the effect of social capital on healthcare utilisation, and its differential effect by neighbourhood characteristics. The mechanism about how social capital affects healthcare utilisation is not entirely clear. 7 17 The main body of literature exploring the relationship between social capital and public health services is derived from developed countries and has inconsistent findings, [18][19][20][21] and there were few studies estimating this relationship in lower and middle income countries. 22 23 These studies showed that different elements of social capital may have different effects on the access to healthcare. One study from a low-income population in New Mexico suggested that community participation had little impact on healthcare use. 24 The effect of social capital may also depend on the type of healthcare services. One study in India showed that social capital with strong bonding ties was positively associated with professional healthcare, but negatively associated with preventive care. 25 The relationship between social capital and utilisation of public health services and the modification effect of neighbourhood characteristics are extremely important when we study migrant populations, since there is a huge disparity in economic status across neighbourhoods in urban China. 14 However, to date no such study has been conducted among domestic migrants in China. In this study, we hypothesised that structural social capital enhanced the local social network that promoted utilisation of public health services. We aimed to test this association, and to explore the differences in the association by neighbourhood characteristics among the domestic migrants in China. --- MethOds --- Data and study design Data for this analysis came from the 2014 National Domestic Migrant Population Dynamic Monitoring Survey (NIMPDMS), conducted by the National Health and Family Planning Commission of China. 26 One of the survey's purposes was to study specifically the social integration and health among domestic migrants. This was a cross-sectional and nationally representative survey of domestic migrants aged 15-59 years who did not have the 'Hukou' of the cities and had been living in those cities for more than 1 month; the survey covered eight cities including Beijing, Qingdao, Jiaxing, Xiamen, Shenzhen, and Zhongshan from Eastern China, Zhengzhou from Central China, and Chengdu from Western China (see online supplementary file 1), representing the regions where the majority of domestic migrants resided. --- Open Access The sample was drawn using the stratified multi-stage sampling method with the Probability Proportional to Size (PPS) approach. Within each city, neighbourhoods in urban or suburban areas were randomly selected using the PPS. In each selected neighbourhood, 20 individuals were randomly selected. Around 2000 migrants participated in the survey from each city, and the total sample included 15 999 respondents from eight cities. Interviewers who were trained by staff from local health bureaus conducted the face-to-face interviews. This study was approved by the Ethics Committee of the School of Public Health, Fudan University, China. All participants gave written consents to the study group. The survey covered six sections: (1) basic sociodemographic information including gender, age, marital status, family size, etc; (2) social economic factors including education, income and occupational status; (3) public health and medical services utilisation including establishment of health records, health education, medical insurance coverage and hospitalisation; (4) family planning services; (5) social capital and social integration including participation in social organisations, social activities, neighbourhood economic status, and community population composition; (6) general health including self-reported health status. --- Measures of utilisation of public health services In China, most public health services were provided by local health agencies including establishment of health records, as well as health education for infectious disease prevention, maternal health promotion, prevention of occupational diseases and injuries, and prevention of non-communicable diseases (NCDs). 3 We used two indicators: having personal health records established in the city; and having received health education to measure service utilisation. Public health services for migrants aimed to address three health problems: infectious diseases, reproductive health, and occupational disease and injuries. 27 However, NCD prevention was given lower priority. Social capital therefore may have a larger impact on the awareness of and access to NCD prevention services than the three previously-provided public health services for migrants. Therefore, according to the content of the health education migrants received, we further categorised health education into three groups: only receiving health education information on prevention of infectious diseases, reproductive health, and occupational disease and injuries; receiving all information covering health knowledge on NCD prevention; not receiving health education information. --- Measures of social capital and neighbourhood characteristics Our study focused on social capital and neighbourhood characteristics. There are two distinctive concepts of social capital: structural social capital measured by individual organisation membership and civic participation; and cognitive social capital measured by trust, reciprocity, and mutual help. 23 28 --- statistical analysis The main objective of this study was to assess the association between structural social capital and public health services utilisation among migrants, and whether the association varied by neighbourhood characteristics. <unk> 2 tests were applied to compare the distributions of social capital, neighbourhood characteristics and individual sociodemographic characteristics by whether they utilised public health services. Multivariate logistic regressions were used to estimate the relationship of social capital, neighbourhood characteristics and their interactions with whether the respondent established health records and whether they received health education information. Wald tests were applied to test if the interaction terms were statistically significant. In the regression models, we adjusted for the following confounding factors: gender (female vs male), age groups in years (15-24 vs 25-34, 35-44 and 45-59), marital status (currently married vs unmarried), educational attainment (primary school or below vs middle school, high school, college degree or above), monthly income (<unk>2000 RMB ($320) vs 2000-3000 RMB, 3000-4000 RMB and >4000 RMB), employment status (working in private sectors vs working in state-owned corporations, working in international companies and unemployed), Hukou status (urban vs rural Hukou), types of migration (interprovincial migration vs within-provincial migration), years lived in the destination regions (<unk>1 year vs 1-3 years, 3-6 years and >6 years), 3 and self-reported health status (excellent/very good/good health vs fair/poor health). City fixed effects were adjusted to account for differences in public health services between the cities. In a sensitivity analysis, we further applied multinomial logistic regressions to explore the association between social capital and the contents of the health education they received. Sampling weights were included in all analyses to adjust for the complex survey design. Odds ratios (OR) and 95% confidence intervals (95% CI) were presented. All the analyses were performed using Stata 14.0 (StataCorp LP, College Station, TX, USA). results --- Open Access Table 1 provides the weighted prevalence of public health services use among the domestic migrants. Of the 15 999 respondents, 23.33% reported that they had health records established in the destination city and 57.16% reported that they had received health education information from their residential communities. Among those who received health education, 22.02% received information only focusing on prevention of infectious diseases, and 35.14% received education information on both infectious diseases and NCDs. Table 2 shows the sample descriptive statistics. Overall, 27.13% and 32.61% of the respondents participated in social organisations and social activities. Among those who had established health records, 37.71% enrolled in social organisations and 48.84% participated in social activities, whereas among those without health records, 23.91% participated in social organisations and 27.68% in social activities (p<unk>0.001). There was also a much higher proportion of respondents participating in social organisations and activities among those who had received health education information (p<unk>0.001). Among the total respondents, 10.38% lived in neighbourhoods with >50% of local residents, and 84.36% lived in urban communities. The majority of respondents were 25-44 years old, married, received education at the middle or high school levels, were employed in the private sector, and had rural Hukou. Those using public health services had a higher level of education and were less likely to work in the domestic private sector or be unemployed (p<unk>0.001). Migrants migrating within a province and living longer in the destination city were more likely to use public health services (p<unk>0.001). Table 3 presents the results of the logistic regressions estimating the association between structural social capital, neighbourhood characteristics and having established health records. Migrants who participated in social organisations (OR 1.467, 95% CI 1.201 to 1.793) and social activities (OR 1.620, 95% CI 1.329 to 1.976) were more likely to establish health records than those who did not. Living with a higher percentage of local neighbours (OR 1.329, 95% CI 1.050 to 1.682) and living in urban communities (OR 1.735, 95% CI 1.224 to 2.460) were also associated with a higher possibility of establishing health records. We further tested the interaction effects between social capital and neighbourhood characteristics, and found that the social activities were protective for establishing health records only among those who lived in urban communities (OR 1.853, 95% CI 1.060 to 3.239). There was no significant interaction effect between social capital and neighbourhood composition. table 4 presents the regression results on whether the respondents received health education. Migrants who enrolled in social organisations (OR 1.729, 95% CI 1.484 to 2.016) and participated in social activities (OR 4.226, 95% CI 3.555 to 5.024) were much more likely to receive health education information. Migrants who lived with a higher percentage of local neighbours were significantly associated with increased odds of receiving health education (OR 1.230, 95% CI 1.031 to 1.467), but community urban status was not significantly associated with receiving health education (OR 1.194, 95% CI 0.936 to 1.522). The interaction effects show that the protective impact of social activities on receiving health education information was significantly greater among those living with a higher percentage of local neighbours (OR 1.451, 95% CI 1.044 to 2.017), while we observed no significant interaction effect between social capital and community urban status. Similarly, results from the multinomial logistic regressions show that participating in social activities was associated with a higher likelihood of receiving health education information including both prevention of infectious diseases and NCDs, particularly when they lived with a higher percentage of local neighbours (see online Supplementary file 2). dIscussIOn Using a national sample of domestic migrants in China, this study examined the relationship between structural social capital and use of public health services, and assessed the heterogeneous effects of social capital according to the neighbourhood characteristics. The results showed that while controlling for other resources and factors, structural social capital was related to a higher likelihood of utilising local public health services among migrants, and some positive associations were greater in urban than in rural/ suburban communities, or greater in communities with a higher percentage of local residents. In particular, we found that engagement in social organisations or social activities were related to establishment of health records and receiving health education information, which may benefit migrants' health eventually. Social capital may impact health through the pathways of healthcare utilisation and lifestyle behaviours. Researchers from developed countries have shown that tests. --- Open Access Note: survey weights adjusted. --- Table 2 Continued social capital is positively related to the utilisation of public health services, 18 20 21 29 which was consistent with our findings. For example, it was found that individuals with a higher social capital had a greater tendency to have health check-ups among a Danish population, 18 or recall of health messages in the USA, 30 increase women's utilisation of mammography screening in South Korea, 31 and improve access to healthcare among low-income populations in the USA. 21 Among African Americans, a higher level of social capital was associated with a greater likelihood of cancer screening. 32 However, it is also noteworthy that social capital may increase the possibility of risky behaviours, such as smoking. It was found that social capital was positively associated with smoking behaviour in rural areas of South Korea. 20 Smoking is a common behaviour for socialisation in China, especially among the migrant population. 33 Future studies should therefore examine whether social capital has a negative impact on risky behaviours, besides its potential positive impact on promoting health education. The reason why engagement in social organisation or activities might increase use of health services was because individuals, through those linkages, could exchange information and share their opinions with others within communities. But previous research among rural Chinese residents found that structural social capital (organisational membership) was not associated with health but cognitive social capital (trust and norm) was positively related with health. 23 It was likely that engagement in social organisations or activities was more important for migrants who lived in new areas than local residents who already had established social ties with other people in the local areas. 26 For migrants, engagement in social organisations or activities may help them better integrate into the destination city and obtain essential resources for health and prosperity. Our findings on the main and modifiable effects of neighbourhood characteristics provided a more nuanced understanding of the impact of social capital on health. First, living in urban communities and in communities with a higher composition of local residents was associated with a higher likelihood of utilising public health services. This finding was consistent with a previous study conducted among immigrants in New York City, which showed that HIV/AIDS prevention behaviours were improved when immigrants had significantly more ties to people outside of their religious organisation. 34 This may be explained by both physical and social environments of the communities. 35 Migrants living in urban communities or with local neighbours may enjoy better access to healthcare, and are also more likely to get information. Second, the interaction effects were only significant for the impacts of participating in social activities, and this may be because in China most social activities are organised in the communities. In contrast, most social organisations are created by the companies, the chamber of commerce or townsmen. Community characteristics may not influence the relationship between organisation membership and use of local public goods. In addition, migrants tend to live in rental housing where migrants congregate, or temporary housing such as dormitories established in workplaces. 33 In our study, only 10% of migrants lived in neighbourhoods where more than half were local residents. This suggested that migrants were more likely to construct social networks with only migrants. Migrants who lived with local residents may be more likely to participate in community-based social activities from which the migrants may benefit reciprocally from an enhanced connection with local residents. This study has several limitations. First, we did not have community-level social capital measures in the data. In addition, variables in neighbourhood characteristics were also measured from individual responses rather than from external sources. Questions were asked among individual respondents, which may be susceptible to recall bias. Further analysis should ascertain such information at the community level. Second, policy implementation may be primarily local. In our study, delivery of public health services to migrants may vary across cities and communities, on which we did not have information. Nevertheless, we included neighbourhood characteristics and city-fixed effects in the analysis to partly account for variations in policy implementation. Third, due to a limited number of domestic migrants participating in social organisations by neighbourhood characteristics, we were not able to classify and estimate what types of social organisations had the largest influence on health and health-related behaviours. Further analysis could provide greater detail about the different effects of social organisation participation. --- Open Access In summary, social capital may be associated with an increased utilisation of public health services among domestic migrants in China, and certain neighbourhood characteristics may enhance this protective effect. The findings of this study provided new evidence for the differential influences of social capital by neighbourhood characteristics in China. In order to improve the use of public health services and overall health status, more interventions should be implemented to enhance social capital among migrants in suburban communities and communities where the majority of the residents are migrants. Specifically, outreach social services should be encouraged in suburban or segregated communities to help migrants participate in community organisations and activities, and build diverse social networks. 36 --- The data used in this paper were provided by the National Health and Family Planning Commission of China. We signed a legally binding agreement with the Commission that we would not share the original data to any third parties. Although researchers who are interested can apply to get access to the data at htt p://www.moh.gov.cn/ ldrk s/s7 848s /201510/ 8d4c6922 3d4c 49ca 871 fdd6fd c57aba5. shtml --- Open Access

Objectives We examined the association between structural social capital and public health services use, and explored the modifiable effect of neighbourhood factors on this association among domestic migrants in China. Methods Data were from a 2014 nationally representative cross-sectional sample of domestic migrants aged 15-59 years in China. Survey-weighted logistic regression models were applied to assess the association between structural social capital, measured by participation in social organisations and social activities, and use of public health services. Interaction terms between neighbourhood urban status, neighbourhood composition and social capital were further assessed in the models. results Migrants who participated in social organisations were more likely to establish health records (OR 1.467, 95% CI 1.201 to 1.793) and receive health education information (OR 1.729, 95% CI 1.484 to 2.016) than those who did not. Participation in social activities was positively associated with establishing health records only in urban communities (OR 1.853, 95% CI 1.060 to 3.239), and it was positively linked to receiving health education information among those living with a higher percentage of local neighbours (OR 1.451, 95% CI 1.044 to 2.017). conclusions Structural social capital was related to an increased utilisation of local public health services among migrants. The findings of this study provided new evidence for the differential influences of social capital by neighbourhood characteristics in China, which suggested the importance to enhance social capital in rural/suburban communities and communities where the majority of the residents were migrants.

Introduction Welfare states are often reduced to their role as providers of social protection and redistribution. However, they also crucially affect employment creation and the structuring of class. This is the argument that Esping-Andersen put forward in The Three Worlds of Welfare Capitalism (1990) and developed further in Changing Classes (1993): The structure of the welfare state is a key feature in the contemporary process of social stratification: it creates and abolishes 'empty slots', it helps decide who fills them and how they are to be rewarded, it defines what is undertaken within them, and, finally, it shapes the pattern of mobility between them. (Esping-Andersen, 1993: 20) 2 --- Journal of European Social Policy Since 1990, the argument that the occupational structures of different welfare regimes evolve differently has come under question. Globalization, unleashed capitalism and austerity have been seen as severely limiting the scope for government intervention and for national idiosyncrasies in job creation (Streeck, 2009). As a result, technological change associated with computerization has been expected to lead to similar patterns of occupational change across countries (Autor et al., 2008). Contrary to this convergence argument, Esping-Andersen predicted that welfare regimes would continue to diverge on their post-industrial employment trajectories. Institutional differences should be particularly consequential for one class: low-paid interpersonal service workers. As technology and globalization have little impact on interpersonal services, people need to provide them locally and in person. At the same time, interpersonal services may be produced by any of the three agents that Esping-Andersen defined as the cornerstones of a welfare regime: the market, the state or the family. First, governments can privilege the market. By permitting wages in interpersonal services to decline, prices for these services will fall, market demand increase and employment rise in the private sector. Second, governments can assume responsibility for employing workers at wages closer to the median by creating public service jobs within the welfare state. Third, the solution can reside in families engaging in selfservicing, with the consequence that home production replaces market-supplied or public services. The three alternatives schematically coincide with the dominant strategies of Esping-Andersen's three welfare regimes. The liberal welfare regime stimulates market growth in low-paid private services. The social-democratic regime creates a disproportionate number of jobs in mid-paid public services. The conservative regime delegates interpersonal service to women within the household. As a result, the occupational structure of service societies should evolve in different directions -and the welfare state continues to be 'the midwife of postindustrial employment evolution' (Esping- Andersen, 1990: 192). The evolution in the ranks of low-skilled interpersonal service workers should thus provide the litmus test for the welfare regime argument. According to Esping-Andersen (1990), this class should strongly expand at the occupational bottom end in the liberal welfare regime, undergo moderate growth around the middle in the social-democratic regime, and stagnate in the conservative regime. Yet since lower growth in low-paid service jobs may lead to higher unemployment, an analysis of occupational change must focus both on qualitative change in the job structure and on quantitative change in the number of jobs. Esping-Andersen convincingly argues that institutions channel firms' labour demand into different occupational outcomes. However, we expect an institutional factor at the margins of the welfare regime to be decisive for change in the employment structure: the evolution of labour supply in terms of skills. The idea is that the number and productivity of lowly educated workers are not a given entity that is immune to government influence. Over the last decades, not only did jobs for the unqualified become scarcer, but so did the unqualified themselves. In the absence of large migrant inflows, educational expansion reduced the number of low-educated workers and increased the productivity of the average worker in interpersonal services. Yet some countries succeeded better than others in taking advantage of educational expansion to produce a compressed skill structure. Moreover, different welfare regimes did not create the same incentives for employers to invest in skills and to adopt technologies enhancing the productivity of interpersonal service workers (Acemoglu, 2003;Gautié and Schmitt, 2010). Accordingly, we argue that the interaction between welfare regimes and labour supply drives the employment structure of different countries into different directions. Esping- Andersen (1990: 197-217) compared the employment structure over the 1970s and 1980s for Germany, Sweden and the United States. This article adopts the same comparative perspective and analyses the pattern of occupational change over the 1990s and 2000s for three welfare regimes: Britain, Germany and Denmark, where Britain stands for the liberal, Denmark for the social-democratic and Germany for the conservative welfare regime. Our analysis is set at the individual level and based on data stemming from Britain and Denmark's labour Oesch 3 force surveys and Germany's Socio-Economic Panel. With only three cases, the added value of our analysis lies in depicting precisely what happened in the employment structure over the last two decades rather than determining why it happened. Our article is structured as follows. The next section reviews the literature on the link between welfare regimes and occupational change and introduces a set of hypotheses. The following section presents our data and analytical strategy. We then provide descriptive evidence for occupational upgrading based on measures for social class and job-quality quintiles, before analysing the change in unemployment and wages. The ensuing section documents educational expansion and the impact of immigration on occupational change. We conclude with a discussion of our key findings. --- Welfare regimes and occupational change Esping-Andersen's book The Three Worlds of Welfare Capitalism has been mainly acclaimed for its typology of welfare states and the independence from the market that welfare states offer to citizens. However, the argument of welfare states as agents of decommodification mainly looked to the past and soon proved outdated as welfare states increasingly turned towards re-commodification (Pierson, 2001) and social investment (Esping-Andersen et al., 2002). In contrast, the book's argument about the stratifying impact welfare states have on post-industrial societies was clearly forward-looking. Esping-Andersen predicted a variety of future employment scenarios for post-industrial societies: Different welfare-state/labor market interactions produce different post-industrial trajectories. They influence not only the rate of growth of services, but also the relative emphasis on social-welfare activities as opposed to personal services; they influence the skill and occupational composition of the labor force. (Esping-Andersen, 1990: 192) In the vast literature on occupational change, a strong focus on political institutions -welfare regimes -is unusual. The consensus view argues that long-term occupational change is driven by technology (Manning, 2004). Over time, workers are displaced from sectors in which technological change has a pervasive impact such as agriculture and manufacturing, to sectors where technology's influence is more limited, such as social and personal services. In the 1990s, economists agreed that skill-biased technological change was leading to a linear increase in the demand for highly educated workers at the expense of the less educated (Berman et al., 1998). The outcome was seen as positive in terms of occupational upgrading, but as negative in terms of bleak employment prospects for the low educated. This consensus view was shattered in the early 2000s by two studies showing a trend towards a polarizing employment structure in the United States (Wright and Dwyer, 2003) and the United Kingdom (Goos and Manning, 2007). The dominant explanation of polarization was again technology, but this time the focus was on tasks rather than skills (Autor et al., 2008). Computers take over routine tasks typically done in mid-paid clerical and production jobs, but have little impact on non-routine analytical tasks required in highly paid professions or on non-routine interpersonal service tasks done in low-paid service jobs. Rather than lead to occupational upgrading, technological change may thus hollow out the middle of the employment structure and therefore result in polarization. While it is uncertain whether technological change leads to upgrading or polarization, it is clear that it should affect West European countries in a similar way -to the extent that Western companies have access to similar types of technology. It is here that a focus on institutions and a comparative research design proves useful. Technological progress may account for common trends in occupational change across countries, but it is clearly insufficient to unearth the causes of cross-country variation. According to Esping-Andersen, institutions should be particularly consequential for how countries deal with the technologically induced 'cost disease' associated with William Baumol (1967). The idea is that technological change increases productivity in manufacturing to a greater extent than in services. Manufacturing will therefore shed workers who, in turn, look for jobs in services. Yet the service sector's capacity for job expansion may be limited by its low productivity growth: interpersonal services such as caring for the elderly, cutting hair or serving drinks have an indispensable handicraft attribute and necessarily involve face-to-face contact. If wages in services follow those in manufacturing, the costs of personal services will constantly rise and'service sector labor will tend to out-price itself' (Esping-Andersen, 1990: 193). The shift from (higher-productivity) employment in manufacturing to (lower productivity) jobs in interpersonal services is mediated by a country's welfare regime. Thereby, Esping-Andersen (1999: 111-2) distinguishes three ideal-typical institutional responses to Baumol's cost disease. One response consists of letting wage inequality increase. By allowing earnings in interpersonal services to adjust to lower productivity growth, the consequence is strong growth in service jobs paid at poverty-level wages. A second response consists of subsidizing personal services by creating these jobs within the public sector -notably in elderly care, childcare, health and education. A third response lets earnings in interpersonal services follow wage developments in the economy -otherwise these services will struggle to recruit workers. As a result, low-productivity interpersonal services become too costly to develop within the market and are mainly carried out within the family. Of course, governments choose a mix of the three ideal-typical responses. Still, countries of the liberal welfare regime tend to favour the first response of private services, whereas countries of the socialdemocratic regime disproportionately resort to the second response of public services, mainly financed through consumption taxes. The Bismarckian welfare state of the conservative regime, geared towards social insurances, has never made the provision of public services a priority. A compressed wage structure and high payroll taxes hamper the job creation in low-skilled private services. This may leave the family as the primary caretaker of young children, the elderly, the sick and the handicapped (Scharpf, 2000: 219-20). Every one of the three responses has a drawback according to Iversen and Wren's (1998) service trilemma. The liberal response of low-paid private services leads to large wage inequality. The social-democratic response of expanding public services creates escalating fiscal demands on the state. The conservative response of delegating services to the family results in high unemployment among the lowly educated. Baumol's cost disease and Iversen and Wren's service trilemma thus lead to bleak expectations about post-industrial employment trajectories. However, they share one questionable premise, namely that the quantity and quality of low-skilled people is constant over time. They presuppose that both the number and productivity of low-skilled workers are a given entity immune to government influence. We argue that this presupposition is at odds with the evolution of labour supply -both in terms of productivity and numbers. By means of a generous benefit system and stringent wage-setting rules, a welfare regime can push the wages of low-skilled workers closer to the median. In this situation, employers have two options: they can abstain from hiring those workers whose marginal productivity is lower than their wage. Alternatively, they can try to increase the productivity of these same workers in order to make it worthwhile hiring them. The reasoning is that if the wages of workers are downwardly sticky, their productivity must be changed upwards. How do you increase the productivity of interpersonal service workers? The basic idea is that high minimum wages and small wage differentials make firms more willing to adopt technologies complementary to low-educated workers. Technological change is thus seen as being, to some extent, endogenous (Acemoglu, 2003: 127). 1 And the potential of technology -and hence productivity increases -in low-skilled services is probably larger than commonly assumed. In supermarkets, self-service check-outs are replacing a great number of cashiers. In airports, self-service check-in is becoming the rule rather than the exception. In large restaurants, radio systems allow waiters to send orders electronically to the kitchen and serve more customers in less time. In cleaning and maintenance, advances made in sensors open up large fields for robotics and thus productivity-increasing devices. In public transport, unmanned trains operate in a growing number of cities. In sum, labour market institutions and, more generally, the welfare regime have an influence on what production techniques are adopted in low-skilled sectors of different countries -and there is considerable scope for productivity growth in interpersonal services, as Wren (2013: 7) shows in her cross-national comparison of productivity growth rates in different subsectors. A large multi-country study led by Gautié and Schmitt (2010) on employment in low-wage sectors finds that nursing assistants and call centre employees tend to be better skilled and more versatile in Denmark and Germany than in the United Kingdom and the United States. This leads to higher worker productivity and translates into wages closer to the national median in the former two countries (Lloyd et al., 2010: 460;Méhaut et al., 2010: 320). Technology adoption and human resources practices thus seem more likely to upgrade the employment structure in the conservative and, above all, socialdemocratic welfare regimes than in the liberal one. However, the reliance on technology and better skilled workers not only improves productivity and justifies higher wages, but also reduces the employment opportunities for low-educated people. The increase in productivity in low-skilled services limits wage inequality, but possibly exacerbates the lack of low-skilled jobs. Do governments, by solving the problem of quality, run into a problem of quantity? Much depends on the labour market's supply side. Over the last two decades, not only jobs for the unqualified became scarcer but also the unqualified themselves. While technological progress increased firms' demand for qualified labour, educational expansion made sure that ever larger proportions of each cohort had at least medium levels of skills. Therefore, in the 'race between education and technology', labour supply driven by rising educational attainment seems to have kept pace with labour demand shaped by continuous technical change (Goldin and Katz, 2008). Some countries succeeded better than others in taking advantage of educational expansion to produce a compressed skill structure. The International Adult Literacy Surveys suggests that both the disparity of literacy among the population as well as the share of people with poor literacy are significantly lower in Denmark or Germany than in Britain or the United States (Freeman and Schettkat, 2001: 584;Gesthuizen et al., 2011: 270-1). Therefore, thanks to strongly rising skill levels, a country may achieve low rates of unemployment without job expansion in the labour market's bottom end. However, the skill distribution of a country's workforce not only depends on its educational system, but also on immigration. The large inflow of low-skilled Hispanic immigrants into the American labour market partly explains the strong expansion of low-end service jobs in the United States over the 1990s (Wright and Dwyer, 2003: 309). Without a growing pool of workers willing to fill these lowwage jobs, the wages of these jobs would have had to rise, these services would have become more expensive and these jobs would not have been created in the market, but been partly substituted by household production (Cortes and Tessada, 2011). In the period under study, a possible equivalent to Hispanic immigration in the United States was the strong surge in Polish and Baltic immigration to Britain in the early 2000s -a migratory flow which was much larger than in Germany or Denmark. 2 These arguments allow us to spell out three sets of expectations about the evolution of (1) interpersonal services workers, (2) occupational change and (3) low-educated unemployment in the three countries under study. 1. Following Esping-Andersen, the category of interpersonal service workers should grow strongly at the bottom of the occupational structure in Britain's liberal welfare regime, expand moderately at wages closer to the median in Denmark's social-democratic welfare regime and stagnate in Germany's conservative welfare regime. 2. As a consequence, the employment structure should expand at both ends and lead to occupational polarization in Britain, whereas occupational upgrading is the more likely outcome in Denmark and Germany. This leads to two competing hypotheses about the evolution of unemployment: --- Country selection, data and strategy of analysis Our analysis focuses on three countries which come close to Esping-Andersen's ideal-typical welfare regimes: Britain as a liberal, Denmark as a socialdemocratic and Germany as a conservative welfare regime. For these three countries, we analyse change in the occupational structure for the period between 1990/1991 and 2007/2008. These two cut-off points are at the end of long cyclical upswings that were followed by two Europe-wide recessions (1991-1993 and 2008-2010). We use large scale micro-level datasets which contain detailed information on individuals' occupation and education: the national labour force survey for Britain (UK-LFS, spring quarter), the Danish labour force survey stemming from Denmark's cooperation with Eurostat (EU-LFS) and the German Socio-Economic Panel (SOEP). Since the Danish labour force survey does not include earnings, we impute earnings of occupations from the merged Danish samples in EU-SILC 2004, 2005and 2006. Our target population includes both employees and the self-employed and is restricted to people aged 18 to 65 years who spend at least 20 hours per week in paid employment. Table 2 in Appendix 1 gives an overview of the key features of these datasets. Our analytical approach based on the three welfare regimes has little causal traction, since our three countries differ in many potentially relevant dimensions. Therefore, we are much better prepared to describe what happened in the employment structure than to determine the causes for why it happened. Accordingly, our objective is to establish the pattern of occupational change as accurately as possible, using two different approaches. First, we use a class measure which combines a hierarchical with a horizontal criterion (see Oesch, 2006). The hierarchical criterion distinguishes between more or less advantageous employment relationships. We simply divide occupations into two hierarchical levels that roughly correspond to the split between the middle and the working class. The second dimension is horizontal and distinguishes occupations according to four different types of work logic: an interpersonal, organizational, technical and independent work logic. By combining the hierarchical and horizontal dimensions, we obtain an 8-class schema (see Table 1). This schema allows us to clearly distinguish interpersonal service workers. 3 Individuals are allocated to different classes based on information about (a) their employment status (to distinguish employees from employers and the selfemployed who are allocated to the independent work logic) and (b) their occupation as measured with International Standard Classification of Occupations (ISCO)-88 four-digit or comparable codes. The schema's rationale and operationalization is discussed in greater detail elsewhere (Oesch, 2006; see also Oesch, 2013: 55-6). Second, we use an analytical strategy which traces the evolution of job-quality quintiles over time -a strategy that has become increasingly popular to document change in the occupational structure (e.g. Fernández Mac<unk>as, 2012; Goos and Manning, 2007;Wright and Dwyer, 2003). This approach implies that occupations are distinguished as precisely as possible given the data at hand (ISCO-88 codes at the four-digit level or comparable codes). 4 We thus distinguish between 108 (Denmark), 145 (Germany) and 171 (Britain) different occupations. We then need to determine their quality. While a Oesch 7 large array of job attributes matter to people and hence affect a job's quality, we consider earnings to be both the most relevant and most reliably measurable indicator of an occupation's quality. Accordingly, we compute the median earning of each occupation by averaging the hourly median earning at the beginning and the end of the period under study. We thus equate occupational upgrading with an expansion of occupations with high median earnings at the expense of occupations with low median earnings. Once we have calculated the median earnings of each occupation, all the occupations are rank-ordered from the lowest-to the highest-paid. These rankordered occupations are grouped into five equally large quintiles, containing as close as possible to 20 percent of total employment at the beginning of the period under study. We then determine the pattern of occupational change on the basis of how occupations in the different quintiles evolve in terms of employment (for more detail, see Oesch, 2013: 37-42). The occupational hierarchy looks surprisingly similar in our three countries: sales assistants and farmhands are in the bottom quintile Q1, bricklayers and truck drivers in the lower-middle quintile Q2, secretaries and machine mechanics in the middle quintile Q3, nurses and police officers in the uppermiddle quintile Q4 and senior officials and medical doctors in the top quintile Q5. --- Occupational change since 1990 We begin our empirical analysis by examining change in the class structure over the last two decades (see Table 1). Three evolutions are noteworthy. First, the evolution in the ranks of interpersonal service workers seems consistent with Esping-Andersen's expectations. This class includes, among others, assistant nurses, waiters and shop assistants and expanded in Britain from 11 to 15 percent of the workforce, but remained stable in Germany at 11 percent and in Denmark at 18 percent between the beginning of the 1990s and the end of the 2000s. Britain thus made up some ground in terms of interpersonal service jobs with respect to Denmark. In contrast, Germany still lingered behind in terms of interpersonal services at the end of the 2000s. Second, the stability in interpersonal service jobs contrasts with the substantial fall in employment among production workers. While taking place in all three countries, the relative decline of the industrial working class was particularly marked in Germany and Britain. Alongside production workers, the ranks of office clerks were also thinning: the workforce employed in occupations such as secretaries, receptionists or mail clerks strongly decreased in Britain and Denmark, but remained unchanged in Germany. Third, we observe in all three countries growing employment shares in the salaried middle class, notably among socio-cultural (semi-)professionals (e.g. medical doctors and teachers) and (associate) managers (e.g. administrators and consultants). While the former are disproportionately employed in the welfare state, the latter mainly work in private business services. Interestingly, the expansion among socio-cultural professionals was smallest in Denmark. Since the welfare states had developed earlier in Sweden and Denmark than in the rest of Europe, socio-cultural professionals had -like interpersonal service workers -already constituted a large category in Denmark in the early 1990s. Hence, although Denmark witnessed slower growth among socio-cultural professionals and interpersonal service workers than Britain or Germany since the early 1990s, it still employed a larger proportion of its workforce in these two categories than the other two countries at the end of the 2000s. These analyses suggest that the occupational structure of our three countries upgraded over the last two decades: the salaried middle class (comprising socio-cultural and technical professionals as well as managers) expanded to reach about 42 to 44 percent of total employment, whereas the employment share of the working and lower-middle class (service workers, production workers and clerks) fell to between 43 and 48 percent. Only in Britain do we observe substantial relative growth in one of the three lower-class categories, namely among interpersonal service workers. Over this period, there was little change among employers and the self-employed which accounted for a stable share of 10 to 15 percent of the workforce. A look at the class structure only provides us with a rough picture of the overall pattern of occupational change. To get a better idea, we examine in Figure 1 how employment evolved across five jobquality quintiles, where quintile 1 is defined as comprising, in 1990, the 20 percent of employment in the occupations with the lowest median earnings and the top quintile the 20 percent of employment in the occupations with the highest median earnings. We further disaggregate the employment change in each quintile according to four occupational classes: (a) (associate) professionals and managers, (b) interpersonal service workers, (c) production workers and (d) clerks. 5 Figure 1 confirms that the employment structure upgraded in all three countries, as net job growth was everywhere strongest in the top quintile Q5. However, upgrading was clear-cut only in Denmark and Germany. In Britain, occupational change between 1991 and 2008 had a polarizing thrust to it as strong growth in the top quintile Q5 went along with moderate growth in the bottom-quintile 1 -a finding consistent with the pattern of change reported for Britain for the period 1979-1999 (Goos and Manning, 2007: 121). A look at the occupational categories shows us that upgrading was driven, in all three countries, by the growing number of managers and professionals in the two top quintiles 4 and 5. In parallel, production workers saw their employment decrease in the four bottom quintiles 1 to 4, whereas clerical jobs disappeared from the lower-middle quintiles 2 and 3. What sets the three countries apart from each other is the evolution among interpersonal service workers. Consistent with Esping-Andersen's expectation, we observe growth of this category within the low-end quintile 1 in Britain. In Denmark, interpersonal service jobs did not expand at the bottom of the occupational hierarchy, but in quintile 2, thus offsetting the small decreases in quintiles 1 and 3. In Germany, there was no growth in the employment share of this category. Since interpersonal service jobs in Britain expanded exclusively in the lowest-paid occupations of quintile 1, differential growth in these jobs goes a long way in explaining why Britain's employment structure polarized and why Germany's did not. In Oesch 9 effect, without growth in interpersonal service jobs, Britain would have witnessed a similar-sized employment decrease in quintile 1 of about three percentage points, as did Germany. The 1990s marked a particular decade for Germany: the short reunification boom giving way to a long recession. Occupational change may thus look very different in the 1990s than in the 2000s. We control for potential timing effects in Germany by analysing occupational change for four periods of six years each (the first period of 1984-1990 applies to West Germany only). At the beginning of each period, occupations are reallocated into the five quintiles so that each quintile again comprises 20 percent of total employment. 6 In order to illustrate the period-differences in employment growth, we compute these changes in absolute numbers. Figure 2 shows that the first two periods 1984-1990 and 1990-1996 coincided with clear-cut occupational upgrading. Jobs expanded primarily at the top of the occupational hierarchy both during the boom of the late 1980s and the bust of the early 1990s when Germany lost more than a million jobs in the lowest-paid quintile 1, while creating half a million jobs in the highest-paid quintile 5. Occupational upgrading was thus particularly strong during the recession, as the burden of economic restructuring, firm downsizing and unemployment disproportionately fell on low-educated workers. The two following periods 1996-2002 and 2002-2007 were marked by a transition from upgrading towards a more polarized pattern. While employment continued to expand most strongly in the highest earning occupations of quintiles 4 and 5 and fell in the middle quintile 3, there was also modest job growth in low-end quintile 1. Germany's evolution from upgrading towards polarization is consistent both with the thesis of polarized technological change (Autor et al., 2008) and the thesis of institutional change from a coordinated economy to an unfettered model of capitalism (Streeck, 2009) -an argument to which we return below. Relative change in employment in quintiles in percentage points: Britain: Q1: 0.6, Q2: -4.6, Q3: -4.8, Q4: 0.2, Q5: 8.7 Denmark: Q1: -2.7, Q2: -4.6, Q3: 1.6, Q4: 0.8, Q5: 4.9 Germany: Q1: -2.6, Q2: -1.7, Q3: -1.9, Q4: -1.0, Q5: 7.2 Data: see Table 2. 10 --- Journal of European Social Policy --- Low-skilled unemployment and relative wages An open question is whether the social-democratic and conservative welfare regimes -exemplified by Denmark and Germany -pay for their sluggish growth of interpersonal service jobs with higher unemployment, notably among low-educated workers. We examine this question in Figure 3 by showing how the unemployment rate of low-educated workers evolved between 1991 and 2008. 7 The unemployment rate of low-educated workers strongly depends on the business cycle and is thus closely related to the evolution of general unemployment: between 1991 and 2008, the correlation coefficient (Pearson's r) between the two time series is 0.98 for Britain, 0.83 for Germany and 0.75 for Denmark. In Germany, low-educated unemployment doubled between 1992 and 2004 -from below 10 percent to 20 percent -and remained at a high level of 15 percent in 2008. In stark contrast, Britain and Denmark witnessed a gradual decline of their low-educated unemployment rate between 1995 and 2005 from over 12 percent to below 6 percent -until the outburst of the global financial crisis in 2008 led again to a rise. Upgrading has thus not wrecked the labour market prospects of low-educated workers. In 2008, their unemployment rate was below 7 percent in Britain and Denmark -and thus moderate despite an on-going process of occupational upgrading. Particularly noteworthy is the evolution in Denmark where the job structure was strongly upgrading, with sizeable job losses in the bottom-end quintile 1 (-42,000 jobs between 1992 and 2007), but loweducated unemployment nonetheless fell to below 4 percent prior to the global financial crisis. Unemployment rates may convey too optimistic a picture of the job opportunities of the low educated if involuntary labour market withdrawal takes other forms such as illness, disability, or domesticity. Many authors thus prefer the employment rate to the unemployment rate. However, the low-educated employment rates (the employment-to-population ratios of low-educated individuals aged 25 to 64 years) do not show any general downward trend either. On the contrary, in Denmark we observe an increase prior to the Great Recession from a 5-year average of 62 percent (1991-1995) to 65 percent (2006-2010). For Germany, there was a substantial decline in the 1990s (from 53 percent in 1991-1995 to 48 percent in 1996-2000), which was followed by a strong increase in Germany stands out as having higher levels of unemployment and lower levels of employment among the low educated than Britain and Denmark. Is this the price a conservative welfare regime has to pay for sheltering its wage structure? We analyse this question by plotting the evolution of interpersonal service workers' relative wages against the evolution of their relative employment in Britain and Germany. 8 Figure 4 shows the results and reveals that in 1996, the hourly wages of interpersonal service workers relative to the national median wage were substantially higher in Germany than in Britain. Interpersonal service workers received, on average, 73 percent of the median wage in Germany as compared to 63 percent in Britain. Since 1996, however, wage-setting institutions became more inclusive in Britain, notably with the introduction of the national minimum wage in 1999. The opposite occurred in Germany where wage-setting institutions eroded under the influence of mass unemployment, employer exits from collective bargaining, the expansion in temporary agency work, the rise of'mini-jobs' and cutbacks in unemployment benefits linked to Hartz IV (Eichhorst and Marx, 2011;Streeck, 2009). Accordingly, Figure 4 shows interpersonal service workers' pay in Britain to have evolved in a U-shaped pattern: relative to the national median, their earnings dropped between 1993 and 1999, stabilized over the period 1999-2002 and increased in the years from 2002 to 2008, when the minimum wage acquired real bite. In parallel, we observe a steady increase in the employment share of interpersonal service workers -with no apparent difference between periods when their relative wages were rising and periods when they were falling. In Germany, the relative wages of interpersonal service workers increased between 1993 and 1996, but then declined steadily up to 2005 and remained stable thereafter. Interpersonal service workers' share in total employment fell during the post-reunification crisis 1993-1996 (when relative wages had Our analysis of SOEP data suggests that job growth among interpersonal service workers primarily took place in non-standard employment: In the bottom quintile 1, Germany lost 415,000 permanent jobs, but created 95,000 fixed-term jobs between 1990 and 2007, notably among the young. The German increase in temporary jobs contrasts with the British experience. In 2008, only one out of twenty jobs in Britain's bottom quintile 1 were on a fixedterm basis (4.8%) as compared to one out of six jobs in Germany's bottom quintile 1 in 2007 (17%; own computations based on UK-LFS and SOEP). Despite the substantial fall in relative wages and the de-standardisation of the employment relationship in Germany, Figure 4 shows that job growth in interpersonal services was anything but spectacular. While the employment share of interpersonal service workers constantly expanded in Britain between 1993 and 2008 -resulting in an increase of 3.1 percentage points -the period of relative job growth was limited in Germany to the years between 1996 and 2005, resulting in an increase of 1.5 percentage points only. Both in relative and absolute terms, Germany created fewer jobs in interpersonal service jobs than Britain -despite having a lower starting point in the early 1990s and having strongly decreased the pay of these occupations relative to the median. The results in Figure 4 leave us with two puzzles: why did interpersonal service jobs stagnate in Germany despite a substantial increase in wage inequality and a systematic de-standardisation of the employment relationship -and why did these same jobs grow in Britain after the introduction of the minimum wage in 1999? We argue that this apparently paradoxical finding is explained, on the one hand, by the business cycle and economic policy and, on the other, by the evolution of labour supply. The 1990s and 2000s were two decades during which Britain and Germany experienced contrasting business cycles. Britain enjoyed uninterrupted economic growth of at least 2 percent of GDP between 1994 and2007. In contrast, Germany's economy struggled with the post-reunification crisis over the period 1993-2004 when the German GDP grew by at least 2 percent in only 2 out of 11 years. The German response to this long crisis was wage restraint. Yet this strategy of internal devaluation did not only decrease the earnings in -and thus prices for -interpersonal services. It also depressed the disposable income of German consumers. This proved Oesch 13 problematic as the price elasticity of demand for interpersonal services is probably not very largeunlike for industrial goods. In other words, consumer demand for interpersonal services is relatively insensitive to prices and hence to relative wages of the workers providing these services (Glyn, 2001: 710). In contrast, consumer demand for these services is strongly dependent on disposable income, and hence on the business cycle (Carlin and Soskice, 2009: 95). As a result of wage restraint, German exports picked up, whereas interpersonal service jobs stagnated under the pressure of austerity. Accordingly, the contribution of private consumption to GDP growth in Germany has steadily declined since the mid-1990s as its economic model became increasingly dependent on exports (Armingeon and Baccaro, 2012: 273). The opposite scenario of growing real wages, growing domestic demand and growing GDP applied to Britain between the late 1990s and 2007, spurring the strong expansion in interpersonal service jobs. ---

Welfare states are often reduced to their role as providers of social protection and redistribution. In 1990, Esping-Andersen argued that they also affect employment creation and the class structure. We analyse the stratification outcomes for three welfare regimes -Britain, Germany and Denmark -over the 1990s and 2000s. Based on individual-level surveys, we observe a disproportionate increase among professionals and managers, and a decline among production workers and clerks. The result is clear-cut occupational upgrading in Denmark and Germany. In Britain, high and low-end service jobs expanded, resulting in a polarized version of upgrading. Growth in low-end service jobs -and thus polarization -is no precondition for full employment. Both Britain and Denmark halved their low-educated unemployment rate between 1995 and 2008. Yet low-end service jobs expanded only in Britain, not in Denmark. The cause is the evolution of labour supply: rising educational attainment means that fewer low-educated workers look for low-skilled jobs.

wage restraint. Yet this strategy of internal devaluation did not only decrease the earnings in -and thus prices for -interpersonal services. It also depressed the disposable income of German consumers. This proved Oesch 13 problematic as the price elasticity of demand for interpersonal services is probably not very largeunlike for industrial goods. In other words, consumer demand for interpersonal services is relatively insensitive to prices and hence to relative wages of the workers providing these services (Glyn, 2001: 710). In contrast, consumer demand for these services is strongly dependent on disposable income, and hence on the business cycle (Carlin and Soskice, 2009: 95). As a result of wage restraint, German exports picked up, whereas interpersonal service jobs stagnated under the pressure of austerity. Accordingly, the contribution of private consumption to GDP growth in Germany has steadily declined since the mid-1990s as its economic model became increasingly dependent on exports (Armingeon and Baccaro, 2012: 273). The opposite scenario of growing real wages, growing domestic demand and growing GDP applied to Britain between the late 1990s and 2007, spurring the strong expansion in interpersonal service jobs. --- Shifting labour supply: education, gender and nationality Differences in the business cycle are only one part of the story. The other part is linked to the differential evolution of labour supply. Between the early 1990s and the late 2000s, the adult population of Britain, German and Denmark underwent a process of massive educational upgrading. The share of the population aged 25 to 64 years without upper secondary schooling declined in all three countries: by 14 percentage points in Britain, by 8 percentage points in Germany and by 1.4 percentage points in Denmark. Over the same period, the proportion of the adult population with upper secondary education, consisting of general degrees or vocational training, remained unchanged in Britain and Germany, but decreased by 12 percentage points in Denmark. These decreases were compensated for by the strong rise in the proportion of adults with tertiary education. The increase amounted to 13 percentage points in Britain and Denmark and to 7 percentage points in Germany (own calculations based on UK-LFS, EU-LFS and SOEP). The increase among university-trained workers at the expense of workers with compulsory schooling partially explains why the number of low-paid jobs could diminish without causing a rise in low-educated unemployment. In Britain, however, skill supplies were also shaped by the strong surge in immigration from Eastern Europe (notably Poland, the Baltic States and the Slovak Republic) after the 2004 enlargement of the European Union. These immigrants were often hired for jobs far below the occupations to which they would be assigned on the basis of their educational attainment (Dustmann et al., 2013). Through this downgrading, they may have provided the abundant and inexpensive labour supply that stimulated job creation at the low-skill end of the British labour market -a factor largely absent from the Danish and German labour markets of the 2000s. We examine this argument in a last analysis by disaggregating relative change in employment for four different nationality-gender groups: national men, national women, foreign men and foreign women. The goal is to determine each group's net contribution to the observed pattern of occupational change. The result is shown in Figure 5 and confirms that, in Britain, expansion in low-paid occupations of quintile 1 was exclusively due to job growth among foreign workers. The relative increase of quintile 1 by 0.6 percentage point was the result of a fall in employment among British men and women (-1.1 percentage points), which was overcompensated by employment growth among foreign men and women (+1.8 percentage points). At the same time, in Britain, all four nationality-gender groups underwent a polarizing pattern of change where job growth was stronger at the bottom and the top than in the middle. Consequently, immigration contributed to the polarization of Britain's employment structure, but it was not the only driving force. In Denmark, foreign workers also increased their employment share in the two bottom quintiles 1 and 2 (by 1.1 and 0.8 percentage points, respectively). But this increase was not large enough to compensate for the large drop in employment among Danish men and, above all, Danish women within these two low-end quintiles. In Germany, employment shifts were very similar for nationals and foreigners. As in the two other countries, occupational upgrading in Germany was strongly driven by national women, 14 Journal of European Social Policy whereas national men saw their relative employment decline in the middle quintiles in all three countries. --- Discussion and conclusion What do our findings imply for Esping-Andersen's argument that the welfare regime decisively shapes post-industrial employment trajectories? Consistent with his hypothesis, we observe an expansion of interpersonal service workers at the bottom of the occupational structure only in Britain's liberal welfare regime. The share of the workforce employed in interpersonal services stagnated in both Denmark and Germany. However, this is less surprising for Denmark than Germany, as interpersonal services accounted for a much higher proportion of employment in Denmark than in Germany at the beginning of the 1990s. This finding underlines that in Denmark -as in Sweden -the period of disproportionate employment growth in public services came to an end in the 1990s and 2000s (OECD, 2009). The class structure of the three countries under study thus became more similar over the last two decades and, contrary to Esping-Andersen's expectation, we observe some convergence. In all three countries, the strong increase in the ranks of professionals and managers and the parallel decline among production workers and clerks resulted in an upgrading of the occupational structure. This process was clear-cut in Denmark. In Britain, the growth in interpersonal service jobs led to a polarized version of upgrading as employment increased at both ends of the occupational hierarchy. Of the three countries studied, we observe the most intricate employment trajectory in Germany. The Schröder government's reform agenda led to employment de-standardisation and greater wage inequality. Germany took steps away from a coordinated economy towards a more liberal model of capitalism (Streeck, 2009). While this evolution is visible in terms of increasing occupational polarization and growing wage inequality, it has not resulted in strong growth in interpersonal service jobs -as the combination of an export-based strategy with wage restraint and welfare state retrenchment depressed internal demand for much of the 1990s and 2000s. Esping- Andersen (1990Andersen (, 1993) ) was right when considering interpersonal service workers' employment trajectory as decisive for post-industrial social stratification. Britain's labour market would not have expanded at its occupational bottom-end without the growth in interpersonal service jobs, mostly filled by foreign workers. However, other factors than those originally singled out explain the divergent employment trajectories of our three welfare regimes. Differential growth in public sector employment no longer plays a major role. Rather, the evolution of labour supply and particularly immigration policy Data: see Table 2. Oesch 15 -more liberal in Britain than in Denmark or Germany over the period under study -led to diverging outcomes in our three countries. Likewise, evidence in favour of the welfare regime hypothesis is mixed with respect to unemployment. Our data do not lend support to the assumption that sectoral change and Baumol's cost disease result in high levels of low-educated unemployment if countries do not create large numbers of (low-end) interpersonal service jobs. True, Britain succeeded both in increasing its share of the workforce in interpersonal services and in decreasing the unemployment rate of low-educated individuals. At the same time, Denmark also managed to halve its low-educated unemployment rate between the mid-1990s and 2008 -but did so without witnessing any net job growth either in the labour market's bottom quintile or in interpersonal services. A very similar scenario applies to another small and affluent European country, Switzerland (Oesch, 2013). The dramatic increase in lower-tail earnings inequality in Germany since 2000 makes the country an ideal test case for the hypothesis that low wage floors lead to job expansion in low-end services. Our data suggest that Germany's socially divisive strategy of internal devaluation was insufficient to set a boom in interpersonal service jobs in motion. While Germany's labour market policy became more liberal, its macroeconomic policy remained conservative. If polarization of the employment structure is no precondition for full employment, what led the believers in Baumol's cost disease model -or, for that matter, in Iversen and Wren's service trilemma -astray? In our view, these models unduly focus on low-end service jobs as the principal source of employment growth in post-industrial societies, on two grounds. First, employment growth has primarily taken place among (associate) managers and (semi-) professionals either working in private business services or in health and education -and these services did not primarily expand at the bottom, but rather the middle and top of the occupational hierarchy (Wren, 2013: 14-5). In contrast, jobs in low-end services have been growing slowly at best, declined at worst -as the combined use of automation and robotics with organizational innovation and upskilling have increased worker productivity in retail trade, hospitals or call centres. Second, it may not be a tragedy that low-end services do not fulfil their role as job machines in postindustrial economies. The constant rise in cohorts' educational attainment over the last decades has meant that there are not only less low-skilled jobs but also less low-educated workers available to staff these jobs. Accordingly, we only observe a substantial job expansion at the labour market's bottom-end in those countries where large inflows of migrants provided an abundant workforce willing to accept low wages: Hispanics in the United States (Wright and Dwyer, 2003: 309), Eastern Europeans in Britain (Oesch, 2013: 96) or Romanians and South Americans in Spain (Oesch and Rodr<unk>guez Menés, 2011: 531). The evolution of labour supply thus appears as the blind spot of Iversen and Wren's service trilemma. It probably also constitutes an unduly neglected key variable of how welfare regimes affect social stratification and occupational change. 370, 615-630, 640-641, 643-644, 651-690, 699, 719-792, 870-871, 873-875, 941-959. 4. Since occupations are coded at a more aggregated level in the Danish survey, we combine them with information on the economic sector in order to obtain a more fine-grained measure of occupations. 5. The eight classes in Table 1 map into these four categories as follows: socio-cultural and technical (semi-) professionals as well as (associate) managers are merged into a single category of professionals and managers. Employers and the self-employed are no longer kept separate on the basis of their employment status, but are attributed to one of the four categories based on their occupation. Interpersonal service workers, production workers and clerks remain unchanged. 6. This implies that some occupations set in quintile 2 in 1984 are allocated to quintile 1 in 1990 if employment in the occupations of quintile 1 has decreased. In other words, more occupations are necessary to provide 20 percent of total employment in this same quintile in 1990 than 1984. 7. Low-educated workers are defined as having an educational attainment of lower-secondary school at most: no more than 9 to 10 years of formal education (ISCED levels 0-2). 8. We did not run these analyses for Denmark as our Danish labour force survey data do not contain information on earnings. --- Notes 1. An alternative way of increasing productivity in interpersonal service jobs is by raising quality and thus obtaining more added value per employee. This seems to be the strategy followed by the hotel industry in the major European cities with a strong expansion of 4-star hotels at the expense of more modest establishments. 2. Between 2002 and 2007, the annual net migration rate per 1000 inhabitants -inflows minus outflows of the foreign population over the resident population -was 4.1 in Britain, 1.8 in Denmark and 1.2 in Germany (OECD International Migration Database). Appendix 1

Welfare states are often reduced to their role as providers of social protection and redistribution. In 1990, Esping-Andersen argued that they also affect employment creation and the class structure. We analyse the stratification outcomes for three welfare regimes -Britain, Germany and Denmark -over the 1990s and 2000s. Based on individual-level surveys, we observe a disproportionate increase among professionals and managers, and a decline among production workers and clerks. The result is clear-cut occupational upgrading in Denmark and Germany. In Britain, high and low-end service jobs expanded, resulting in a polarized version of upgrading. Growth in low-end service jobs -and thus polarization -is no precondition for full employment. Both Britain and Denmark halved their low-educated unemployment rate between 1995 and 2008. Yet low-end service jobs expanded only in Britain, not in Denmark. The cause is the evolution of labour supply: rising educational attainment means that fewer low-educated workers look for low-skilled jobs.

INTRODUCTION In modern society, life values are changing rapidly from preservation and extension of life to enhancement of well-being and happiness in life [1]. It has also been pointed out often in recent times that increases in income levels, until now typically measured by gross domestic product (GDP), do not always correspond with satisfaction and happiness in life [2], and that economic growth is an incomplete indicator of national welfare and well-being [3]. As such, with stronger recognition that economic prosperity is not directly related to quality of life, interest in not only materialistic, but also mental, quality of life and happiness are on the rise worldwide [4]. Accordingly, the importance of measuring subjective quality of life perceived by an individual has been highlighted, and the happiness index is receiving global attention as a new welfare index to replace economic growth [3]. Relating this to earlier events, in 1974 then King Jigme Singye Wangchuck of Bhutan announced that he would govern the country based on gross national happiness rather than GDP, and in 1981, the University of Michigan Institute for Social Research conducted the World Values Survey, which surveyed 1,000 to 2,000 citizens each from countries around the world with regard to happiness and life satisfaction and scored the results to compile subjective well-being rankings, which meant the happiness index was born [5]. Thereafter, in 2003, Rohwell, a British psychologist, and Cohen, a British life coach, announced their happiness formula, which reflected an individual's personality traits, adaptability to cope with new situations, basic elements of survival, such as money, health, and sense of belonging, and high-level needs, such as personal pride and ambition. In 1999 in Canada, the Atkinson Charitable Foundation began a study on the Canadian Index of Wellbeing, eventually establishing 8 categories. In 2003, a research center at the Chinese University of Hong Kong (CUHK) announced the CUHK Hong Kong Quality of Life Index, which included 21 categories about society, economy, and environment. The level of happiness is primarily influenced by personal characteristics, but it is also heavily influenced by the socio-physical environment and socioeconomic characteristics of residential areas. Within the municipal-level divisions (si, gun, and gu) of residential areas, there are administrative divisions with diverse socioeconomic backgrounds, and even for the same municipallevel division, there exist various submunicipal-level communities (eup, myeon, and dong) [6]. Because submunicipal-levels, as units of community, represent places where one's own life directly influences or is directly influenced by the relationships among the community's residents [7], the level of happiness should vary among submunicipal-levels. As such, since individuals form relationships and live with people within their area of residence, it is necessary to understand the influence of the residential area's characteristics on individuals' happiness [8]. Recently, there has been heightened interest in the influence of regional characteristics on individuals, and many studies have been conducted on the subject. Regional characteristics are being considered in various fields, and many studies have shown that regional characteristics affect the behavior or health conditions of individuals. Deprivation index, one of the representative variables that exhibit regional characteristics, is a numeric representation of quality of life based on housing environment, with a higher deprivation index signifying a poorer housing environment, and it is widely used as an index to reflect the socioeconomic level of a region. In each study of such a deprivation index, the sub-indices that comprise it vary slightly, and although many studies have used it as a regional characteristic, they have only considered its influence on health status, not satisfaction in life or happiness. We aimed to investigate the correlation between deprivation index and happiness index, which is closely correlated with health status. Although there have been many studies on happiness index, few have considered regional factors and even those that have [9,10] were focused on city-level and county-level effects so rather than regional effects. Most studies on happiness index have examined specific groups or the outcomes of specific programs, based on one-dimensional analysis without distinguishing personal, group, or regional characteristics; no studies have considered region-specific variables for large groups. Moreover, when a one-dimensional analysis is performed on a data set that forms a hierarchical structure consisting of individuals and regions in which they live, the correlations among groups or individuals within a region are not been taken into account, which can yield inaccurate results. In addition, with a recent increase in the need to obtain individual and regional statistics, interest in small-area statistics format a submunicipal-level rather than municipal-level divisions is increasing day by day. To address this need, the present study applied a modified deprivation index generated from various personal characteristics, obtained from the Korean Community Health Survey (CHS), and regional characteristics and personal characteristics at the submunicipal-level, obtained from the Population and Housing Census data from Statistics Korea, to decompose the happiness index for residents of South Gyeongsang Province into different levels by individual and region and performed a multilevel analysis to closely examine the factors that influence happiness and contribute to the enhancement of quality of life for the people of Korea. --- MATERIALS AND METHODS --- Participants and data Based on 16,270 respondents from 20 cities and counties in South Gyeongsang Province who participated in the 2011 CHS, which was conducted for three months between August and November 2011, data were compiled for major observed variables and were used as a secondary source of data for the present study. The measure of the dependent variable, happiness index, was one of the questions from the South Gyeongsang Province CHS conducted in 2008 by the Korea Institute for Health and Social Affairs. In the first stage, the institute reviewed precedent studies, domestic and foreign, on happiness index and happiness-related theories and worked with an expert advisory council to develop 10 categories regarding mental stability, family and marriage, personal relationships, community, daily life, demographic characteristics, economic stability, work, health, and residence. In the second stage, a total of 41 happiness indices, covering each of the 10 categories, were developed. Finally, in the third stage, a Delphi survey of the general population and the experts was conducted, to prioritize the 10 categories and the indices in each category. The result was a measurement tool that contained 9 categories and 21 total questions (Appendix 1) [10], with each question scored on a scale of 0 to 10 points. The sum of the scores for all questions in a category was converted to a category happiness index with a maximum of 10 points, and the sum of the 21 total questions' scores was converted to a overall happiness index with a maximum of 100 points. For personal characteristics, variables used were those predicted to be related to happiness index by the 2011 CHS and by existing studies related to happiness index [9][10][11][12][13]: participants' degrees of physical activity, frequency of skipping breakfast, unmet healthcare needs, number of diseases, average sleep time, social network connections, and participation in social activities (Appendix 2). For regional characteristics, raw data from Statistics Korea's survey of the entire South Gyeongsang Province in the 2010 Population and Housing Census was used to calculate submunicipal-level regional deprivation indices. Submunicipal-level was the smallest unit for all items in the Population and Housing Census, which included information about population, households, and housing for a total of 3,160,154 people. In order to calculate the deprivation index, the Carstairs index [14], Townsend index [15], and the index of multiple deprivation (all originally developed for the UK)-existing deprivation indices that reflect community characteristics-and component indices from existing studies [16][17][18] were referenced. From these, "less than high school graduation rate (25-64 years old)," "rate of population 65 years or older," and "rate of widowed or divorced (15 years or older)" were selected to represent the population category and "rate of non-home-ownership," "rate of lease or rent," "rate of overcrowdedness," "rate of female head of household," "rate of poor housing environment," and "rate of single person household" were selected for the household category (Appendix 2). The method of calculating the deprivation index was the standard one of obtaining the value of each variable and, to compensate for influence, converting to Z-score before summation. Moreover, in the process of matching the personal characteristic variables and the deprivation index, Jisu-myeon in the city of Jinju and Ssangchaek-myeon in Hapcheon county were ex-cluded from the analysis, because their community health survey data were missing. In addition, towns with population less than 10 were combined with nearby communities that had similar geographical traits. As a result, 304 of the 323 towns in South Gyeongsang Province were included in the analysis (Appendix 3). --- Statistical analysis SAS version 9.2 (SAS Institute Inc., Cary, NC, USA) was used for the statistical analysis. To gain an understanding of the data, means were calculated and frequency, mean comparison, and correlation analysis were performed. To identify the factors that influence the level of happiness index, a multilevel analysis that simultaneously considered both personal-level and regional-level characteristics was performed. Multilevel analysis is a method that can be used to analyze how personal-level dependent variables are influenced by personal-level and regional-level variables; such an analysis is appropriate when relying on data with hierarchical structure, such as data on individuals in submunicipal-levels (eup, myeon, and dong.) The basic model in multilevel analysis, designed to confirm the basic data, tests whether the differences among the variance values are significant without inputting the variables and can extrapolate the variance ratio based on regional characteristics among all variances [19]. This approach is called intraclass correlation, with the intraclass correlation coefficient (ICC) calculated as the ratio of the regional variance to the sum of the two levels of variances. The study models are those to which personal-level and regional-level variables can be inputted either separately or together. The explanatory power of each of the study models can be estimated as the ratio of the variances explained by inputting the variables from the study model into each level variance of the basic model. For the analyses, the Glimmix procedure in SAS was used. In the present study, four models were established for the multilevel analysis. Basic model: This model, which did not include any of the personal-level or regional-level variables, was constructed to estimate interregional variance. Model 1: This model was constructed with personal-level variables, such as sex, age, education level, monthly household income, frequency of skipping breakfast, degree of physical activity, number of diseases, unmet healthcare needs, social network connections, and participation in social activities. Model 2: This model was constructed with regional-level variables of deprivation indices for each town. Model 3: This model included both personal-level and regional-level variables. All statistical significance was determined based on a significance level of 0.05. --- RESULTS --- Participant characteristics and happiness index levels Demographics, health status, and healthcare use The participants included more females (55.8%) and the mean age was approximately 53 years. In terms of education level, the highest frequency was high school graduate (32.5%), while the average monthly household income was approximately 2.46 million Korean won (KRW). The rate of performing moderate or greater physical activity was 29.9%, the rate of skipping breakfast was 14.8%, and the average sleep time per day was 6.6 hours. Based on lifetime medical diagnoses, disease rates were 22.2% for hypertension, 7.9% for diabetes, and 16.9% for arthritis, with each participant having an average of 0.5 diseases. The rate of unmet healthcare needs was 16.8%. The mean happiness index was significantly higher in males (64.6 points) than in females (62.0 points, p<unk> 0.001), and the overall happiness index was higher for individuals who had attained higher education levels (p<unk> 0.001). Age and happiness index showed a significantly negative correlation (r= -0.201, p<unk> 0.001), whereas monthly household income and happiness index showed a significantly positive correlation (r= 0.233, p<unk> 0.001). The mean happiness index for the group engaging in moder- In the past week, engaged in high-intensity physical activity for at least 20 minutes per day for 3 or more days or moderate physical activity for at least 30 minutes per day for 5 or more days. ate or greater physical activity (64.6 points) was significantly higher than that for the group that does not engage in such activity (62.6 points, p<unk> 0.001), while the mean happiness index was significantly lower for the group that skipped breakfast (62.4 points) than for the group that did not do so (63.3 points, p= 0.002). The mean happiness index was significantly lower for the group with unmet healthcare needs (58.8 points) than for the treated group (64.0 points, p<unk> 0.001). Sleep time and the happiness index showed a significantly positive correlation (r= 0.102, p<unk> 0.001), whereas the number of diseases and the happiness index showed a significantly negative correlation (r= -0.164, p<unk> 0.001) (Table 1). --- Socio-physical environment With regard to social network contact of one or more times per week, surprisingly, contact with friends occurred with the smallest proportion of people (47.3%), while the proportions of people who had contact with relatives and neighbors were 49.6% and 69.0%, respectively. With regard to participation in social activities one or more times per month, 20.2% of people participated in religious activities, 59.0% in social activities, 23.3% in leisure activities, and 6.7% in community service activities. The mean happiness index was significantly higher for the relatives contact group (64.5 points) than for the non-contact group (61.9 points, p<unk> 0.001), while the mean happiness index was significantly higher for the neighbor contact group (63.9 points) than for the non-contact group (62.8 points, p<unk> 0.001) and the mean happiness index was significantly higher for the friends contact group (65.7 points) than for the non-contact group (60.9 points, p<unk> 0.001). The mean happiness index was significantly higher for the group participating in religious activities (65.2 points) than for the non-participation group (62.6 points, p<unk> 0.001), while the mean happiness index was significantly higher for the group participating in social activities (65.9 points) than for the nonparticipation group (59.2 points, p <unk> 0.001). The mean happiness index was significantly higher for the group participating in leisure activities (69.5 points) than for the non-participation group (61.3 points, p<unk> 0.001), while the mean happiness index was significantly higher for the group participating in community service activities (70.1 points) than for the non-participation group (62.7 points, p<unk> 0.001) (Table 2). --- Multilevel analysis results In the basic model of the multilevel analysis for identification of factors that can influence the happiness index, the personallevel variance-the variance generated by personal differences among the participants-was 159.51, and the regional-level variance-the variance generated by differences among regionswas 19.351, showing a statistically significant difference. This result showed that interregional differences existed in the personal happiness index. In other words, a region can influence a person's happiness index. Regional-level variance accounted for 10.8% of the total variance in happiness index, calculated by ICC= 19.351/(19.351+159.51)= 0.108. In model 1, all variables except age had a significant influence on the happiness index, and their variances accounted for 18.7% ance. This result indicated that regional-level differences were explained by personal-level variables. In model 2, a higher deprivation index was correlated with a significantly lower happiness index. Adding the regional-level variable, deprivation index, to model 1, explained 26.3%, (19.351-14.262)/19.351= 0.263, of regional-level variance. In model 3, the same influences of the independent variables from models 1 and 2 were seen. Higher happiness index was associated with being a male, being highly educated, having high income, engaging in moderate or high-intensity physical activity, getting sufficient sleep, having more social contact with relatives, neighbors, and friends, and actively participating in religious, social, leisure, and community service activities (p<unk> 0.001), whereas skipping breakfast, having unmet healthcare needs, and having more diseases meant a lower happiness index (p<unk> 0.001). Moreover, as the deprivation index increased, the happiness index decreased (p= 0.025). Through the processes above, the personal-level variance explained in the final model, model 3, was 18.7%, (159.51-129.75)/ 159.51 = 0.187, and the regional-level variance was 26.2%, (19.351-14.277)/19.351= 0.262. In comparison to model 1, although 24.8% of regional-level variance was explained by personal-level variables, inclusion of the regional-level variables increased the explanatory power of the model by 1.4%. As such, interregional differences in happiness index were influenced by the deprivation index, a regional-level variable, but also by the majority of personal-level variables. Based on examination of <unk> 2 values, each model was determined to fit (Table 3). --- DISCUSSION There have been claims that more attention should be paid to assessment of welfare and sustainability rather than pure economic numbers as indices for measuring the level of welfare and benefits of citizens. There is an increased opinion, domestically and abroad, that standards that can measure not only economic growth but also social advancement and happiness of citizens are needed. Since the United Nations World Happiness Report of 2012, the importance of the happiness index has been emphasized. As such, the present study used data from the CHS to perform a multilevel analysis, incorporating both personal and regional levels, to identify the factors that influence the happiness index for residents of South Gyeongsang Province. The intent was to present evidence for prioritizing improvement-related efforts and investments. The multilevel analysis of the happiness index showed personal-level and regional-level variances in the basic model of 159.51 and 19.351, respectively, and because the ICC was 10.8%, interregional differences in happiness index appeared significant; hence, there was sufficient evidence to include regionallevel factors in the model. In looking at regional-level influences, a higher deprivation index meant a lower happiness index. In a sense, this is an obvious result: although no studies have considered the influence of deprivation index on happiness index, study has reported that good overall health status lead to a higher happiness index [12]. The findings of the present study are consistent with the results of Heo et al. [20] who used those aforementioned studies to examine the influence of deprivation index on health, which is highly correlated with happiness index, and reported that more experiences in socioeconomic deprivation lead to lower subjective health levels. The present study confirmed that deprivation index, a regional-level characteristic, had an effect on the happiness index. This result showed the need to consider a region's environmental factors when attempting to improve the happiness index of its residents. With regard to personal-level influences, the happiness index was higher for males than for females. This result is consistent with studies by Kim & Han [9] and Abdel-Khalek [21] but is contrary to studies by Kim et al. [10] and Piqueras et al. [13], which showed higher happiness index for females. Moreover, studies by Vera-Villarroel et al. [22] and Choi & Moon [23] showed no gender-based differences in happiness index. However, as age increases, the happiness index generally decreases, so varying study results with regard to gender can be attributed to the age distribution of the study data. In other words, age is believed to affect the study results. Although not statistically significant, an increase in age meant lower happiness index in the present study. This is consistent with studies by Vera-Villarroel et al. [22] and Choi & Moon [23], but slightly different from another study [24] that reported that recently in Europe and welfare states not in Europe happiness decreased with increasing age until the age of late 40s, after which it increased again, giving a U-shaped happiness profile over time. This U-shaped profile is believed to result from those countries having stable social security for the elderly, whereas in Korea, due to customary support for children, preparation for social security for the elderly and aging population is weak. A higher education level meant higher happiness index. This result is consistent with studies by Kim et al. [10] and Choi & Moon [23]. The relationship is believed to be a result of education level's effect on personal confidence, occupation, and income level, which can also influence family and social life. Similarly, higher monthly household income, which is closely related to education level, also meant higher happiness index. This is consistent with the study results by Campbell [25] and Diener et al. [26]. However, even with similar income, the relative values can vary, depending on individual circumstances, causing happiness index to vary [12]. In this way, Bhutan, with per capita income of only 1,200 US dollars, was ranked first in national happiness index as reported by the New Economics Foundation in 2010. In terms of health behavior, greater engagement in moderate or high-intensity physical activity and longer average sleep time lead to higher happiness index, while more frequent breakfast skipping lead to lower happiness index. This is consistent with the study results of Chu [12] and Piqueras et al. [13]. Engaging in physical activity, which fundamentally requires good health, is believed to build strength and resistance to diseases, take one's mind off tiring daily life, relieve stress, and provide a feeling of self-satisfaction. Eating breakfast and securing sufficient sleep contribute to physical and mental health by providing energy for daily activities, relieving fatigue from the previous day, and strengthening immune functions. With regard to illnesses and healthcare use, having unmet healthcare needs and a greater number of accompanying diseases meant a lower happiness index. Such health-related problems have obvious results and are also related to economic problems. As for socio-physical environmental characteristics, more contact with relatives, neighbors, and friends meant higher happiness index, as did more participation in religious, social, leisure, and community service activities. These findings are consistent with studies that reported participation in community service elevates subjective happiness [27,28] and religious and social activities [28] increase happiness index, as well as a study [29] that indicated leisure activities increase happiness index. In the culture of Korea group life is important: pride and satisfaction of participating in social activities is believed to lead to enhanced psychological stability and bonding, which increases subjective wellness and the happiness index. However, the present study's univariate analysis showed that more frequent contact with neighbors resulted in lower happiness index. In contrast to contacts with relatives and friends, which are comfortable encounters based on blood ties, friendship, or familiarity, encounters with neighbors require a certain degree of etiquette, even with those known for a long time. These encounters, such as monthly neighborhood meetings, may not even be voluntary. Moreover, amount of contact with neighbors increased rapidly from age 50 years onward, which lead to the conclusion that there may be a relat-Epidemiology and Health 2015;37:e2015019 ed age-based effect on happiness index; the multilevel analysis compensated for such an effect. With regard to the models' explanatory power, model 1, which included only personal-level variables, explained 24.8% of the regional-level variance. In model 3, which included both personal-and regional-level variables, the explanatory power increased by 1.4% to 26.2%. This indicated that even though regional-level deprivation index influenced happiness index, the effects of personal-level variables were greater. In other words, interregional differences in happiness index were explained, almost entirely, by personal-level variables, meaning that most interregional differences resulted from personal-level characteristics. In the process of calculating the deprivation index, which was the regional variable in the present study, one limitation was the inability to obtain male unemployment rate and rate of not owning a vehicle-they are both important variables that were not available at the submunicipal-level. As such, the raw data from the South Gyeongsang Province 10% sample survey (for which city and county were the smallest units) of the Population and Housing Census were used to perform a comparative analysis of the deprivation index from the study by Shin et al. [18] and the deprivation index from the present study; after checking the deprivation index's reliability in this way, the present study was continued. Furthermore, although there was a question in the CHS about the length of residence in the corresponding area, differences based on regional characteristics can be seen within the same municipal-level divisions; hence, a more thorough assessment, with more detailed data, was not performed on the differential effects of regional characteristics based on length of residence in the community. Despite these limitations, the present study was a systematic analysis to identify the population characteristics of South Gyeongsang Province based on sample data that well represented the region. As a study on happiness index, it is significant in that it is the first to include a multilevel analysis including both personal and regional characteristics. Although the effect of the regional variable, deprivation index, was relatively small compared to those of the personal characteristics, confirmation of the effect itself is significant. It is also meaningful that, to verify the influence of deprivation index more accurately, deprivation indices were derived at the submunicipal-level (eup, myeon, and dong). It is hoped that, in the future, developing additional indices that can better reflect regional characteristics and incorporating the length of residence in the corresponding region can provide more accurate assessments. Happiness index of community residents is influenced by not only personal characteristics but also regional characteristics. In a data analysis with such a hierarchical structure, multilevel anal-ysis is required. Enhancement of happiness index and improved quality of life requires not only personal-level but also regionallevel efforts, and for vulnerable areas-those with relatively high deprivation index-efforts should be made to create social rapport and engage in selective efforts. --- CONFLICT OF INTEREST The authors have no conflicts of interest to declare for this study. --- SUPPLEMENTARY MATERIAL Supplementary material (Korean version) is available at http: //www.e-epih.org/. --- Appendix 1. Happiness index survey questions Subcategory

The objective of the present study was to identify the factors that influence the happiness index of community residents, by considering personal and regional aspects, and to use as evidence of efforts for improvement of the happiness index.The study was conducted based on information from 16,270 participants who met the data requirement among those who participated in the 2011 South Gyeongsang Community Health Survey. Of the factors that can influence the happiness index, socioeconomic characteristics, health behavior, morbidity, and healthcare use, social contact, and participation in social activities were classified as personal factors; for regional factors, data from the 2010 census were used to extrapolate the regional deprivation indices at the submunicipal-level (eup, myeon, and dong) in South Gyeongsang Province. The happiness index for each characteristic was compared to that for others via t-test and ANOVA, and multilevel analysis was performed, using four models: a basic model for identification of only random effects, model 1 for identification of personal factors, model 2 for identification of regional factors, and model 3 for simultaneous consideration of both personal and regional factors.The mean happiness index was 63.2 points (64.6 points in males and 62.0 points in females), while the mean deprivation index was -1.58 points. In the multilevel analysis, the regional-level variance ratio of the basic model was 10.8%, confirming interregional differences. At the personal level, higher happiness indices were seen in groups consisting of males with high educational level, high income, high degree of physical activity, sufficient sleep, active social contact, and participation in social activities; whereas lower happiness indices were seen in people who frequently skipped breakfast, had unmet healthcare needs, and had accompanying diseases, as well as those with higher deprivation index.The study confirmed that the happiness index of community residents was influenced by not only personal aspects but also various regional characteristics. To increase the happiness index, interests at both personal and regional levels, as well as community emphasis on creating social rapport and engaging in selective efforts, are needed in vulnerable regions with relatively high deprivation index.

INTRODUCTION COVID-19 has severely impacted social and economic development, as well as individuals' work and family lives. As the COVID-19 pandemic continues to develop, medical workers on the frontline face increasing difficulties to balance their daily working and family lives. Moreover, frontline medical workers live with the constant threat of death and often witness many deaths. This situation can be difficult to change over a long period of time, and post-traumatic growth among workers may be particularly inhibited in the context of conflict, stress, and trauma. The relationships between family-work conflict and post-traumatic growth, the results have not been consistent, and the specific underlying mechanisms remain unclear. Therefore, the current study sought to examine the impact of family-work conflicts on post-traumatic growth and explore the mediating effect of positive psychological capital and perceived social support in this process, as well as explore the impact of emotional regulation strategies on this process. --- Impact of Family-Work Conflict on Post-traumatic Growth Family-work conflict is a role conflict in which family and work pressures are in some way incompatible (Netemeyer et al., 1996), manifesting as conflict between fulfilling family responsibilities and the overall requirements, time-investment, and pressures of work. Family-work conflict includes both the time conflicts involved in caring for the family and completing work tasks, and the pressure of family roles hindering the completion of work responsibilities (Vaziri et al., 2020). The COVID-19 pandemic has caused changes in working status for many individuals, significantly exacerbating the conflict between family and work in some cases, and it has also directly affected individuals' mental health. One previous study reported that family-work conflict was a significant factor contributing to poor health in women (López-N<unk>ez et al., 2021). While many medical workers have made outstanding contributions in the fight against pandemic, workers have also made great sacrifices regarding family care. The pressure of family-work conflict during continuing pandemic, and interference with the working status of medical workers, increases the dual physical and psychological risks, and increases the likelihood of psychological trauma such as anxiety, obsessivecompulsive disorder, depression, and panic (Kang et al., 2020;Zhang et al., 2020). Post-traumatic growth refers to positive psychological changes experienced after overcoming a challenging life crisis (Tedeschi and Calhoun, 1995). Individuals who experience traumatic events (e.g., earthquakes, cancer, pandemics) often exhibit not only negative psychological responses, but also positive changes in their appreciation of life, personal strength, relationships with others, spirituality, and outlook on new possibilities (Tedeschi and Calhoun, 1996). COVID-19 is a negative life event for medical workers which can trigger traumatic experiences, and family-work conflict can strengthen the impact of negative life events, and inhibit the occurrence of growth (Netemeyer et al., 1996;Tedeschi and Calhoun, 2004). Many medical workers have experienced immense pressure and uncertainty during the COVID-19 pandemic, as well as psychological trauma related to the risk of death, which has caused some medical workers to undergo a process of self-reconstruction (Tedeschi and Calhoun, 2004). Previous studies have reported that the realization of post-traumatic growth is affected by many factors, including individual assessment control, helplessness, availability of personal resources, and transactional stress (Sheikh, 2008). Family-work conflicts can consistently induce these factors, such as feelings of helplessness and transactional pressure (Vaziri et al., 2020), which can restrain post-traumatic growth. Therefore, we proposed Hypothesis 1: Under the background of normal pandemic prevention and control, medical workers' long-term family-work conflicts will hinder the realization and improvement of post-traumatic growth. --- Family-Work Conflict and Post-traumatic Growth: The Mediating Roles of Perceived Social Support and Positive Psychological Capital The job demands-resources (J-DR) model and conservation of resource (COR) theory argue that work requirements, including family-work conflict, are closely negatively related to work resources such as perceived social support and positive psychological capital (Bakker and Demerouti, 2017), while perceived social support and positive psychological capital are positively related to positive factors under pressure (Hobfoll, 1989). Thus, we speculate that the effects of family-work conflict on post-traumatic growth are likely to be achieved through perceived social support and positive psychological capital. Perceived social support is the perceived availability of resources, including support provided by individual social networks, such as support from spouses, colleagues, friends, and family (Cohen and Wills, 1985). Family-work conflict is negatively related to perceived social support, which can help individuals reduce stress and adopt positive behaviors to cope with stress (Cohen and Wills, 1985). In the process of post-traumatic growth and improvement, individuals typically integrate positive changes, such as enhancing personal and social resources, independence, and efficiency into their lives (Tedeschi et al., 1998). According to the model of post-traumatic growth proposed by Tedeschi, perceived social support can help individuals with trauma to view things from different, more helpful, and adaptive perspectives and to develop new schemas (Tedeschi and Calhoun, 2004). Similarly, in the conceptual model proposed by Schaefer and Moos, perceived social support is regarded as a critical environmental resource used to understand the positive outcomes of life crises and transformation (Schaefer and Moos, 1998). Positive psychological capital refers to a psychological state of individual positive development, which is a relatively new personality construction in positive organizational behavior, mainly manifested in self-efficacy, hope, optimism, and resilience (Luthans et al., 2007). In a study of nurses, the results revealed a significant negative correlation between family work conflict and resilience (Chen et al., 2021). In stressful situations, optimism, resilience, self-efficacy, and hope are all strategies that can help traumatized individuals recover from stress and achieve positive changes (Shand et al., 2015). In particular, hope about introducing expectations and goals for the future can help individuals shift their attention from practical difficulties and fear of negative outcomes to problem-solving behavior (Reff et al., 2005), exerting a direct positive impact on post-traumatic growth (Casellas-Grau et al., 2017). At the same time, perceived social support as a perceived external support resource, and positive psychological capital as an internal positive resource, can improve the post-traumatic growth of individuals. The positive effects of both factors on post-traumatic growth can be explained by adaptive strategies (Zoellner and Maercker, 2006). Other studies have also confirmed that perceptive social support and positive psychological capital, which act together as an individual's internal resources and perceived environmental resources, play a mediating role between psychological factors of trauma and post-traumatic growth (Jia et al., 2015). Therefore, we propose Hypothesis 2: Positive psychological capital and perceived social support play mediating roles between family-work conflict and posttraumatic growth. --- The Moderating Role of Suppression Some previous studies reported that the impact of familywork conflict on post-traumatic growth is not simply a stable negative predictive relationship. Gross and John (2003) proposed two mood regulation strategies: cognitive reappraisal and suppression. In their model, suppression is considered to be a reaction-centered emotional regulation strategy, which regulates emotional responses by controlling emotional expression behaviors that are about to occur or are occurring (Gross, 2010). In stressful situations, suppression may be used in an attempt to change or avoid negative thoughts and feelings (Kashdan et al., 2006). Previous studies have reported that mood regulation strategies are often important regulatory variables affecting psychological changes in task conflict situations. For example, suppression can moderate the effect of social anxiety on positive emotion (Kashdan and Breen, 2008). Similarly, we speculate that suppression moderates the impact of family-work conflict on positive psychological capital and perceived social support, affecting the improvement of post-traumatic growth. According to the above argument and speculation, when an individual's level of suppression is high, their perceived social support and positive psychological capital levels decrease slowly with increased family-work conflict. Thus, high suppression maintains the level of perceived social support and positive psychological capital under conditions of increased family-work conflict, contributing to the realization and improvement of post-traumatic growth. Strong negative emotions are typically stimulated in family-work conflict situations, and suppression is likely to inhibit the expression of negative emotion. First, suppression strategies minimize the effects of negative stimuli by ignoring negative stimuli (e.g., family work conflicts) and avoiding paying attention to or recalling negative stimuli (Olson and Zanna, 1979). Second, suppression has a buffering function. By reducing the expression of negative emotions in stressful situations, suppression can prevent the expansion of negative emotions, playing a protective buffer role for emotions (Coifman et al., 2007). Third, regarding suppression as a targetoriented strategy, positive cognitive style has been examined using negative stimuli for a wide range of thoughts (Langens and Mrth, 2003), including a sense of mission, recognition of the importance of community, and the occurrence of familywork conflict from family concerns and care, which can be adopted as ways of helping individuals experience positive emotions and attitudes (Boden and Baumeister, 1997). When the suppression level is low, individuals do not suppress negative emotional expression. When negative emotions are experienced as overflowing, the individual experiences an increasing influence of negative emotions, which can lead to a gradual increase in stress. On the one hand, positive psychological capital and perceived social support can alleviate the individual's response to pressure. On the other hand, the individual can also be exhausted by constant stress (Zhang et al., 2013;Yang and Ye, 2014). Therefore, with increased family-work conflict, the levels of perceived social support and positive psychological capital decrease sharply, which is not conducive to the realization and improvement of post-traumatic growth. Thus, we proposed Hypothesis 3: Suppression plays a moderating role in the relationships among family-work conflict, psychological capital and social support. Besides, high suppression can buffer the negative psychological impact of family-work conflict. --- MATERIALS AND METHODS --- Participants A total of 1,347 Chinese medical workers took part in the survey, including 333 men with an average age of 35.59 years (standard deviation [SD] = 8.057, range = 20-60 years) and 1,014 women with an average age of 31.34 years (SD = 6.920, range = 20-60 years). The participants had different operational roles (doctor, medical technician, nurse, administrative logistician). Among the participants, 458 were unmarried, 871 were married, 17 were divorced, and one was widowed. --- Measures --- Family-Work Conflict The five-item Family-Work Conflict Scale (Netemeyer et al., 1996) was used to measure participants' family interference with work (FIW) conflict. Example items included "The demands of my family or spouse/partner interfere with work-related activities" and "Family-related strain interferes with my ability to perform job-related duties." Participants were instructed to evaluate each statement against their own situation on a fivepoint Likert scale (1 = strongly disagree, 5 = strongly agree). The family-work conflict index was calculated as the total score of these five items (Cronbach's <unk> = 0.935, Guttman split half = 0.908), with higher scores representing a greater degree of family-work conflict. --- Post-traumatic Growth The Post-traumatic Growth Inventory (PTGI), (Tedeschi and Calhoun, 1996) was used to assess the general tendency to experience difficult events that produce perceived benefits, focusing on various benefits that may be found or explained. The inventory contains 21 items divided into five dimensions: appreciation of life, personal strength, new possibilities, relating to others, and spiritual change (Cronbach's <unk> = 0.959, Guttman split half = 0.928). Participants responded on a six-point scale from zero ("I did not experience this change as a result of my crisis") to five ("I experienced this change to a very great degree as a result of my crisis"). Higher scores indicate more post-traumatic growth. --- Positive Psychological Capital The 26-item Positive Psychological Capital Questionnaire (PPQ), (Zhang et al., 2010) was used to measure the general positive psychological state of individuals during their growth and development (Cronbach's <unk> = 0.908, Guttman split half = 0.847). The questionnaire was divided into four dimensions: self-efficacy (items included "My insights and abilities are above average"), resilience (items included "When I encounter setbacks, I bounce back very quickly"), hope (items included "I study and work actively to realize my dreams") and optimism (items included "I think life is good"). Participants responded to each item on a 7-point Likert scale, with higher total scores indicating a higher level of psychological capital. --- Perceived Social Support Multidimensional Scale of Perceived Social Support (MSPSS), (Zimet et al., 1988) is a self-report method for subjective evaluation of social support. Twelve items were used to measure the degree to which individuals perceive support from various social support sources such as family and friends (Cronbach's <unk> = 0.965, Guttman split half = 0.940). Items included "My family really tries to help me" and "I can talk about my problems with my friends." Participants responded on a 7-point scale from one (strongly disagree) to seven (strongly agree). The total score of the scale represents the overall social support, and higher total scores indicated a greater degree of social support. --- Suppression Suppression was measured using the items of the suppression dimension of the Emotion Regulation Questionnaire (ERQ), (Gross and John, 2003), (Cronbach's <unk> = 0.742, Guttman split half = 0.723). Four items were used to measure the emotion regulatory process by suppression strategy, which included "I control my emotions by not expressing them" and "When I am feeling negative emotions, I make sure not to express them." Each item was scored on a 7-point Likert scale from one (strongly disagree) to seven (strongly agree). Higher scores indicated greater use of suppression strategies. --- Procedure This research has been reviewed and approved by the Committee of Protection of Subjects (ICNL IRB) at Renmin University of China. We collected data on family-work conflict, post-traumatic growth, positive psychological capital, perceived social support, and suppression among medical workers in a city in China. The survey was conducted from October 14 to 24, 2020. After providing informed consent, medical workers were instructed to participate in an online survey via a questionnaire platform. The survey included the family-work conflict scale, the post-traumatic growth inventory, the positive psychological capital questionnaire, the multidimensional scale of perceived social support, and the suppression dimension of the emotion regulation questionnaire. Upon completion of the online questionnaires, medical workers were asked to fill out their demographic information. --- Statistical Analysis SPSS Statistics 21.0 software was used for statistical analyses, including correlation analyses and linear regression analyses. To further test the moderated mediation effect, the Bootstrap method was applied and Process Model 4 was used (Hayes, 2013). The mediating and the moderating effects were integrated into the same analytical framework to verify the moderated mediation model. --- RESULTS --- Preliminary Analyses Table 1 shows the descriptive statistics and correlations among all variables. The results revealed that post-traumatic growth was significantly negatively correlated with family-work conflict (r = -0.255, p <unk> 0.01), partially verifying Hypothesis 1. Positive psychological capital (r = 0.644, p <unk> 0.01) and perceived social support (r = 0.554, p <unk> 0.01) were significantly positively correlated with post-traumatic growth to different degrees. Family-work conflict was negatively correlated with positive psychological capital (r = -0.405, p <unk> 0.01) and perceived social support (r = -0.407, p <unk> 0.01). There was no significant correlation between suppression and family-work conflict (r = 0.01, p = 0.722), indicating that the two factors were independent. --- The Mediate Effect of Positive Psychological Capital and Perceived Social Support In linear regression, family-work conflict negatively predicted post-traumatic growth (B = -1.136, 95% CI [-1.367, -0.906], SE = 0.117, t = -9.676, p <unk> 0.001). To examine whether positive psychological capital and perceived social support mediated the correlation between family-work conflict and post-traumatic growth, the Bootstrap method was applied, and Process Model 4 was used (Hayes, 2013) Further analysis revealed that positive psychological capital and perceived social support played mediating roles in the path from family-work conflict to post-traumatic growth (see Figure 1). The Bootstrap method was used to test the significance of mediating effects with 1,000 Bootstrap samples (Preacher and Hayes, 2008). The results revealed that family-work conflict had a significant indirect effect on post-traumatic growth through positive psychological capital (B = -0.910, 95% CI [-1.090, -0.732], SE = 0.092). Family-work conflict had a significant indirect effect on post-traumatic growth through perceived social support (B = -0.450, 95% CI [-0.600, -0.322], SE = 0.073), (see Table 2). Thus, Hypothesis 2 was supported. --- The Moderate Effect of Suppression The results revealed that the interaction between family-work conflict and suppression had no significant predictive effect on post-traumatic growth (B = -0.045, 95% CI = [-0.102, 2). The regression coefficients of the three models are presented in Table 3. To further analyze the moderating effect of suppression, we constructed a moderating effects diagram of suppression. When participants exhibited high suppression (+1 SD from the mean), the mediating effect of positive psychological capital (B = -1.046, 95% CI [-1.312, -0.833]) was lower than that for participants with low suppression (-1 SD from the mean), (B = -0.774, 95% CI [-0.994, -0.597]). The results revealed that high suppression can buffer the negative effect of family-work conflict on positive psychological capital (see Table 4 and Figure 3). 4 and Figure 4 shows that the mediating effect of perceived social support under conditions of high suppression (B = -0.356, 95% CI [-0.511, -0.235]) was lower than that under conditions of low suppression (B = -0.547, 95% CI [-0.768, -0.397]). The results revealed that high suppression can buffer the negative effect of family-work conflict on perceived social support. Thus, Hypothesis 3 was verified. --- The analysis of results shown in Table --- DISCUSSION The current study examined the roles of positive psychological capital, perceived social support, and suppression in familywork conflict and post-traumatic growth among medical workers during the COVID-19 pandemic. The results revealed that family-work conflict negatively predicted post-traumatic growth, and reducing family-work conflict effectively enhanced posttraumatic growth. Furthermore, positive psychological capital and perceived social support were found to play a mediating role in this process, and family-work conflict decreased positive psychological capital and perceived social support, further reducing post-traumatic growth. Moreover, suppression played a moderating role in this process, and a high level of buffer the harm of family-work conflict to positive psychological capital and perceived social support. With a high level of suppression, the negative effects of family-work conflict on positive psychological capital and perceived social support were reduced, thus reducing the negative effect of family-work conflict on post-traumatic growth. The most important implication of the current findings is that, under the severe pressure of COVID-19 prevention and control, and the reality of substantial conflicts between family and work, medical workers with low levels of suppression in a state of constantly heightened, constantly to express their emotional expression were less able to resolve practical difficulties; rather, because negative emotions were experienced as overflowing, make it continue in the negative or pessimistic thoughts (Kim et al., 1998). A high degree of suppression can significantly alleviate the negative effects of family-work conflict on positive psychological capital and perceived social support (Zhou and Wang, 2012). These findings suggest that, when medical workers are subjected to severe family-work conflicts, efforts to restrain the expression of emotions can help maintain their level of positive psychological capital and perceived social support, thus improving post-traumatic growth. Although this result conflicts with a previous report that suppression is associated with low self-esteem and is detrimental to establishing intimate relationships with others and thus to individual growth (Farmer and Kashdan, 2012), it is consistent with the conclusions of previous studies in some stress or disaster scenarios. For example, some studies have found that the transformation of post-traumatic stress disorder to post-traumatic growth leads to more emotional expression suppression strategies (Tian et al., 2016). In the current study, this may have occurred because medical workers who had experienced pandemic trauma were still experiencing high family-work conflict. By adopting a high level of suppression strategies, individuals may have been able to buffer the negative consequences of family-work conflicts, effectively protecting their internal positive states and external support resources. Moreover, our results also suggest that the applicability of suppression strategies can be discussed in a wider range of applications, and may be related to environmental features (Aldao, 2013), particularly cultural factors. A previous study reported that, in countries with more individualistic cultures, the role of suppression is typically negative, whereas in countries with more collectivist cultures, suppression tends to have positive influences on emotional experience, interpersonal relationships, and psychological and social adaptation, which can weaken or even reverse negative relationships with positive outcome variables (Liu et al., 2016). This finding was supported by the current results. In collectivist cultural contexts, individuals are often required to exhibit restraint and remain calm (Soto et al., 2011), and self-dependence involves a tendency to adopt inhibition strategies to achieve interpersonal harmony (Yang and Lu, 2009). Therefore, high levels of suppression may be encouraged and praised. If this behavior persists over a long period of time, the stress state can become aggravated. Thus, in this continuous stress state, the individual's positive psychological capital and perceived social support may also be damaged, which is not conducive to the realization of post-traumatic growth. In the face of pandemic trauma and objectively intensified family-work conflict, medical workers controlling emotions by suppressing emotional expression, avoiding emotional expression in positive or negative mood states, and hiding emotions can effectively alleviate family-work conflict. In turn, this process can promote self-efficacy, resilience, hope, and optimism among medical workers, helping to maintain the feeling that there are others around to share happiness and sorrow with and who can offer help and support, which facilitates the maintenance of good interpersonal relationships. Further investigation of cross-cultural dynamics and the complexity of this model will be required to elucidate these issues in more detail. Consistent with previous cross-cultural studies, the current findings support the positive effects of suppression, which is consistent with previous cross-cultural studies and extending the findings of previous studies of suppression. The current results also revealed negative effects and path mechanisms of family-work conflict on post-traumatic growth. The results revealed that positive psychological capital and perceived social support played mediating roles in the negative impact of family-work conflicts on post-traumatic growth. This conclusion fits with the logic of the J-DR model and COR theory. Family-work conflict and work requirements can impair positive psychological capital, perceived social support, and other work resources, which is not conducive to the growth and development of the individual. Furthermore, individuals can fully utilize personal resources (such as positive psychological capital), and, with the help of external factors (such as perceived social support), cope with high-pressure environments to achieve good outcomes (Hobfoll, 2002). The current study has several limitations, and the findings should be treated with caution. First, the survey was conducted <unk>6 months after the outbreak of pandemic, and, as pandemic developed, the various conditions and performances of medical workers may have changed accordingly. Thus, it may be useful to further track the study population and extend the current findings. Second, the current study only involved academic research, and interventions with medical workers have not yet been conducted to promote appropriate psychological adjustment based on the relevant conclusions of this study. Third, the current study only used self-report measures, and did not assess personality traits involved in post-traumatic growth and suppression strategies. In the future, a variety of assessment methods can be added, and the corresponding influencing factors can be added to make the research results more effective. Therefore, based on the current findings in the context of the COVID-19 pandemic, we propose the following recommendations: first, medical workers should be encouraged to use methods to avoid family-work conflict, reduce negative emotion expansion, and enhance positive cognition, and effectively use suppression strategies to enhance their individual internal strength and external resources; second, rather than focusing excessive attention on medical workers themselves, we should avoid exacerbating the pressure they experience and depleting their psychological resources and should direct more care to the families of medical workers, helping to effectively resolve difficulties and needs in the family. --- DATA AVAILABILITY STATEMENT The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- ETHICS STATEMENT The studies involving human participants were reviewed and approved by Committee of Protection of Subjects (ICNL IRB) at Renmin University of China. The patients/participants provided their written informed consent to participate in this study. --- AUTHOR CONTRIBUTIONS ML and XT contributed to all aspects of work for this article. CX contributed to conception, and design and revising the article critically. JZ contributed to data analysis and revising the article critically. SH contributed to revising the article critically. All authors contributed to the article and approved the submitted version. --- Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Publisher's Note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Under the impact of COVID-19, the status and mechanisms of post-traumatic growth among medical workers facing challenges related to family-work conflict are of great concern. In view of the complex relationship between family-work conflict and post-traumatic growth, the present study sought to explore the specific relationships between family-work conflict and post-traumatic growth as well as the specific roles of positive psychological capital, perceived social support, and suppression. We recruited 1,347 participants. The results revealed that positive psychological capital and perceived social support played mediating roles, while suppression strategies moderated the mediating effect. Compared with the low suppression group, the negative impact of family-work conflict on positive psychological capital and perceived social support was reduced in the high suppression group. Thus, a higher level of suppression was more conducive to post-traumatic growth. The current study enriches and expands the findings of previous studies in theory and provides practical ways to promote post-traumatic growth in medical workers.

INTRODUCTION The United Nations' (UN) Sustainable Development Goals (SDGs), the triple bottom line approach to sustainability (i.e. economic, social and environmental value) and the Environmental Social and Governance (ESG) agenda have led to an increased interest in social value. The definition of the term'social value' is under construction and is often used interchangeably with 'wellbeing'. Despite a broad acknowledgement of the importance of social outcomes (e.g. a sense of belonging, pride, and cohesion to individuals and communities), social needs, challenges and opportunities continue to be misunderstood and deprioritised. There is a widely recognised need for social considerations to be better defined, interpreted, negotiated, measured, assessed, and designed into buildings and places. Advocates of social value tend to be motivated by this desire to find a way to define, optimise, and measure impacts on quality of life and wellbeing. These outcomes have traditionally been considered hard to measure. However, definition and measurement are needed to ensure they are taken into account within the valuation exercises that characterise many societies' audit culture. Wellbeing is a dimension of 'intrinsic value' (Bunting 2008), an aspect of experience of the individual, community or society, that is 'best evaluated qualitatively, or with a mixture of qualitative and quantitative methods' (Crossick & Kaszynska 2016: 8). Yet it is difficult to include intrinsic value in the spreadsheets that dominate the value management of our built environment, which is why it is so frequently omitted from these critical documents. There is also a need to understand better the relative importance of different dimensions of social value. A consistently strong and well-understood theme within the literature of wellbeing, quality of life and social value is a connection with nature. Should it therefore be more heavily weighted in models of social value measurement? An absence of means to enumerate quality of life has led to its neglect as a field, a situation which is rapidly changing with the advance of the social value agenda as well as improvements in technology. --- CONTEXT As guest editors of this special issue, we span industry and academic expertise on social value with a particularly British outlook that has been expanded through the process of writing this editorial. In the UK, the Public Services (Social Value) Act 2012 1 sets out a requirement for organisations being awarded public money to demonstrate social value delivery. It took a while for social value to catch on in procurement and bidding processes, with construction companies taking the lead with a highly professional approach to enumerating the social value of the construction phase, most notably through the creation of jobs and local supply chains, yet often governed by tick-box processes that are prone to exploitation. It was out of a sense of frustration with the problematic and erratic way in which project bids are evaluated and won that a group of leaders on research in architectural practice (including us) began work on the Royal Institute of British Architects' (RIBA) Social Value Toolkit for Architecture. This set out a range of ways in which the design of housing could impact the wellbeing of people (Samuel et al. 2020). We started by reviewing the literature of 'wellbeing', defined in the Oxford English Dictionary as 'the state of being comfortable, healthy or happy'. We also examined measures relating to the value of green spaces such as 'natural capital' (Natural England 2011;GLA 2017) and 'ecosystem services', which also address the positive impacts of nature on people. The New Economics Foundation's Five Ways to Wellbeing (Aked et al. 2011) was a particularly useful resource, as was the Canal and River Trust's (2017) review of wellbeing literature, Waterways and Wellbeing (2017). Our conclusion was that although there was much agreement on the constituent attributes of wellbeing across a range of grey (industry and charity) literature reports, a wide variety of different wordings was being used for the same thing. At the same time there is a multitude of overlapping definitions of social value, social assets and social capital (Alesina & La Ferrara 2002). This lack of clarity on what constitutes wellbeing is typical of a private sector-driven field that lacks government leadership in developing an agreed shared framework for evaluation. Drawing together the findings of a literature review, Samuel et al. (2020) argued that the social value of housing is in: fostering positive emotions whether through connections with nature or offering opportunities for an active lifestyle, connecting people and the environment in appropriate ways and in providing freedom and flexibility to pursue different lifestyles (autonomy). Participation, supporting communities to help design and build their homes and neighbourhoods has social value too. These, we argued, could be used as headline outcomes for capturing the social value of housing. We offered a range of post-occupancy evaluation (POE) questions which could then be used to tease out aspects of each theme, e.g.'my neighbourhood gives me opportunities to stop and communicate with other people'. The Social Value Toolkit for Architecture has since been enshrined within RIBA's Sustainable Outcomes Framework, and social value has been built into its (post-Brexit) educational requirements meaning that, at last, budding architects will learn how to take it into consideration. During the process of writing the Social Value Toolkit for Architecture we became increasingly aware that social value is highly context and place specific. The spatialising of social value in maps was the focus of the Mapping Eco Social Assets project, which involved the making of layered maps using the measures set out in the Social Value Toolkit for Architecture. In 2019, focusing on a council-owned estate in Reading (UK), Samuel working with Eli Hatleskog led a series of workshops with residents of different ages and backgrounds, including school children, in which they cocreated social value maps of their area based on Social Value Toolkit criteria. 'Asset mapping' with communities has become a common occurrence in the UK. What made this exercise innovative was the creation of layered value maps, with potential for quantification, revealing social value hotspots across the area. It also showed how important it is for social value to be spatialised, calling into question the recent UK tendency to monetise social value using social return on investment (Hatleskog & Samuel 2021). Much debate exists about whether it is best to collect data from people by asking them questions (active data) or to use the census and other sources to infer what is needed (passive data). Stated preference research shows how little correlation there can be between what people say and what they do (revealed preferences) (Engstrom & Forsell 2018). In one interesting case, the citizens of Yarmouth (UK) complained of misrepresentation through the statistics about levels of social infrastructure (Thomas 2021). Their lived experience was at odds with the things that had been measured. There is a delicate balance to be achieved between active and passive data, the main thing being that communities must have the power to understand, and contest if necessary, the data being collected about them as well as the methodologies used to collect them. As Criado Perez (2019) has made clear, the way that data are collected is rarely objective. --- VALUE AND AUDIT Value, the worth of something, is a contradictory word. On the one hand, it is 'the capitalist category par excellence' (Phillips 2015) and a medium of control, and, on the other, it can be a tool for accountability, and inclusion (Groak 1992: 117). The way in which the built environment sector too often talks about 'value' has to change, not least because it designates as valueless all 'forms of economic activity that are informal, community based, and driven by collaboration and sharing' (Fioramonti et al. 2019: 207). That there is an inherent problem in the way economies are measured and audited is widely recognised (Raworth 2017;Mazzucato 2018). In an audit culture, performance is measured against predetermined targets. Audit always begins with classification. Classifications are 'powerful technologies' that are both 'political and ethical' (Bowker & Leigh Star 2000). The basis for government decision-making in the UK is HM Treasury's Green Book (UK Government 2013), which weighs up costs against benefits. This process is performed in an increasingly evidence-based way (Donovan 2013: 4). Recent positive improvements to the Green Book point in the direction of a system based on environmental and social, as well as economic, value, i.e. the triple bottom line of sustainability. Whilst there is a long tradition of economic valuation, however flawed, and some solid measures for environmental value-carbon (embodied and operational), biodiversity, etc. However, social value (the focus of this special issue) is very much a work in progress. Housing must be valued against social, environmental and economic indicators over long periods of time as the UK Green Building Council's (UKGBC) Social Value Framework makes clear. According to the UKGBC, social value 'encompasses environmental, economic and social wellbeing' (UKGBC 2021: 7). Notice the slippage here between 'value' and 'wellbeing'. It is also important to note the rise of 'cultural value', not as a subset of social value but as a category in its own right. In the UK work continues apace on the development of valuation systems for procurement, most notably the very considerable investment that has gone into the creation of the Construction Innovation Hub Value tool, which is founded on a 'five capitals' approach. Here social value sits uneasily across categories of 'human' and 'produced' value. It also has an uneasy fit with the commonly used UN SDGs as can be seen from the RIBA Sustainable Outcomes Guide (Clark 2019). --- DEFINING SOCIAL VALUE Social value as a terminology originally emerged from early ideas of corporate responsibility, ethical economics, and the social enterprise and valuation literatures (Zadek 2004;Richmond et al. 2003). The need to measure and evidence the social value delivered by organisations led to the rise of increasingly sophisticated social auditing and accounting techniques (Zadek 2004), and a third-sector explosion in innovative impact reporting practices specifically (Nicholls 2009). In terms of the built environment, the concept of social value has been previously applied to consider the impact of design to wider society beyond the building, such as in built environment policy (Macmillan 2005), and has also been considered in terms of its applicability to people-focused post-occupancy research (Mulgan et al. 2006). Social value has more recently achieved significant traction in UK public sector policy through the Public Services (Social Value) Act 2012, and it remains both an increasingly high-profile yet elusive concept. In the Act it is defined as the 'economic, social and environmental wellbeing of the relevant area', emphasising the triple bottom line of sustainability, alongside a geographical component that encourages the localising of benefit. Social Value UK, a recognised industry body for social value, takes a wellbeing measurement-focused definition that emphasises the need for a people-led perspective. More recently, the concept of 'quality of life' has further contributed to the agenda through the work of the Quality of Life Foundation and others (URBED 2021). A key issue that still needs articulation is the question of social value for whom. The advent of the Well-being of Future Generations (Wales) Act 2015 2 brings into relief the fact that social value extends beyond our own generation and into the future, a principle that has been adopted by wellbeing economy (WEGO) governments such as Iceland and New Zealand. --- CONTRIBUTIONS IN THIS SPECIAL ISSUE The call for papers attracted 33 abstracts. Twelve full papers were submitted and, of these, eight (plus this editorial) are published in this special issue (Table 1). --- THE CONSTITUENTS OF SOCIAL VALUE The constituent dimensions of social value are fluid. The creation of jobs reads strongly in construction sector definitions of social value. This tends to be limited to the ability to wrap mechanisms around the construction process to encourage more inclusive employment and skills opportunities during delivery of projects. Instead Troje describes a novel approach in which housing companies in Sweden build employment opportunities for tenants in the longer term, delivering a wider range of constituent outcomes relating to social value. This speaks to the changing role of housing companies and associations as the shapers and stewards of place, community and wellbeing. Their ability to do this depends very largely on the way in which they are funded and evaluated. --- CONTEXTUALISING SOCIAL VALUE Defensible Space on the Move (Lees & Warwick 2022) charts the history of the concept of defensible space as it has morphed over time. It feels a similar account of social value is very much needed, hence the value of Raiden & King's critical enquiry into the topic herein, which unpacks the tension that exists between universalist approaches to social value as opposed to those that recognise its contextual nature, uncovering the diversity of current social value practice and measurement. The impact of different types of subjectivity on understandings of social value is profound. This is a theme also explored by <unk>d<unk>k on the politics of social value. <unk>d<unk>k usefully introduces three types of politics of social value: analytical politics, participatory politics and lived politics, revealing the underlying negotiation, compromise and decision-making that occurs in efforts to create social value in the built environment, with implications for a deeper and more democratic understanding of what social value means. --- METHODOLOGICAL SCHEMAS Social value is often deployed as a metric that attempts to capture quality of life so that the'social' can be seen alongside other kinds of valuation in national accounting. The capabilities approach resists the idea that important elements of quality of life 'can be reduced to a single metric without distortion' (Nussbaum 2011: 18), but offers a means to 'package comparative information in such a way as to reorient the development and policy debate' ( 17). That there is potential to use a capabilities approach as a foundation for measurement of wellbeing is an underexplored area (Robeyns 2016), particularly in the context of the built environment. There is work to be done in aligning social value with capabilities, the focus of Dissart & Ricaurte who provide a useful exploration of their relationship in the context of housing. --- CONSERVATION AND SOCIAL VALUE The heritage sector has its own distinct social evaluation categories such as Historic England There is dislocation between discussion of 'heritage value' and construction industry definitions of intangible impacts. The process of assigning significance to buildings is increasingly being recognised as a socio-cultural activity, not just a technical one (De La Torre & Mason 2002). The case for intangible heritage was advanced through the Burra Charter (instigated by Australian ICOMOS (International Council on Monuments and Sites) in 1979 and regularly updated), a groundbreaking moment in conservation debate (ICOMOS 1999). More recently, Madgin and others are developing more 'people centred' approaches to conservation practice (Madgin & Lesh 2021), but further work in this area is needed, hence the importance of Skoura & Madden's paper on the social value of historic shopping arcades, which conceptualises heritage as a varying process by which communities ascribe value in different ways to heritage places, and emphasises the need for more inclusive heritage narratives that recognise the many ways that value is derived from built heritage assets. --- EVALUATING INFRASTRUCTURE AND PLACES There is a lack of examples of social value-based evaluation of housing. Three papers in the special issue form an important body of work in this area. These papers help to demonstrate how wellbeing and empowerment can be included in design and development decision-making, and what more democratic planning processes might look like which take a more nuanced appreciation of stakeholders and the differing ways they place value on place. --- NEW KNOWLEDGE GAINED The papers herein offer a transect of social value research across the globe in ageing industrialised societies often oriented around a neoliberal (economic) agenda. They give flesh to a currently very schematic understanding of the subject. It is notable that a large number of the submissions come from the field of architecture, a field that has much to gain from the advance of social value because of its ability to capture the intangible impacts of good design. Much of the knowledge gained pertains to POE at the scale of a building and the ways in which POE might be theorised and refined to address the'social'. --- CURRENT CHALLENGES FOR RESEARCH AND PRACTICE --- GAPS IN UNDERSTANDING It is notable that no authors from the disciplines of finance, asset management or real estate responded to the call for papers. This is a shame as the concept of social value is increasingly being considered within practitioner discussions about the genuine measurement and meaningful reporting of ESG and the discipline of social performance. This is just one example of the ways in which disciplinary and professional silos are impacting the development of the field. In the UK, the Department of Levelling Up, Housing and Communities is seeking to align the way data are collected across local authorities in order to facilitate the development of a more data-driven and automated planning system. The hope is that such initiatives will inspire greater cross-disciplinary collaboration in these areas. Samuel & Watson Buildings and Cities DOI: 10.5334/bc.399 --- LEADERSHIP AND SILOS Although it is increasingly broadly applied, the term'social value' comes from the parlance of procurement. Whilst other disciplines, e.g. design (Design Council 2018), are interrogating the nature of their contribution to the world, they are not connecting meaningfully with debates on social value. There is a lack of leadership to develop frameworks of social value that are inclusive enough to embrace a wide range of fields while being baggy enough to encompass variety. Samuel ( 2023) is moving away from specific measuring schemas. Instead, she advocates the collection of data layers that can be reconfigured and clustered in relation to local outcomes framework. In the case of her most recent project, the Public Map Platform, a method will be developed to cluster data layers in order to report on progress towards the Future Generations (Wales) outcomes. which will create baseline maps to reveal the attainment of the Future Generations (Wales) outcomes spatially using geographic information system (GIS) technologies. It is interesting to speculate what the impact of the recently developed indoor GIS system, coming with an ability to pinpoint outcomes on the interior of buildings, will be. The Happy Homes Toolkit currently in development by the architectural practice Pollard Thomas and Edwards in collaboration with the University of Reading is developing a mechanism to map and predict social value through building information modelling (BIM). 5 Such projects anticipate the automation of social value capture and the development of a digital planning system built on data. There is much talk of digital twin-city models that anticipate the performance of places and buildings. That these are currently being developed with little consideration of wellbeing is alarming. --- SPATIALISING AND DIGITISING SOCIAL VALUE --- IMPLICATIONS OF SOCIAL VALUE FOR LESS ECONOMICALLY DEVELOPED NATIONS The potential of social value for valorising buildings and places of high value to communities in less economically developed nations must be acknowledged. This is particularly important in circumstances of economic investment and gentrification. Expert-led post-occupancy and neighbourhood assessment frameworks such as Leadership in Energy and Environmental Design (LEED) and the WELL Building Standard, 6 prevalent across the globe, claim to be holistic tools, but have traditionally put a strong emphasis on environmental performance and building amenities, perhaps because wider social outcomes are considered so hard to measure. More effort needs to be made to make them more sensitive to cultural and environmental context (Alabbasi 2023). The Building Research Establishment Environmental Assessment Method (BREEAM) has recently been reviewed to pay greater emphasis to 'health, wellbeing and social impact'. 7 This is particularly welcome if such tools are to be used in the context of less developed nations where professional claims to sustainability have powerful traction with planners, funders and governments. An example might be the building of a tower with an 'excellent' sustainability rating that displaces an established 'informal' settlement. It is highly questionable whether such a tower is truly 'holistically' sustainable in the long term. Social value provides a language to change the dominant narrative of economic development. Social, environmental and economic value need to be treated as equals in order to address long-term and interconnected challenges such as climate change. After all, climate change can be framed as a social justice issue. --- COMPETING INTERESTS The authors have no competing interests to declare. Samuel Selected writings of Richard Zadek, 1993-2003. Greenleaf.

The concept of social value has gained significant prominence in recent years in some countries, yet remains misunderstood. There is a recognised need for it to be better defined, interpreted and embedded in planning, design and operation. This will entail measurement and assessment. Social value is increasingly being considered alongside issues of quality of life and wellbeing, to both the individual and the community, but it remains challenging to reconcile social value in a meaningful way with the present value management approaches that dominate the construction and real estate industries. This special issue brings together a series of contributions to current thinking and critical discussion on social value, including empirical research from across the UK, Europe and Australia. It points to both new practices for the planning, design, construction and operation of projects. It identifies a series of gaps in the research, most notably a discussion of social value in the context of real estate, valuation and 'environmental, social and corporate governance' (ESG).

Introduction Almost two years after the initial outbreak of SARS-CoV-2, the virus that causes COVID-19, several variations of the virus that appear to be more infectious continue to pose a grave threat to global public health. The World Health Organization (WHO, Geneva, Switzerland) and the U.S. Food and Drug Administration (FDA, Silver Spring, MD, USA) have recommended effective vaccine coverage as the single most important strategy to control the ongoing COVID-19 pandemic. Several vaccines are now approved under the emergency authorization for administration to the public [1], and federal, state, and local governments have prioritized their effort to improve vaccination rates [2]. However, minority groups who choose not to be vaccinated or do not have access to COVID-19 vaccines may complicate those efforts [3]. Substantial barriers to vaccine uptake include one's ability to access the vaccine (e.g., transportation, cost, and location of services). In addition to these concerns, a significant barrier to uptake, particularly among minority populations, is vaccine hesitancy, which refers to the delay in the acceptance or refusal of vaccines despite availability [4], at least partly attributed to mistrust in the health care system and in the vaccine itself. The accelerated development and approval of COVID-19 vaccines has led to increased skepticism about the safety and effectiveness of these vaccines, particularly among people with lower socioeconomic and education status, minority racial and ethnic populations, and persons with co-morbidities [5][6][7][8]. Latkin et al. [6] used a social-ecological model to describe the lack of trust in the COVID-19 vaccine on individual (e.g., concerns about side effects and purity of vaccine ingredients, fear of vaccine-induced infection, preventive misconception, and medical and government mistrust), social (e.g., norms of social approval of vaccine), and societal (e.g., trust in sources of information and equitable access to the vaccine) levels [6]. Groups with higher levels of COVID-19 vaccine hesitancy are often the same groups with higher co-morbidities rates due to various issues related to the intersectional stigma, accessibility, and affordability of healthcare services [9][10][11][12][13]. Individuals with some medical co-morbidities are at greater risk of a severe disease once infected with COVID-19, particularly those with compromised immune systems [14][15][16][17]. People with HIV (PWH) may be at higher risk of developing a severe case of COVID-19 due to overlapping co-morbidities, especially among those with unsuppressed HIV [17][18][19][20]. Additionally, COVID-19 has also disrupted healthcare services for PWH, including behavioral therapy [19,21]. Nonetheless, barriers to vaccination (e.g., accessibility, affordability, and mistrust) among PWH are limiting vaccine uptake, increasing their risk for adverse consequences, and greater rates of COVID-19 deaths among this population [16,22,23]. These factors place this subgroup in a unique circumstance to maximize efforts to avoid compounded threats to their immune systems [18]. Additionally, ongoing systemic discrimination and a perceived failure of health care organizations to build trust with PWH contribute to medical mistrust and potential hesitancy to receive COVID-19 vaccines among PWH [8,23]. Understanding and addressing vaccine hesitancy is important to ensure improved vaccine uptake. Given the increased risk for compounded consequences of COVID-19 among PWH, we sought to investigate vaccine hesitancy among a national sample of PWH in the United States. --- Methods --- Study Design and Participants We conducted a cross-sectional online survey of PWH living in the United States between December 2020 and January 2021 to evaluate their attitudes toward the COVID-19 vaccine. At the time of the study, the FDA was in the process of granting emergency use authorization to two mRNA vaccines (Pfizer/BioNTech: 11 December 2020 and Moderna: 18 December 2020). In the U.S., healthcare workers and nursing home residents were prioritized for initial vaccination. --- Study Procedures Study procedures are reported as per the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines [24]. We used G*Power 3.1 (Heinrich Heine Universitat Dusseldorf, Düsseldorf, Germany) [25,26] to conduct a power analysis to determine the minimum sample necessary to detect significance, assuming <unk> = 0.05 and power (calculated as: 1-<unk>) = 0.80, with a conservative effect size of d = 0.10 [27], resulting in a minimum sample size of 779. We recruited a convenience sample of PWH using an online recruitment strategy. Specifically, participants were recruited through paid advertisements on social media and social networking platforms (e.g., Facebook, Instagram, and Grindr), HIV/AIDS service and community-based organizations within the U.S., and peer referrals. On the social networking site, we used targeted banner advertisements that appeared in two ways: (1) a static ad on the right-hand panel of the website; or (2) an ad that resembled a standard post in users' social media feed. Interested users who clicked on advertisements were directed to an eligibility self-screening tool and a brief online consent form hosted by Qualtrics. The eligibility criteria included adults aged 18 and over, currently residing within the U.S. and its dependent areas, and living with HIV. Eligible volunteers completed an online consent form acknowledging that they understood the study's purpose, risks, and benefits before completing the survey. Participation in the survey was voluntary, and participants were not paid for completing the survey but instead were eligible for a lottery to win 1 of 5 $100 Amazon gift cards; no participation was necessary to enter the random drawing. Those who declined to participate were provided instructions on how they could enter the lottery. Participants who completed the survey and were interested in entering the lottery were redirected to a different website where they entered an email address that was not linked in any way to their data. On average, participants took 10 min to complete the anonymous online survey. The study protocol and the consent form were approved by the Yale University Institutional Review Board. We followed a protocol based on published standards for removing potentially duplicate cases while erring on the side of keeping, rather than removing, data in cases where a determination could not be made [28]. In particular, we first identified potential duplicates based on age, sexual orientation, and ethnicity. All cases sharing those features in common were manually examined, focusing on responses to other questions such as education, relationship status, income, device and browser information, and the survey duration. During the one-month recruitment period, 1228 participants entered the survey, and 1210 (98.5%) consented and completed the screening tool. Of the 1210 who completed screening and met inclusion criteria, 35 (2.8%) did not complete the survey. As such, the completion rate (i.e., the ratio of users who finished the survey/users who agreed to participate) of this survey was 97%. Of the 1175 who completed the survey, 42 participants were eliminated because they failed validation checks (e.g., survey duration), and 103 were not included in the analysis because they did not respond to the primary outcome question (vaccine-hesitancy items), leaving a final analytic sample of 1030 (Figure 1). --- Study Measures Sociodemographic and health characteristics: Participant characteristics included age, gender, race, sexual orientation, educational attainment, income, relationship status, political orientation (conservative, moderate, liberal, or other), years since HIV diagnosis, HIV viral load status (whether or not they are most recently virally suppressed), and whether they receive a vaccine for influenza annually. In addition to the recent (past 30 days) use of substance, participant alcohol use was measured using the AUDIT-C (screening cut-offs of <unk>4 for men and of <unk>3 for women correlated with the presence of an alcohol use disorder (AUD) [29]. Participants were also asked if they had been tested for COVID-19, if they had experienced any symptoms of COVID-19 since March 2020, and if they or anyone in their households had been diagnosed or died from COVID-19. COVID-19 vaccine-related concerns were assessed using seven items with a dichotomized response of "Yes" and "No", including "I am worried about side effects from the vaccine", "I am against vaccines in general", and "I don't trust the government to distribute vaccine fairly". COVID-19 vaccine hesitancy was measured using a modified version of the 8-item Vaccine Confidence Scale (VCS) [30]. Originally designed to assess parental hesitancy toward early childhood vaccination, we modified the VCS to measure vaccine hesitancy in adult respondents. Three new items were added to this modified scale (e.g., "Vaccines are important for the health of others in my community"). Sample items from the modified VCS included "Vaccines are important for the health of others in my community", "Vaccines are necessary to protect the health of individuals", and "Vaccines are safe." Responses were collected on a Likert-type scale ranging from 1 (strongly agree) to 5 (strongly disagree). To confirm the factor structure of the modified VCS, we conducted an exploratory factor analysis (EFA) using principal axis factoring and oblique rotation, which generated a 1factor solution with a strong internal consistency (<unk> = 0.873). The overall vaccine hesitancy score was obtained by generating a mean score for the 10 items, ranging from 1 (low vaccine hesitancy) to 5 (high vaccine hesitancy). --- Data Analysis We summarized the study participants' characteristics with descriptive statistics such as the mean, standard deviations (SD), and frequencies and their bivariate correlations with COVID-19 vaccine hesitancy. Multivariate linear regression analysis was conducted to assess factors associated with the primary outcome-COVID-19 vaccine hesitancy, assessed as a continuous variable. Covariates for the multivariate model included (if p <unk> 0.05 in a bivariate model) sociodemographic characteristics, political orientation, HIV and healthrelated attributes, personal experience with COVID-19, and concerns related to the COVID-19 vaccine. Estimates were evaluated for statistical significance based on probability criteria of p <unk> 0.05. All analyses were performed using SPSS 25.0 (IBM, New York, NY, USA). --- Results Table 1 provides a summary of the characteristics of 1030 participants (median age = 53.0 y, interquartile range (IQR) = 60.0 -41.0 y) recruited from across the United States (Figure 2). Participants had lived with HIV for 16.0 y (IQR = 26.0 -7.0 y), and most were male (89.7%), White people (66.0%), and identified as gay or lesbian (84.5%). The majority of the participants self-reported having an undetectable HIV viral load (95.5%) and a CD4 count of 200 cells/mm 3. Most (65.5%) had been previously tested for COVID-19, with 7.9% (81/1030) having tested positive at least once. Side effects (39.3%), safety (14.7%), and inequitable vaccine distribution by the government (13.6%) were the dominant concerns about COVID-19 vaccination. The mean score of vaccine hesitancy was 1.5 (SD = 0.6; in the range of 1 to 5), although 935 participants (90.8%) had a score greater than 1.0, indicating most participants reported some degree of vaccine hesitancy. The univariate and multivariable linear regression showed that the greater COVID-19 vaccine hesitancy was associated with being Black (b = 0.149, p = 0.005), single (b = 0.070, p = 0.018), politically conservative (b = 0.157, p = 0.010), "anti-vaxxer" (b = 1.791, p <unk> 0.001), concern about side-effects (b = 0.226, p <unk> 0.001), concern about safety (b = 0.260, p <unk> 0.001), and being worried that the vaccine will not be effective (b = 0.169, p = 0.008) and they were being experimented on (b = 0.287, p <unk> 0.001). Participants who were male White (b = -0.093, p = 0.008) and university graduates (b = -0.093, p <unk> 0.001) and had a CD4 count of 200 cells/mm 3 (b = -0.082, p = 0.048) and a liberal political orientation (b = -0.131, p <unk> 0.001) were associated with lower vaccine hesitancy (Table 2). --- Discussion Our study contributes to the limited literature on vaccine hesitancy among the nationwide sample of PWH living in the U.S., revealing most participants having some levels of hesitancy concerning COVID-19 vaccination. Previously reported vaccine hesitancy rates range from 22% to 42.4% among the adult American population [5][6][7]31] and 27.5% to 38.4% among PWH across various settings [32][33][34]. It is troubling that the vaccine hesitancy among PWH in our sample fell on the higher side of these ranges, as the pandemic adversely impacts HIV care with increasing loss to follow-up or disengagement [8,35]. Although most of the participants were virally suppressed, which indicates their active engagement in health care, they were hesitant about vaccination. The context of reduced vaccination rates due to hesitancy and increasingly disengaged PWH being at an increased risk of contracting COVID-19 [36] constitutes fertile grounds to exacerbate health-related inequalities in this population. Vaccination programs need to be culturally congruent and informed by people with lived experiences to reach people who would otherwise be hesitant. Our results also indicated that race is associated with vaccine hesitancy, showing that Black PWH were more vaccine-hesitant compared to White PWH. Medical mistrust surrounding COVID-19 is high among Black PWH and presents an important and legitimate barrier to vaccination; it is rooted in systemic racism and arises as a sustained historical response to poverty, residential segregation, and previous and ongoing events featuring police violence [8]. Other factors may also contribute to this overall vaccine hesitancy, such as pre-existing reluctance towards vaccination due to prior side effects, such as decreased access to healthcare and less awareness and education regarding vaccine importance [5]. This association between race and vaccine hesitancy has been reported in the literature [5][6][7]31,37] and is concerning, as racial minorities (including Black PWH) have worse health outcomes associated with COVID-19 infection [5], with higher incidence and mortality rates among non-Latinx people who are Black, compared to among White people [38][39][40]. COVID-19 vaccine implementation should, therefore, imperatively consider racial differences in vaccine acceptance [6], especially in the context of chronic comorbidity such as HIV. Participants who had higher education levels (i.e., bachelor's degree or higher) reported lower levels of hesitancy in our sample. Other studies have found the same correlation [5,31,37], with other interlinked factors being lower income and rurality, which were not explored in our study. Decreased awareness regarding vaccination, reduced trust in and interaction with healthcare, and possible cost-related barriers within healthcare could explain why participants with a lower education level were more hesitant to get vaccinated [41][42][43][44][45]. Individuals in our sample who had an undetectable viral load or a CD4 count of >200 cells/mm 3 were less hesitant to get the vaccine. This finding is concordant with prior reports in the literature (particularly regarding an undetectable viral load), validating that individuals who are more proactive about their HIV health are more likely to have higher intentions to be vaccinated [46]. The political ideology in our sample of PWH in the U.S. was associated with vaccine hesitancy. This finding is not surprising in the context of highly polarized sociopolitical grounds across states, differential risk perceptions among individuals, and the politicization of the COVID-19 pandemic. We found that self-defined political conservatism was associated with greater vaccine hesitancy, whereas liberalism was associated with less hesitancy. Individuals identified as politically conservative may have greater distrust in the government [47][48][49], perceive lower risks of COVID-19 infection and may be less likely to engage in preventative health behaviors [50], all of which might contribute to increased hesitancy in this subgroup. Interestingly, political ideology also appears to be a stronger predictor of vaccine acceptance than political party affiliation, as found by a recently published study, highlighting the complexity of the factors at play [6]. Participants who were not in a relationship at the time of our survey (i.e., single participants) were more hesitant to get the vaccine. We speculate that a substantial proportion of single people tend to live alone, which may render them less preoccupied with transmission to family, making vaccination less of a priority. In contrast, prior published research has reported that having children at home or being a parent are negative predictors for COVID-19 vaccination, potentially because of concern for vaccine side effects that might hinder their ability to care for their children [5,51]. Further research is needed to elucidate why being a parent or caregiver contributed to vaccine hesitancy among PWH. Vaccination efforts targeting whole family involvement could be considered in this case, perhaps through school campaigns, especially as the vaccine is approved for children aged 12 years and older [52]. General concerns about COVID-19 vaccine safety and their influence on vaccine hesitancy have been a frequent finding in the literature [6,7,31] and could be linked to the expedited vaccine development and rollout in response to the global health emergency [6]. In this study, several COVID-19 vaccine-related concerns were, in the same way, correlated with vaccine hesitancy. These included concerns about the efficacy, safety, and side effects of the vaccine. Although COVID-19 vaccine hesitancy among PWH across the globe is still advancing, multiple studies have already highlighted similar findings across various settings [32][33][34]. This finding becomes especially relevant in the context of the reported mistrust in COVID-19 or COVID-19 vaccine information sources, which has also been correlated with vaccine hesitancy [8,32]. Public doubts on vaccine safety have also been strongly linked to the use of social media in organizing offline action [53]. Being against vaccination in general and believing in conspiracy theories around COVID-19 (i.e., the belief of being a part of vaccine-related experiments) were also linked to increased hesitancy in participants. Further research is still needed to effectively reduce social media misinformation [54]. However, vaccine concerns and misinformation are addressable, as future vaccine programs or interventions are implemented [7]. This study was not without limitations. It was conducted, before COVID-19 vaccines were made widely available to the public. These limitations are inherent to a survey study design, such as self-reported information from participants, social desirability and recall biases, and the lack of a control group. Given the continuous nature of the primary outcome variable (i.e., vaccine hesitancy), we were unable to make a comparison between those who were vaccine-hesitant vs. non-hesitant. Furthermore, additional, unmeasured confounding factors could have influenced vaccine hesitancy on a personal level, such as previous experiences with vaccination and hesitancy presented against flu vaccine (but not other vaccines). Our sample was also a convenient sample of participants recruited using social media advertising. Therefore, this sample is limited to individuals with access to communication technologies (e.g., phones, tablets, and laptops) and the Internet. Finally, this survey likely excluded non-English speakers, as well as those who are illiterate or not able to read and understand its contents. The findings from this study have important implications for the future implementation and planning of COVID-19 vaccine programs across the U.S. We were able to leverage an understanding of why PWH in the U.S. might be hesitant to receive vaccination and therefore attempt to guide future vaccination programs. A number of key predictors of vaccine hesitancy were identified and should be addressed in future efforts to mitigate the spread of COVID-19 through vaccination. Efforts to raise awareness about the COVID-19 disease and vaccines through messaging and education should be tailored for high-risk groups, sexual minorities, and communities of color [37,55]. Culturally competent strategies that were shown to improve health outcomes and preventive behavior in minorities should be considered in the context of COVID-19 vaccines rollout as well [41][42][43]45]. Medical mistrust surrounding COVID-19 and negatively impacts vaccination among Black PWH in the U.S. should also be addressed by dismantling its causes at the societal level (e.g., poverty, residential segregation). Systemic racism should also be addressed at the national level through leadership voices. Community-based engagement, informed by people with lived experiences, can also be used to effectively tackle COVID-19-related and -unrelated inequities [8]. In addition to tailoring public health messaging for race and ethnicity, successful mass COVID-19 vaccination also requires public health interventions to respond to safety and efficacy concerns, as well as be adapted according to political orientation, gender-based differences, and political ideologies [5]. Responding to these different factors will require a multifaceted approach incorporating clinicians, public health professionals, and authorities. In terms of general recommendations, it has been shown that advice concerning COVID-19 vaccination stemming from health care professionals is more trusted by the general American population (as compared to information from social media, for example) [6,37], including Black PWH [8]. Investing in provider-led interventions, emphasizing motivational interviewing, may support vaccine implementation efforts [31]. The increased use of telemedicine during the pandemic remains to be explored to advance vaccine implementation [6]. Potential recommendations to mitigate the effect of the fear of vaccine adverse events and safety concerns on vaccine hesitancy stress the importance of accurate and easily accessible and understandable information, as well as balancing risk and benefit information, positively framing adverse side effects, and dismantling related misinformation [56]. In order to overcome an ever-growing social media COVID-19 infodemic filled with misinformation, social media platforms must be held accountable for dismantling anti-vaccination content. Foreign disinformation should also be addressed at its source, since information warfare and anti-vaccination propaganda can be extremely harmful and fatal around the globe [53]. --- Conclusions Our findings provide important insights regarding COVID-19 vaccine hesitancy among PWH, which represents a significant barrier to successfully implementing the nationwide vaccination campaign. As new variants emerge, there is an urgent need to ensure that PWH are prioritized for COVID-19 vaccination. Ongoing efforts must ensure that PWH continue to have equitable access to vaccines and up-to-date vaccine information. The findings from this study can inform how to implement mass vaccination campaigns and reach PWH who would benefit from vaccination by leveraging an understanding of independent factors associated with vaccine hesitancy. --- Data Availability Statement: The data that support the findings of this study are available from the authors upon reasonable request. --- Author Contributions: All authors (R.S., J.P.M., S.S., A.K., F.L.A., C.M., L.A.-B., M.V., M.O. and J.A.W.) meet the criteria for authorship and have made substantial contributions to various facets of the manuscript. This manuscript was initially conceptualized and written by R.S. and J.A.W. --- Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board at Yale University (ID: 2000029426). Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. --- Conflicts of Interest: The authors declare no conflict of interest.

Introduction: Scaling up vaccination against COVID-19 is central to controlling the COVID-19 epidemic in the United States. Several vaccines are now approved for the prevention of COVID-19, but public concerns over safety and efficacy have heightened distrust and vaccine hesitancy. This is particularly concerning among people with HIV (PWH) who may be vulnerable to more severe COVID-19 disease. Here, we aimed to identify and understand COVID-19 vaccine hesitancy in a sample of PWH in the U.S. Methods: We conducted a cross-sectional online survey among PWH in the U.S. between 6 December 2020 and 8 January 2021. Measures included demographics, participants' HIV and health-related attributes, COVID-19 history and experiences, COVID-19 vaccine-related concerns, and standardized measures of attitudes towards COVID-19 vaccines. Multivariate linear regression was used to identify factors associated with vaccine hesitancy in this sample. Results: Among the 1030 respondents, most were male (89.7%), White (66.0%), and identified as gay or lesbian (84.5%). Participants' mean time living with HIV was 17.0 years (standard deviation (SD) = 11.1). The mean score for vaccine hesitancy was 1.5 (SD = 0.5; range: 1-5); 935 participants (90.8%) had a score greater than 1.0, indicating most participants had some degree of vaccine hesitancy. The final multivariate linear regression showed that greater vaccine hesitancy was associated with being Black (b = 0.149, p = 0.005), single (b = 0.070, p = 0.018), politically conservative (b = 0.157, p = 0.010), "anti-vaxxer" (b = 1.791, p < 0.001), concern about side effects (b = 0.226, p < 0.001), concern about safety (b = 0.260, p < 0.001), and being worried that the vaccine will not be effective (b = 0.169, p = 0.008) and they were being experimented on (b = 0.287, p < 0.001). Participants who were male White (b = -0.093, p = 0.008) and university graduates (b = -0.093, p < 0.001) and had a CD4 count of 200 cells/mm 3 (b = -0.082, p = 0.048) and a liberal political orientation (b = -0.131, p < 0.001) were associated with lower vaccine hesitancy. Conclusions: Our findings provide important insights regarding COVID-19 vaccine hesitancy among PWH. Further efforts are required to understand how various social, political, and psychological factors contribute to COVID-19 vaccine hesitancy among key populations.

Introduction The global rise of urbanization is linked to past challenges. Prioritizing economic, social, and environmental resilience with effective governance is crucial for having sustainable cities. Urbanization will continue with the urban population projected to reach 68% by 2050 [1]. Informal settlements and marginalization status are one of the social problems of human societies [2]. Informal settlements are places created without permission and outside the official and legal planning of urban development that do not comply with authorized regulations [3]. As reported by the United Nations, more than one billion of the world's population and about 43% of the population of urban areas in developing countries live in informal settlements. The massive growth of informal settlements has become a major challenge and debate in sustainable development of cities. Paying attention to sustainable development of cities is very important in reaching Sustainable Development Goals (SDG) of the United Nations. Goal number 11 focuses on transforming cities and informal settlements into inclusive, safe, resilient and sustainable places, which is itself related to goal number 3 that deals with providing a healthy life and promoting well-being for all ages [4]. Informal settlements do not have a suitable condition in terms of social determinants of health, and this can result in social damages and diseases [5]. People living in informal settlements are exposed to economic and social inequalities in accessing and utilizing healthcare services and experiencing health outcomes [6]. Residents of informal settlements face challenges such as lack of proper access to healthcare services; shortage of centers providing healthcare services; extreme poverty; unemployment; illiteracy and low education; gender discrimination; insufficient and poor diet; social exclusion; unhealthy living environment; non-standard housing; lack of water, electricity and basic sanitary facilities; lack of educational and recreational facilities; and high prevalence of diseases [7][8][9]. In Iran, urbanization without proper planning causes the creation of informal settlements around the cities over time [10]. According to statistics, about 11 million people of Iran live in informal settlements [11]. Marginalization can be seen in many regions of Iran. Kurdistan province is one of the provinces with the highest ratio of marginalization in Iran, so that the ratio of marginalized population in this province is three times the national average and more than half of the urban population in this province lives in marginal and isolated urban areas [12]. Providing evidence of status of need, access and unmet healthcare needs along with their causes in informal settlements is very important in order to design interventions, have planning and public health policy [13,14]. In developing countries, information related to situation and needs of marginalized and vulnerable groups is less documented. Unmet healthcare needs are the difference between the health care services people need and the services people actually receive [15]. Unmet healthcare needs play an important role in creating health inequalities [16]. Identifying the gap between "perceived needs for healthcare services" and "use of healthcare services" and recognizing the causes of this gap is very important in order to design targeted interventions to reduce it and improve access to health care services [15]. To the best of our knowledge, no study has ever been done on investigating unmet healthcare needs in informal settlements in Iran. Also, there is not adequate evidence for evidence-based policy-making in this regard. Thus, our research questions included: What is the prevalence of unmet outpatient healthcare needs in informal settlements in Sanandaj city (the capital of Kurdistan province)? What are the reasons behind these unmet outpatient healthcare needs? What are the socio-demographic and contextual factors related to these unmet outpatient healthcare needs? --- Methods and materials This descriptive-analytical and cross-sectional study was conducted on households living in informal settlements of Sanandaj city with a population of about 500 thousand people as the capital of Kurdistan province in west of Iran. The study population included 1354 people by taking into account p = 17% (unmet outpatient healthcare needs) [20], d = 0.02 (accuracy level) and <unk> = 0.05 (type 1 error). We collected files and data of the households in health centers of informal settlements of Sanandaj city (including the areas of Nayser, Nanleh, Hasan Abad, Asaule, Dushan and Ghareza). In this study, we used stratified random sampling, where each center was proportionally represented based on its size in total population. Households were selected in two phases: first, each household was assigned a unique identification number, and then they were selected based on random number generator in Excel software. After going to the door of the house, the questionnaire of benefiting from health services was completed for the first person over 18 years of age who was available. This standard questionnaire has been used in several national and provincial studies in Iran [15]. Finally, 1346 people (response rate: 99%) were interviewed. Participants were asked about the need for outpatient healthcare services in the last 30 days. Next, people with a history of need were asked questions about using these services. History of need for outpatient health care services was obtained from the following question: During the past 30 days, was there a time when you needed outpatient healthcare services? Respondents who required outpatient health care services (n = 505) were included in this study. People who did not use health care services were asked about the reasons for not using such services. --- Variables In this study, unmet outpatient healthcare needs as an outcome variable (have or don't have) was classified based on demographic and background variables including gender (male or female), age (under 30 years, 30 to 59 or over 60 years), education (illiterate, below diploma, diploma or university degree), employment status (employed or unemployed), basic health insurance status (have or don't have), supplementary health insurance status (have or don't have), and economic status. The economic status was defined using a wealth index. This Index was calculated based on selected household assets including ownership of a computer/laptop, dishwasher, washing machine, air conditioner, vacuum cleaner, microwave, color TV, types of regular travel, car and home ownership. Principal component analysis (PCA) was conducted on asset ownership data to generate total wealth scores for participants. Participants were then ranked according to their wealth scores. Natural breakpoints in the distribution were identified using quantiles, which divided the range into five probability groups with equal proportions. The resulting three categories formed the wealth index groups: "poor", "middle", and "rich". This allowed the classification of participants' economic status based on their household assets and possessions. --- Statistical analysis As widely used in previous studies [17,18], data including having computer/laptop, dishwasher, washing machine, air conditioner, vacuum cleaner, microwave, color TV, travelling, owning a car and house were used to create an economic status by the help of principal component analysis (PCA). We also used Pearson's chi-square test in order to clarify the differences between the respondents regarding unmet and met outpatient healthcare needs. In addition, the determinants of unmet outpatient healthcare needs were analyzed using a logistic regression analysis with maximum likelihood. The odds ratio (OR) and 95% confidence interval (CI) were also calculated. We investigated the independent relationship of all variables with a P-value <unk> 0.2 in the univariate analysis using adjusted logistic regression method and provided crude and adjusted OR with their CI with a significance level of 0.05. Using the wealth index, we also applied the concentration index (C) and concentration curve (CC) to understand the socioeconomic-related inequality in the study population. In order to create CC, subjects are categorized based on their socioeconomic standing, and then the cumulative percentage of people is plotted against the cumulative percentage of unmet outpatient healthcare needs. CC above (below) the line of equality shows that health variable is concentrated among poor (rich) population. C values range from + 1 to -1. Positive (negative) value shows that the health variable is concentrated among rich (poor) individuals, and C equaling zero means there is no inequality [18]. Data were analyzed using STATA software version 16.0 (Stata Corp, College Station, TX, USA. --- Results --- Descriptive results In this study, 37.5% of subjects (505 out of 1346) perceived the need for outpatient health care services during the last 30 days, and their data were analyzed. Overall, out of 505 participants, 62.2% were female and only 12.7% of them were over 60 years old. In general, 8.5% of the participants were illiterate, and 61.0% were employed. 89.1% of the participants had basic health insurance coverage, and the economic status of 20.6% of the participants was classified as the poorest. Of this number, 31.7% (160 out of 505) had not received any formal outpatient health care services for their perceived needs. The characteristics of people who reported met and unmet needs for outpatient health care services are presented in Table 1. The highest perceived need is related to visiting a specialist doctor (21.4%) and using dental services (11.5%). Also, the highest met need was related to general doctor (70.7%) and specialist doctor visits (51.3%) and the highest unmet need was related to dental (80.6%) and rehabilitation services (78.8%). The reasons for unmet outpatient healthcare needs are shown in Fig. 1. Lack of financial ability with 56%, insufficient payment of basic health insurances with 37%, lack of coverage of health services by basic health insurances with 31%, and lack of physical access with 11% were the main reasons for unmet outpatient healthcare needs (Fig. 1). --- Socioeconomic determinants of unmet outpatient healthcare needs The results of the adjusted multiple logistic regression model are shown in Table 2. The variables of age group, employment status, and household economic status were significantly associated with odds of experiencing unmet outpatient healthcare needs. Being elderly with about 2.3 times (OR: 2.37, 95% CI: 1.19-4.75), not having a job with about 1.7 times (OR: 1.70, 95% CI: 1.13-2.57) and having a low economic status with about 4 times (OR: 4.46, 95% CI: 2.39-9.70) increased the odds of experiencing unmet outpatient healthcare needs (Table 2). The value of concentration index showed that unmet outpatient healthcare needs is significantly concentrated among people with lower economic status (C= -0.330, 95% CI: -0.432 to -0.227). As can be seen in Fig. 2, the concentration curve is placed above the line of equality; showing a more concentration of unmet outpatient healthcare needs among people with a more deprived economic status (Fig. 2). --- Discussion The growing trend of unmet needs in informal settlements is a serious humanitarian crisis that authorities and policy makers of different countries are trying to overcome [2]One of the challenges of residents of informal settlements is lack of adequate access to health care services [7]. Understanding the unmet healthcare needs of the residents of informal settlements, identifying its causes and creating strategies to increase the access of these residents to needed healthcare services will help us have better cities to live in. Based on the findings of this study, a significant percentage (about one third) of the need for outpatient health care services in informal settlements remains unmet. There is no similar study in Iran conducted on residents of these settlements for comparison, but this percentage is higher compared to the percentage reported in other studies conducted on general population of Iran. For instance, based on a national study among general population of Iran in 2016, the unmet outpatient healthcare needs was reported 17% [15]. In other studies conducted in developing countries, the percentage of unmet healthcare needs has been reported to be high and more than the general population [6,7,19]. The unmet need for women's healthcare services in informal settlements in Kenya was reported to be more than 37% [20]. In this study, financial and physical barriers were the most important barriers to using outpatient healthcare services. This finding is consistent with the findings of other similar studies conducted in Iran [17]. In a national study conducted in 2016, the most important obstacle to using outpatient healthcare services was lack of financial access and provision of services [15]. According to our study, the highest percentage of unmet outpatient healthcare needs was related to dental and rehabilitation services. Poverty is one of the serious problems of residents of informal settlements, and this problem limits the household's ability to pay for health expenses. In addition, in Iran, dental and rehabilitation services are not covered by service package of basic health insurances [18]. This issue can lead to an increase in both unmet outpatient healthcare needs and out-of-pocket costs for these services. This finding indicates that having health insurance does not necessarily guarantee the use of services. About 90% of people participated in this study had basic health insurance. Also, weak service and cost coverage are other weaknesses of basic health insurance system in Iran [21]. In our study, the remoteness of the centers providing health services and the lack of a suitable public transportation system were other important barriers to use healthcare services. One of the problems of informal settlements is lack or shortage of health service providers in these areas. In developing countries, centers providing health services are not evenly distributed at the level of cities and are often concentrated in city centers [22,23]. Due to illegal violations, informal settlements do not have access to basic health services, public transportation, roads, passages and electricity [6,13]. Addressing the unmet healthcare needs of these settlements requires inter-sectoral cooperation between different actors in both public and private sectors. According to the field visit by the research team of this study, the per capita index of health service providing centers such as comprehensive health centers, clinics, and pharmacies in informal settlements of Sanandaj city was very low compared to other parts of the city. So, in these settlements, the presence of government centers was very limited and the presence of the private sector was very weak. In Iran, most of the burden of outpatient healthcare services is on shoulders of private sector, and according to statistics, more than 70% of outpatient healthcare services are provided by this sector [17]. Therefore, it is suggested to have a fair distribution of health service centers in Sanandaj city with an emphasis on poor and deprived areas and neighborhoods and strengthen the public transportation system to increase the access of those living in informal settlements to city center. As indicated by the findings of this study, the variables of being elderly, not having a job, and having a low economic status increased the odds of encountering unmet outpatient healthcare needs. In other similar studies in Iran, these variables have been reported as factors affecting the access and use of health services [15,17]. Older individuals experience more health issues and have higher healthcare needs, which can increase the likelihood of encountering unmet outpatient healthcare needs. Moreover, age-related factors such as mobility limitations or cognitive decline can create barriers to accessing healthcare services [24]. Also it should be noticed that an unfriendly urban structure in urban informal settlements may contribute to an increase in unmet healthcare needs, including medical care requirements [24]. Not having a job or being unemployed removes a primary source of income for many people. Without a steady paycheck, it becomes difficult to afford copays, deductibles, prescriptions, and other out-of-pocket healthcare costs [25]. Unemployment, along with job loss, is associated with a decrease in preventative care-seeking behavior [26]. In addition, unemployment may endanger existing health insurance benefits obtained through an employer [25]. Our results showed that unmet outpatient healthcare needs were not equally distributed among different economic classes and it was mostly concentrated among poor groups of the society. Living in informal settlements disproportionately affects certain groups more. Unmet outpatient healthcare needs increase as the economic situation of informal settlements worsens, and poorer people are at higher risk in this regard [18]. Having a Fig. 1 Reasons for subjective unmet need for outpatient healthcare services (Note: Every participant could choose more than one option) low economic status often associates with limited access to healthcare services. Financial limitations can lead to unmet needs for outpatient care, including difficulties in affording medications, transportation to healthcare facilities, or even co-pays for doctor visits which is associated with worse health outcomes and even premature death [24,27,28]. Considering the limited resources of the health sector, it is suggested to focus reform policies on poorer households. It is also necessary to design policies with the participation of all actors in order to target the root causes of poverty in these settlements and put them on the agenda of public policy makers. The current study had some limitations. First, the data of this study was collected on the basis of self-report. It may be associated with recall bias, although the research team tried to reduce it by reducing the recall period to the last 30 days. Second, this study was conducted in one city; its findings may not be generalizable to the entire province and the entire country. --- Conclusion Examining unmet healthcare needs can assist policymakers in evaluating access to healthcare services. There is a significant prevalence of unmet outpatient healthcare needs in informal settlements of Sanandaj city. A substantial portion of the residents in these settlements lacks access to necessary healthcare services. Disregarding the needs of individuals in these settlements, which constitute a large population of Iran, makes it difficult to achieve universal health coverage and other SDG3 goals. Financial barriers and inefficiencies in health insurance systems were identified as primary obstacles to accessing needed outpatient healthcare services in this study. Addressing these identified barriers requires the participation of all stakeholders, including the government, the nation, and civil society. To improve access to outpatient healthcare services for residents in these areas, policy recommendations include considering health subsidies, exemptions for low-income households from healthcare costs, establishing mobile clinics in these areas, and ensuring equitable distribution of healthcare facilities within the city. Additionally, creating suitable public transportation to facilitate access to urban centers is suggested. By implementing these policy suggestions, the aim is to enhance access to necessary outpatient healthcare services for the residents of these areas and work towards achieving equitable healthcare provision. --- Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. --- Fig. 2 Concentration curve for subjective unmet need for outpatient healthcare services Author contribution BP and AS, contributed to study conception and BP, YZZ, GM,and AMB gathered data design and all authors were involved in analysis and interpretation process of data. FM, HS, AS and BP drafted and translated the manuscript and all the authors contributed by their comments of improvement in several revisions to reach a final manuscript. --- Declarations Ethics approval and consent to participate This study was approved by ethics committee of Kurdistan University of Medical Sciences with the code IR.MUK.REC. 1401.178. Participation in the study was voluntary and written consent was obtained from the participants. Also, we confirm that all the experiment protocol for involving human data was carried out in accordance with relevant guidelines and regulations. --- Consent for publication Not applicable. --- Competing interests The authors declare no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background The growing trend of informal settlements is a serious humanitarian crisis. Unmet need for health care services is an indicator to measure the state of equality and access to healthcare services. This study, for the first time in Iran, examined the prevalence of unmet needs for outpatient healthcare services and related socioeconomic inequalities among residents of informal settlements in Sanandaj city. Methods This cross-sectional study was conducted on informal settlements of Sanandaj city with a sample size of 1345 people. Data were collected using a questionnaire. Multivariate logistic regression was used to determine significant predictors of unmet needs for healthcare services. Concentration index (C) and concentration curve (CC) were calculated to measure inequality in the prevalence of unmet needs for healthcare services.The prevalence of unmet needs for outpatient healthcare services was 31.7%. Financial and physical barriers were the most common reasons for not using the needed services. The highest unmet need was related to dental (80.6%) and rehabilitation services (78.8%). Being elderly with about 2.3 times (OR: 2.37, 95% CI: 1.19-4.75), not having a job with about 1.7 times (OR: 1.70, 95% CI: 1.13-2.57) and having a low economic status with about 4 times (OR: 4.46, 95% CI: 2.39-9.70) increased the odds of experiencing unmet need for outpatient healthcare services. The value of concentration index showed that unmet need for outpatient healthcare services was significantly concentrated among people with lower economic status (C= -0.330, 95% CI: -0.432 to -0.227).The unmet need is high among people living in informal settlements of Sanandaj city and a significant part of the residents of these settlements does not have access to required healthcare services. Regardless of the needs of people living in these settlements, who constitute a large population of Iran, access to universal health coverage is not possible in such areas. Removing the identified obstacles and causes behind the unmet needs requires the interdisciplinary participation of all actors, including the government, the nation, and civil society.

Intergroup communication occurs when people in a social interaction define themselves and/or others in terms of their social group membership(s) (i.e., social identity) rather than their idiosyncratic characteristics (i.e., personal identity; Tajfel & Turner, 1979). Various factors can make people's social identity salient during social interaction, including language (Dragojevic & Giles, 2014; see also the Editorial of this special issue). Indeed, past research has shown that language, and more generally voice, is a highly salient cue to social group membership (Kinzler et al., 2010;Raki<unk> et al., 2011). Unsurprisingly, a large body of research has considered how linguistic variation signals social variation and the evaluative consequences that follow from such inferences (Dragojevic et al., 2021). For instance, research on language attitudes, or people's evaluative reactions toward different language varieties and their speakers, has repeatedly shown that people readily make inferences about others' social group membership based on how they speak and attribute to them stereotypic traits based on those inferred group memberships (Dragojevic et al., 2021;Giles & Marlow, 2011). Such psychological processes, namely the social categorization of speakers as members of a given social category and the subsequent attribution of stereotypes (Dragojevic, 2017), define communication as intergroup and provide a framework to understand phenomena such as stigmatization. However, extant research on this topic is limited in two important respects. First, past studies have primarily focused on the listeners' perspective, documenting how majority group listeners perceive others' speech. Yet, to fully understand intergroup communication, it is necessary to also adopt the speakers' perspective and examine how speakers perceive their own speech. Indeed, just as people use speech to socially categorize others, they also use speech to selfcategorize and tend to be highly cognizant of the inferences others make about them based on the way they speak (Gluszek & Dovidio, 2010a). This may be particularly the case for individuals who belong to low status and minority groups, who may expect that disclosure of their group membership will expose them to stereotyping and stigmatization. For instance, research has shown that implicit gender self-categorization is stronger for women than men, and sexual orientation self-categorization is stronger for sexual minorities than heterosexual individuals (Fasoli, Cadinu et al., 2018), regardless of whether individuals are reminded of their gender or sexual orientation. This suggests that group membership for minority people may be salient even in the absence of explicit intergroup comparisons. Second, past studies have primarily been restricted to documenting attitudes toward regional and ethnic accents (Giles, 1970;Lippi-Green, 2012), whereas other ways of speaking, such as 'gay speech', have remained largely unexplored (but see, e.g., Fasoli et al., 2016). The present study attempts to address these limitations. Namely, we sought to investigate the psychological processes involved in speakers' voice-based self-perceptions. In doing so, we adopted an intersectional approach that has been overlooked in the intergroup communication literature (see Abrams, 2018). Specifically, we considered intersecting identities and tested the unique and combined effects of multiple social categories conveyed by voice. We examined whether self-identified gay and heterosexual British nationals (all of whom were native English speakers) and foreigners living in the UK (all of whom were non-native English speakers1 ) believed their voices cue their national and sexual orientation identities, have internalized stereotypes, and believed they are stigmatized because of the way they sound. --- Voice as a Social Category Cue Past research has examined how listeners categorize others based on their voices but has rarely examined what speakers themselves believe about their voices as social cues. Listeners can distinguish between native and non-native speakers of their own language with a high degree of accuracy (Kinzler & DeJesus, 2013; see also Hansen et al., 2017), but they struggle to accurately detect non-native speakers' actual nationalities (Dragojevic & Goatley-Soan, 2022;Eades et al., 2003). Consequently, foreigners who speak with a foreign accent may be recognized by others as non-native speakers because of their accent, but their actual nationality may remain unrecognized. This may be one reason why foreign-accented speakers tend not to consider their own accent as an accurate indicator of their national identity (Beinhoff, 2013), but rather as a general cue of foreignness. At the same time, non-native speakers consistently express negative attitudes toward their accent and a desire to sound more native (Derwing, 2003; see also Jenkis, 2007). Indeed, there is a general perception of native English accents, particularly standard varieties, as being prestigious and highlighting high-status compared to non-native English accents (Carrie & McKenzie, 2018;Fuertes et al., 2012;Marlow & Giles, 2008). People also believe that a person's voice can reveal their sexual orientation. Indeed, both heterosexual and gay individuals tend to believe that a speaker's voice allows listeners to identify the speaker's sexual orientation and that some vocal differences are fixed and immutable (Fasoli et al., 2021). Beliefs of voice as cuing sexual orientation go hand in hand with beliefs that a speaker sounds gender typical. It has been found that heterosexual men who believed they sounded masculine, and sexual minority men who believed they sounded feminine, reported that their voices were likely revealing their actual sexual orientation (Fasoli, Hegarty et al., 2018). Moreover, heterosexual men particularly desire for their heterosexuality to be disclosed by their voices when meeting a stranger (Fasoli, Hegarty et al., 2018). Arguably, this may be because heterosexual men are often concerned about being misperceived as gay (Bosson et al., 2012;Vandello & Bosson, 2013), which would mean losing the high-status typically associated with heterosexuality. On the other hand, sexual minority men are less motivated to have their sexual orientation disclosed by their voice, as such disclosure could lead to stigmatization and negative evaluation (see Fasoli et al., 2021;Herek & McLemore, 2013). --- Stereotyping Simply hearing a speaker say "hello" is sufficient for listeners to make an impression about the speaker's personality (McAleer et al., 2014). Person perception is generally organized around two main evaluative dimensions, namely, status/competence and solidarity/warmth (see Fiske et al., 2002), even when it is based on auditory cues (see Gluszek & Dovidio, 2010a;Schoel et al., 2013). Foreign-accented speakers are usually perceived as having less status/ competence and solidarity/warmth than native speakers (Baquiran & Nicoladis, 2020;Dragojevic & Giles, 2016;Roessel et al., 2018). With regards to speakers' sexual orientation, gay-sounding male speakers tend to be perceived as less masculine (Daniele et al., 2020;Painter et al., 2021), and less competent (Fasoli & Hegarty, 2020) but warmer (Fasoli & Maass, 2020) compared to heterosexualsounding speakers. Research on speakers' self-perception has shown that foreign-accented speakers attribute lower status to themselves and their group compared to native speakers (see Kinzler & DeJesus, 2013;Lambert et al., 1960). Gay male speakers also report perceiving their voices and themselves as less gender typical than heterosexual male speakers do (Kachel et al., 2020;Rieger et al., 2010). These findings suggest that foreigners and sexual minority speakers may internalize stereotypes associated with their own group and low-prestige language variety. Minority speakers also have expectations about how others may perceive them, or so-called "meta-perceptions" (see Derwing, 2003). Foreign speakers expect others to struggle to understand them and, hence, attribute less competence/status to themselves (see Gluszek & Dovidio, 2010a). For instance, a study by Yzerbyt et al. (2005) examined meta-stereotypes in relation to high-prestige (French) and low-prestige (Belgian) language varieties. They found that French and Belgian speakers had similar impressions of the Belgian speakers, who were attributed lower competence but higher warmth than French speakers. Hence, regardless of their group membership, participants had similar expectations of how others would perceive members of their own linguistic group, as well as members of the linguistic outgroup. Concerning sexual orientation, a recent study found that gay men's beliefs about sounding gay and sounding masculine went hand in hand with their perception that other people would perceive them as gay-sounding and masculine-sounding (Fasoli et al., 2021), in line with work on self-and metastereotype endorsement in gay men (see Hinton et al., 2019). However, these studies have not considered how intersecting categories signaled by voice may affect self-and meta-stereotypes. One study (Campbell-Kibler, 2007) manipulated speakers' vocal cues in order to signal a gay sexual orientation and/or a high social class and asked listeners to form an impression about the speakers. In doing so, they examined whether each vocal cue alone or in intersection affected listeners' impression. It was found that speakers who sounded gay and high social class were attributed more status/competence than speakers who simply sounded gay, suggesting that vocal cues conveying high social class allow the speaker to gain status. At the same time, sounding gay allows working class speakers to gain in solidarity (Levon, 2014). These findings seem to suggest that different self-and meta-perception may occur as a function of group membership intersections conveyed by voice. --- Stigmatization Literature has shown that having a foreign accent and sounding gay can trigger stigmatization enacted by majority group listeners (i.e., native speakers and heterosexuals, respectively). Such stigmatization varies from being evaluated negatively (Fuertes et al., 2011;Nelson Jr et al., 2016), being discriminated against in contexts such as education (Gill, 1994;Taylor & Raadt, 2021), workplace (Raki<unk> et al., 2011;Roessel et al., 2019), parenting (Fasoli & Maass, 2020), and interpersonal interactions (Bourhis, 1984;Fasoli et al., 2017). Some recent work has also shown that speakers whose voice signals that they belong to a double minority (i.e., a lesbian-sounding woman) can face stronger discrimination than speakers whose voice signals that they belong to a single minority (i.e., gaysounding men, Fasoli & Hegarty, 2020). However, this is not always the case. For instance, foreign-accented speakers from low status countries are sometimes preferred over native speakers from high-status countries, perhaps because the former are seen as less threatening than the latter (Birney et al., 2020). Less is known about speakers' own perceptions of stigmatization. Studies have shown that foreign-accented speakers report being stigmatized (Derwing, 2003;Gluszek & Dovidio, 2010b;Goto et al., 2002) and that gay-sounding men expect to be avoided, stigmatized, and discriminated against (Fasoli et al., 2021). This may lead them to try to modulate their voices or engage in other coping strategies to navigate possible stigmatization (see Moyer, 2007;Fasoli et al., 2021). Whether vocal cues signaling a speaker's double minority status elicit double stigmatization remains to be understood. Moreover, it is important to disentangle between perceived stigmatization and experiences of actual discrimination. Indeed, while the latter refers to explicit behaviors enacted by the majority group (e.g., treating someone with less respect, insulting someone), the former refers to the expectation of being considered and treated differently. --- Study Overview and Hypotheses The current study examined how speakers whose voice simultaneously signals multiple social categories self-perceive based on the way they sound. In particular, we focused on speakers who simultaneously belong to groups defined by nationality (i.e., British or foreign) and sexual orientation (i.e., heterosexual or sexual minority). Being British and/or heterosexual implies belonging to a majority group associated with high status. On the contrary, being a foreigner and/ or sexual minority implies belonging to a minority or a double minority group associated with low status. In the present study, we examined beliefs concerning voice as a social category cue that reflect social categorization expectations and self-attribution of traits reflecting stereotyping. Moreover, we assessed perception and expectancy of voice-based stigmatization. British and foreign participants, who were either heterosexual or belonged to a sexual minority group, were asked to report the extent to which they believed their voices revealed their nationality and sexual orientation, as well as their desire to have those group memberships revealed by their voice. Based on the literature presented above, we advanced several predictions. First, given that listeners are highly accurate at identifying foreign-accented speakers' non-native status but are much less accurate at identifying the specific country they come from based on voice alone, we predicted that: H1a: Foreign speakers would be less likely than British speakers to believe that their voice reveals their actual nationality. Related, to the extent that listeners stereotypically associate masculinesounding voices with heterosexuality and feminine-sounding voices with homosexuality, we predicted that: H1b: The more masculine sounding heterosexual men believed their voices to be, the more they would believe their voices accurately reveal their heterosexual sexual orientation. Conversely, the more feminine sounding sexual minority men believed their voices to be, the more they would believe that their voices accurately reveal their sexual minority orientation. Second, since native-accented speakers are typically attributed higher status than foreign-accented speakers, and heterosexual men are typically attributed higher status than sexual minority men, we predicted that: H2a: British speakers would express more desire than foreign speakers for their voices to disclose their nationality to strangers. H2b: Heterosexual men would report a greater desire than sexual minority men for their voices to accurately signal their sexual orientation to strangers. RQ1: We also explored whether the nationality and sexual orientation intersection would affect beliefs of voice as a cue of group memberships and the possibility that sexual minority foreigners would be the most reluctant to have their voices reveal their group memberships, as that would highlight their double minority status. Next, we assessed speakers' self-perception in terms of status/competence, solidarity/warmth, and gender typicality to examine the extent to which speakers have internalized the stereotypes listeners typically attribute to their groups. Based on the foregoing, we hypothesized that: H3a: Foreign speakers (vs. British speakers) would attribute to themselves and would expect others to attribute to them less status and solidarity. H3b: Sexual minority men (vs. heterosexual men) would perceive themselves and expect others to perceive them as less gender typical. RQ2: Additionally, since stereotyping has not been studied in the context of nationality and sexual orientation simultaneously, we explored whether nationality and sexual orientation would interact to produce unique patterns of self and meta-perceptions in speakers. Finally, we assessed discrimination experiences, expectations of stigmatization, and consciousness for foreign and 'gay' accent stigmatization. In light of the preceding literature review, we advanced the following predictions: H4a: Foreign and sexual minority speakers would report more experiences of discrimination and higher perceived stigmatization than would British and heterosexual speakers, respectively. H4b: Participants belonging to a double minority (i.e., sexual minority foreigners) signaled by voice would report the highest level of discrimination and perceived stigmatization compared to all the other groups. RQ3: We were also interested in whether belonging to a double minority group would enhance consciousness for specific types of stigmatizations. Thus, we explored whether sexual minority (vs. heterosexual) foreigners would report more national accent-based stigmatization and whether foreign (vs. British) sexual minority speakers would report greater stigmatization for sounding gay. --- Method Participants Two hundred and seven male participants completed the study and provided consent to data use. We excluded one participant who was under 18 years old. To avoid possible confounds due to nationality and/or language, we only retained (a) self-identified British nationals whose first language was English and (b) foreigners living in the UK whose first language was not English in the sample. The final sample (M age = 31.77, SD = 11.66) consisted of British nationals, all of whom were native English speakers (n = 107, 57.5%), and foreigners, all of whom were non-native English speakers (n = 79, 42.5%). The foreign participants spoke different languages (i.e., Arabic, Bengali, Bulgarian, Chinese, Czech, Dutch, Filipino, Flemish, French, Greek, Hebrew, Hungarian, Indonesian, Italian, Lithuanian, Mandarin, Marathi, Nepalese, Persian, Polish, Portuguese, Russian, Slovak, Spanish, Tamil, Thai, and Turkish). The sample consisted of heterosexual (n = 101, 54.3%) and sexual minority participants (n = 85, 45.7%; gay: n = 57; bisexual: n = 28). Sexual orientation assessed on a Kinsey-like scale (1 = exclusively heterosexual; 7 = exclusively gay) showed that heterosexuals self-rated on the heterosexual pole of the scale (M = 1.31, SD =.80), whereas sexual minority participants self-rated on the gay pole of the scale (M = 5.80, SD = 1.63), t(183) = 24.37, p <unk>.001. Sexual minority participants reported moderate levels of coming out (M = 2.70, SD =.99; scale 1 = The person does not know, 4 = the person knows, and we have talked about it). A G*Power (Faul et al., 2007) sensitivity analysis (<unk> =.05, power.80) for a 2 <unk> 2 analysis of variance (ANOVA) that was conducted on most of our dependent variables indicated that our final sample of 186 allowed us to detect small to medium effect sizes equal to.21 (see Cohen, 2013). --- Procedure Participants were recruited on Prolific Academic and rewarded £1.50. They were pre-screened to ensure that they identified as either heterosexual or sexual minority, and as either British or foreigners living in the UK. They were invited to participate in a study on voice self-perception and everyday social interactions. After agreeing to participate in the study, participants completed a survey containing the dependent measures, were debriefed, and provided final consent to data use. Filler items and additional measures (i.e., participants' attempts to conceal their nationality and sexual orientation) are reported in the Supplementary Information. --- Measures --- Voice Self-Perception Participants were asked to indicate how they perceived their own voices. One item (i.e., "How strong do you think your national accent is?") measured participants' perception of their national accent (Gluszek et al., 2011). Two items (i.e., "How much do you think your voice sounds masculine?," "How much do you think your voice sounds feminine?" reverse-coded, <unk> =.79; see Fasoli et al., 2021) assessed perceived voice gender typicality. Answers were provided on a scale from 1 (not at all) to 7 (very). Ratings on the two gender typicality items were averaged. Higher scores indicated higher voice gender typicality. --- Voice as a Social Category Cue Participants were asked to think about the way they normally speak and to indicate the degree to which they believed their voice was revealing of their nationality and sexual orientation (voice-related beliefs). Next, they were asked to indicate the extent to which they would desire their voice to disclose their nationality and sexual orientation when encountering a person for the first time (disclosure desire). These single-item scales (see Fasoli et al., 2018) used 7-point scales (1 = not at all; 7 = completely). --- Self-and Meta-Perception Participants were asked to rate themselves as individuals on different traits corresponding to status, solidarity, and gender typicality, based on how they think their voices sounded. We used five traits to assess status (i.e., competent, intelligent, smart, educated, successful; <unk> =.91) and five traits to assess solidarity (i.e., friendly, nice, sociable, pleasant, warm; <unk> =.87), as done in previous research on language attitudes (see Dragojevic et al., 2017). We assessed self-perceived gender typicality on two traits (i.e., masculine, feminine, reverse-coded, Fasoli & Hegarty, 2020; <unk> =.76). Answers were provided on a scale from 1 (not at all) to 7 (very much). Items comprising each scale were averaged. Higher scores corresponded to higher self-perceptions of status, solidarity, and gender typicality. Participants also rated how they thought other people would rate them on the same traits based on their voices using the same answering scale (1 = not at all; 7 = very much). Reliability (status: <unk> =.91, solidarity: <unk> =.90, and gender typicality: <unk> =.77) and average scores were calculated for each construct. Higher scores corresponded to higher meta-perceptions of status, solidarity, and gender. --- Everyday Discrimination and Perceived Stigmatization To assess everyday discrimination, we adapted eight items (e.g., "People treat me rudely or disrespectfully because of how I sound," "People make comments and joke because of how I sound," <unk> =.90) from previous scales assessing discriminatory behaviors that happen in everyday interactions (Williams et al., 2002). Answers were provided on a scale form 1 (strongly disagree) to 7 (strongly agree). Ratings were averaged to form a score of everyday discrimination. The higher the score, the higher the experience of discriminatory behaviors in everyday interactions. Perceived stigmatization was assessed with the voice perceived stigmatization scale by Gluszek and Dovidio (2010a). The scale consisted of 6 items (e.g., "I feel like an outsider because of how I sound," "I think that others are biased against me because of how I sound," <unk> =.76). Answers were provided on a scale from 1 (strongly disagree) to 7 (strongly agree). Ratings were averaged to form a score of perceived stigmatization. The higher the score, the higher the perceived stigmatization. --- Foreign Accent and "Gay Voice" Stigma Consciousness We adapted items of the stigma consciousness scale by Pinel (1999) to foreign accent and gay-sounding voices. Hence, seven items ("My national accent does influence how British people act with me;" <unk> =.83) assessed stigma consciousness for having a foreign accent among participants who were foreigners. Moreover, sexual minority participants completed seven items ("Sounding gay does influence how heterosexual people act with me;" <unk> =.83) assessing stigma consciousness for sounding gay. Answers were provided on a scale from 1 (strongly disagree) to 7 (strongly agree) and ratings were averaged to form scores of stigma consciousness for having a non-standard accent among foreigners, and for having a gay sounding voice among sexual minority participants, respectively. --- Results Correlations between variables completed by all participants, means, and standard deviations across groups are reported in Tables 1 and2. Nationality was operationalized as belonging to two main groups: British participants (i.e., those who reported being British nationals and English native-speakers) and foreigners (i.e., those who reported a nationality other than British and to be non-native English speakers; see participants' description for the languages they spoke). Sexual orientation referred to two main groups: participants who identified as heterosexual and participants who identified as a sexual minority (i.e., gay or bisexual). --- Voice Self-Perception Although no specific hypotheses were advanced on these variables, we examined the differences in voice self-perception. Since self-perceived accent strength was assessed with a single item, a multiple ordinal regression analysis including nationality (British vs. foreigner), sexual orientation (heterosexual vs. sexual minority), and their interaction term as predictors was carried out. Foreigners and sexual minorities were included as reference groups. The model showed a good fit, <unk> 2 (3) = 14.14, p =.003, as also shown by the goodness of fit test, Pearson: <unk> 2 (15) = 5.53, p =.99, with pseudo-R 2 (Nagelkerke) equal to.03. Results showed a statistically significant main effect of nationality on self-perceived accent strength, B = -1.10, SE =.39, 95% CI [-1.87, -.03], p =.040, indicating that foreigners reported lower cumulative for scores than British participants. No other effects were statistically significant, Bs <unk>.44, ps >.40. A 2 (Nationality: British vs. foreigner) <unk> 2 (Sexual orientation: heterosexual vs. sexual minority) ANOVA was performed on self-perceived voice gender typicality. It showed a statistically significant main effect of sexual orientation, F(1, 182) = 32.79, p <unk>.001, <unk> p 2 =.15, indicating that heterosexual participants perceived their voices as more gender typical (M = 5.46, SE =.12) than did sexual minority participants (M = 4.41, SE =.13). No other statistically significant effects emerged (Fs <unk> 1.82, ps >.18). --- Voice-related Beliefs and Disclosure Desires We conducted a series of multiple ordinal regressions including nationality (British vs. foreigner), sexual orientation (heterosexual vs. sexual minority), and their interaction term as predictors since the dependent variables consisted of single items and were analyzed separately. Foreigners and sexual minorities were included as reference groups. --- Voice-related Beliefs We first examined perceptions of voice as a cue to nationality. The model did show a small fit, <unk> 2 (3) = 7.43, p =.059, with pseudo-R 2 (Nagelkerke) equal to.04. However, the goodness of fit test (Pearson: <unk> 2 [15] = 12.93, p =.61) indicated that the data are consistent with the fitted model. Results showed a significant main effect of nationality, B = -.75, SE =.37, 95% CI [-1.47, -.03], p =.040. Foreigners reported lower cumulative scores than British participants concerning beliefs of voice as a cue revealing their nationality, confirming H1a. No other effects were significant, Bs <unk> -.03, ps >.94. The model for perceptions of voice as a cue to sexual orientation did not show a good fit, <unk> 2 (3) = 5.56, p =.087, and no statistically significant main or interaction effects were observed, Bs <unk> -.28, ps >.43. However, we proceeded to test H1b by running an ordinal regression analysis including sexual orientation, self-perceived voice gender typicality, and their interaction as predictors. The model showed a good fit, <unk> 2 (3) = 29.69, p <unk>.001; goodness of fit test: Pearson: <unk> 2 (129) = 140.26, p =.23, with pseudo-R 2 (Nagelkerke) equal to.15. The interaction between sexual orientation and voice gender typicality was statistically significant, B = 1.08, SE =.22, 95% CI [.64, 1.51], p <unk>.001. To better understand the interaction, we ran an ordinal regression analysis with voice gender typicality as the only predictor for heterosexual and sexual minority participants separately. Both models showed a good fit, <unk> 2 > 5.18, ps >.023; pseudo-R 2 (Nagelkerke) >.23. For heterosexual participants, the effect of voice gender typicality was positive and statistically significant, B =.36, SE =.16, 95% CI [.05,.67], p <unk>.021, indicating that the more masculine-sounding they believed their voices to be, the more they believed their voices revealed their heterosexual orientation. Conversely, for sexual minority participants, the effect of voice gender typicality was statistically significant but negative, B = -.78, SE =.16, 95% CI [-.1.10, -.46], p <unk>.001. The more femininesounding sexual minority participants believed their voices to be, the more they believe their voices revealed their sexual orientation. Hence, H1b was confirmed. --- Disclosure Desire The model for nationality disclosure desire showed a lack of good fit, <unk> 2 (3) = 5.36, p =.147, and no statistically significant effects of nationality or any other variable (Bs <unk>.41, ps >.08), disconfirming H2a. The model for sexual orientation disclosure desire showed a good fit, <unk> 2 (3) = 12.68, p =.005, Pearson: <unk> 2 (15) = 13.61, p =.55, with a pseudo-R 2 (Nagelkerke) equal to.07. A statistically significant effect of sexual orientation, B = 1.03, SE =.41, 95% CI [.23, 1.84], p =.012, showed that the cumulative score was higher for heterosexual than sexual minority participants, confirming H2b. No other statistically significant effect or interaction were found (Bs <unk>.30, ps >.58). --- Self-and Meta-Perception To examine the effects of nationality and sexual orientation on self-and metaperceptions of status, solidarity, and gender typicality, we submitted each outcome to a 2 (Nationality: British vs. foreigner) <unk> 2 (Sexual orientation heterosexual vs. sexual minority) <unk> 2 (Perception: self vs. meta) mixed ANOVA, with the first two factors treated as between-subjects, and the third factor treated as within-subject. --- Perceived Status A statistically significant main effect of perception, F(1, 182) = 6.72, p =.01, <unk> p 2 =.04, showed that participants believed others would attribute more status to them (M = 4.77, SE =.08) than they attributed to themselves (M = 4.63, SE =.08). No other effects were statistically significant (Fs <unk> 3.38, ps >.07). Since the main effect of nationality was not statistically significant, H3a was disconfirmed. --- Perceived Solidarity A significant main effect of perception, F(1, 182) = 12.70, p <unk>.001, <unk> p 2 =.06, indicated that participants believed others would attribute more solidarity to them (M = 4.87, SE =.08) than they attributed to themselves (M = 4.68, SE =.08). No other statistically significant effects emerged (Fs <unk> 1.90, ps >.17). Hence, since the main effect of nationality was not statistically significant, H3a was disconfirmed. --- Perceived Gender Typicality A statistically significant main effect of perception, F(1, 182) = 14.14, p <unk>.001, <unk> p 2 =.07, indicated that participants believed others would perceive them as less gender typical (M = 4.64, SE =.10) than they perceived themselves (M = 4.85, SE =.09). Moreover, a statistically significant main effect of participants' sexual orientation, F(1, 182) = 33.20, p <unk>.001, <unk> p 2 =.15, indicated that sexual minority participants perceived themselves and believed others would perceive them as less gender typical (M = 5.25, SE =.12) than did heterosexual participants (M = 4.24, SE =.13). Hence, H3b was confirmed. No other significant effects emerged (Fs <unk>.68, ps >.41). --- Discrimination Experiences and Perceived Stigma A 2 (Nationality: British vs. foreigner) <unk> 2 (Sexual orientation: heterosexual vs. sexual minority) ANOVA, with both variables being between-participants factors, was performed on discrimination experiences and perceived stigma. No statistically significant effects were found on discrimination experiences, Fs <unk> 2.07, ps >.15, indicating that the different groups had similar experiences of discrimination. Regarding perceived stigma, a statistically significant main effect of nationality, F(1, 182) = 18.22, p <unk>.001, <unk> p 2 =.09, showed that foreign participants experienced more voice-based stigmatization (M = 3.24, SE =.12) than did British participants (M = 2.57, SE =.10). Moreover, a statistically significant main effect of sexual orientation, F(1, 182) = 4.19, p =.04, <unk>p2 =.02, indicated that sexual minority participants experienced more voice-based stigma (M = 3.07, SE =.11) than did heterosexual participants (M = 2.75, SE =.11). These results are in line with H4a. However, since no statistically significant interaction between nationality and sexual orientation occurred, F(1, 182) = 1.72, p =.19, <unk> p 2 =.01, H4b was not confirmed. --- Stigma Consciousness Foreign Accent Stigma Consciousness Foreigners experienced moderate stigmatization due to sounding foreign (M = 4.47, SD = 1.12, one sample t test against the scale midpoint: t[77] = 3.69, p <unk>.001, d =.42), and sexual minority foreigners experienced less accent-based stigmatization (M = 4.23, SD = 1.12) than heterosexual foreigners (M = 4.76, SD = 1.07), t(76) =

When voice signals nationality and sexual orientation: Speakers' selfperceptions and perceived stigmatization Research has shown that individuals speaking low-prestige language varieties are often negatively evaluated and stigmatized by others. However, less is known about how speakers of such language varieties perceive their own speech. Here, we examined self-perceptions and perceived stigma of speakers who belong to multiple social categories signaled by auditory cues. Specifically, we examined beliefs of sexual minority and heterosexual male speakers who were either British nationals (native English speakers) or foreigners living in the UK (non-native English speakers). British speakers believed their voices cue their nationality more than foreigners. Heterosexuals believed their voices reveal their sexual orientation, but only when they self-perceived as sounding masculine. Sexual minority and foreign speakers felt more stigmatized because of the way they sound than did heterosexual and British speakers, respectively. These findings have implications for intergroup communication and voice-based stigmatization literature.

, a statistically significant main effect of sexual orientation, F(1, 182) = 4.19, p =.04, <unk>p2 =.02, indicated that sexual minority participants experienced more voice-based stigma (M = 3.07, SE =.11) than did heterosexual participants (M = 2.75, SE =.11). These results are in line with H4a. However, since no statistically significant interaction between nationality and sexual orientation occurred, F(1, 182) = 1.72, p =.19, <unk> p 2 =.01, H4b was not confirmed. --- Stigma Consciousness Foreign Accent Stigma Consciousness Foreigners experienced moderate stigmatization due to sounding foreign (M = 4.47, SD = 1.12, one sample t test against the scale midpoint: t[77] = 3.69, p <unk>.001, d =.42), and sexual minority foreigners experienced less accent-based stigmatization (M = 4.23, SD = 1.12) than heterosexual foreigners (M = 4.76, SD = 1.07), t(76) = -2.32, p =.02, d =.53. --- Gay voice Stigma Consciousness Sexual minority participants experienced moderate stigmatization due to sounding gay (M = 4.54, SD = 1.26, one sample t-test against the scale midpoint: t[84] = 3.94, p <unk>.001, d =.43). No statistically significant differences between British (M = 4.69, SD = 1.19) and foreign (M = 4.34, SD = 1.32) sexual minority participants emerged, t(83) = 1.30, p =.20, d =.28. --- Discussion The current study considered the role of speakers' perspective in relation to psychological processes involved in intergroup communication (i.e., social categorization beliefs, stereotyping, and stigmatization). Understanding the expectations speakers have about their voices is important in making sense of language attitudes and intergroup communication (see Giles & Marlow, 2011). First, we showed that speakers differ in their beliefs about voice as a social category cue. In line with H1a, British participants believed their voices were more revealing of their nationality than foreign participants. This supports the idea that foreigners do not believe that their voices are clear cues of their actual nationality (see also Beinhoff, 2013). Indeed, while a foreign accent may be a clear cue to foreignness, it may not lead to accurate categorization of actual nationality (see Dragojevic & Goatley-Soan, 2022). However, it is worth noting that our participants varied a lot in their first language, with many belonging to small linguistic minorities (e.g., Flemish) whose language background would likely be relatively unfamiliar to most British nationals and, therefore, render their true nationality relatively undetectable. When looking at sexual orientation, the more heterosexual men self-perceived as masculine-sounding, and the more sexual minority men self-perceived as feminine-sounding, the more they believed their voices accurately revealed their true sexual orientation, supporting H1b and replicating previous work (Fasoli et al., 2018). Hence, participants appeared to be aware of the association between gender stereotyping and sexual orientation assumptions that has been observed in past auditory gaydar research (see Fasoli et al. 2016;Kachel et al., 2020). Second, we examined participants' social identity disclosure desires, given that such expectations can define intergroup communication dynamics (Giles et al., 2010). One's desire to have their voice reveal their group membership(s) implies that they wish their status to be known, and potentially guide the communicative exchange. We did not find support for the prediction that British nationals would express a higher desire than foreigners to have their voices disclose their nationality, disconfirming H2a. However, in line with H2b, heterosexual men desired to have their voices to disclose their sexual orientation when meeting a stranger more than sexual minority men did. Hence, heterosexual men wished their high-social status and belongingness to the normative group to be subtly conveyed by their voices (see Fasoli, Hegarty et al., 2018). The fact that heterosexual speakers, but not British speakers, desired for their group membership to be disclosed suggests that being miscategorized as gay may be perceived as a greater threat by heterosexual men (see precarious manhood, Bosson et al., 2008) than being miscategorized as a foreigner by British men. Overall, these findings concerning voice-related beliefs and disclosure desire contribute to a better understanding of what speakers think about their own voices and complement existing literature showing that listeners use voice to socially categorize speakers (Dragojevic et al., 2021). This suggests that speakers are highly cognizant that their voices are not neutral, but are rather cues of their social group membership, even in the absence of explicit intergroup comparisons. This implies that while social categorization defines one of the first steps of intergroup communication, speakers' beliefs, expectations, and desires can influence interactions (see Gluszek & Dovidio, 2010b). Third, we found that neither speakers' nationality nor sexual orientation influenced speakers' self-and meta-stereotypes concerning status/competence and solidarity/warmth, disconfirming H3a. British participants did not attribute nor expect others to attribute to them more status and solidarity than did foreign participants. This is in contrast with previous work that found foreign speakers to report more internalized negative stereotypes and attribute lower competence to themselves than do native speakers (Kinzler & DeJesus, 2013;Lambert et al., 1960). Instead, participants expected others to attribute to them more status and solidarity than they attributed to themselves, regardless of their nationality. This suggests that participants may expect a general positive bias toward them when status/competence and solidarity/warmth are concerned. However, this unexpected result may be explained by a methodological issue. Indeed, the measure concerning status/solidarity was assessed by asking participants to think about how their voices sounded without asking them to think about their nationality or native/non-native accent. However, we found gender typicality self-and meta-stereotyping to be consistent with previous work (Fasoli et al., 2018;Kachel et al., 2018). Indeed, in line with H3b, heterosexual men believed themselves to be more masculine and for others to perceive them as more masculine on the basis of how they sounded like than did sexual minority men. This shows once again that sexual minority men have internalized the stereotype of being and sounding less masculine. Fourth, we did not find experiences of actual everyday discrimination to differ based on participants' group memberships. Overall, our sample did not report experiencing many instances of discrimination, making it difficult to detect differences across groups. Instead, we found that belonging to a sexual minority or foreign group elicited higher perceptions and expectations of being stigmatized. Indeed, foreign and sexual minority men were more likely than British and heterosexual men, respectively, to believe that they would be stigmatized because of their voices, in line with H4a. This extends the work by Gluszek and Dovidio (2010a), who showed that foreign-accented speakers reported more voice-based stigmatization than native-accented speakers, as well as more recent findings associating sounding gay with stigmatization (see Fasoli et al., 2021). Hence, although our groups of speakers had experienced a similar low incidence of actual discriminatory behaviors, being a foreign or sexual minority speaker elicited higher expectations of being judged differently or being rejected because of one's voice. This result is particularly important, as it not only extends research on intergroup communication but also more general research on stigmatization. On the one hand, it shows that intergroup communication not only involves actual voice-based stigmatization enacted by listeners (see Dragojevic et al., 2021), but also speakers' own expectations of stigma. Stigma expectancies represent a social stressor that can have consequences for mental and physical health (see Frost, 2011, for a stigma model), as well as engagement in other behaviors like being vigilant or engaging in various coping strategies (see Fasoli et al., 2021). Finally, we explored the role of intersecting social categories signaled by voice on our dependent variables (RQ 1, 2, and 3). Our data suggest that intersectionality did not play a major role in terms of voice-related beliefs, disclosure desire, stereotyping, or perceived stigmatization. We found that each social category elicited separate effects rather than triggering double stigmatization (see Remedios & Akhtar, 2019). The only effect that seemed to suggest intersectionality was that heterosexual foreigners reported more accent-based stigma consciousness than sexual minority foreigners, but no effect occurred when comparing British and foreign sexual minority men regarding sexual orientation voice-based stigma consciousness. Heterosexual men, whose heterosexuality indexes high status, may be conscious and afraid that their foreign accent could threaten their social status more than sexual minority foreigners, who already belong to a (sexual) minority group. Overall, these findings suggest a prominence effect, with one social category assuming perceptual dominance over another. In other words, speakers do not appear to think about their voices in intersecting terms, but rather as a cue of one category at a time. This may suggest an inhibitory process that has been observed in person perception research but has not been studied much from the targets' perspective (see Macrae et al., 1995). To the best of our knowledge, this is the first study to test intersectionality in the voice domain from the speakers' perspective. Thus, it provides useful evidence to fill this gap in the literature (see Abrams, 2018). Previous work showed that listeners' perceptions of speakers can be influenced by vocal cues signaling contrasting social categories (see Campbell-Kibler, 2007;Levon, 2014), at least in terms of stereotyping. Our data suggest a more complex picture when considering intersectionality from the speakers' perspective, which requires more research. The fact that speakers believe their voices to convey information about their social group membership and that those belonging to foreign and sexual minority groups expect to be stigmatized because of their voices can have consequences for intergroup communication. Research has shown that group membership guides communication. Communication accommodation theory (CAT, Giles, 2016), initially developed around speech, suggests that individuals make shifts in their communication and speech in social encounters. Indeed, the desire to gain social approval and attempt to emphasize common group membership often leads minority group speakers to converge to the communication style (and speech) of majority group interlocutors. In some cases (e.g., sexual orientation), such convergence may reflect a desire to conceal one's minority status and, instead, be perceived as belonging to the majority group (see Daniele et al., 2020;Mann, 2012). On the contrary, some speakers may engage in divergence that accentuates differences between interlocutors. This may be particularly the case for individuals belonging to high-status groups who, by emphasizing and making their distinct group membership salient, can maintain a positive image of themselves and define status dynamics in the exchange (see also Gallois et al., 2005). For instance, heterosexual individuals maintain a physical distance when interacting with someone perceived as gay (Knöfler & Imhof, 2007), with the aim of dissociating themselves from gay minority individuals, but also use conversational schemas that reinforce stereotyping about homosexuality (see Hajek & Giles, 2005). Therefore, speakers' self-perceptions and expectations are key in influencing these intergroup communication dynamics. Expecting to be stigmatized because of the way speakers sound may create boundaries to positive intergroup exchanges (see Gallois et al., 2005). --- Limitations and Future Directions This study has several limitations. First, our sample included foreign speakers who spoke different languages. Since different languages are perceived differently (Schoel et al., 2013) and some are associated with more status than others, future research should replicate these results by examining or comparing specific foreign languages. Second, we only included men in our sample, which did not allow us to consider how speakers' gender may interact with their nationality and sexual orientation. This is an important direction for future research. For instance, lesbian women expect to be less stigmatized because of their voices than gay men (Fasoli et al., 2021) and voice femininity in men and women affects perceptions of competence (Ko et al., 2009). Third, it would be important to integrate speakers' voice self-perceptions with listeners' perceptions and social categorization to understand the extent to which the two converge (see Kachel et al., 2020). This would provide a better understanding of the relative role speakers and listeners play in defining intergroup communication. Fourth, we assumed that British and heterosexual speakers would perceive themselves as high-status group members and foreigners and sexual minorities as low status. However, we did not explicitly assess participants' perceptions of their ingroup's status compared to relevant outgroups. Fifth, our study focused on understanding general perceptions and expectations of speakers in the absence of explicit intergroup comparisons. Accordingly, the effects observed herein may be even stronger, and those not observed may emerge, in contexts that involve explicit intergroup comparisons which may further increase the salience of people's social group memberships. --- Conclusion This research shows that it is important to consider speakers' perspective when analyzing communication. Speakers endorse beliefs about their voices as cues of their group membership, which leads foreigner and sexual minority speakers to expect to be stigmatized because of how they sound; such beliefs and expectations can influence intergroup communication and relations. --- Conflict of Interest Disclosure The Authors have no conflicts of interest to declare. --- Authorship Details Fabio Fasoli:research concept and design, collection and/or assembly of data, data analysis and interpretation, writing the article, critical revision of the article, final approval of the article. Marko Dragojevic: research concept and design, writing the article, critical revision of the article, final approval of the article. Tamara Raki<unk>: research concept and design, critical revision of the article, final approval of the article.

When voice signals nationality and sexual orientation: Speakers' selfperceptions and perceived stigmatization Research has shown that individuals speaking low-prestige language varieties are often negatively evaluated and stigmatized by others. However, less is known about how speakers of such language varieties perceive their own speech. Here, we examined self-perceptions and perceived stigma of speakers who belong to multiple social categories signaled by auditory cues. Specifically, we examined beliefs of sexual minority and heterosexual male speakers who were either British nationals (native English speakers) or foreigners living in the UK (non-native English speakers). British speakers believed their voices cue their nationality more than foreigners. Heterosexuals believed their voices reveal their sexual orientation, but only when they self-perceived as sounding masculine. Sexual minority and foreign speakers felt more stigmatized because of the way they sound than did heterosexual and British speakers, respectively. These findings have implications for intergroup communication and voice-based stigmatization literature.

Introduction Neighborhood socioeconomic (nSES) factors have been implicated in prostate cancer (PCa) disparities. In line with the Precision Medicine Initiative that suggests clinical and socioenvironmental factors can impact PCa outcomes, we determined whether nSES variables are associated with time to PCa diagnosis and could inform PCa clinical risk assessment. --- Materials and methods The study sample included 358 high risk men (PCa family history and/or Black race), aged 35-69 years, enrolled in an early detection program. Patient variables were linked to 78 nSES variables (employment, income, etc.) from previous literature via geocoding. Patientlevel models, including baseline age, prostate specific antigen (PSA), digital rectal exam, as well as combined models (patient plus nSES variables) by race/PCa family history subgroups were built after variable reduction methods using Cox regression and LASSO machine-learning. Model fit of patient and combined models (AIC) were compared; p-val-ues<unk>0.05 were significant. Model-based high/low nSES exposure scores were calculated and the 5-year predicted probability of PCa was plotted against PSA by high/low neighborhood score to preliminarily assess clinical relevance. --- Results In combined models, nSES variables were significantly associated with time to PCa diagnosis. Workers mode of transportation and low income were significant in White men with a PCa family history. Homeownership (%owner-occupied houses with >3 bedrooms) and unemployment were significant in Black men with and without a PCa family history, --- Introduction In 2020, 191,930 new cases and 33,330 deaths from prostate cancer (PCa) are expected in the US [1]. Despite high survival rates, PCa remains the 2 nd leading cause of cancer death in US men [1]. Early detection of PCa through prostate specific antigen (PSA) testing is being re-visited to determine if PSA screening reduces PCa deaths [2] with mixed results [3]. PSA screening was not associated with reduced risk of prostate cancer mortality in both a US [4] and UK [5] randomized control trial, but was associated with reduced mortality in a European trial [6]. However, in the US trial, significant control group contamination (i.e., control group participants were still getting screened for PCa) [4], as well as low adherence to PSA screening in the UK trial [5], could have biased results towards the null [3]. Given the inconsistent findings and potential study biases, most professional organizations, including the American Urological Association [7], United States Preventive Services Task Force [8], American Cancer Society (ACS) [9], and National Comprehensive Cancer Network [10] generally recommend shared decision-making about undergoing PSA testing for men in the general population at average risk of PCa at age 55 up to age 69 (age 50 for ACS). However, the impact of PSA screening may be more substantial in high risk subgroups where the risk of dying from PCa is higher than expected [11]. Men with a PCa family history and Black men have a 2-7 fold increased risk for PCa compared to the general population [12,13]. Further, Black men compared to White men are more than twice as likely to be diagnosed with and die of PCa [1], and are less likely to be screened for PCa [14]. These racial disparities in PCa outcomes have persisted for three decades [15,16] and remain an important public health priority. However, the optimization of surveillance protocols and the effectiveness of current PCa screening guidelines for high risk men (i.e., shared decision-making about undergoing PSA testing at ages 40-54 in high risk men vs ages 55-69 in the general population [17]) continue to be understudied areas [18]. Identifying additional risk factors, beyond PSA, PCa family history, and race, could help to further risk stratify high risk men and improve clinical decision-making related to PCa screening and surveillance. Given the role racial disparities play in PCa outcomes, it seems plausible to also consider other measures of disparity, particularly socioeconomic (SES) determinants of health, such as a person's education or income. As detailed by a number of multilevel conceptual frameworks [19,20], beyond a person's race/ethnicity or SES, social determinants of health, particularly macro-environmental factors, such as the social environment or neighborhood in which a person lives, may also impact cancer health disparities [20] and health more broadly [21]. Neighborhood or social environment is often defined in cancer studies by US Census variables related to socioeconomic status (SES) that describe the economic (e.g., employment, income), physical (e.g., housing/transportation structure), and social (e.g., poverty, education) characteristics of a census tract (smaller geographic boundary than a county) in which a person lives [22,23]. Previous population-based studies of PCa found that neighborhoods defined by variables for low SES and higher deprivation were associated with greater risk of late-stage/high grade PCa in both Black and White men [22,24,25], and less aggressive treatment in Black men [22,26]. Further, associations between neighborhood SES and PCa often remained, even after adjustment for race/ethnicity [22,23]. Thus, given neighborhood is also correlated with access to care measures, such as screening utilization [27,28], it is possible that social environmental variables could serve as novel metrics or environmental markers for high risk men on a disparity-related pathway to PCa. The Precision Medicine Initiative calls for the consideration of multilevel risk markers-a person's genes, lifestyle, AND environment-when making clinical decisions related to screening, treatment, and disease surveillance [29,30]. Over 60% of PCa clinicians use risk assessment tools, such as nomograms to support clinical decision-making [31]. However, most PCa risk assessment tools focus only on patient-level clinical factors to identify which men are at risk for developing PCa or having poor outcomes [32][33][34]. More recently, an emphasis has been placed on the inclusion of genetic markers from genome-wide association studies (GWAS) [35][36][37][38], though validation of these GWAS markers is needed. Overall few, if any of these prediction studies considered social environment, and in some cases even patient-level racial/ethnic differences [31], despite well-known racial disparities in PCa. Capitalizing on a novel neighborhood-wide association study (NWAS) we developed [39], we propose to comprehensively assess whether neighborhood social environmental (nSES) variables (from our NWAS study [39] and additional published literature [40][41][42][43][44][45][46][47][48][49]) are associated with time from study enrollment to prostate cancer diagnosis in an ethnically-diverse, longitudinal cohort of high risk men (e.g., Black men and those with a PCa family history) participating in an early detection prostate cancer risk assessment program (PRAP). In an exploratory analysis, we then assess whether social environment factors found to be significant in the proposed association study could inform the probability of developing PCa in high risk men. Thus, this study begins to bridge the gap between health disparity research at the populationlevel and the clinic by preliminarily assessing whether the incorporation of neighborhood data with patient-level clinical data could be useful for PCa clinical risk assessments. --- Materials and methods --- Study population The Prostate Cancer Risk Assessment Program (PRAP) at Fox Chase Cancer Center (FCCC) in Philadelphia, Pennsylvania (PA) is a research, education, and screening program for men who are at high risk for PCa. It was established in 1996 to develop a registry of patients at high risk for PCa and to facilitate screening and early detection in these men [50]. As described previously [51], high risk men between the ages of 35-69 years and who were cancer-free at enrollment were recruited into the study [50]. High risk men were defined as: 1) having one or more first-degree relatives diagnosed with prostate cancer, 2) having 2 second-degree relatives on the same side of the family diagnosed with prostate cancer, 3) being of African American/ Black race, or 4) having a known BRCA1/2 mutation [50]. Informed consent was obtained from all study participants for the PRAP cohort. This study was approved by the Fox Chase Cancer Center Institutional Review Board (Protocol #16-9007). Men were recruited into PRAP from the community through radio advertisements broadcast in the Philadelphia metropolitan area and from community partner hospitals [52]. PRAP participants are followed annually with clinic visits that include prostate specific antigen (PSA) testing and digital rectal exam (DRE) screening. Prior to November 2005, criteria for prostate biopsy included PSA > 4.0ng/mL or any abnormality on DRE. Given PCa detection rates were high in the cohort at this criteria, the criteria for prostate biopsy were lowered after November 2005 and included having a PSA 2.0ng/mL or any abnormality on DRE [51]. 73% of the PRAP cohort were recruited between 1996 and 2006. Within the PRAP cohort, 358 of 444 men residing in PA had complete residential address information, at least one follow-up visit, and were not missing relevant clinical (i.e., PSA, DRE) and demographic information (race/ethnicity; educational attainment) for analysis. --- Outcome Our main outcome of interest was time to prostate cancer diagnosis. Men in PRAP were followed from time of study entry to PCa diagnosis or censoring (date of last study visit). The median follow-up time was over 55 months, with PCa occurring in 56 men. --- Patient-level factors The following clinical factors were assessed for association with our outcome: age at baseline or enrollment (continuous variable), race/ethnicity (self-report White or Black), PCa family history (yes/no to having one or more first-degree relatives and/or 2 second degree relatives on the same side of the family diagnosed with PCa), PSA at baseline (ng/mL), and DRE at baseline (abnormal vs normal/benign prostatic hyperplasia [BPH]). Beyond these factors, we also evaluated models with and without a patient's education level (high school or less vs. college education or more), given previously reported associations between education, PCa outcomes, health disparities, AND neighborhood circumstances [45][46][47][48][49]; however, education was not found to significant in any of our tested models. --- Social environmental factors Neighborhood or social environment (nSES) is defined here by the economic (e.g., employment, income), physical (e.g., housing/transportation structure), and social (e.g., poverty, education) characteristics of a census tract in which a patient lives. Census tracts are typically smaller geographic boundaries than counties, containing on average 4000 residents. Neighborhood variables at the census tract level were ascertained from the Year 2000 US Census Summary File 1 (SF1) and Summary File 3 (SF3) data and downloaded via Social Explorer (http:// www.socialexplorer.com) [53,54]. Year 2000 census data were used because over 70% of the study participants were recruited between 1996 and 2006. We previously designed a neighborhood-wide association study (NWAS), which is a multiphase, empiric variable selection method derived from genome-wide association studies (GWAS) [39,55] to agnostically analyze the independent association of over 14,500 US census variables and their association with aggressive PCa (Stage 3 or greater and Gleason grade 7) by race using the Pennsylvania State Cancer Registry data. We identified 22 variables (17 in White men; 5 in Black men) that were not highly correlated (S1 Table ) and that remained significantly associated with aggressive PCa [39,55]. In a subsequent replication study, 9 of 22 NWAS hits (4/5 from the NWAS in Black men; 5/17 from NWAS in White men) replicated across both Black and White men; whereas, 13 of the 22 variables appeared to be race-specific (S1 Table [56]) [57][58][59]. To further allow for a comprehensive investigation of social environment, we then coupled our NWAS findings [39] with findings from previous neighborhood and cancer studies [49,[57][58][59]. Thus, we identified and evaluated a total of 78 unique social environmental variables (e.g., nSES; representing the physical, social and economic landscape of Pennsylvania census tracts) for this analysis (see S1 Table ). Residential addresses of PRAP participants were geocoded up to the census tract level and assigned a Federal Information Processing Standard (FIPS) geocode [60,61] at the census tract level using ArcGIS software v. 10.6. (ESRI; Redlands, CA). Patient information was then linked to the 78 variables representing nSES from the US census via the FIPS code using Stata v. 11.0 (College Station, TX). Thus, patients residing in the same census tract were assumed to have the same neighborhood characteristics. There were 235 unique census tracts included in this analysis. --- Statistical analysis Distribution of study variables, including medians, ranges, and percentages were summarized overall and by race/ethnicity. nSES variables, age and PSA were evaluated as continuous variables. Variables with skewness >2 were log transformed; all variables were standardized to have a mean of zero and standard deviation of 1. Association study. We assessed the relationship between all 78 nSES variables and time to PCa diagnosis using a series of univariable Cox proportional hazards regression models. Census variables with P<unk>0.10 were included in a subsequent multivariable Cox model along with patient-level factors (age, DRE, PSA, race, and family history), using robust standard errors to account for clustering within census tract (S1 Table ). Hazards ratios, 95% Confidence Intervals, and p-values (significance at p-value <unk>0.05) from refined multivariate models (that only include significant neighborhood variables to reduce potential over-fitting) are reported. Due to the ascertainment strategy of the PRAP cohort and to account for confounding, we also divided the sample by race, and assessed the nSES variables which were applicable to the given racial group (S1 Table ). The Black population was further subdivided by family history. We evaluated model fit/performance of patient-only factors versus combined models by comparing AIC estimates [62]. As a secondary analysis, we also used the lasso machine learning method [63,64] to assess whether nSES variables were predictive of time to PCa diagnosis. This analysis was used 1) as an alternative variable reduction/selection technique, as it can accommodate correlation amongst nSES factors, given census variables are often highly correlated with one another and race/ethnicity [39]; 2) to confirm results from our association study, i.e., to demonstrate whether the same neighborhood variable could be identified across multiple methods, which would be relevant for the preliminary assessment of clinical relevance (described below). Variables with non-zero coefficients were considered to be of interest, with the penalty parameter chosen via cross-validation. Preliminary assessments of clinical utility. Next, we calculated the predicted 5-year rates of PCa diagnosis for each participant based on the coefficients of the Cox regression models. Similar to genetic risk score calculations, we then calculated a neighborhood exposure score as the weighted sum of the neighborhood covariates (values weighted by the regression coefficients) in the total population and each race-specific group [65]. Neighborhood exposures were dichotomized at the median to categorize participants as residing in a neighborhood with either high or low exposure to identified nSES conditions. For each individual, the 5-year predicted probability of being diagnosed with PCa was then plotted against baseline PSA level, grouped by high/low neighborhood exposure score, to preliminarily demonstrate potential clinical utility. --- Results Baseline characteristics of the PRAP cohort are presented in Table 1. The median age at study entry was 50 years old; 56% of the study cohort included Black men. The median baseline PSA levels were 0.95ng/mL, and the percentage of patients with a normal DRE was 96.9% for the total sample. The median duration of follow-up was close to 5 years, with Black men having longer median follow-up than White men (60 vs 50.7 months, respectively). 42% of Black men report having a PCa family history. Black men were also more likely to be diagnosed with PCa (18.9% vs 10.8%) and to have a high school education or less (35.3% vs 19.5%) compared to White men. Black men also lived in neighborhoods with a higher percentage of persons living below poverty (median = 16%) compared to White men (median = 3.7%). Approximately 60% of Black men and 36% of White men lived in a neighborhood with high exposure to nSES circumstances associated with shorter time to prostate cancer in this analysis. Men in the high neighborhood exposure group (i.e., those exposed to significant social environmental conditions) compared to those in the low exposure group had a higher percentage of men diagnosed with PCa (21% vs 10%) and advanced PCa (Gleason grade 7) (29% vs 13%). --- Association study In the full study sample and in race/PCa family history-specific models, nSES variables were associated with time to PCa diagnosis, along with patient and clinical characteristics, but the findings did differ across race/ethnic groups (Table 2 andS2 Table). For this reason and due to the ascertainment strategy (i.e., recruiting Black men and White men with a PCa family history) we focus on results in stratified models. In multivariate models, as expected PSA was strongly associated with time to PCa diagnosis across all statistical models (HR = 1.47; 95% CI = 1.33-1.63 p-value = <unk>0.001) (Table 2). A neighborhood housing variable (% Owneroccupied housing units with 3 or more bedrooms) was consistently associated with a shorter time to PCa diagnosis in the total study population and in Black men with a PCa family history. In Black men without a PCa family history, % unemployed workers was associated with time to PCa diagnosis (HR = 1.80; 95%CI = 1.11-2.92 p-value = 0.02). In White men, an Lasso results were similar to variables identified with univariate analysis (S2 Table ). For patient level variables, race, PSA at baseline, and age had non-zero lasso coefficients, but family history and DRE did not. We also explored interactions with race, but no interactions were non-zero. Neighborhood variables found to be significant in multivariable models also had non-zero penalized coefficients in lasso (e.g., pct_sf3_p030007 [coefficient = 1.01] and pct_sf3_p084006 [coefficient = 0.72] for the White population; pct_sf3_h042006 [coefficient = 0.14] for Black participants with PCa family history; and pct_SE_T069_y [coefficient = 0.14] for Black men without a PCa family history). In both lasso and cox regression models, model fit was improved in combined models (patient plus neighborhood variables) compared to models with only patient level data (S2 Table ). In cox regression, the AIC for patient models compared to combined models for the total population was 528. 18 Moving forward, we chose to work with the Cox regression findings from the combined models (Table 2), given the significant neighborhood variables identified in these models were found to be informative across both regression and lasso methods. --- Preliminary assessments of clinical utility Utilizing the findings from combined (patient plus neighborhood) Cox models above, we calculated the 5-year predicted probability of a PCa diagnosis, and it was higher in men from social environments with a high neighborhood exposure score (high exposure to weighted combinations of significant nSES variables from the multivariable model) compared to those with a low exposure score (low exposure to weighted combinations of significant nSES variables from the multivariable model) in the total population and in White and Black men with/ without a PCa family history (Fig 1A -1D). Differences in predicted probabilities were most notable for participants with larger PSA values at baseline. For example, White men with a PCa family history residing in the high neighborhood exposure group with a baseline PSA level of 4ng/mL had a 26.7% (compared to 7.7% from the low exposure group) 5-year predicted probability of PCa. For Black men with a family history residing in the neighborhood high exposure group, the 5-year predicted probability of PCa was 56.2% versus 29.7% in the low exposure group (Fig 1C). For Black men without a family history of PCa, the 5-year predicted probability of PCa was 64.4% (extrapolated) in the high neighborhood exposure group, and 33.3% in the low neighborhood exposure group (Fig 1D). --- Discussion This study is one of the first to consider both the association between neighborhood or social environmental determinants and time to PCa diagnosis in a clinical sample of high risk men, as well as to assess the potential clinical utility of nSES variables. Time to PCa diagnosis is a relevant outcome to study, given the increased interest in evaluating the effectiveness of current PCa screening guidelines for high risk men (i.e., Black men or those with a PCa family history), and the growing interest in improving surveillance protocols for men who choose "watchful waiting" [17,18]. Neighborhood SES factors are important to consider because they are implicated in PCa health disparities, specifically differential diagnosis of PCa risk and survival outcomes and differential access to care [40][41][42][43][44][45][46][47][48][49]. Given neighborhood social environment could serve as an additional indicator of poor PCa outcomes, it is possible they could also impact clinical outcomes such as time to PCa diagnosis. Thus, investigations into whether neighborhood can improve the identification of men at high risk for PCa, particularly those who may be impacted by disparities, seem plausible. However, neighborhood findings are rarely tested in clinical settings, where more detailed patient and clinical data (that might correlate with or fully account for neighborhood effects) are available. In a clinical cohort of men at high risk for PCa (PRAP), our initial study suggests that when jointly evaluated social environmental factors remain associated with time to PCa diagnosis, even in the context of patient clinical factors. However, findings were slightly different by race/ethnicity. Further, the incorporation of neighborhood data appeared to modestly improve the five-year predicted probability of being diagnosed with PCa in high risk men (Black race and/or PCa family history), suggesting continued investigations into the clinical utility of social environmental factors are needed. --- Association study We took a comprehensive approach and analyzed many nSES variables because across cancer studies, different neighborhood variables are often selected to represent the same general SES domains (e.g., education, income, employment). For instance, one study might define poverty in terms of income, another in terms of percentage of households above or below the State poverty line. This has complicated conclusions about the relationship between neighborhood and cancer outcomes [59] and has made the translation of neighborhood findings to the clinic challenging. Therefore, in this association study, we used patient clinical variables that have been shown to affect time to PCa diagnosis [36,51], and neighborhood variables that were previously found to be associated with health outcomes across the cancer continuum (incidence, aggressiveness, mortality) (S1 Table ). Thus, the patient and neighborhood-level variables identified in multivariate models are also biologically plausible in that they have previously been shown to be associated with poor outcomes. However, census variables across SES domains are often correlated [39], and our comprehensive approach to include multiple variables also introduces possible multicollinearity. To address these challenges, we applied empiric methods approaches to allow for systematic variable selection (univariate analysis and prior NWAS) and to account for correlation within the data prior to building the multivariable models (using lasso). Given the study ascertainment strategy and potential for confounding by race [1,66], we focus on interpretation of results in stratified models. Prior PCa studies have found associations with nSES extremes (measured in terms of education, employment, and poverty variables [58,67]). More specifically, both high and low nSES have been reported to have associations with poor PCa outcomes [22,39,56,67,68]. Low SES is often associated with increased PCa stage or grade and increased mortality [22,39,56,69,70]; whereas studies of PCa incidence have found associations with higher SES, partially attributed to increases in PCa screening in men from higher socioeconomic groups [67,68]. Similarly, in this study, we also found significant associations between time to PCa diagnosis and low nSES variables. Although numbers were small, men with high exposure to these low nSES variables also accounted for the majority of advanced PCa diagnoses (12 of the 14 Gleason grade 7 diagnoses). Specifically, we found that in Black men without a PCa family history, neighborhoods with a higher percentage of unemployment were associated with shorter time to PCa diagnosis [69,70]. In White men with a PCa family history, neighborhoods with a higher percentage of men with low incomes were also associated with shorter time to PCa diagnosis [22]. A joint domain variable related to employment and transportation was also identified in White men (%workers taking trolley or street cars to work). This variable (pct_sf3_p030007) was positively correlated with poverty-like variables (S1 Fig/ S3 Table ), relates to urban compared to rural environments, and can be used as a surrogate measure for access to care [71,72]. In Black men with a PCa family history, one nSES variable related to housing and homeownership (i.e., owning a home with greater than 3 bedrooms) was associated with shorter time to diagnosis of PCa. In prior literature, housing factors, particularly renting a home and overcrowding (i.e., having more than one occupant per room), both of which often correlate with lower SES and unequal housing policies, have been shown to contribute to disparities in the Black community [56,68,73,74]. Thus, our finding that housing related to homeownership was associated with a poor PCa outcome was surprising. To further understand this variable, we reviewed correlations with other variables in our study population (S1 Fig). We found the highest correlations with this variable (range 0.41-0.58) were with variables representing favorable housing conditions (i.e., owner-occupied, single family units) and blue collar occupations (i.e., % working in construction and/or male public service occupations); however, inconsistent correlations were observed with income and poverty variables (e.g., negative correlations reported with both high income >$150K and low income <unk>$15K) (S1 Fig). Thus, the homeownership variable, pct_sf3_h042006, may reflect living in a middle class neighborhood. Few studies in cancer have specifically evaluated the effect of middle class socioeconomic status on cancer outcomes, particularly in race-specific analyses. PCa incidence studies have found associations with higher neighborhood SES (measured as a composite SES score that included variables related to education, employment, and income) [67,68]. The positive associations reported for nSES and PCa incidence in these studies have been attributed to access to care, suggesting men with higher SES are more likely to get PCa screening and get diagnosed at lower stage disease [67,68]. However, in our study cohort, participants were enrolled in an early detection program, where all participants received annual PSA screening and subsequent biopsies, with some receiving more aggressive screening (e.g. at younger ages) and biopsies (e.g. based on PSA of 2ng/mL) than recommendations specify for a general population. When screening is broadly accessible, associations between race/ethnicity [75], high nSES and PCa outcomes have been shown to attenuate [67]. Thus, it's possible our low and mid-level SES findings were impacted by the availability of screening. Additionally, in one of the prior PCa incidence studies using California (CA) cancer registry data, the middle quantiles (Q) of nSES (i.e., Q3 and Q4 from Q1-Q5), which likely represent middle class status, were also significant in Black and White men [68]. However, in this study, important clinical factors, including PSA and PCa cancer family history were not available. In another PCa incidence study in Detroit, a matched case-control design was employed, and the analysis included adjustments for PCa cancer family history [67]; however, nSES was assessed continuously and cases and controls were matched by race, so associations with mid-level SES alone and by race could not be ascertained. Further, this study also used a ZIP-code level nSES composite score [67] compared to smaller census tract level nSES measures used in our study and the study conducted in CA. Level of geography has been shown to affect study results [76]. Additionally, a limitation of prior studies is the use of a nSES composite score that might include variables that are not relevant for specific race/ethnic groups [68]. This is one of the reasons we evaluated each nSES variable separately [56]. Our study population contained more Black men and men with a PCa family history, tended to be younger, and varied geographically (our patients were from PA compared to CA and Detroit) [67,68], which could also influence findings. Further, previous studies show that certain racial/ethnic groups at the same level of SES may not share the same level of power or opportunities, and it's possible that the race-specific nSES variables identified in this study may provide insight into this phenomenon [77]. Thus, race-specific findings warrant further study [73], as most cancer studies focus on general neighborhood effects with less emphasis on which/why social environmental factors may be different across race/ethnic groups [40][41][42][43][44][45][46][47][48][49]. Further, it is also possible that neighborhood factors not included in this analysis, particularly variables related to access to care, such as distance/travel time to health care facilities [78], could also impact time to PCa diagnosis [79,80]. In general, this study provides additional evidence that nSES can impact time to PCa diagnosis; however, these relationships are complex and additional studies are needed to further explore the direction of the association, in the context of race/ethnicity. Our study also showed interesting differences within Black men based on family history (i.e., associations with shorter time to PCa diagnosis were found with a moderate nSES variable in Black men with a PCa family history AND with low nSES (i.e., unemployment) in Black men without a family history). Family history of PCa is strongly influenced by genetics [79,80], and it is possible that genetics or tumor biology play a strong role in poor PCa outcomes [73,74]. Similarly, neighborhood environment compounded with underlying genetic susceptibility may also affect PCa development. Studies do show differences in molecular mechanisms for PCa by race [81]. Further, neighborhood circumstances have been found to affect DNA repair pathways that are also implicated in PCa family history [82][83][84]. However, under a chronic stress hypothesis, it is also possible that residents from disadvantaged neighborhoods may experience greater emotional stress and constant "wear and tear" on the body that can influence not only DNA repair, but epigenetic changes that can ultimately result in cancer development [85][86][87][88][89]. Thus, although our interpretations are limited because we have a small sample of Black men without a PCa family history, and we lack a comparison group of White men without a PCa family history, our findings do suggest that future cancer investigations centered on gene and social environment interactions and social epigenetic changes by race appear warranted. While a handful of neighborhood variables were identified in the association study, 3 of 4 significant nSES variables from race-stratified models came from our previous empiric NWAS studies [39,56]. NWAS variables tend to be more specific (i.e., gender/age/specific income range) and represent more than one domain in a single variable compared to traditional, single domain variables (i.e., % unemployment). While it is possible that findings could be due to chance, this is unlikely given that across multiple methods (S2 Table ) and study populations (the PRAP population here and the PA cancer registry from the previous NWAS [56]), % of owner-occupied housing units with 3 or more bedrooms in Black men, and % of workers taking trolley or street cars to work and % of males earning low income in White men) continue to replicate and show associations with PCa outcomes. Thus, coupling NWAS approaches with commonly used single domain variables may be informative in future studies. --- Preliminary assessments of clinical utility Multivariate models that contained both patient and neighborhood variables modestly improved model fit for time to PCa diagnosis compared to patient only models across race/ ethnic groups. Similarly, the 5-year predictive probability of developing PCa was higher in men from neighborhoods with a higher nSES exposure score compared to men from neighborhoods with a lower neighborhood exposure score. The neighborhood exposure scores were derived from significant nSES variables from the association models, and this effect (i.e. higher exposure scores or higher percentages of significant nSES variables) remained regardless of the direction of the nSES variable (i.e. low SES or mid-level SES), and was more pronounced in men with higher PSA values. If this finding is validated in large independent datasets, it could potentially help identify participants from geographic areas at particularly high risk of developing PCa. For instance, the 5-year predicted probability of PCa was close to triple for White men (PCa family history) with a baseline PSA of 4ng/mL who lived in neighborhoods with high exposure to unfavorable socioeconomic circumstances (26.7%) compared to men with the same PSA level from low exposure neighborhoods (7.7%). The probability was 5 times greater for White men with a PCa family history and a baseline PSA of 2ng/mL living in a high exposure neighborhood (16.1%) compared to a low exposure neighborhood (3.4%). Similarly, Black men with a PCa family history from high exposure neighborhoods who had a baseline PSA of 4ng/mL had close to double (closer to triple at a PSA of 2ng/mL; 26.9.2% vs 9.4%) fiveyear predicted probability of PCa. In Black men without a PCa family history, we had to extrapolate the high neighborhood score at a PSA of 4ng/mL due to sample size (i.e., few men with a PSA of 4ng/mL lived in areas with higher percentages of unemployment). However, patterns were similar to the other stratified analyses at a PSA of 2ng/mL. Black men without a PCa family history who had higher neighborhood exposure scores had greater than 3 times the five-year predicted probability of PCa (29.5% vs 8.8%). We chose to evaluate the 5-year probability of developing PCa at the 4ng/mL and 2ng/mL PSA cutpoint, since this is the value often used to determine whether to move forward to a prostate biopsy or continue active surveillance in PRAP participants [51]. Prostate cancer has a long latency period and we would have liked to assess the probability of developing PCa at longer time intervals (i.e., 10 or

The 5-year predicted probability of PCa was higher in men with a high neighborhood score (weighted combination of significant nSES variables) compared to a low score (e.g., Baseline PSA level of 4ng/mL for men with PCa family history: White-26.7% vs 7.7%; Black-56.2% vs 29.7%).Utilizing neighborhood data during patient risk assessment may be useful for high risk men affected by disparities. However, future studies with larger samples and validation/replication steps are needed.

closer to triple at a PSA of 2ng/mL; 26.9.2% vs 9.4%) fiveyear predicted probability of PCa. In Black men without a PCa family history, we had to extrapolate the high neighborhood score at a PSA of 4ng/mL due to sample size (i.e., few men with a PSA of 4ng/mL lived in areas with higher percentages of unemployment). However, patterns were similar to the other stratified analyses at a PSA of 2ng/mL. Black men without a PCa family history who had higher neighborhood exposure scores had greater than 3 times the five-year predicted probability of PCa (29.5% vs 8.8%). We chose to evaluate the 5-year probability of developing PCa at the 4ng/mL and 2ng/mL PSA cutpoint, since this is the value often used to determine whether to move forward to a prostate biopsy or continue active surveillance in PRAP participants [51]. Prostate cancer has a long latency period and we would have liked to assess the probability of developing PCa at longer time intervals (i.e., 10 or 15 years); however we chose to evaluate the probability of developing PCa at 5 years post enrollment, given the majority of our study sample had follow-up of at least 5 years. Thus, while findings preliminarily suggest the incorporation of social environmental factors might be useful for screening and active surveillance decisions, more studies are needed, given we could not evaluate the probability of developing PCa over a longer time period due to loss of follow-up, and the majority of the study sample did have a PCa family history. --- Conclusions There has been a recent increase in both the recognition and importance of utilizing social determinants of health to improve cancer treatments and interventions [21]. In line with the Precision Medicine Initiative's emphasis on environment [29,30], to our knowledge, this study is one of the few to investigate the association of neighborhood or social environment with time to PCa diagnosis in a clinical sample of high-risk men. While this study introduces new systematic and empiric methods that can inform future PCa neighborhood and clinical studies, it was not an etiologic study designed to conclusively identify the most important neighborhood factors impacting PCa risk. Further, the cross-sectional assessment of neighborhood circumstances only at the time of enrollment, the modest sample size (particularly when stratifying by race and PCa family history), the study ascertainment strategy, the lack of availability of additional patient level clinical data (i.e., repeated measures of PSA) as well as patient SES data [90], and the limited generalizability of our findings due to the high proportion of men with PCa family history, limit our conclusions. However, our results can serve to be hypothesis-generating for future investigations into the role of PCa health disparities in the clinic. Finally, preliminary findings from this limited sample demonstrate a proof of concept that predicted probability of PCa may be augmented with the addition of publicallyavailable, readily accessible nSES factors from the US Census. While additional studies with larger sample sizes and additional validation and replication steps are needed, findings suggest that neighborhood variables could potentially add useful clinical information for high risk men undergoing PCa risk assessment. --- These data include sensitive patient information, including geocodes, which are considered identifiable data. Per the provisions to maintain the confidentiality of data outlined in the approved IRB protocol (FCCC IRB #16-9007), these data cannot be shared publicly but de-identified data may be provided upon request by contacting Michael Hall (Michael. [email protected]; 215-728-2861 --- Supporting information S1

The 5-year predicted probability of PCa was higher in men with a high neighborhood score (weighted combination of significant nSES variables) compared to a low score (e.g., Baseline PSA level of 4ng/mL for men with PCa family history: White-26.7% vs 7.7%; Black-56.2% vs 29.7%).Utilizing neighborhood data during patient risk assessment may be useful for high risk men affected by disparities. However, future studies with larger samples and validation/replication steps are needed.

INTRODUCTION Decentralization is seen as the best solution to cultivate local democracy in Indonesia after the collapse of centralized governance under Soeharto's regime. The aspiration of the community is expected to be channelled into the decision-making process. They can access the resources equally and cultivate them responsibly. However, failure has appeared since the control of resources and social relations were determined by the capacity of power relations tied among the producers. Their extensive control implied the socio-economic livelihood of the islanders, including the exploitation of marine resources to generate their livelihood (Amorim, et al. 2020). The challenges among fishing communities in Indonesia are depicted as complicated issues that were constituted from a socio-ecological context (Chapsos et al., 2019;Eriksson et al., 2019). Fishing production currently is configured by human behaviour around the fishing ground, mostly characterized by the operationalization of illegal fishing methods, issues of marine debris, and other climate events. Unfortunately, control from the local authority is so limited for efficiency reasons. Decentralization that has been implemented by the municipality of Makassar City was intended to bring the public services closer to the local community who live on the islands, including to optimize the control of local government regarding the potential illegal fishing method. The use of illegal fishing in Sangkarrang islands has been revealed by many scholars. Mostly, they contested this issue as the impact of weak law enforcement (Nurhidayah & McIlgorm, 2019). Fishing blasting is so easy to find on this site. Cyanide injection is also performed by local traditional divers to increase production, particularly to collect higheconomic commodities. These methods are triggered by the high demand of the global market. Hence, it can Decentralization and the Unraveling of Power Relations in Sangkarrang Islands, City of Makassar. (Sudarmono) be assumed that these illegal methods are performed by the global market network and controlled under the global market mechanism. Moreover, the study of Radjawali (2012) reveals that the authorities cultivate these conditions to take more advantages and benefits. They collect a small amount of money frequently as a consequence of illegal fishing methods performed by local producers. As it is commonly found, local people prefer to overcome their criminal problems by giving the authorities some money. By reinforcing the decentralization, it is expected that the deal with the local elite (who are also the illegal fishing producers) can be settled. From the lens of politics and administration, natural resources management faces the weaknesses of government policies to overcome poverty issues, food security, social protection policies, and the representation of local people in a formal community institution. In the coastal area, the poverty issue emerged from the failure of the administration to put correct indicators of poverty based on its local context. Although the local government strives to elevate community representation in formal institutions, some local elites utilize the issue to control the mechanism of the decision-making process (Indriani, D., & Sudarmono, S. (2021), including a cash transfer policy for local people. Consequently, the policy does not reach the core of the issue. By reinforcing the decentralization, local people can be represented in a local formal institution. Despite the enactment of promising new laws and policies, implementation still faces a number of challenges. It is argued that these challenges resulted from strong pressures of the social institution to accommodate the interest of elites. They have a chance to steer and interfere with the formal mechanism conducted by the local government. Unfortunately, this articulation has actually begun since capitalism penetrated into traditional articulation of power and has continued until today. Apparently, the legal framework has resulted from ineffective governance due to the complicated regulation, and also it indicates the implementation of inefficient public services. Moreover, the disempowered situation of the poorer ecosystem largely continues (Wever et al., 2012). It is argued that leakage in governance extensively influences the social relation of producers. In general, the fishing community is characterized by its cohesive social relation. Mostly, they are tied in a reciprocated patron-client relationship. Patrons are usually responsible for providing social protection for their clients. Consequently, the client must follow all of the patron's directions. From the lens of social capital, the patron controls the network that connects all the social systems of the community, including dealing with local government. For instance, patrons usually have access to interfere with the timing of cash transfer programs from the government for their clients. If the local government cannot provide the cash, they will provide money/debt for their client immediately, without formal procedures. As this relationship indicates a strong power relation, the relationship is maintained as peripheral capitalism and reflects a political relation, particularly between the patron to local elite, as well as the patron to local politicians. From the lens of local politicians, the patrons are seen as stationary bandits (Yusoff, 2010) who obviously control the production flow. It is assumed that the real votes from a patron are their clients and the clients' family members who have been eligible to vote. On the other perspective, patrons assume that they should expand their influence broadly to strengthen their power among the fisher-folk. Strong access to politicians will also ensure their control of the distribution of the community. Patrons need politicians to protect their businesses. For business purposes, market information plays a significant role, particularly in controlling the fluctuation of commodities' prices as well as their distribution. However, since the establishment of the new sub-district, it is argued that the patron has been unable to control the market information. The patron needs to reset the way of interpersonal communication with the local elite; politician, government official, and another local elite. Due to the rearrangement of administrative governance in Sub District Sangkarrang, the local officials should penetrate the existing cohesive political structures, particularly the patron-client relationships. The objectives of this study are 1) to overview the dynamic of social relations after the implementation of decentralization and 2) the articulation of political ties among the community. As Osei-Tutu et. al. (2021) explained that decentralization seemed to devastate natural resources. However, this study firstly indicates that decentralization has brought the bureaucracy closely to the fishing ground, which finally eliminates the destructive fishing activities. To scrutinize the articulation of power relations affected by decentralization, this research utilizes the theory of access developed by Jesse Ribot and Nancy Lee Peluso (Ribot, Jesse & Peluso, Nancy, 2003). They argue that this theory can be utilized to explain the way of actors to gain, maintain, or control resource access. Furthermore, the actor who get advantages will be discovered. They explain the definition of access as the certain possibility to get an advantage from material objects, people among the networks, institutions, and symbols of power. In a broader context, it brings attention to social relationships that can disturb or support producers to benefit from resources. They theorize access and then examine a broad set of factors that constitute and configure webs of access. It is intended to enable scholars and others to map dynamic processes and relationships of access to resources. They intend to facilitate a grounded analysis of who actually benefits from things and through what processes they are able to do so. Access analysis also helps us understand why some people or institutions benefit from resources, and whether or not they have rights to them. Access is about all possible means by which a person is able to benefit from things (Ribot, Jesse & Peluso, Nancy, 2003). The analysis is focused on the dynamic of access relation, depending on the actors' role and power in the social relations. Social control emerges as a significant variable, depending on how these relationships were established. These bundles of powers become nodes in larger webs and, simultaneously, can be disaggregated into their constituent strands (Ribot, Jesse & Peluso, Nancy, 2003). By placing this frame as political analysis, it is expected that whoever is involved and obtained benefits will be revealed. Therefore, it is important to analyse social action as access control and access maintenance. Access control is defined as the ability of an actor to mediate the access of other actors. It refers to the checking and direction of action, the function or power of directing and regulating free action, while maintenance of access needs expanding resources or powers to ensure the flow of resources and their accessibility. Furthermore, the analysis of access theory is required to identify the circulation of the benefit of interest; identify the articulation of power by which different actors involved gain, control, and maintain the benefits flow and its distribution; and an analysis of the power relations underlying the mechanisms of access. If the benefits are discovered, the multiple mechanisms will also be identified by which individuals, groups, or institutions gain, control, or maintain access within particular political and cultural circumstances. This shapes the access processes and relations, including technology, capital, markets, labour, knowledge, authority, identities, and social relations (Ribot, Jesse & Peluso, Nancy, 2003). However, this theory must take administrative dynamics into account. By justifying these processes as 'decentralization processes', it is assumed that citizen participation had been mainstreamed. Though obviously developed from the social relations of a community, the distribution and access of resources equally still need to be discovered. Decentralization was commonly understood as a process of transferring the authority from a higher level of a government institution to a lower hierarchy pf government institution. The aim was to improve accountability and public participation (Ribot, 1991;Satria & Matsuda, 2004), yet it was simultaneously a threat to higher authorities and elites who feared the loss of income or patronage resources. The degree of decentralization and its outcomes were shaped by many factors, such as local capacities; incentive structure; political and social histories; the form of local social organization; degree of social stratification; and government, NGO, and development agency commitment to 'traditional' or private and third-sector institution over democratic authorities (Larson & Ribot. 2004). In general, Indonesia was facing a complicated legal framework of natural resources management as marine ecosystems and coastal resources are managed and controlled through a very extensive and complex policy and regulatory framework (Dirhamsyah, 2006). The analysis of the current Indonesian legislation has indicated that the current sectoral legislation does not provide adequate protection for groups with existing social, economic or physical vulnerability. Poor communities were less likely to be able to afford to rebuild their infrastructure following extreme climate events (Nurhidayah & McIlgorm, 2019). In addition, remote and indigenous people would generally have less access to emergency services during natural disasters. Gaps between the theory and practice of decentralization were persistent. Although it aimed to improve the 'voice' of the local community, the reality was quite different. There was a reluctance from authority holders to delegate their authority and resources significantly (Colfer & Capistrano. 2012). This study reflected a decentralization mechanism, where the mayor (district level) transferred his authority to the new form of sub-district government (kecamatan). By establishing this new administration unit, the municipal government distributed a broader authority to the sub-district governments to manage these islands, including promoting local indigenous ways of protecting the coastal ecosystem. To strengthen the authority, some potential staff has been appointed to run the administration process. This new form was dominated by local people, so the local context was embedded with a formal administration. This phenomenon indicated democratic decentralization (Ribot, 2002). However, it is important to anticipate the potential threats when the decentralization policy is brought to the lower level of governance. Definite resistance would be issued by those who feel threatened. In some traditional communities, this power was taken over by local strongmen or Decentralization and the Unraveling of Power Relations in Sangkarrang Islands, City of Makassar. (Sudarmono) roving bandits (Yusoff, 2010). In the context of local democracy, the powerful influence of informal rulers was commonly found at the micro-level of local government. For instance, the composition of local staff in sub-district administration (including the village government and kelurahan) was interfered with by informal power. Their appointment was beyond an administrative process or public service. It reflected a patronage relationship and indicated compartmentalized social status. In this study, the patron-client relationship was scrutinized extensively, more than a production relationship. The patron-client relationship was conceptualized as the same as indicated by Platteau (1995) and Roniger (2004). These relationships were understood as asymmetrical relationships, established in long-term and multifaceted relations that consisted of a strong element of affection and stretched over a wide and loosely defined domain. This latter feature implied that the mutual obligations of the two parties did not end with the exchange of specific goods and services because these relations were mainly motivated by the need to insure against unforeseen or random fluctuations, such as fluctuations in labor requirements for the patron or fluctuations in income for the client. More precisely, by establishing clientage relations, the patron secured access to a readily available, trustworthy, and compliant workforce, which enabled him to economize on a variety of transaction costs. As for the client, by entering into such a relationship, he obtained guaranteed access to the necessities of life through regular employment and/or various kinds of flexible assistance provided by the patron when special (emergency) needed arise. This study examined the occurrence of patronclient relationships, caused by decentralization, in political context. However, this relationship was not always running as expected by the patron. Resistance and rebellion also existed between them. A study by Firth (1946) explored the resistance of clients among the traditional fishermen in the Malay Peninsula. On the other hand, Satria, A., & Matsuda, Y. ( 2004) also explained the resistance of fishermen in East Java, Indonesia. There were various forms of resistance but usually started by being disobedient. Social polarization in fishing communities was ultimately inevitable. The patron-client relationship among the fishermen was not only to strengthen their engagement socially and economically, but this relationship had also brought patrons to the social class which was increasingly high, leaving their clients who are experiencing social involution. In addition to the manifest social system in this relationship, capitalistic economic relations also frequently led the client to a difficult situation. They were not only weak, but they also manifested themselves in underdeveloped conditions. However, under certain conditions, decentralization could provide positive results and can contribute to poverty reduction by utilizing local resources in a sustainable manner (Colfer and Capistrano. 2005). They also stated that stated the reform of territorial administration was an effort for local government to manage the size of governance according to administrative and political objectives. In this study, the creation of a new sub-district was defined as redistricting.. Based on experiences in several developing countries, there were three variants of this form of policy. One of them was regional proliferation which prioritizes geographical proximity. --- METHOD This study discussed the socio-political dynamic that resulted from decentralization policy using a case study design to reveal the dynamic of social cohesiveness and power among fisherfolk. It focused on the proliferation of Kecamatan Sangkarrang as the main context of the study. Since being established at the end of 2016, Kecamatan Sangkarrang had triggered some discussion on the sustainability of indigenous livelihood that was configured by formal regulation enactment. This qualitative case study examined the reallife context in Sangkarrang islands as an effort to investigate a contemporary phenomenon, where this context needed to be discovered. Yin (2009) stated that the all-encompassing feature of a case study was its intense focus on a single phenomenon within its real-life context. To do so, this case study investigated how embedded social relation was configured by a decentralization phenomenon, where power relations tied among the traditional fishing community were also undergoing significant dynamics. In specific, this study was also bounded by intimate patron-client relations that existed in the small archipelago, where social norms emerged traditionally and continued to be practiced. As stated by Miles and Huberman, the study case should have occurred in a bounded context. The research approach used in this study was an instrumental case study, in which the proliferation of Sangkarrang islands followed by fishing behavior is assumed as a particular case. At the beginning of this policy, this phenomenon brought a significant impact on social relations, power relations, and sustainability. --- Research site This study was carried out on three small islands in the sub-district of Kepulauan Sangkarrang (KKS), Municipality of Makassar. The selected islands were Barang Lompo, Barang Caddi, and Kodingareng. They were chosen as they had a dense population. The livelihood of islanders was highly dependent on the availability of marine resources. Also, fishing production was characterized by traditional methods within the various fishing gear and typically utilized small boats and small vessels. It indicated that the articulation of the patron-client relationship was easy to be described. Previously, those were parts of the subdistrict of Ujung Tana. Since the proliferation of sub-district of Sangkarrang, this archipelago underwent a structural dynamic that impacted the socio-political relation of the indigenous community. (see Figure 1.). --- Data collection method Data were collected in two phases. In the first phase, pilot projects were conducted to identify the dynamic of their fishing method. In specific, this study tried to discover the difference in fishing behavior before the proliferation policy was implemented, compared to the current condition. Usually, fishing methods were chosen by considering the potential volume of production. Some of them demonstrated collective work under a certain social network. Most of the chosen informants dwelled in Baranglompo and Kodingareng Island, where fishermen usually landed their catch (Glaser et al., 2022). Secondly, the fishing production that tied among them was analyzed to identify the type of social network that they performed. This study focused on the hierarchic working relationship (patron-client relationship) and its extension to formal administration in the islands. In the local context, the patron was called Punggawa (Ferse et al., 2014;Glaser et al., 2022). Besides analyzing the patron-client relationship, some information on the economic aspect was also obtained. To identify the empirical evidence of how decentralization had brought an impact power relation of community, the in-depth interview had been conducted to obtain data from prospective informants. I employed a stratified random sampling design, interviewing approximately twelve informants, including: • two of three village leaders (lurah); • three community leaders (Ketua RW); • three local people who had been appointed as staff of subdistrict office; • two punggawa (higher-patron); • one punggawa (middle-patron), • one independent fisherman; • two informants representing the female group and • one local community.; They were chosen purposively according to their engagement in fishing production and their extensive relation to formal administration, and vice versa. Green (2018) stated that "In-depth study undertaken of one particular 'case', which could be a site, individual or policy" (p. 284). Besides, observations were conducted extensively, from June 2021 to December 2021. Some secondary data were collected from documents in the city council. --- Data Analysis Data analysis of this research employed three steps, as stated by Turinawe et al (2015) and Hirose, M., & Creswell, J. W. (2023), namely reducing, displaying, and verifying. 1. Data were reduced by a certain process, such as summarizing and selecting the primary ones that are closely related to the research objective. However, some data are not related to the research and considered unnecessary. Only related data were processed into the next step. 2. Secondly, data were displayed to ensure that the available data were already sufficient to answer the research questions. Therefore, this research employed the following steps, namely: a. Describing related events experienced by the fishermen, patrons, and local leaders (both traditional leaders and office staff). b. Assessing each verbal statement obtained from the informants. In this step, assistantship from the local staff was very helpful due to some statements being delivered in the local language c. Recording relevant questions. d. Creating lists or meaning units for specific themes. These steps dominantly used interpretation which were based on the context and required logical reasoning. For instance, some informants might be Decentralization and the Unraveling of Power Relations in Sangkarrang Islands, City of Makassar. (Sudarmono) involved in the political process during the elections. Their statement would be divided into two contexts, some informants agreed with the policy, while some others were resistant. 3. Finally, data were verified for the synthesis process before drawing a conclusion. --- RESULTS AND DISCUSSION Arguably, the most significant impact of the decentralization and the improvement of public services was the presence of the government who serve the traditional community on these small islands. Before the proliferation policy was implemented, there were no accurate data available in the kelurahan (sub-district) offices. Administrative data were also rarely updated, so the available data did not reflect the real situation. There was also another problem which was related to work-hour flexibility. To ensure the office-hour appointment, people usually tend to contact the staff at their home for public service affairs. Consequently, the public services were running in a very traditional manner. Since the establishment of Kecamatan Kepulauan (islands district) Sangkarrang, administrative data began to be recovered. The capacity of staff was improved and some authorities were delegated to the lower layer of governance (kelurahan, RW, RT). In order to optimize the public services, Kecamatan Kepulauan Sangkarrang decentralized some authorities to the kelurahan, namely Kodingareng, Barang Caddi, and Barang Lompo. Kodingareng is occupied by the highest density of population within the smallest size of the island. It also indicates the complexity of problems faced by the people who reside there. Undoubtedly, insufficient basic needs (water, electricity, and housing) and climate issues (marine debris, abrasion, and other unpredictable geographical circumstances) are among the critical issues faced by the people. Consequently, public services would be available based on the availability of electricity. The livelihood of local people in the islands highly depends on economic activities which are determined by some peripheral capitalists and indigenous local leaders. This condition was determined by how close their economic activities were to the patron-client relationship tied among them (Sudarmono et al, 2012). One of the significant influences was identified in the public service changes, as displayed in Table 1. Since the proliferation of Sangkarrang was implemented at the end of 2016, the political dynamic in these islands has escalated. The local politicians should adjust the pattern of communication to strengthen their political influence among the fishermen community. If they failed to maintain communication with the patrons, they would lose a large number of ballots. For instance, In Cambayya (the largest fishermen community on the mainland of Makassar city), political events (presidency election, mayor election, and legislative election) become an opportunity for clients to show their resistance to the patrons. If the clients did not want to obey the patrons anymore, the clients would choose a candidate who was not recommended by the patrons (Ferrol-Schulte et. al., 2014) --- The impact of decentralization on social relations against the patron-client relationship. a. Market Concerning the fishery products marketing, the establishment of the sub-district of Sangkarrang did not trigger any change in social relations. Due to the high demand of the global market, marketing relation is fully determined by the flow of globalization which has no relation to government affairs at the subdistrict level. From the interviews with sea cucumber traders (Dg. M, 67 years), it is revealed that the high pressure resulting from the global market network has shaped the pattern of resource exploitation. It appeared from the use of air compressor machines as the main instrument in catching sea cucumbers on the seafloor. The demand of global market causes the price of this commodity to be very expensive so these risks were increasingly being ignored by the fishermen. These global controlling traders are already involved in a complex network of markets, so the efficiency is being improved constantly. Meanwhile, the results of interviews with HS (55 years old), it is known that marketing for fish commodities is more volatile. The price often declines to occur due to unpredictable weather factors, market speculation at auctions, and decreasing fish stocks. Most of the fish are caught by illegal fishing (fish bombing) to meet domestic market demand, especially in Makassar City. Closed market information had pushed the inability of local governments to manage this marketing network. Their marketing network is getting stronger because each of these export collectors has a network of fellow retainers. Thus, the relationship between the production economies continues to strengthen. Due to the high demand for commodities (fish and sea cucumber), it is clear that the social relations were triggered by the marketing aspect, either before the expansion or after the expansion takes place. --- b. Labor In terms of labor relations, power relations have undergone relatively many changes. An informant (HS, 55 years old) stated that since this area emerged as a potential fishing ground, labor was a significant issue, especially to meet the demand for sea cucumbers in the global market. Based on the period of traditional fishing trajectory, he divided this issue into two periods; New order (before 1998) and after the collapse of New Order (1998 until now). In the decade of 1990s, the workforce for traditional fishing was still dominated by local people on the island. It slightly transformed at the end of 1999 when the global market penetrated massively and boosted illegal exploitation from local capitalists. Consequently, these have led to the following phenomena: a. Many patrons began to apply for capital loans through banking schemes. Without any bankable asset, many loan providers lend them money for the high demand of the global market and the availability of marine resources in Sangkarrang. b. Desired to recruit new workers so that the capital they borrow can be used immediately. Social relations between patrons and clients also experienced dynamics related to the availability of credit guarantees (debt) among clients. For clients who are natives of the island, there is usually no difficulty in requesting a loan from the patron. In addition, the imposition of loan interest is now rarely found. Patrons usually provide flexibility in terms of time and method of paying off debt. Native islanders can pay off their debts flexibly. This is quite reasonable because clients are usually very easy to find at their homes. Thus, the level of their social relationship is very cohesive. --- The impact of decentralization toward political relation against the patron-client relationship. a. Technology Establishing the Sangkarrang sub-district has encouraged the disclosure of information obtained through formal activities from the local government or social media. They received real-time information regarding the national and local political dynamics by accessing information from social media. Regardless of social status, each community member could express their opinion and discuss more sensitive political issues. The conservative patron disliked disclosing information and worried that client resistance would arise. Nevertheless, the political position of clients became more independent than previously. A patron had to rearrange the communication method they have practiced so far. This study reveals that the articulation of power relations has changed since the implementation of proliferation. It appeared in the pattern of political communication conducted by local politicians, patrons, and local indigenous leaders. Before establishing the Sangkarrang as a sub-district, political communication among the patrons and politicians did not count the clients as a significant variable in political events (such as local elections). The politicians only considered the patron, then the patron would drive the client to vote based on the patron's reference. The direction of the patron would extensively influence the choice of the client's family members. After the formation of the Sangkarrang subdistrict, political communication channels were more open. Information can be distributed directly from politicians to subordinates without the need to go through courtiers. Although there might be differences in political views, this would not happen openly. However, from the results of an interview with HM (55 years old), it is known that subordinates' obedience to their retainer is still absolute, including in terms of political choices. Although there might be differences of opinion, there were moral and Decentralization and the Unraveling of Power Relations in Sangkarrang Islands, City of Makassar. (Sudarmono) economic aspects in the people's daily life in Sangkarrang, where the subordinates are still very obedient to their retainer. --- b. Authority amidst the capital flow dan market protection The practice of illegal fishing has sparked the formation of power relations between groups that have authority in the security sector and their retainers. This research reveals that at least two main patterns were practiced. Both before the formation of the Sangkarrang sub-district and after the sub-district was formed. c. Compradorization practices to protect illegal fishing Before establishing the Sangkarrang subdistrict, comparative practices were prevalent around the Sangkarrang islands. Unscrupulous officials often exploit the amount of capital turnover managed by a retainer. The officers took advantage of the courtiers' dependence on illegal fishing mechanisms (fish bombs, anaesthetics, and diving). They let the retainer do illegal fishing and provide legal protection if the retainer got into legal trouble. That way, the practice of illegal fishing continues as long as the police officers apply a pattern of 'protecting' the perpetrators. According to one informant, it was known that each retainer would deposit 5 million for one arrest trip. Each retainer does this. It is also known that this has been practiced since the New Order. Informants in this study who have been operating for 30 years admit that during the New Order era, bribery was carried out by giving money to village officials. The money is handed over at night, which is considered safe. Regarding the amount, there is no information on the exact amount. It all depends on the margin of fish sales. Informants consider that these patterns have persisted to this day. The only difference is the method. A similar thing was found in the relationship between the retainer and the local government. Before decentralization was implemented, patrons always followed directions from the Ujung Tanah subdistrict government. Usually, patrons must allocate a small budget to maintain their good relationship with the Ujung Tanah sub-district. However, this is only an initiative from the retainer to anticipate often unexpected requests, as for the celebration of national holidays. This caused the patron to have to allocate a small budget for this. Thus, the relationship with the government should be maintained so that aid distribution will still be distributed to the islands. After the reforms, the police received a strong delegation of authority, particularly in regional security. This then encourages the formation of a new pattern, where previously fishermen gave deposits to government officials turned into payments to security forces. --- d. Monopoly practice The informant also admitted that in addition to the pattern above, a monopoly practice happened. For example, police officers' ice to be bought by the patron. Although it seems like ice sales in general, the patron assumed that this as an unwritten obligation. If the retainer did not buy ice from the police, their illegal fishing activities would not be safe. That kind of practice created unhealthy business patterns. This monopoly has forced the patron and retailers to allocate a small budget in the hope that their business can continue to run. As the controller of the economic cycle in Sangkarrang, the courtier's power went beyond the mere economic aspect. This power was also often used to gain political influence from their subordinates. Based on the interview with Rny (42 years old), a retainer's capital capacity can reflect his social and political strength. The more enormous the capital controlled, the stronger the political influence. Observing this, politicians would try to approach the retainer in the hope that the retainer could recommend the politician to be elected by followers (followers and their families). This pattern of power relations is obvious and has become a common understanding. --- CONCLUSION This study finds that decentralization is an effective tool for decreasing the spread of destructive fishing methods. Local government should strengthen the controlling system by decentralizing the authority to the sub-district level. Besides, the role of the indigenous community system can be more effective in channeling the voice of local people. This study indicates that this new sub-district provided better services than the previous institution. Hence, the new sub-district has placed its control and supervision to reduce destructive fishing methods. Several vital points are related to power relations (politics), especially after the proliferation implemented: 1. The establishment of this new subdistrict has reshaped the form of political relations between the patron and the client. The patron's political power greatly influences the clients' political choices because client loyalty is the primary indicator for the patron to have subordinates. Therefore, the client has no choice but to follow the direction of the patron. 2. If the patron did not provide direction for making political choices, the client might have had different political views from his patron at that time. However, this is very rare.

How does decentralization provide good public services among traditional fisherfolk and diminish the exploitation of marine resources? This article discusses the positive impact of decentralization on the patron-client relationship of the fishing community by depicting the articulation of social relations and power relations tied among the fisherfolk Sangkarrang Islands, City of Makassar. By employing the theory of access, this study revealed that the proliferation of the Sub District of Sangkarrang had configured the landscape of socio-political interaction. This condition was restructured by the relation of production among producers and successfully eliminated the over-exploitation of marine resources in Sangkarrang Islands. Social hierarchy became more opened and allowed the vulnerable group to access the services provided by the government. They could also channel their political aspiration without being interfered with by a higher social class. At the same time, the political landscape had been rearranged and control from elites tended to be declined. In conclusion, decentralization had increased democratization for local people and had brought public services to be more efficient, including the decreasing of marine exploitation.

Introduction Catchment resilience is the dynamic capacity of interacting social and ecological elements of an area bounded by a river basin to cope with disruptions and shocks, and to adapt to and change in new circumstances. The extent of catchment resilience and the processes through which it is generated have been extensively researched, giving the concept meaning and making it observable and measurable. Social analysis of catchment resilience emphasizes process and action, rather than assets or competences, and the metrics to assess catchment resilience are diverse. However, catchment resilience is not only empirically observed, it is also a normative concept -a goal to be desired and enacted, assuming that resilience is universally and always a desirable trait of a system. This paper conceptualizes catchment resilience as a characteristic of a complex dynamic social ecological system. We review insights from studies and research that examine catchments as social ecological systems; they characterize catchments as involving interactions between human society and the environment. This view emphasizes how rivers, land use, settlements, hazards and institutions interact to produce systems in stable and less stable states. While the original objective of social ecological systems analysis was descriptive, subsequent work aimed to present a more analytical framework, which could also be used for comparative analysis. Anderies, Janssen, and Ostrom [1], for example, developed a simple model to analyze the robustness of social ecological systems which aims to identify the key interactions within systems, recognizing both the designed and self-organized components of a social ecological system and how they interact. Ostrom [2] sets out a generic framework that can be applied and refined by scholars to clarify the structure of a social ecological system to understand how any particular solution might affect management outcomes and sustainability, applied to diverse governance systems and contexts. The focus in this paper is on the social dynamics of catchments, so differs from a more structural approach. Here we highlight key dimensions including: the role of institutions and decision-making, the role of communities within a catchment, and the potential for trade-offs between community resilience and other dimensions. We explore the role of social science concepts and methods in both describing the state of catchment resilience, and in providing insights into the malleable and fluid nature of catchment resilience. In other words, social research can both advance explanation of catchment resilience and contribute to fostering and building it. --- Key Features of Catchments as Social Ecological Systems Catchments are social ecological systems in the general sense that elements of the biophysical world affect each other in bounded timescales and spatial scales (e.g. vegetation cover affects hydrology), while social responses and parameters also directly affect parts of the system, through altering land use or other processes [3,4]. Yet social systems are much less geographically bounded and are affected by processes at multiple scales, up to global processes and markets [5,6]. Hence, only examining actions or decisions by social agents on the ground within catchments misses many of the challenges to which social-ecological systems are subject. For example, the decision of multiple independent farmers to plant maize, or plough up hedgerows cannot be explained by contagious behavior or even by current prices of commodities, but rather through understanding diverse economic motivations and social pressures and perceptions of duty and stewardship. We develop a re-configured social ecological systems perspective that includes the incorporation of the hitherto under-emphasized, and often hidden, social dimensions that determine catchment resilience. This addresses some of the common criticisms of social ecological systems approaches, that they exclude a nuanced and dynamic analysis of social and political aspects [7]. The emphasis here is on attachment to place, identity, and the imperatives that shape how agencies and institutions make decisions in their own interests. These insights are derived from social ecological systems research; from sociological, geographical and psychological insights into place and identity; policy sciences on environmental governance; and political ecology perspectives on the nature of power relations that structure how catchments are managed [8][9][10][11]. Diverse evidence shows that people and communities living within catchments clearly cope with and respond to change and to unforeseen but predictable hazards, such as floods and drought. But the evidence also shows that the ability to bounce back from such impacts is highly uneven in society [12]; that lessons are often not learned by individuals or institutions; that responsibilities fall between cracks with institutions not necessarily fit for purpose [13]; and that many impacts in the social realm are hidden, and extend way beyond the forms of economic disruption that tend to dominate analyses [14], and may be temporally and spatially displaced. Are some of these challenges, revealed by social science and interdisciplinary analyses, easily explained, or amenable to action and intervention? We suggest that understanding catchments as social ecological systems provides key insights into how social and ecological dynamics interact and how some of the negative consequences can be ameliorated to identify sustainable catchment management options. In essence, this requires recognition of the potential for community resilience as a core element of catchment resilience. By studying community resilience, we can gain insights into the social dynamics of catchments as complex adaptive systems to inform science and practice. For social ecological systems, resilience refers to the magnitude of disturbance that can be absorbed before a system changes to a radically different state. Much systemsoriented research shows that the societal elements fundamentally regulate the extent of that resilience and include dimensions such as, the capacity to self-organize and the capacity for adaptation to emerging circumstances [15]. Recently, emphasis has moved away from persistence to understanding resilience related to adaptability and transformation, recognizing that social ecological systems are often radically changed, particularly as a result of human intervention. The terminology is often difficult to penetrate in these areas because it is used in a scientific and analytical sense on one hand, and as a policy goal on the other. In systems science, elements of emergence, timescale and the likelihood of stability of a system are understood as determinants of resilience of a system as an analytical construct. But in environmental management, resilience is often presented as a normative goal of policy or management to be sought after, rather than as a system property. The key elements of resilience relating to society are the capacity of people and institutions to adapt, and the feasibility of their doing so within the constraints they face. The most commonly identified elements of robust catchments across all studies, identified in a meta-analysis by Rodina [16] are robustness of systems, and having some buffering or redundancy in the system. The analysis also shows, however, that integrated assessments of catchment resilience highlight social dynamics, particularly social learning and participation, collaboration and local knowledge, as critical elements [14]. Hence current catchment management at least recognizes that social responses are integral, even where agencies are somewhat wary or have less capacity to influence such social processes [17]. A second key element is how resilience is directly beneficial to individuals and collectively to society. These latter elements can be observed and measured in terms of well-being, or in the absence of well-being through stress and health. Hence one set of indicators of catchment resilience may be the health and well-being of the populations living within it. There is significant evidence that where catchments are characterized as non-resilient, when populations are exposed to hazards they cause severe impacts on health and well-being, including burdens of disease, risk of injury, loss of material assets and wellbeing, and mental ill-health [18][19][20][21]. Social ecological system resilience rests on robust institutional arrangements and arrangements that recognize vulnerable populations and risks within them. Risks to people and property are unevenly distributed across catchments, with upstream and downstream risks, but also have diverse sets of property rights and responsibilities. Hence a key element in catchment resilience is the distribution of public and private responsibility for risks, as elaborated in the sections below. The public and private mix of responsibilities is not fixed, but rather evolves and is mediated through markets, amongst other things. Flood insurance for example, is often dominated by private sector investments and individuals voluntarily adopting and taking out insurance. But it is underwritten by public investments. The ability of catchment planning to foster harmonious communities depends then on the acceptability of the burden of risks between the public and private sectors. In many instances, the expectations that communities have for their protection are not met when extreme events occur, leading to crises in the legitimacy of public agencies. Such crises have been documented for unprecedented failures, such as the government response to the Hurricane Katrina disaster in Louisiana in 2005 [22]. One general lesson from these insights is that public expectations and responsibilities themselves are important components of the dynamics of social ecological systems. --- The Relationship between Catchment Resilience and Community Resilience Understanding social dynamics of catchment resilience might well start with understanding the resilience of communities that live within a catchment. Community resilience is a topic of interest across a range of scientific fields, including community development, social work, disaster studies and so on, as well as being a focus of much policy work around responses to extreme events, such as floods and other emergencies. Catchmentbased approaches to resilience in this sense involve drawing on, developing, and engaging the capacities and capabilities of those that live within its boundaries, but as noted above, resilience will be influenced by social, political, economic, and cultural processes beyond the boundaries of a catchment. Community resilience encompasses a range of aspects and components, emphasized by different sub-fields and sectors, leading to challenges for definition and measurement. --- Defining Community and Defining Community Resilience Community resilience has been broadly defined as 'a community's collective capacity to function in, respond to, and potentially influence an environment characterized by continuous change, uncertainty, and crisis' [23] (p. 24). Similarly, the concept of social resilience highlights the collective and systemic nature of the phenomenon: 'the ability of communities to withstand external shocks to their social infrastructure' [24] (p. 361), including both physical, social, and economic shocks. Hence community resilience relates primarily to collective capacity and related processes and social relations, rather than being a sum of attributes of individuals. But 'community' is variously defined and often a'slippery' concept. The term can mean different things to different people at different times: it cannot be simply or satisfactorily defined by location or by attention to networks. Yet at its core, community involves a necessary focus on the spatial and material aspects of members. Communities of locality, communities of interest, and communities of identity are not necessarily found in a single locality [25]. In the context of catchments as social ecological systems, the features of communities of locality are critically important. In their review of community resilience to climate change, Twigger-Ross et al. [26] suggest three elements of community are relevant for resilience: spatial or geographical; social relations and structures; and psychological elements, such as sense of belonging and othering. These locality, interest and identity dimensions of community are the key ways to understand communities in the context of catchment resilience and are clearly manifest at different scales. --- Measuring Community Resilience There is a diversity of approaches in research and practice to identify and work with community resilience. The most common approaches to measurement of community resilience involve indirect proxies, focusing on the presence of resources, capital and competences that build different capacities in communities [27]. Integrative methods used to measure community resilience in this way often involve aggregation of perceptions or capabilities of individuals within communities [28]. However, emerging insights show how the elements of space, interest and identity highlighted above can expand the measurement of community and make it more useful and comprehensive. For example, Norris et al. [29] emphasize the ways that integrated sets of linked capacities, such as social capital and community competence, enable community resilience by merging and rebounding in various ways, rather than operating as separate entities that can be understood as distinct or independent elements. Hence emerging cross-disciplinary social science analysis of community resilience moves away from the idea that it can be reduced to a simple measure or index, toward recognition of the relational, subjective, cross-scale and dynamic nature of resilience [23,30]. An accompanying shift has seen calls for a need to understand community resilience in the face of multivariate, intersecting, and uncertain risks. In these social ecological systems framings, resilience is treated as an emergent property of community interaction and can only be understood with attention to particular cases in practice [23]. These approaches in effect emphasize the system-level dimensions of resilience, highlighting interactions between scales, capacities, and multiple risks in any given context. This has seen new efforts to characterize different dimensions of community resilience that are most important for understanding such interactions and offer a deeper basis for engagement. Table 1 summarizes consensus on dimensions that are core to community resilience: place attachment; leadership; community cohesion and efficacy; community networks; knowledge and learning [23]. --- Community Resilience Capacity Description Explanation --- Place attachment The affective, cognitive and material relationship people have with place Place attachment has been shown to enhance community resilience, but within limits as it may cause people to want to live in high-risk situations and make them less likely to accept new ideas and practices. --- Leadership People (leaders, entrepreneurs, champions), organisations, characteristics, roles and actions that affect outcomes Leadership is important for knowledge and trust building and for effecting community action, but not sufficient for resilience. --- Community networks The bonding and bridging ties that enable people to act collectively Community resilience is strengthened by access to diverse networks, providing essential support, help identify new opportunities and provide a focus for hope and optimism. --- Community cohesion and efficacy Community ability to act together and belief in one's own ability to take action and manage situations Supports community ability to act independently and to build resilience within the community itself. --- Knowledge and learning Individual and group capacity to respond to local needs and issues Iterative, continuous and reflective learning supports community to respond to change, and enhance social memory. Adapted from [23]. Research in different contexts has shown the importance of these dimensions of community resilience in understanding impacts of external stresses. For example, in an empirical analysis of community recovery after major flood events at two sites in the UK, Quinn et al. [27] have shown that there is a strong relationship between people's feelings of belonging and connections with their wider community, and their sense of their own wellbeing. Results such as this suggest the importance of understanding community resilience processes for responses to disasters, as well as attempts to anticipate and prepare for them. The wider literature on community resilience highlights again the centrality of direct forms of engagement with the people living in any given catchment in order to understand emergent dimensions of community resilience, their interactions, and implications for outcomes in terms of health, wellbeing, and more broadly capabilities [31]. Active involvement in communities facilitates cooperative efforts, such as shaping social institutions [32], as well as having a positive impact on wellbeing [33]. But engagement of communities and actions of individuals is limited in promoting overall catchment resilience, when power structures and governance structures constrain actions at different scales. Understanding capacities is not about passive or static traits but about understanding relations and processes. In essence, communities matter and are a key aspect of the social dimensions of catchment resilience, but community resilience does not equate to catchment resilience. Importantly, dynamic linkages and interactions between individuals, households, organizations and institutions at different scales act as constraints and challenges to community resilience. --- Challenges and Constraints to Catchment Resilience --- Issues of Scale: Fit, Misfit and Risks Any systems approach to catchment resilience must be clear on the boundaries of the system and the scale and scope for action. A significant hurdle in the operationalization of catchment management is clearly the diverse actors and jurisdictions that cut across scales. There is, however, significant policy science evidence on decision-making on catchment planning when the boundaries, jurisdictions and temporal scales of decisionmaking are not aligned. It draws on core concepts of institutional fit and misfit [34][35][36], and of understanding risks in decision-making processes to demonstrate challenges and limitations of implementing catchment resilience. Transforming to a catchment-based approach which integrates diverse landscapes, stakeholders and communities is demanding. Whilst it makes scientific sense, it creates a series of challenges for institutions and decision-making. Many of these challenges relate to cross-scale interactions and misfits between the remit or jurisdiction of different agencies, the different sectorial agencies involved in different parts of the catchment system and the different subsystems, outlined in Box 1. Box 1. Challenges of scale and fit in catchment resilience. Temporal scale-trade-offs exist between maintaining or optimizing what exists now (infrastructure, economies, and values) and long-term options. This temporal dimension leads to moral hazard-short-term actions and interventions that compromise, limit, or trade-off actions in the future (e.g., maladaptation) Spatial scale-actions in one place may have negative impacts elsewhere-either immediately downstream or in more remote places (e.g., teleconnections) Transboundary issues-parts of the catchment have shared jurisdiction or cross boundaries Social-ecological interactions-environmental variability interacts with complex social dynamics, such as place, identity, and human mobility Nonlinear dynamics-social-ecological systems exhibit nonlinear or threshold responses to changes in climate variability and other stressors Cross-scale feedbacks-complex interactions at different spatial or temporal scales generate thresholds and alternate stable states Institutional fit-the scale of governance must be capable of responding to the scale of the policy problem and to the multiple scales of system processes, activities and uses. Adapted from [37]. So what does this mean for catchment resilience? Walker et al.'s integrative study of the Goulburn Broken catchment in Australia [38] is one of the first analyses of catchment resilience to examine these scale dynamics. They show that intervening to address any one of these (e.g., financial viability of farms, water extraction or tree cover), or acting at a single scale will have significant knock on effects -or potentially trade-offs -for other parts of the catchment which ultimately mean sustainable management of the catchment overall is likely to fail. Anderies et al. [39] analyzing the same catchment, further explain how failure to account for cross-scale and sub-system interactions, means that sequential management decisions historically have resulted in erosion of resilience of the system. A series of crisis-driven decisions have increased vulnerability, and thereby reduced future options. They identified a pattern they describe as a 'pathological cycle of resource degradation', where optimizing for high output from irrigated dairy activities has made the system more vulnerable to shifts in weather and climate, and social and political processes. Institutional fit is an especially demanding problem in complex social ecological systems such as catchments. Epstein et al. [40] examine the issue of institution fit, delineating three types of problems. Ecological fit represents a technical approach focusing on whether institutions match the ecological or biophysical problems they are meant to address. Social fit is concerned with congruence between institutions and the preferences, values, and needs of human actors. Social-ecological system fit seeks to uncover context-specific institutional arrangements that are likely to contribute to the sustainability of social ecological systems, such as catchments. Bunce et al. [35] demonstrate the problem of misfits through their examples of river basin management in southern Africa, where downstream farmers are negatively impacted by upstream water management, increasing their vulnerability to weather extremes. This results in transferring vulnerability -from one place to another and from one set of actors or stakeholders to another -and also in this case between countries and jurisdictions (South Africa and Mozambique). This is also analyzed for catchments in France, UK and South Africa by Barreteau et al. [41]. Therville et al.'s study of land use planning and coastal management in the Languedoc in southern France provides an example of how mis-coordination between multiple sectors and complex cross-scale interactions results in renewed or emergent fragilities [42]. They outline three challenges in managing dynamic complex landscapes or catchments such as the Languedoc. The first relates to the constraints and opportunities represented by crossscale implementation challenges. Second are the consequences of implementation on others at different scales and levels (the trade-offs and vulnerability transfers). Third concerns the mismatch that occurs when authority or jurisdiction is not coterminous with either the problem (flood management) or the resource (the river basin). In a complex system such as a large catchment, add the impacts of climate change, changes in demography, and increased urbanization and competition for land, then the tendency to manage day-today problems and avoid strategic action is accentuated. In this case, the commitment to catchment resilience must be shared across institutions and decision-makers at all scales and jurisdictions. The Languedoc study explores the extent to which major shifts -for example relocation of coastal development and new planning controls are enabled and constrained. In the current context of budget cuts which mean authority is transferred to local level, but without corresponding financial support, this might result in greater fragmentation or new partnerships between public, civil society and non-government groups. This shift is documented in the case of the UK by Naylor et al. [43] who show how new partnerships forged by fiscal austerity amplify certain risks for different policy actors. --- Second Order Risks and Challenges to Management Institutions Even where institutions can be aligned in terms of spatial scale, the processes of decision-making within them can act against catchment resilience. But why do institutions not act for long term resilience? Analyses from political science that examine the internal dynamics of organizations show that the continuity and reputation of the organisations themselves is foremost and often dominant in decision-making [13,44]. So rather than make decisions solely on the basis of external perturbations to catchments, responsible organizations are enthralled to so-called second order risks to their own legitimacy and continued operation. The role of second order risks in decision-making on resilience has been examined for the case of Cornwall in UK, and in response to severe winter storms from 2013 and 2014. Second order risks-particularly reputational risks-were found to influence decisions and to prompt actions [43]. First order risks refer to both the physical risks to society such as flooding or storm events, and the explicit societal obligation or responsibility of an organization or individual to reduce uncertainty or harm-for example building flood defenses. Second order risks refer to the risks to the organization relating to legitimacy and blame, namely reputation management, that the individual and organization need to manage in order to maintain the successful continuation of the organization. With increased public accountability managers are increasingly integrating second order risk concerns into their decision-making processes and this might militate against innovation or adaptive management, when second order risks require particular responses or defensive actions, for example focusing on predictive statistics rather than probabilistic approaches in order to manage interactions with the public. In Cornwall building back existing coastal defenses went against longer-term coastal management strategy (articulated through Shoreline Management Plans) but were instigated as a form of crisis-management response during the 2013 and 2014 period of winter storms. --- Evolving Multi-Level and Polycentric Solutions Multi-level and polycentric governance are often suggested as a means of managing complex cross-scale and multiple use systems such as catchments. Morrison's review [37] shows how polycentric governance has increasingly gained traction among both scholars and policymakers. Polycentrism is a model of governance that actively steers local, regional, national, and international actors and instigates learning from experience across multiple actors, levels of decision-making, and temporal scales. A polycentric system is made up of many autonomous units that are formally independent of one another but which choose to act in ways that take account of others through self-organized processes of cooperation and conflict resolution. But these governance systems are not without problems, especially in terms of power and access to decision-making by different actors within the governance system. Pahl Wostl et al.'s comparative study of catchment resilience in integrated flood management [45] provides evidence that effective implementation is a multilevel process that cannot be prescribed from the top nor driven from the bottom only. A balance is required which fluctuates, meaning that over time, one or the other direction of influence may dominate. Long-term sustainability depends on the effectiveness of the links between informal settings and formal policy processes. Informal spaces are important to support the integration of knowledge and experimentation with innovative approaches. Vertical integration is important to involve actors from the implementation level in policy development and to support feedback experiences from implementation to strategic goal setting and policy formulation. --- Methods, Metrics and Action for Catchments Resilience Exploration, identification and measurement of catchment resilience requires a range of methods and metrics. Traditionally, a focus of catchment resilience research has been the measurement of stocks and flows of biological, hydrological and environmental components to identify potential strengths and vulnerabilities of catchments to shifts in social and ecological processes. The focus is on keeping catchments functioning similarly to their existing regime and the measurements of stocks and flows inform modelling of catchment dynamics to analyze susceptibility to change [46]. These studies set out to model the interactions and the metrics used including components such as precipitation and discharge, daily temperatures, which are either measured in the field or from already modelled data. Falkenmark and Folke [3] emphasize that the integration of social with ecological and hydrological elements is needed for sustainable catchment resilience. However, integration of various systems at the catchment scale sets up methodological challenges, especially integrating broader connected social and environmental processes. The resilience framework is an analytical framework that allows multiple interconnecting dimensions of catchments to be measured in an integrated fashion. An example of this, as mentioned above, is Walker et al's work in the Goulburn Broken Catchment [38], where a resilience assessment was used to assess the sustainability of the basin. Here, the researchers focused on biophysical, economic and social elements of a region as components of a unified social ecological system. In such an assessment, whilst the focal scale is the region, there is an awareness of the scale below-farmers and householders-and the scale above-state and national legislation-that shapes the functioning of the catchment system at the regional scale. A resilience framing also includes the consideration of the possibility of regime shifts, and the identification of potential tipping points. Attempts to broaden the components of a system allows institutional and collective action elements to inform analysis of resilience. The social elements of catchment resilience are diverse, and require a full range of observational, interactive and action-oriented research to both generate explanations of behavioral and institutional responses, but also to enact transformational change and study such processes from the inside out (known as action research). The diversity and richness of the social and integrative science methods, and the dimensions of the social dynamics they seek to explain are illustrated in Table 2. The commonalities of the three approaches, from observational to action research, include that they require significant resources, including time and labor, to ensure their rigor; that results are not always welcome to agencies and often challenge received wisdom concerning how societies and individuals act in apparently non-predictable manner; and that diversity of methods enhances rather than detracts from overall explanation. Hence, the use of qualitative observational methods, for example, often provide significant insight into causality and meaning that is lost in pattern-oriented quantitative descriptive analysis. --- Challenges to Inclusive Planning for Catchment Resilience Resilience emerges from the interaction between different people as well as environmental processes: hence subjective desires of communities inform the definition of catchment resilience. As decision makers have to plan for multiple possible futures the use of novel participatory and deliberative processes, provide an opportunity for social learning, where new behaviors are acquired by observing, modelling and imitating others and learning takes place in a social context [58], amongst participants and improved foresight for landscape planning. Ultimately, methods that integrate aspects of learning seek to build resilience as well as measure and plan for it. A companion modelling approach is a multi-agent systems methodology that facilitates information sharing that can improve coordination among stakeholders for future collaboration and decision making. This research process begins with a problem definition developed by stakeholders and institutions and then the co-construction of models of the system with stakeholders. These system models are then tested using a number of simulations and subsequently actively run through participatory simulations with stakeholders exploring different possible scenarios e.g. the impacts of a flood event or new infrastructure on decision making. This iterative process of co-creation with stakeholders and running of scenarios means that the final models are more likely to often prominently reflect stakeholders needs. However, stakeholder and participatory approaches cannot be applied uncritically: it must be recognized that stakeholders often have diverging perspectives, interests and values, and different power and agency to shape and influence outcomes. Participatory processes often require a significant time investment to get to know stakeholders, to agree on system dynamics, to run participatory simulations and then validate the final model. This means that, as well as resulting in catchment models, it potentially generates improved social networks for participants [59]. Serious games are a method that takes a futures approach -there are a broad collection of methods that allows an exploration of possible and preferable futures -these methods focus on desirable futures and generate insight into decisions that can be made in the present to improve management of social ecological systems with a particular future regime in mind [60]. Where the focus of enquiry is to examine the social impacts of different strategies for resilience, and to ask resilience for whom?, creative practice and participatory planning provide useful methodologies. Methods that enable input from local populations can introduce a focus on emotional aspects of catchment resilience into assessment [61]. This requires a move away from simply integrating social components into a model of catchment dynamics to an approach that puts normative aspects of fairness at the forefront of resilience assessments. This refocusing of resilience requires an investigation of the lived experience of people who live in, or are connected to, specific social ecological systems. For example, work using qualitative methods by Sims et al. [61] focused on a particular population group and studied the impact of flood events on carers, and their ability to continue their role of caring. The researchers used diary-based methodologies to understand how everyday practices of care are interrupted by floods. Such studies give rich insight into how social and environmental systems are related, and how nuanced resilience is when social processes are more fully integrated. The question of resilience for whom can be extended beyond human interests to the interests of trees, rivers, and mountains. Indeed, in New Zealand in 2017 a river was given the same legal rights as a human. In giving these elements of a catchment voice and agency in research and planning processes the focus of resilience also shifts. Methods to extend the community of justice beyond humans require a certain degree of empathy with biotic and abiotic parts of social ecological systems. Here, existing methods such as scenarios and serious games could be adapted so that participants take on the identity of the non-human world. In this way marginal or sometimes unconsidered elements of a catchment can be placed more centrally in discussions of what constitutes and what supports catchment resilience. --- Conclusions and Implications for Governance Catchment resilience has significant potential as an organizing framework for the integrated and collaborative management of water resources in their social context. It is intuitively appealing, provides a way of understanding trade-offs and looking across specific sectoral or site-based interests, as well as being widely understood to be beneficial. Adopting catchment resilience also necessitates a recognition that elements outside the control of the system are likely to be important, ranging from global climate change, through to policy imperatives over which authorities at catchment level have little or no control. These include, for example, urban expansion, demands for infrastructure, or competing policy initiatives in other sectors. A second implication for adopting an integrated catchment resilience approach is the need to recognize the benefits of diversity and capacities for self-organization and localized initiatives. The evidence from much social science is that the resilience of communities is enhanced by their perception of their own autonomy and agency, and that synergistic relationships with management authorities, rather than more combative ones, yield innovation and sustainability. Putting social processes central to catchment resilience assessments requires inclusive participatory processes from the beginning. In this way the definition of resilience can be co-determined by individuals, communities and public bodies. This process may then lead to suggestions of engagement with wider sets of people, systems or scales, for example engaging with businesses outside of the catchment whose supply chain is rooted in the catchment under consideration. By including such broader components into assessments the subsequent definition of what a resilient catchment is may change. In this way the methods used and the components analyzed as part of a resilient catchment can dynamically feed back into each other. Ultimately, this results in an ongoing negotiation of what catchment resilience is, which, whilst relatively resource intensive, promotes adaptiveness in responding to social and environmental change. Managing catchment resilience is challenging for many reasons. First, a catchment may be shared amongst diverse institutions and communities who have different and sometimes opposing interests, as well established in existing watershed or catchment anal-ysis [62]. Second, there are aspects of path dependency in how catchments are managed that make new practices difficult to implement. For example, when management has relied upon 'hard engineering' structures involving sunk costs, organizational practices and established knowledges and expertise, then it might be very difficult to make a shift towards new approaches, be they ecosystems-based approaches or more participatory management [63]. Furthermore, it must be acknowledged that participatory processes, no matter how innovative, may not be sufficient to overcome these challenges. The political dynamics within catchments suggest that there are significant constraints on making decisions that maximize diversity and re-distribute power: reputational risks to individuals and institutions in decision-making have been shown to be major sticking points for implementing catchment-oriented decision-making processes. For example, managing consultative processes and engagement with diverse stakeholders requires building trust and having transparent processes and clear roles and responsibilities. Consultation processes that lack legitimacy because they are not inclusive, or are seen as meaningless or empty gestures, and result in communities and stakeholders lose trust in management authorities. This paper has highlighted that community resilience is an important dimension of catchment resilience. By using a social ecological systems lens, and emphasizing social processes and relations, some core challenges for catchment resilience are outlined, highlighting the critical role of social relations and the need to understand and accommodate cross-scale social and environmental dynamics, and to design institutions to address their complexities. --- Data Availability Statement: No new data was produced or used for this paper. --- Conflicts of Interest: The authors declare no conflict of interest.

Catchment resilience is the capacity of a combined social ecological system, comprised of water, land, ecological resources and communities in a river basin, to deal with sudden shocks and gradual changes, and to adapt and self-organize for progressive change and transform itself for sustainability. This paper proposes that analysis of catchments as social ecological systems can provide key insights into how social and ecological dynamics interact and how some of the negative consequences of unsustainable resource use or environmental degradation can be ameliorated. This requires recognition of the potential for community resilience as a core element of catchment resilience, and moves beyond more structural approaches to emphasize social dynamics. The proposals are based on a review of social ecological systems research, on methods for analyzing community resilience, and a review of social science and action research that suggest ways of generating resilience through community engagement. These methods and approaches maximize insights into the social dynamics of catchments as complex adaptive systems to inform science and practice.

Background Injury deaths, which include poisonings, are the third leading cause of death in the United States (US), after heart disease and cancer [1]. In 2019, poisonings accounted for 75,795 deaths in the US, making up 30.8% of injury deaths [1]. This increase is thought to be primarily driven by increases in opioid poisonings, and in 2019, there were 49,860 opioid-related deaths in the US, representing approximately 70% of the total poisonings [2][3][4]. Alcohol poisonings also represent a significant proportion of unintentional injuries and alone or in combination with other drugs caused 12,954 deaths in 2017 [5]. Poisonings overall significantly increased from 12,186 poisoning deaths in 1999 [6,7]. Opioid and alcohol poisonings also increased substantially over this period from 8050 opioid-related and 2486 alcohol-related poisonings in 1999 [3,5]. Alcohol is often used together with other substances, including opioids, and when used concurrently, the effects of each can be amplified [8,9]. Thus, the risk of overdose is elevated due to sedation and respiratory depression caused by the use of opioids with alcohol. In a sample of chronic opioid users in the US, 12.4% of individuals reported concurrent alcohol use [8]. In Canada, it was estimated that in 2013, 1 in 5 fatal opioid overdoses involved alcohol [10]. In the US, alcohol was estimated to be involved in 22% of deaths associated with opioid pain relievers in 2010 [11] and 15% of opioid overdose deaths in 2017 [12]. Case and Deaton described sharp increases in "deaths of despair" between 1999 and 2013, defined as deaths from alcohol and drug poisonings, suicide, and alcoholic liver disease, affecting life expectancy among US middleaged White males without a bachelor's (BA) degree [13]. More recently, Case and Deaton [14,15] argued that education is now a sharper differentiator of life expectancy than race and ethnicity. This is especially evident when comparing individuals with a BA degree, who saw life expectancy increase, to those without a BA degree, for whom life expectancy decreased since about 2010 [16]. For those with a high school degree only or less, poisoning deaths were 4 times higher in 1999, and 7.2 times higher in 2013, compared to those with a BA degree or more [14]. Richardson et al. [17] analyzed the number of US deaths from drug poisonings between 1994 and 2010 by sex, race, and educational attainment. Over this period, drug poisoning rates were highest and increased the fastest among Whites with low education. In line with Case and Deaton's observations, drug and alcohol poisonings appear to be increasingly related to socioeconomic status: Shiels et al. [18] also observed a gradient whereby US counties in the highest quintile of unemployment had the highest drug poisoning mortality rates and vice versa. However, the studies currently available either have not included alcohol poisoning [17] or have not decomposed poisonings by substance [14,18] and it is unclear whether socioeconomic differences in drug and alcohol poisonings are driven by opioid, alcohol, or joint opioid and alcohol poisonings. There is also evidence that mortality rates from drug poisonings can differ substantially by racial and ethnic group. A recent study documented disparities by race and ethnicity, with American Indian and Alaska Natives having the highest age-standardized death rates for drug poisonings, followed by non-Hispanic White and Black groups, and Hispanic and Asian groups having the lowest mortality [18]. No research to date has examined how opioids and alcohol individually and jointly contribute to socioeconomic inequalities in drug and alcohol poisonings and how these inequalities have changed over time for different racial and ethnic groups. In addition, much of the work exploring increasing socioeconomic inequalities with respect to drug and alcohol poisoning has focused on educational inequalities observed in the non-Hispanic White group, and in particular men. The aims of this study are to investigate (1) absolute disparities between (a) educational and (b) racial and ethnic groups in mortality rates for alcohol, opioid, and combined alcohol and opioid poisonings over time (2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019) and (2) whether relative educational inequalities in poisonings from alcohol, opioid, and combined alcohol and opioid are observed to the same extent within different race and ethnicity groups over time (2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019). --- Methods --- Data Mortality data from individual death records for the years 2000-2019 were obtained from the National Vital Statistics System (NVSS) [19]. Aggregate-level Multiple Cause of Death Files were used, containing nearly complete information on education, race and ethnicity, age, and sex of the deceased (recorded at time of death) in addition to the underlying and up to 20 contributing causes of death coded according to the ICD-10. Corresponding population estimates were based on Current Population Surveys (CPS) [20]. --- Measures Sex was classified as men and women. Race and ethnicity group was determined from the Hispanic origin/race recode measure and was categorized into four groups: (1) non-Hispanic White, hereafter White; (2) non-Hispanic Black, hereafter Black; (3) Hispanic; or (4) non-Hispanic others (mixed). Education was determined from two types of reporting systems (1989 or 2003 revision) and was classified into three categories: (1) high school degree or less (12 years or less of school, less or equal to high school graduate, or GED completed), hereafter low education; (2) some college (1-3 years of college, some college credit but no degree, or associate degree), hereafter medium education; or (3) college degree or more (at least 4 years of college or bachelor's degree or higher), hereafter high education. Complete data was available for sex and race and ethnicity. Approximately 3.8% of alcohol or opioid deaths were missing for education, which were re-assigned as low to high education based on the education distribution within a given sex-race/ethnicity-(5-year) age group for each year. --- Classification of poisoning deaths We defined opioid and alcohol poisoning deaths using ICD-10 underlying and contributing cause-of-death and then recoded them into three non-overlapping groups: (1) alcohol-only poisoning, (2) opioid-only poisoning, or (3) both alcohol and opioid poisoning. Cause-of-death codes for alcohol and opioid poisoning classifications are displayed in Additional file 1: Table S1 and Fig. S1. Three versions of classifications were explored to define alcohol poisoning, each affecting the coding of deaths from alcohol, opioid, and combined alcohol and opioid poisoning (see Additional file 1 for details). Opioid poisoning must meet both of the following criteria: (1) X40-X44 (unintentional poisoning), X60-X64 (suicide, i.e., intentional self-poisoning), X85 (homicide, i.e., assault by drug medicaments and biological substances), or Y10-Y14 (poisoning with undetermined intent) from underlying cause with drug overdose among deaths and (2) T40.0-T40.4 or T40.6 (opioid) from contributing cause [21,22]. Our main analysis focused on individuals aged over 25 years as education may still be ongoing before that age, and to be consistent with the US Census Bureau, with sensitivity analyses conducted including all individuals aged 18 and older [23]. Additional file 1: Table S2 shows the number of deaths from alcohol-only poisoning, opioid-only poisoning, and alcohol and opioid poisoning for the total US population, age 18 and older and age 25 and older, separately. The number of cause-specific deaths dropped by a maximum of 10% when restricting the age range to 25 and older. All mortality rates were age-standardized using population age distributions for 5-year age groups for the year 2019 CPS data and expressed as deaths per 100,000 population. --- Statistical analysis Sex-specific trends (2000-2019) in US mortality rates on the three poisoning outcomes (alcohol-only, opioid-only, and alcohol and opioid) by education (with and without stratification by race and ethnicity) are presented. Generalized least square (GLS) regression models were fit to estimate differences between educational and race and ethnicity groups. Modeling results aim to provide estimates on the poisoning mortality rate over time for (1) independent effects of education and race and ethnicity groups (objective 1) and ( 2) differential education effects by race and ethnicity (objective 2). Two types of GLS models were fit to answer the two research questions. In the first analysis (objective 1), the effects of education and race and ethnicity on mortality over time were quantified for all three poisoning outcomes. For each sex, a panel was constructed with agestandardized mortality rates (in 100,000 population) split by education and race and ethnicity category for each year, i.e., n = 240 for each model (20 years <unk> 4 race/ethnic groups <unk> 3 education groups). The GLS model allows for heteroskedastic variances and panel-specific, firstorder auto-regression. The three poisoning outcomes were fit in separate models. Predictors were education and race and ethnicity dummy variables, linear year, year squared, and the interactions between linear and squared year and education and between linear and squared year and race and ethnicity. Both year measures were centered at 2010; thus, the main effects from education and race and ethnicity estimate the average absolute difference in mortality rates across education and race and ethnicity groups in 2010. Year squared was included to capture the non-linear increase that has been observed in poisoning mortality rates over the time period. Interaction effects estimate average differences in changes in mortality rate over time across groups. Several sensitivity analyses were performed to check the robustness of the results. Both analyses were repeated with all individuals aged 18 and older included. As an alternative to GLS modeling, Poisson random effect models were estimated on mortality death counts with population as an offset. The first analysis assumed no interaction between education, race and ethnicity, and time. In the second analysis (objective 2), this assumption is relaxed and the relative differential effects of education across race and ethnicity groups were quantified. Mortality rate ratios were calculated by dividing mortality rates for individuals with low or medium education by mortality rates for individuals with high education. Using GLS models, the mortality rate ratios were regressed on race and ethnicity dummy variables, the linear year (centered at 2010), and the interaction between year and race and ethnicity. The main effects of race and ethnicity estimate the average differential education effects by race and ethnicity in the year 2010, while the interactions indicate whether and how educational inequalities in poisoning deaths changed over time in different race and ethnicity groups. --- Results In individuals aged 25 and older, there were 3747 alcoholonly, 5997 opioid-only, and 1641 combined alcohol and opioid poisoning deaths in 2000, compared with 7742 alcohol-only, 38544 opioid-only, and 7497 combined alcohol and opioid poisoning deaths in 2019 (Additional file 1: Table S2). This represented a 2.1-fold increase in alcohol-only poisonings, a 6.4-fold increase in opioidonly poisonings, and a 4.6-fold increase in combined alcohol and opioid poisonings. Opioid-only poisonings represented 53% (2000) and 72% (2019) of the total poisonings studied while alcohol-only represented 33% (2000) and 14% (2019) and combined alcohol and opioid represented 14% (2000) and 14% (2019). Men with low education had an age-standardized mortality rate of 5.2 (2000) and 8.4 (2019) per 100,000 population for alcohol-only, 6.8 (2000) and 44.6 (2019) for opioid-only, and 2.5 (2000) and 9.7 (2019) for combined alcohol and opioid poisonings. By contrast, the agestandardized mortality rate for men with high education was 1.3 (2000) and 2.1 (2019) for alcohol-only, 1.3 (2000) and 5.1 (2019) for opioid-only, and 0.3 (2000) and 1.2 (2019) for combined alcohol and opioid poisonings. For women with low education, the age-standardized mortality rate was 1.2 (2000) and 2.7 (2019) for alcohol-only, 2.7 (2000) and 22.1 (2019) for opioid-only, and 0.4 (2000) and 2.9 (2019) for alcohol and opioid poisonings. Women with high education had lower corresponding mortality rates of 0.6 (2000) and 1.0 (2019) for alcohol-only, 0.9 (2000) and 2.6 (2019) for opioid-only, and 0.1 (2000) and 0.4 (2019) for alcohol and opioid poisonings (Fig. 1). Text comparisons below will focus on inequalities between low and high education groups, with comparisons between medium and high education groups Fig. 1 Age-standardized mortality rates for alcohol-only poisoning, opioid-only poisoning, and combined alcohol and opioid poisoning for men and women by educational attainment categories from 2000 to 2018. Note: Alcohol-only poisoning: ICD-10 code X45 or F10.0 from underlying or contributing cause or T51.0 or T51.9 from contributing cause, and not opioid poisoning, i.e., both (a) X40-X44, X60-X64, X85, or Y10-Y14 from underlying cause and (b) T40.0-T40.4 or T40.6 from contributing cause. Opioid-only poisoning: both (a) X40-X44, X60-X64, X85, or Y10-Y14 from underlying cause and (b) T40.0-T40.4 or T40.6 from contributing cause, and not alcohol poisoning, i.e., X45 or F10.0 from underlying or contributing cause or T51.0 or T51.9 from contributing cause. Alcohol and opioid poisoning: alcohol poisoning, i.e., X45 or F10.0 from underlying or contributing cause or T51.0 or T51.9 from contributing cause, and opioid poisoning, i.e., both (a) X40-X44, X60-X64, X85, or Y10-Y14 from underlying cause and (b) T40.0-T40.4 or T40.6 from contributing cause summarized in Tables 1 and2. For all sensitivity analyses, results were broadly consistent with the main analyses (Additional file 1: Tables S3, S4 and S5). Objective 1: Educational and racial and ethnic differences in poisoning mortality Educational inequalities were observed for most poisoning outcomes and these inequalities were largest for opioid-only poisonings for both men and women, finding that low education (relative to high education) was associated with 21.8 (men) and 6.3 (women) additional deaths per 100,000 persons in 2010. For alcohol-only poisonings, those with low education had 5.6 (men) and 1.2 (women) additional deaths per 100,000. For combined alcohol and opioid poisonings, mortality rates in 2010 were higher by 3.1 (men) and 0.04 (women, not significant) deaths per 100,000 for low compared to high education groups. Positive interactions between education and linear year were observed for most poisoning outcomes and the positive interactions between education and quadratic year were observed for opioid only and combined alcohol and opioid, indicating that not only the absolute educational inequality in poisoning mortality rates widened over time, but also the inequality accelerated in more recent years particularly for opioid poisoning. Differences in poisoning death rates between race and ethnicity groups were observed with some interaction effects between linear and quadratic year and race and ethnicity group (Table 1), consistent with the trend in Additional file 1: Fig. S2 (not stratified by educational attainment). The results largely show that in 2010, White men and women had the poorest outcomes for all poisoning types. Poisoning mortality rates for Hispanic individuals did not increase as fast as Whites did over time. However, some positive interaction effects for Black men and women indicate the racial and ethnic differences in 2010 diminished or even reversed over time in some cases. For example, Black men's combined alcohol and opioid death rates accelerated and surpassed White men's rates by 2019 (Additional file 1: Fig. S2). --- Objective 2: Educational inequalities within race and ethnicity groups in poisoning mortality Figure 2 summarizes mortality rates over time (2000-2019) from alcohol-only, opioid-only, and combined alcohol and opioid poisonings split by educational attainment and race and ethnicity. As shown in Table 2, for Whites, the largest relative educational differences were observed for opioid-only poisonings with 7.5 (men) and 7.2 (women) times more opioid poisonings in those with low education compared to high education. There were large inequalities in combined alcohol and opioid poisonings, particularly for men with a mortality rate 7.4 times higher in low education groups. For women's combined alcohol and opioid poisonings, educational inequalities were smaller but substantial (4.9 times higher in low compared to high education). The smallest inequalities were observed for alcohol-only poisonings, with mortality rates being 3.8 (men) and 2.6 (women) times higher. A significant positive effect of year was observed for all poisoning types for White women and for opioidonly poisoning for White men, indicating widening relative educational inequalities in each year. The educational inequality in mortality rates (comparing low with high education) for Black men (relative to White) was 1.5 (both alcohol-only and combined alcohol and opioids) times greater in 2010, but with no difference observed for opioid-only poisonings. This resulted in mortality rates for Black men that were 5.3 (alcoholonly) and 8.9 (combined alcohol and opioid) times higher in low compared to high education groups. A significant interaction between time and race and ethnicity for combined alcohol and opioid poisonings indicated that educational inequalities have increased more for Black men compared to White men over time. For Hispanic men and women, the trend for opioid-only poisonings followed the opposite pattern, indicating that educational inequalities increased less for Hispanic compared to White men and women. Among Black women, educational inequalities for combined alcohol and opioid mortality rates were larger by 6.0 compared to White women, resulting in mortality rates 10.9 times higher in Black women with low compared to high education. For women, there was no interaction effect between time and race and ethnicity, indicating that widening inequalities over time were similar to Whites. --- Discussion This study provides for the first time a detailed overview of poisoning mortality from alcohol-only, opioid-only, and combined alcohol and opioids by educational attainment and race and ethnicity in US men and women. Large and increasing educational inequalities were found between those with and without a college degree in alcohol-only, opioid-only, and combined alcohol and opioid poisonings, with particularly high mortality in those with a high school degree or less. The relative educational inequalities in alcohol-only, opioid-only, and alcohol and opioid poisonings between racial and ethnic groups over time were also quantified. We find that educational inequalities in poisoning deaths were most pronounced in non-Hispanic White and Black men and women. It appears that these socioeconomic differences in drug and alcohol poisonings have been primarily driven by opioid-only poisonings, which caused 53% of the poisonings studied in 2000, rising to 72% in 2018. Despite a dramatic increase in opioid poisonings, the proportion of poisonings caused by combined alcohol and opioids remained stable. These findings support previous work by Case and Deaton, which found large inequalities between non-Hispanic White individuals with and without a BA degree in poisoning mortality [13]. They also support more recent findings by these authors that suggest that while gaps in mortality between race and ethnic groups have decreased, inequalities in mortality between educational groups have increased. Our results build on this work and suggest that for poisoning deaths, these widening educational inequalities are occurring both in the adult population overall and within racial and ethnic groups. We have shown growing inequality between educational categories for non-Hispanic Black and White groups for all types of poisoning deaths considered and that the inequalities have grown dramatically between those with a high school degree or less compared to those with a college degree. Additionally, our results suggest that relative educational inequalities in combined alcohol and opioid poisoning mortality may be the largest and increasing the most over time for non-Hispanic Black individuals. Consistent with this, a recent report by the US Substance Abuse and Mental Health Services Administration (SAMHSA) highlights dramatic growth in opioid overdose deaths in Black communities [24]. A number of factors could be driving this, including increased availability of pure heroin, greater presence of potent synthetic opioids such as fentanyl in illicit drug markets, and racial and ethnic and neighborhood disparities in access to medications for treating opioid use disorders [24,25]. In addition to providing a detailed overview of the poisonings from different substances by race and ethnicity and education, we provide a new method for categorizing both alcohol and combined alcohol and opioid poisonings. This method avoids previous issues noted with the changing of ICD-10 codes F10.0 that has been previously documented [26]. This provides a new methodology for capturing trends in alcohol poisonings that avoids jumps in the data. --- Limitations We were unable to separate US-born and non-USborn Hispanic individuals; however, there may be key differences between these populations. Prior research shows that non-US-born Hispanic individuals are less likely to use substances and more likely to have lower educational attainment [27,28], and thus aggregating across these groups could potentially obscure important patterns and trends. One further limitation is that we were not able to consider a breakdown of the rather heterogeneous, non-Hispanic others group including mixed race and ethnicity, due to the small numbers of poisonings observed in some sub-categories (e.g., alcohol poisonings in those with a BA degree). Although we were unable to draw conclusions about this group from our data, our results for the non-Hispanic other race and ethnicity group are similar to previous findings, specifically, differences in unintentional injury mortality (including poisonings) in Native American and Alaska Native individuals, with these individuals having a rate eight times higher than non-Hispanic Whites for alcohol poisoning [26]. Since these individuals are more likely to be in the high school degree or less educational category [29], this could explain the disparities in the present study in alcohol-only poisonings between non-Hispanic others with low and high education. While we did not consider substances other than alcohol and opioids, there are other substances that may be contributing to the pooled drug and alcohol poisonings [13]. Specifically, recent data suggests that a "fourth wave" of the opioid epidemic may have been entered, characterized by substantial co-involvement of opioid poisonings with cocaine, amphetamine, and benzodiazepines in 2019 [30]. One substance that is important to consider in future work is benzodiazepines, which have recently been estimated to be involved in 21% of opioid poisonings. It is unclear whether there are socioeconomic inequalities in these. In this study, we were only able to explore differences by educational attainment and race and ethnicity. Future work should consider other demographic factors, including additional facets of socioeconomic status, specific age groups, and urban vs. rural locations [31]. The results of this study are only applicable to a US context and would not be generalizable to other countries with differing socioeconomic inequalities and access to healthcare. Although our method for defining alcohol Fig. 2 Mortality per 100,000 alcohol-only, opioid-only, and alcohol and opioid poisoning for men and women aged 25 and oldere split by educational attainment and race and ethnicity categories for 2000-2018. Note: Alcohol-only poisoning: ICD-10 code X45 or F10.0 from underlying or contributing cause or T51.0 or T51.9 from contributing cause, and not opioid poisoning, i.e., both (a) X40-X44, X60-X64, X85, or Y10-Y14 from underlying cause and (b) T40.0-T40.4 or T40.6 from contributing cause. Opioid-only poisoning: both (a) X40-X44, X60-X64, X85, or Y10-Y14 from underlying cause and (b) T40.0-T40.4 or T40.6 from contributing cause, and not alcohol poisoning, i.e., X45 or F10.0 from underlying or contributing cause or T51.0 or T51.9 from contributing cause. Alcohol and opioid poisoning: alcohol poisoning, i.e., X45 or F10.0 from underlying or contributing cause or T51.0 or T51.9 from contributing cause, and opioid poisoning, i.e., both (a) X40-X44, X60-X64, X85, or Y10-Y14 from underlying cause and (b) T40.0-T40. poisonings avoids previously documented inconsistencies in the data, this method is yet to be validated by an external expert committee. Finally, there are potential biases in the coding of poisonings, which could lead to an underestimation of the number of opioid poisonings presented in the current analysis [32]. It is also possible that due to stigma, these biases are unequally distributed across groups, for example, individuals with higher socioeconomic status may be less likely to be assigned an opioid poisoning category. It is important to consider in future work how these biases may relate to the under-recording of opioid-only and combined opioid poisonings and how these differ across sociodemographic groups. Our findings demonstrate the increasing concentration of poisoning deaths among individuals with low socioeconomic status. This may be indicative of specific developments in the opioid crisis as well as societal trends of growing despair. In more recent years, a shift in the opioid crisis has been observed with declining opioid prescription rates, increases in poisoning deaths from illicitly manufactured opioids, and greater presence of opioids mixed with toxic adulterants [33]. This has coincided with increasing exposure to more potent substances such as cheaper synthetic opioids like fentanyl in illicit drug markets. Combined with disparities in access to effective substance use treatment [24,25], these developments might be driving the increasing concentration of poisoning deaths in lower SES and Black populations we observed. These underlying dynamics of the opioid crisis might explain an increase in opioid-only and combined alcohol and opioid poisonings in lower socioeconomic groups. However, we also find rising alcohol-only poisonings in these groups, which cannot be explained by these mechanisms alone and may instead be a symptom of wider despair in society [15,34]. Large parts of society at the lower end of the socioeconomic spectrum have experienced increasing levels of economic hardship, job insecurity, uncertainty about the future, and disruptions in the social fabric of their communities [15,34]. Public health strategies should focus on intervening through a combination of these mechanisms. These include harm reduction strategies such as the provision of safer drug use spaces and expanded access to naloxone [35], equitable access to effective treatments for opioid use disorders, and a wider health-in-all-policies approach that encompasses policies on affordable or universal health care and strengthening of social welfare systems to decrease despair. Our finding that those with low education have dramatically rising poisoning death rates is also important to consider in the context of educational attainment patterns by race and ethnicity. In 2017, nearly half (46%) of Black Americans aged 25 or older had only a high school degree or less compared to one-third (34%) of White Americans [36] and thus might be disproportionately affected by these recent trends. Finally, the COVID-19 pandemic appears to have exacerbated mortality trends. Deaths from drug poisonings have increased further [37], especially in Black populations [38], and this trend has corresponded with increases in socioeconomic [39] and racial and ethnic [40] inequalities in mortality that are directly and indirectly related to COVID-19. Therefore, it is likely that there will be further widening of socioeconomic inequalities in poisoning mortality with differences across US racial and ethnic groups. --- Conclusions Educational inequalities are present in alcohol-only, opioid-only, and combined alcohol and opioid poisonings and have increased substantially between 2000 and 2019, particularly for non-Hispanic Black and White groups. Opioid poisonings continue to represent the largest proportion of poisonings and have the highest inequalities in mortality between those with low and high education. Quantifying these differences highlights where interventions should target to aim to reduce harms from poisonings in the USA, including a focus on groups with low education. Future research is needed to understand drivers of these inequalities to inform targeted interventions to reduce poisoning mortality rates and socioeconomic inequalities. --- Abbreviations --- Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12916-022-02590-z. Additional file 1: Fig. S1. Total number of deaths aged 18 or older in US 2000-19 from alcohol poisoning only, opioid poisoning only and alcohol and opioid poisoning using three different versions of alcohol poisoning definition. Fig. S2. Age-standardized mortality rates for alcohol poisoning, opioid poisoning and combined alcohol and opioid poisoning for men and women by race and ethnicity categories from 2000 to 2019. Table S1. ICD-10 Codes used to define alcohol and opioid poisoning cause-ofdeath. Table S2. Number of deaths by three versions of alcohol poisoning definition (raw, adjusted and final) for alcohol poisoning only, opioid poisoning only and alcohol and opioid poisoning, for the total population, age 18 or older, and age 25 or older. Table S3. Coefficient estimates of generalized least square (GLS) models predicting racial and ethnic and educational differences in US poisoning mortality rates (per 100,000) aged 18 and over 2000-2019. Table S4. Coefficient estimates of generalized least square (GLS) models predicting racial and ethnic differences in educational inequalities in US poisoning mortality ratios calculated from mortality rates (per 100,000) aged 18 and more 2000-2019. --- Declarations Ethics approval and consent to participate Not applicable --- Consent for publication Not applicable --- Competing interests The authors declare that they have no competing interests. • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year --- • At BMC, research is always in progress. --- Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research? Choose BMC and benefit from:? 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Background The ongoing opioid epidemic and increases in alcohol-related mortality are key public health concerns in the USA, with well-documented inequalities in the degree to which groups with low and high education are affected. This study aimed to quantify disparities over time between educational and racial and ethnic groups in sexspecific mortality rates for opioid, alcohol, and combined alcohol and opioid poisonings in the USA.The 2000-2019 Multiple Cause of Death Files from the National Vital Statistics System (NVSS) were used alongside population counts from the Current Population Survey 2000-2019. Alcohol, opioid, and combined alcohol and opioid poisonings were assigned using ICD-10 codes. Sex-stratified generalized least square regression models quantified differences between educational and racial and ethnic groups and changes in educational inequalities over time.Between 2000 and 2019, there was a 6.4-fold increase in opioid poisoning deaths, a 4.6-fold increase in combined alcohol and opioid poisoning deaths, and a 2.1-fold increase in alcohol poisoning deaths. Educational inequalities were observed for all poisoning outcomes, increasing over time for opioid-only and combined alcohol and opioid mortality. For non-Hispanic White Americans, the largest educational inequalities were observed for opioid poisonings and rates were 7.5 (men) and 7.2 (women) times higher in low compared to high education groups. Combined alcohol and opioid poisonings had larger educational inequalities for non-Hispanic Black men and women (relative to non-Hispanic White), with rates 8.9 (men) and 10.9 (women) times higher in low compared to high education groups. Conclusions For all types of poisoning, our analysis indicates wide and increasing gaps between those with low and high education with the largest inequalities observed for opioid-involved poisonings for non-Hispanic Black and White men and women. This study highlights population sub-groups such as individuals with low education who may be at the highest risk of increasing mortality from combined alcohol and opioid poisonings. Thereby the findings are crucial for the development of targeted public health interventions to reduce poisoning mortality and the socioeconomic inequalities related to it.

INTRODUCTION Religious behavior is a reference to a person's awareness of their beliefs so that their actions are appropriate based on values, ethics, religion and norms (Elizabeth, 2002). To understand religious values, a religious person should obey the commandments and stay away from prohibitions sincerely from within body and soul (Siahaan, 1996). Karl Marx, quoted from Adnan, argued, religion is a view of life that must be applied in the lives of individuals and groups. Both have an interdependent relationship with all the factors that shape the social structure of any society (Adnan, 2020). Meanwhile, according to Durkheim, religion serves as a unifier of society. Religion is a collective force of society that overcomes individuals in a particular society (Baidi, 2010). Durkheim said that religion can only be understood by looking at the social role it plays in uniting communities under a unified common ritual and belief (Durkheim, 1961). In his opinion, religion strengthens people in the face of suffering, frustration and misfortune. Through religious ceremonies, individuals can establish a special relationship with His God. Those rituals guarantee life, freedom and responsibility for moral values in society (King, 1987). In this study, religious behavior is all forms of actions carried out by the people of Mbawa Village in accordance with the teachings of their respective religions related to local traditions. The religious practices of the Mbawa people have an adaptive tendency to traditional practices as is found elsewhere in Indonesia. However, the religion of the Mbawa community is unique because it is very thick and adaptive to local culture, which is syncretic but inherits religious tolerance practices as a result of the socio-cultural construction of the local community. The religious practice of the Mbawa people presents a very sensitive portrait of interreligious relations, as it concerns the values or beliefs embedded in each individual. However, the fabric of plural religious life can coexist harmoniously and peacefully because it is knitted with the local traditions of Raju customs which are common beliefs of the community. Clearly, the religious behavior of the Mbawa village community has practiced religious harmony through a commitment to preserving local wisdom together. Religious harmony is an important part of national harmony. If this problem is ignored, it will be fatal to human survival. Various problems will arise in society, especially in Indonesia which incidentally is a country consisting of various races, tribes, languages and cultures. In this case, of course, all levels of society will play a role in achieving inter-religious harmony (Ardiansyah, 2013). Nurcholish Madjid views the true value of Muslim religion can be measured through his attitude in building tolerance between followers of different religions. According to him, the perfection of Islam is because the religion is protective, because that attitude is what the companions of the Prophet Muhammad taught to other people (Madjid, 1998). Zuhairi also argued, tolerance should be the most important part in the scope of intra-and inter-religious associations. He explained that tolerance is an effort to understand other religions because it is undeniable that other religions also have the same teachings about tolerance, love, and peace (Misrawi, 2010). The practice of tolerance and efforts to understand and appreciate the existence of people of different beliefs occurred in the Mbawa community for a long time. One of the practices of tolerance is manifested by the community in the form of mutual cooperation on every holiday of each religion. Mbawa Village Head Abdul Gani M. Saleh admitted that the practice of interfaith tolerance occurred among its residents, especially pioneered by teenagers who collaborated with each other to succeed in carrying out their respective traditional ceremonies during the Great Holidays of the three religions (Gani, 2023). Research examining the value of tolerance in Mbawa Village is actually not a new object. There have been many previous studies that discuss this, but the subject matter discussed is still centered on the aspect of tolerance. For example, research written by Purna, Hanafi, and Anwar. The three studied the Raju Traditional ceremony practiced by the people of Mbawa Village in realizing the value of tolerance and its relationship with the agricultural activities of the local community (Purna, 2016). These studies are still stuck in the general description of the traditional Raju ceremony, still talking to the understanding and who is involved in the ceremony (Hanafi, 2017) (Anwar, 2021)nilai-nilai estetika, religi, norma dan budaya. Sehingga untuk menjamin keberlanjutan dari nilai-nilai luhur yang diwarisi oleh nenek moyang sehingga dapat membentuk karakter generasi, maka generasi penerus sebagai pewaris budaya harus menjaga dan merawat budaya rumah adat, tardisi dan nilai-nilai luhur ini, dijadikan sebagai kekayaan budaya masyarakat Mbawa. Potensi budaya tersebut akan sangat menunjang bagi wisata Uma Ncuhi untuk itu perlu adanya analis lebih lanjut terkait dengan penganggalian potensi wisata yang ada di Desa Mbawa lebih khususnya dan Kecamatan Donggo pada umumnya.Jenis penelitian deskriptif dengan pendekatan kualitatif. Tempat penelitian di Desa Mbawa Kecamatan Donggo Kabupaten Bima. Subjek penelitian masyarakat Desa Mbawa, pemerintah desa Mbawa, tokoh pemuda dan tokoh adat di desa Mbawa. Teknik pengumpulan data menggunakan observasi, wawancara dan dokumentasi. Keabsahan data menggunakan triangulasi sumber. Teknik analisis data dengan pengumpulan data, reduksi data, penyajian data, dan kesimpulan. Objek wisata utama Uma Ncuhi biasa atau sebut uma leme oleh orang Mbawa rumah ini berbentuk kerucut dan bentuk bangunan dari atap dan dinding terbuat dari alang-alang. Selain itu terdapat pula objek wisata penunjang diantaranya 1. Meanwhile, Muawanah's research focuses on the importance of education to instill tolerance in the community. The study concluded that it is very important to provide education to the community in order to be able to foster an attitude of tolerance (Muawanah, 2018). Then, Yusuf and Fidyansari's work which highlights the local wisdom of the Komba indigenous people in Komba Village, Larompong District, Luwu Regency, states that local traditions serve as a maintenance of the pattern of unity and togetherness of farmers. The tradition is carried out to start the rice planting and harvesting period simultaneously (Yusuf dkk., 2019), Aulia and Nawas, in their findings, discussed the implementation of religious tolerance values at the Rambu Solo traditional ceremony in Toraja land (Aulia dkk., 2021), Muthmainnah studied the concept of religious tolerance in the Qur'an, the perspective of Buya Hamka and Thoifur Ali Wafa (Muthmainna, 2021), Tamaeka studied the cultivation of tolerance values through character education in elementary schools (Tamaeka, 2022), Muhammad Mishbahurrizqi in his article on the cultivation of tolerance values through Islamic religious education subjects (Muhammad Mishbahurrizqi, 2022). Through these previous researches, there have been many studies questioning local traditions with the dissemination of religious tolerance. It's just that none of these studies have really focused on mapping the pattern or form of teaching the values of religious tolerance through local traditions involving educational institutions and elements of society. This study is expected to answer the void of scientific discourse by explaining the pattern of teaching the value of tolerance through the traditional Raju ceremony of the Mbawa community. In general, the ceremony aims only to eradicate pests and determine the harvest period. However, in substance the local tradition of Raju tradition passes down the values of religious tolerance (deliberation, cooperation, respect and respect for other religions) in practice directly in the midst of the socio-cultural life of the indigenous Mbawa people. Solemnly researchers, the ceremony could not have been carried out properly without mutual respect and desire between residents in maintaining ancestral heritage. The pattern of teaching tolerance through Raju traditional ceremonies is manifested in a number of local wisdom practiced by the local community by living the values of mutual cooperation, mutual respect, deliberation, and commitment to maintaining harmony between followers of different religions. The teaching pattern referred to in this study is a dissemination of tolerance values practiced by the Mbawa community through formal, informal, and non-formal forms or patterns of teaching. All teaching activities involve educational institutions, families, and local social elements from cadet reefs, youth communities, to religious leaders, and Raju or Donggo ethnic stakeholders. Various patterns of teaching the value of tolerance are very important for Mbawa residents. Apart from maintaining the preservation of local traditions, what is more important is as a forum that glues together the social relations of a plural community. If the traditional Raju ceremony as a local wisdom is not practiced, it is very likely that segregation of citizens between religions and between ethnicities will easily occur because of the absence of ritual unity as a social glue that unites all citizens in one common belief that is recognized together. The ceremony actually also holds the potential for religious conflict, because each of the followers of different religions living in the village has a mission to invite religious conversion (Purna, 2016). However, because of the forms of value teaching based on tolerance and moderation in religion, the potential conflict can be bridged properly. --- RESEARCH METHOD This research uses qualitative research methods with descriptive analysis approach. The purpose of this descriptive approach analysis is to provide an explanation of the facts that are the object of research in this article systematically and accurately, especially as a subject of study on the values of tolerance at the traditional Raju ceremony of the people of Mbawa Village, Donggo District, Bima Regency, West Nusa Tenggara. According to Sugiyono, the descriptive approach of analysis wants to obtain in-depth data, and present the relationship between researchers and participants or objects and research subjects directly (Sugiyono, 2018). The first step taken by researchers to achieve in-depth data mining is by literature study of religious practices related to customs and traditions in Indonesia in general, as well as the traditional Raju ceremony in Mbawa Village specifically. After that, researchers codified the various existing literature and analyzed it to understand the religious pattern of traditional communities and their relationship with the harmony of their lives. From all this literature, the author identifies that this research has novelty because there has been no previous research that explains the pattern of teaching the value of tolerance from the traditional Raju ceremony in Mbawa Village. To obtain valid and scientific data, researchers completed the literature review by making direct observations in the field, namely on indigenous people in Mbawa Village, Donggo District, Bima Regency for one full month (April, 2023). Previously, researchers also participated in the Raju Traditional ceremony which took place on October 25-November 2, 2021. In these observations, researchers had the opportunity to interview a number of actors who are directly involved in the practice of Raju traditional ceremonies and those who teach the values of tolerance in Raju customs. Researchers follow the Raju traditional ceremony from preparation to its implementation which is held at the traditional house, where the Raju traditional ceremony (uma leme) is held. Researchers also interviewed 50 residents who could be categorized by age (20-72 years), gender (27 women and 23 men), as well as Muslims (62%), Catholics (26%), and Protestants (12%). The respondents included village heads, traditional tribal leaders, religious leaders, a number of religious and art teachers, the Mbawa Youth Association (HPM), and general residents of Mbawa Village. Researchers also complement data mining through documentation. Meanwhile, informants in this study used purposive sampling techniques. The selection of informants was based on criteria in the following interview order: village heads, traditional tribal leaders, religious leaders, a number of religious and art teachers, HPM, and local communities. After the researcher writes the interview results into the transcript, then the researcher makes data reduction by means of abstraction, which is taking data that is in accordance with the research context. In this study, the collected data is processed and data processing is carried out by triangulation, reduction, data presentation, and conclusion drawing. The analysis of this research used the thesis of Emile Durkheim in his book, The Elementary Forms of Religious Life (Durkheim, 1961) and Yusuf Al-Qardhawi in Fiqh al-Aqaliyyat al-Muslimah (Al-Qardhawi, 2004). According to Durkheim, ritual unity plays a role in bonding the relationship between religious communities. To unite a plural community, there needs to be a social role in the unity of rituals and common beliefs held by all citizens. While Al-Qaradawi explained, Islam is a tolerant religion that places tolerance as the main principle in interreligious relations. Tolerance in Islam is an active attitude in maintaining harmonious relations between people of different religions. Al-Qaradawi stressed the importance of teaching the values of tolerance for a heterogeneous pluralistic society. The value of tolerance must be taught intensively and continuously to plural societies so that they can coexist peacefully. In knitting harmony in the life of a plural society, he emphasized the importance of cooperation between religious communities through social activities, economic empowerment, and inclusive education. --- RESULTS AND DISCUSSION Islam obliges every adherent to be respectful, behave kindly and justly, and know each other regardless of differences in ethnicity, race, gender, group, and religion (Q.S. Al-Hujurat: 13) (Salim, 2002). This is an implementation of the values of religious tolerance taught in Islam. Moreover, according to M. Hasyim Kamali in Cekli Setya Pratiwi, the purpose of Islamic sharia itself is none other than to create good for all humans, both in world affairs and the hereafter (Kamali Hasyim et.al, 2022). Hamka, in Muthmainnah, argues that Allah Almighty gives freedom to every human being to choose his religion. Religious tolerance also means not imposing religion on someone because all humans are given the freedom to choose their religion without any coercion. According to Hamka, faith is an independent choice, with the approval of one's own conscience and reason, not an external coercion (Muthmainnah, 2021). Meanwhile, according to Mustafa, tolerance is the attitude of someone who recognizes the existence of religious plurality and respects every religious believer (Mustafa, 2016) a child is considered not achieve adult status if he has not reached the age of 21 years. Meanwhile in Indonesian culture, a person is considered officially reached adult status if already married, even though he has not yet reached 21 years. psychologists set around the age of 20 years as early adulthood and lasts until around the age of 40-45 years. Adulthood can be said to be the longest period in the life span. During this long period, physical and psychological changes occur at times that can be foreseen that pose adjustment problems, pressures, and expectations. In the teachings of Islam, that the need for religion because man as a creature of God is equipped with a variety of potential (nature. That is because every religious believer has the right to receive equal treatment from everyone, another view says that tolerance is a condition that must exist in an individual or society to fulfill its purpose. The purpose of religious tolerance is to create a peaceful life in the midst of differences, whether because of history, identity, or culture (Walzer, 1997). Mbawa Village, Donggo District, is one of the areas in Bima Regency, West Nusa Tenggara (NTB) which has the privilege of diverse religions and ethnicities. The Mbawa community always maintains solidarity and cooperation between people even though they embrace different religions. So far there has never been a religious conflict in the village, because local residents always knit harmony by carrying out local wisdom inherited from their ancestors. One of the local wisdom that unites them to always live in society is through the implementation of traditional Raju ceremonies. The traditional Raju ceremony as a local wisdom of Donggo ethnicity bequeaths the meeting of heterogeneous citizens in terms of religion and belief in the spirit of mutual respect for differences, cooperation, and deliberation. Cultural ties framed through the implementation of Raju traditional ceremonies are always maintained because the community is mutually committed to maintaining and passing on the local tradition to their sons and daughters. In Yusuf Al-Qardhawi's view, he requires that people living in the midst of pluralism must prioritize the teaching of religious tolerance, mutual respect, and cooperate with different communities intensively in order to coexist peacefully (Yusuf Al-Qardawi, 2004). Therefore, the practices of teaching the value of religious tolerance carried out by the Mbawa community have fulfilled the requirements described by Al-Qardhawi. There are three patterns of teaching the value of religious tolerance of the Mbawa community which include formal, informal, and non-formal teaching. Basically, the traditional Raju ceremony is a community activity to eradicate pests and determine the planting season (Ahmad, 2013). This ceremony contains cultural values that are in line with the religious teachings adopted by the Donggo ethnicity, such as believing in divine power, and establishing a harmonious relationship between all residents and the environment (Jamaludin, 2023). This ceremony is a product of local culture that contains messages of wisdom based on long-standing community agreements in order to maintain a harmonious life among a multicultural population. This is in line with religious doctrine which always contains moral messages derived from religious dogma. Raju customs actually have no connection with any religious doctrine. This ceremony is purely a local tradition passed down from generation to generation in the life of the Donggo ethnic community. This tradition existed before state-sanctioned religions entered the region. This tradition is very close to people's lives, but it has nothing to do with religious doctrine. Raju is related to the customs of the ancestors from a long time ago that the Mbawa people continue to follow, while religion is something related to faith and obedience to God (Zakariah, 2023). Although associated with religious doctrine, Raju is actually a kind of ritual to deny the occurrence of disaster hazards by praying for the good of the community in farming (kanggihi). It is a tradition that has been practiced for a long time and continues to be followed by Raju indigenous adherents until now (Ismail, 2023), with the aim of strengthening fraternal relations. Through the Raju custom, people can learn to understand and appreciate the differences between one citizen and another, including in terms of embracing religion or belief. According to Sambiring, the traditional Raju ceremony does not affect a person's faith at all, whether they are Muslim, Catholic, or Protestant. It is closely related to ancestral beliefs and social relations between local residents, where the community cooperates in carrying out the Raju ceremony until it succeeds (Sambiring, 2023). By prioritizing local wisdom as a cultural strategy in realizing religious tolerance, the Donggo ethnic community has maintained the peace of the surrounding environment and avoided conflicts, especially those motivated by ethnic and religious differences. Moreover, the case that occurred in the Donggo ethnic community, although they have embraced monotheistic religions, in fact the local indigenous people still uphold indigenous beliefs and local culture as their unification and identity. In addition, the Raju traditional ceremony is one of the local wisdom oriented towards internalizing value education, especially in teaching children about the traditions, values, and culture of the Donggo ethnic community. Through this upara, members of the Donggo ethnicity will get to know themselves and their local characters. Muslims residing in Mbawa do not feel worried or afraid of the existence of other people or traditions that cause their faith to fade. Likewise with followers of other religions who are local residents in Mbawa. Instead, these traditions are passed down as a symbol of the unification and tolerance of the Mbawa people. The symbol of unification is manifested in the form of a traditional house called uma leme, which annually holds a traditional Raju ceremony (Budi, 2015). Raju custom is one of the important ceremonies in the historical records of Mbawa Village. This ceremony has been held for generations since their ancestors long ago. For a long time, the division of labor in the implementation of this custom included all religions. In fact, Muslims can become traditional leaders in the implementation of this activity (Aksa dkk., 2020). In this case, Raju customs are not only implemented by the Mbawa community, but also people outside Mbawa, such as people in neighboring villages, one of which is Sowa Village (Hanafi, 2017). The Raju ceremony contains prayers in the native language of the Mbawa people, which is usually called the kasaro prayer. Gani, Head of Mbawa Village, said that people from these three religions came and gathered to carry out the Raju ceremony without alienating each other, but as a whole community that had a common goal. The community still maintains and fosters local beliefs, because the traditional Raju ceremony is one of the goals to avoid conflicts related to local beliefs (Gani, 2023). In carrying out the Raju traditional ceremony, people should not make it as a joke because this is an important part of the tradition that has been preserved for a long time. Traditional Chief Raju Jamaludin said, the Raju ceremony has existed since before the major world religions entered and developed in West Nusa Tenggara. This tradition can be said to be an effort to introduce and provide an understanding of the importance of tolerance through cultural practices, traditions, and traditional ceremonies to local residents (Jamaludin, 2023). Religious harmony for the Mbawa community is very important, because it aims to accommodate the existence of the entire population. For local residents, as long as people still practice the Raju ceremony, the problem of inter-religious conflict is impossible. In fact, when people of different beliefs coexist and maintain each other's traditions, maintain a culture of deliberation, and mutual cooperation as a reference for living together, there can be no tension. "We are the same family and the same family, only different beliefs (Anwar, 2021)nilai-nilai estetika, religi, norma dan budaya. Sehingga untuk menjamin keberlanjutan dari nilai-nilai luhur yang diwarisi oleh nenek moyang sehingga dapat membentuk karakter generasi, maka generasi penerus sebagai pewaris budaya harus menjaga dan merawat budaya rumah adat, tardisi dan nilai-nilai luhur ini, dijadikan sebagai kekayaan budaya masyarakat Mbawa. Potensi budaya tersebut akan sangat menunjang bagi wisata Uma Ncuhi untuk itu perlu adanya analis lebih lanjut terkait dengan penganggalian potensi wisata yang ada di Desa Mbawa lebih khususnya dan Kecamatan Donggo pada umumnya.Jenis penelitian deskriptif dengan pendekatan kualitatif. Tempat penelitian di Desa Mbawa Kecamatan Donggo Kabupaten Bima. Subjek penelitian masyarakat Desa Mbawa, pemerintah desa Mbawa, tokoh pemuda dan tokoh adat di desa Mbawa. Teknik pengumpulan data menggunakan observasi, wawancara dan dokumentasi. Keabsahan data menggunakan triangulasi sumber. Teknik analisis data dengan pengumpulan data, reduksi data, penyajian data, dan kesimpulan.Objek wisata utama Uma Ncuhi biasa atau sebut uma leme oleh orang Mbawa rumah ini berbentuk kerucut dan bentuk bangunan dari atap dan dinding terbuat dari alang-alang. Selain itu terdapat pula objek wisata penunjang diantaranya 1. In the past, Mbawa was a remote village located on a mountain with limited social conditions. There are no decent roads to pass, and electricity and internet access has not yet entered. However, in recent years, modernization has made people experience worry for fear that the traditions and culture of their ancestors have not been inherited. Mbawa people rarely travel to the city. They have experienced a comfortable life in the hills. For them, children wandering to seek knowledge is fine, but their old age should live in Mbawa (Arban, 2023). Mbawa traditions and culture teach people to be tolerant and respect differences (Pusat Bahasa Departemen Pendidikan Nasional, 2017). This attitude of tolerance can be found through the holding of Raju traditional ceremonies. This traditional celebration is followed by all residents from various religions and beliefs believed by the local community. Each resident serves typical foods, such as beef, buffalo, chicken or mutton to the Muslim population. But non-Muslims can serve pork (by not imposing the will of Muslims to eat it) (Wahidi, 2008). Although the traditional Raju ceremony is carried out by all residents of different religions, their purpose is the same, which is to celebrate the harvest together. There are several restrictions during the traditional Raju ceremony, including: all villagers may not leave the village except for emergency purposes, cannot hold events that invite noise in the village, are prohibited from carrying young wood for any reason. Do not dry clothes, dry rice (lete fare) and pound rice (mbaju) on the fence in front of the house, clear forests, cut trees, steal, wash with coconut milk or hazelnut oil, do not do strenuous activities such as walking, vacationing out of town, and organizing events. Although these rules seem irrational, Mbawa residents believe that these rules are made to harmonize the life of local residents. Even they believe that there are those who do not obey it, people who violate it will be affected by disaster (bala). The disaster is very likely to attack agricultural crops, the people concerned, and the village and its inhabitants. Usually there are just violators. But if someone gets sick because they violate the rules, immediately respected traditional leaders will be able to treat them with prayers (Siti, 2023). When the Raju ceremony takes place, the rice harvest must not be lowered at Uma Jompa, the building in the residents' yard is devoted as a granary to store the harvest, which usually consists of three floors, namely: First, it is used to store livestock, second, for family gathering, weaving, and weaving, third, to store crops such as ikat rice, grain rice, and other types of crops (Daniel, 2019). This tradition is preserved as social learning which becomes a control mechanism in the life of a plural society. This mainly teaches people about learning to work together, caring for togetherness, and creating values of submission and social obedience. As when Nyepi Day is celebrated in a silent social situation, then when carrying out the Raju traditional ceremony there should also be no noise from residents. All sounds and music in the room should be set to the lowest volume. The government also banned all local radios and TV stations from broadcasting, and citizens were asked to turn off the internet and mobile phones (Ganesha, 2021). The Mbawa people believe that the celebration of Raju traditional ceremonies can bring blessings. If the implementation of the event starts from the north following the flow of the river, it is believed that the diseases suffered by residents will be wasted following the river. However, if this celebration starts from the north, then the people will pray according to their respective religions so that their farms and plantations become fertile. Likewise, if it starts from the east, then it aims to repel the threat of caterpillars and locust pests. If it starts from the south, it will repel rats and other pests. If it is from the west, it is believed to be able to bring a better life and achieve the blessing of life (Jamaludin, 2023). The process of carrying out the Raju traditional ceremony began with the existence of the Mbawa community consisting of three religious believers gathered in uma leme. Members of the Mbawa community present at uma leme there is no grouping based on religion or belief. Furthermore, residents attended prayers together in the hope that the ceremony would go smoothly. The next event was hunting (ngalo) on Mount Iku. This tradition is believed by local residents to remove all plant diseases through the flow of water from upstream to downstream. This is because the flow of water often carries diseases so the return must also be through the flow of water. The next Raju ritual is to travel to the top (lao ese). This lao ese tradition is intended to dispose of pests in the form of caterpillars, snakes, and other types of pests. Caterpillars, snakes and others are believed by farmers to come from above so that the return must also be upward. The next ritual is to travel north (lao ta da) to avoid the threat of locusts (kasanto ro komoa). Animals such as grasshoppers are believed to have come from the north, so they must be returned to the north. Then, the journey to the south (lao ta do) aims to throw rat pests towards the sea. For Donggo ethnic farmers, the arrival of rats is believed to come from the south, so the return is towards the sea. Finally, the journey to Sondosia, to throw everything towards the sea to melt with sea water (Hanafi, 2017). The value of local wisdom in Raju traditional ceremonies contains aspects of religious tolerance. This reality is manifested, among others, through mutual cooperation, mutual respect, and promoting deliberation, as well as mutual commitment to maintaining harmony in community life. The mutual cooperation in the Raju traditional ceremony can be seen when every resident hunts wild boar on the first day of the Raju traditional ceremony. Muslim villagers also hunted pigs, but when they got the hunt, they were cooked and eaten by Catholic and Protestant villagers. So, in this case, Muslim citizens also prepare all hunting needs and prepare various equipment to be cooked by their non-Muslim neighbors. Thus, even though those who do Raju (Nggalo) are Christians and Catholics, because local customs encourage every citizen to take part in the ceremony, it is an effort to maintain solidarity between residents so that the harmony that has been established does not fade. In addition, the traditional house (Uma Ncuhi) became a symbol of the unification of three religions in Mbawa Village. The traditional house is a gathering place for traditional leaders to deliberate on tribal issues, customs, and local residents, including discussing the implementation of Mbawa ancestral traditions, one of which is the Raju traditional ceremony (Aulia dkk., 2021). Deliberation in solving problems or decision making has become a traditional way that has often been done by residents to solve problems. --- Forms of Religious Tolerance Teaching The teaching of the value of religious tolerance that occurs in the Mbawa community through the Raju Traditional ceremony is carried out in three forms of teaching including: (1) formal teaching; (2) informal teaching; and (3) non-formal teaching. First, formally, values containing religious tolerance are taught to students through formal educational institutions, such as schools and madrasas. The educators have had the awareness to include local content lessons by introducing the traditions of the people of Mbawa Village, especially the traditional Raju ceremony. Before the ceremony began, the teachers reminded all students to follow suit, asking them to pay attention to discipline, responsibility and not to discriminate between their peers (Asmawati, 2023). Usually, educators introduce Raju traditional ceremonies to them as local heritage that teaches each citizen to work together, respect, deliberate, and commit to maintaining a peaceful life together. The value of tolerance of Raju traditional ceremonies is also taught to students through extra-curricular arts activities. The students learn Kalero dance, which is the original dance of the Mbawa people. Kalero dance is performed during major local traditional events, one of which is during the Raju traditional ceremony. In addition, there are also teachers who give field assignments to students to pay attention to the practices of Raju traditional ceremony activities held by residents and Mbawa traditional stakeholders. The educators deliberately included the students in the traditional Raju ceremony, because according to them, participating in this event is like paying tribute to parents, traditions, the environment, and teaching them about the importance of gotong-royong, cooperation, and commitment to maintaining local wisdom. Second, the form of teaching the values of tolerance in traditional Raju ceremonies is informally seen in the role of the family in Mbawa. It has been a legacy for generations, parents in the village tell their children about the Raju tradition which is full of learning tolerance, not reproaching each other's neighbors, and always helping fellow indigenous people. In practice, most parents in Mbawa involve their children in the implementation of the ceremony directly. In fact, the value of tolerance of Mbawa residents is very active with many families in the village giving names to their children with names that characterize the merger of several religions. Therefore, in the tradition of giving names in the family, it is very easy to find the names of family members in Mbawa who use two religions such as Albertus Arban, Yohanes Ibrahim, Anderias Ahmad, Bernadus Abu Bakr, Ignatius Ismail, Matinus Tamrin, Markus Jafar, and others. Meanwhile, female names such as Kristin Siti Hawa, Marta Maemunah, Natalia Hadijah, Fabiona Halima, Sicilian Aisyah, Margareta Sarti, Maria Juleha and others. The giving of such a name is inherited, whether it occurs in Catholic, Protestant, or Islamic families in Mbawa, which aims

This study aims to explore information related to the teaching pattern of religious tolerance, especially at the traditional Raju ceremony of the Mbawa Village community, Donggo District, Bima Regency. Mbawa residents are a diverse entity, both from religious and ethnic backgrounds. There are three different religions believed by the local community, namely Islam (78%), Catholicism (20%), and Protestantism (2%); and there are three ethnicities they profess namely Donggo, Flores, and Ambon. This article uses qualitative research methods with a descriptive analytical approach that aims to explain field data systematically and accurately, especially regarding the pattern of teaching religious tolerance values at the Raju traditional ceremony of the Mbawa community. This article uses Yusuf Al-Qaradawi's thesis in his thought which emphasizes the importance of teaching the values of religious tolerance for a pluralistic society. According to him, the teaching of the value of religious tolerance needs to be given to the community intensively, without discrimination towards certain religions or ethnicities. This study also wants to explain the traditions and cultural heritage of the Mbawa people through Emile Durkheim's thoughts on the role of socio-culture in bonding the relationship between religious communities. Durkheim said that to unite a plural community there needs to be a social role in the unity of rituals and common beliefs held by all citizens. This study concluded that the awareness of the Mbawa community to disseminate the values of tolerance in Raju traditional ceremonies through teaching patterns within families, educational institutions, and village and tribal government structures, succeeded in knitting positive relations between religious communities. Through the ceremony, residents also have a common awareness to coexist peacefully and nonviolently.

tell their children about the Raju tradition which is full of learning tolerance, not reproaching each other's neighbors, and always helping fellow indigenous people. In practice, most parents in Mbawa involve their children in the implementation of the ceremony directly. In fact, the value of tolerance of Mbawa residents is very active with many families in the village giving names to their children with names that characterize the merger of several religions. Therefore, in the tradition of giving names in the family, it is very easy to find the names of family members in Mbawa who use two religions such as Albertus Arban, Yohanes Ibrahim, Anderias Ahmad, Bernadus Abu Bakr, Ignatius Ismail, Matinus Tamrin, Markus Jafar, and others. Meanwhile, female names such as Kristin Siti Hawa, Marta Maemunah, Natalia Hadijah, Fabiona Halima, Sicilian Aisyah, Margareta Sarti, Maria Juleha and others. The giving of such a name is inherited, whether it occurs in Catholic, Protestant, or Islamic families in Mbawa, which aims to instill the values of tolerance. Although this tradition of giving (may) not be acceptable to most religious communities, for the Donggo ethnic who live in Mbawa, it is a manifestation of their social and religious life to still feel safe, have high moral standard, and peaceful (Purna, 2016). Third, non-formal forms of teaching are carried out by residents by providing cultural studies to children and adolescents through the Mbawa youth community. This cultural study usually contains an introduction to local traditions, such as the Raju tradition in which there are traditional ceremonial practices that aim to teach young people about tolerance towards other groups. In addition, the teaching of tolerance in other non-formal forms is manifested in the habits of local residents who when holding social activities, from children, adolescents, to parents and traditional stakeholders (regardless of religious differences) are very enthusiastic about working together to make the event a success. In fact, those who play a more important role in completing the work, it is precisely people who are different religions from the event organizers. Similarly, Muslims and Protestants do not feel awkward when side by side with followers of the Catholic (Proctor, 2005). This reality occurs naturally because the style of the Mbawa people is a mountain society that is thick with oral tradition. This has implications for the way local traditions are taught through storytelling, art events, ceremonial rituals, and various other cultural practices, traditions, and ceremonies (Jamaludin, 2023). This traditional Raju ceremony is also part of the local community's way of teaching children in the local environment to love culture and tradition. Examples of this oral tradition seem to be the custom of traditional leaders or parents teaching their children about how to use pandan leaves and coconut leaves to weave mats, bakula, and kambuti (commonly used as a place for chickens to lay eggs and hatch), even how to dress according to Raju customs, which is done through art events in traditional traditional houses (uma leme). In uma leme also memorials of the dead are held, even important deliberative meetings to decide certain customary issues are resolved held in this traditional house. Uma Leme plays an important role in addition to being a meeting space for all different residents, it is also a place to teach the values of tolerance through good practices of local culture of Mbawa residents. Uma leme filled by indigenous leaders is a control tool that maintains community harmony and prevents the emergence of certain group sentiments. Uma leme is a forum for dialogue that brings together many local interests, which in fact each citizen entity consists of many diversity. --- Picture 1&2: When the researchers were in Uma Leme, the traditional house of the Donggo ethnic community of Mbawa Village, West Nusa Tenggara. The house was used for local art events, as well as a place for local traditional leaders to deliberate. This house is a symbol of the meeting of three different religions in Mbawa. Other forms of teaching the value of tolerance are not formal carried out by leaders in each religion. Some local ustadz, for example, often provide an understanding of the importance of inter-religious harmony. They do this in mosques in the form of lectures, as well as at village religious events such as the commemoration of the Prophet Muhammad's birthday or others. Usually they message the importance of citizen harmony by quoting several verses of the Qur'an, such as QS. al-Kafirun: 6 and QS. al-Baqarah: 256 which teaches about the absence of compulsion in religion. The same is true for Protestant and Catholic religious leaders who provide understanding during Sunday services and some holidays, which refers to the Bibles Romans 10:12 and Thessalonians 3:12 which speak of the urgency of tolerance and respect for differences, as well as the religious doctrine of loving others. If there is tension in the community, religious leaders and local traditional leaders respond wisely by prioritizing ratio over emotion. A number of Mbawa Muslim leaders said that although the majority of Mbawa residents are Muslim, they still respect Catholics and Protestants. They are natives of Mbawa which means they are brothers. This attitude of mutual respect for one another also occurs during the celebration of the holidays of the three different religions (Wiediharto dkk., 2020). Every community representative from different religions is always invited to attend community events that are holding religious holidays (Hakiki dkk., 2015). Thus, through various forms of teaching the values of tolerance practiced by the indigenous Mbawa people, there seems to be a conformity with the thoughts of Yusuf Al-Qardhawi as in his book, Fiqh al-Aqaliyyat al-Muslimah (Yusuf Al-Qardawi, 2004). In the book, Al-Qaradawi emphasizes the importance of interreligious dialogue in public life. Dialogue can open up better communication spaces between different groups. Dialogue can also strengthen understanding and appreciation of the differences that exist in a pluralistic society. Mbawa residents, whose society is very heterogeneous in terms of religion and belief, have a number of local wisdom that serves as a tool for dialogue to find a way out of the threat of conflict, tension, and violence based on religious differences. Al-Qaradawi also underlined the importance of teaching the values of tolerance to a pluralistic society. The value of tolerance, such as respect and cooperation with different groups, must be taught intensively and continuously to people so that they can coexist peacefully. This is important because a pluralistic society consists of different religions, cultures, and social backgrounds, so the risk of conflict between groups becomes more manageable. The traditional Raju ceremony teaches children to respect each other, understand each other, help each other, share and respect each other. Thus, Raju traditional ceremonies play an important role in building peace between followers of different religions in Mbawa. If analyzed through Durkheim's thought, then actually the traditional Raju ceremony is a unity of rituals that become a common belief practiced by plural communities in order to create a harmonious community life. Thus, the traditional Raju ceremony has succeeded in gluing the relationship between religions embraced by Mbawa residents who are actually diverse in religion. Because, to unite the plural, there needs to be a social role in the unity of rituals and common beliefs held by all citizens (Durkheim, 1961). Meanwhile, Yusuf Al-Qaradawi views tolerance as an attitude that includes a willingness to understand and appreciate differences, as well as a willingness to share and cooperate despite different views or beliefs. He also emphasized that the teaching of tolerance values must start from the family and educational environment, because these two environments are the main bases in shaping a person's attitude and character. He emphasized that education is not only limited to instilling knowledge and skills, but also forming strong character and morals in a person (Yusuf Al-Qardawi, 2004). Based on the thoughts of Yusuf Al-Qardhawi, various teaching patterns of tolerance values that have been practiced by the Mbawa community are in accordance with the thesis put forward by the Muslim scholar. The pattern of teaching the value of tolerance in schools or formal educational institutions, families and communities is a good practice taught by Mbawa villagers to children and adolescents so that they knit a harmonious life through Raju Traditional ceremonies. An important example as an implication of the value of tolerance found in the traditional Raju ceremony, is that when Muslims celebrate Eid al-Fitr, they will still visit the homes of other Catholics and Protestants to forgive each other. Likewise, when Muslims fast in Ramadan, followers of other religions also carry out activities like Muslims. Even Catholics and Protestants do not cook or do activities that can interfere with or cancel fasting of Muslims during Ramadan (Kurniati, 2023). The traditional Raju ceremony became a meeting space for people of different religions in Mbawa to strengthen the bond of unity between residents. Every citizen can learn to tolerate and respect each other. Although some parties say the traditional Raju ceremony tends to be syncretic, the positive value of local wisdom of residents in the southern mountains of West Nusa Tenggara interprets the activity as gratitude to the Creator and begs Him to avoid disaster. According to Mbawa residents, the Raju Traditional ceremony is an expression of gratitude so that people are aware and think about God's creation that must be guarded and protected. The Raju Traditional Ceremony is a way for residents to build a good relationship with nature. Through the ceremony, local village traditional and religious leaders teach the community to be disciplined or obey social norms and interact with nature. --- CONCLUSION The realization of a real life of religious tolerance can be learned through the cultural practices of the Mbawa people in Donggo District, West Nusa Tenggara Regency (NTB). Every year, to commemorate the harvest period, Mbawa residents hold a Raju Traditional ceremony which is attended by all villagers who in fact have a plural pattern in religion. The local community consists of three religions, namely Islam, Catholicism and Protestantism. Although each religion has its own house of worship (Islam, Jaba Nur Mosque; Catholic, St. Paul's Church; and Protestant, GKII Church/Tabernacle), but when there is a religious holiday celebration held in each place of worship, the youth of each religion invite each other as a form of mutual belonging and respect between residents (Jauhari, 2018). In essence, the multicultural Mbawa people are very proud of a harmonious life. Each individual practices mutual tolerance, mutual respect, and understanding each other's differences by upholding local traditions, one of which is through the practice of Raju Traditional ceremonies. Raju customs have succeeded in uniting people of different religions to be committed to creating a peaceful community life and avoiding mutual suspicion. The key to the preservation of Raju's local traditions is influenced by the involvement of all educational and social institutions in Mbawa in disseminating the values of religious tolerance. The Raju Traditional Ceremony has played a vital role as a socio-cultural ritual that strengthens the relationship between the local plural community. According to Durkheim, the role of socio-culture is a pillar of success to unite a plural community. Certain religions or common beliefs can be a collective force that can bridge the barriers of difference in society (Durkheim, 1961). In this case, the active involvement of every social and educational element in teaching the values of tolerance in Raju traditional ceremonies has become an important factor for the creation of religious harmony in Mbawa Village from the past until now.

This study aims to explore information related to the teaching pattern of religious tolerance, especially at the traditional Raju ceremony of the Mbawa Village community, Donggo District, Bima Regency. Mbawa residents are a diverse entity, both from religious and ethnic backgrounds. There are three different religions believed by the local community, namely Islam (78%), Catholicism (20%), and Protestantism (2%); and there are three ethnicities they profess namely Donggo, Flores, and Ambon. This article uses qualitative research methods with a descriptive analytical approach that aims to explain field data systematically and accurately, especially regarding the pattern of teaching religious tolerance values at the Raju traditional ceremony of the Mbawa community. This article uses Yusuf Al-Qaradawi's thesis in his thought which emphasizes the importance of teaching the values of religious tolerance for a pluralistic society. According to him, the teaching of the value of religious tolerance needs to be given to the community intensively, without discrimination towards certain religions or ethnicities. This study also wants to explain the traditions and cultural heritage of the Mbawa people through Emile Durkheim's thoughts on the role of socio-culture in bonding the relationship between religious communities. Durkheim said that to unite a plural community there needs to be a social role in the unity of rituals and common beliefs held by all citizens. This study concluded that the awareness of the Mbawa community to disseminate the values of tolerance in Raju traditional ceremonies through teaching patterns within families, educational institutions, and village and tribal government structures, succeeded in knitting positive relations between religious communities. Through the ceremony, residents also have a common awareness to coexist peacefully and nonviolently.

In Government's review of waste policy in England (Defra, 2011), it pledges to work in partnership with local authorities and businesses to facilitate the uptake of best practice in waste prevention and resource management, amongst other ways through: -Reducing barriers to innovation and wherever possible the burden of regulation on compliant businesses, -Supporting capacity building in local communities and giving them freedom to take initiatives in service design and provision. The Review also includes reference to using the Localism Act 2011 (DCLG, 2011) and Big Society concepts to "empower local communities". It promotes a partnership between local communities and allows community stakeholders to participate in the decision making processes with regard to how the community deals with environmental issues, including waste management (Defra, 2011). This approach builds on the recommendations of the Sustainable Development Commission (SDC) that concluded that Government policy should prepare the ground for communities to deliver sustainable actions, coordinate support and provide access to funding (SDC, 2010). Within the context outlined above the role of voluntary and community sector (VCS) organisations have been viewed as the agents of change at the local level, to deliver and facilitate more sustainable strategies (Defra, 2011). However, while there has been much research on community level initiatives to promote sustainability, there is limited practical evidence to guide policy, or indeed to inform successful public engagement with such initiatives (Forest and Weik, 2014). According to Weerawardena et al. (2010), the issue of building long-term sustainability within the third sector is fragmented and relatively under developed. Using three towns in the East Midlands of England as case studies, this study aimed to examine and understand the levels of public engagement with VCS organisations and the factors that influenced this engagement. --- VCS organisations and the sustainability agenda VCS organisations (or third sector or community-based organisations) are "groups within which individual members associate of their own volition with others in the pursuit of common objectives" (Kim, 2011, p. 643). The term 'Voluntary and Community sector' (VCS) is generally applied to entities that are value driven and which principally reinvest their surpluses to further social, environmental or cultural objectives (London Borough of Hounslow, 2011). The sector ranges in scale from small, local charities to nationally important bodies. Due to its range and diversity, segmenting it by type of organisation can be helpful, particularly for sharing best practice and maximising the impact of sector activities. Voluntary organisations working internationally are sometimes referred to as nongovernmental organisations (NGOs). Community groups (defined as purely voluntary, without paid staff) may be differentiated from voluntary organisations (defined as having paid staff). These entities are collectively referred to as voluntary and community organisations (VCO) or the voluntary and community sector (VCS), (Defra, 2009). Various VCS organisations form a cornerstone of civic society and an institutional basis of society's 'third sector'. In many countries they have grown considerably in scope and scale within recent decades, and play a key role in engaging with and empowering society in a manner in which top down approaches are unable to (Fahmi and Sutton, 2006;Wilson et al., 2006;Colon and Fawcett, 2006;Parrot et al., 2009;Bailey 2012;Middlemiss, 2011;Seyfang and Haxeltine, 2012;King and Gutberlet, 2013;Forrest and Wiek, 2014). For example it is at the community level that notions of climate change adaptation and mitigation, and wider sustainability should best be developed and implemented at the local levels (Tudor et al., 2011;Shaw et al., 2014;Forrest and Weik, 2014). In this way, opportunities to embed these concepts into existing mandates, budgets and governance structures at the local and regional levels can best be realised (Bizikova et al., 2008;Burch, 2011). There are also emerging narratives around the significance of community structures as means of maintaining the fabric of the community by embedding and facilitating notions of urban resilience (Adger, 2006;Lüthie et al., 2009;Lee and Maheswaran, 2010;Ernstson, 2010;Collier et al., 2013). Thus community governance structures such as third sector bodies and engagement with these structures play a vital role not only in promoting sustainability, but also in enabling the capacity for change within communities and the society at large (Tudor et al., 2011;Collier et al., 2013;Shaw et al., 2014). --- 2.Methods Two main approaches were employed in the project, namely a: (1) meta-analysis and (2) questionnaire surveys. The meta-analysis utilised both academic and grey literature (non-academic, but reputable sources) to examine the nature and key operations of VCS organisations, in the UK and beyond. The selected papers were obtained mainly from the Science Direct database, as well as key UK Government agencies such as the Waste and Resources Action Programme (WRAP), Department of the Environment, Food and Rural Affairs (Defra), the Audit Commission, the Office of the Third Sector, and publically available environmental consultancy reports. The questionnaire surveys were undertaken in three adjacent towns, in the East Midlands region of England, namely: Luton, Milton Keynes and Northampton. The aim wasn't to be undertake a statistically significant sample from each town, but rather to capture a snap shot in terms of the socio-economic profile of the population, as well as the main activities of the organisations operating in the three towns. The surveys were conducted during the first three weeks of April 2013, with Milton Keynes being first, followed by Northampton and lastly Luton. Each of the three surveys employed 50 questionnaires, with respondents randomly selected from people walking in the streets, usually the high street. Respondents were handed the questionnaire and it was collected back on completion. A total of 149 questionnaires were completed and returned. The main purpose of the questionnaire was to determine public perceptions, attitudes to and use of the organisations in the case study areas. The questionnaire, a four page document with an introduction and contact information for reference and feedback purposes, was divided into four sections, namely: (1) Generic questions on recycling and shopping from charity shops; (2) Evaluation of shopping practices at furniture reuse shops; (3) Examination of general environmental attitudes and beliefs; and (4) Socio-demographic information. The majority of the responses utilised tick boxes and Likert scales ranging from 1 -5, with 5 indicating agreement and 1, non-agreement. There were also spaces for open questions provided. To facilitate the analysis, all questions were coded. Likert scales ranging from 1-5 were used to code the questionnaires. The coded information was initially entered into MS Exel and these data were then transferred into SPSS (version 20) for analysis. The normality of the data was first ascertained using the Shapiro-Wilk Test. As p>0.05, the data were assumed to be parametric. Descriptive analyses were first performed to determine frequencies. Bivariate analyses, using Pearson's Correlation were then undertaken to examine and evaluate the nature of the key antecedents to the perceptions and attitudes of the participants towards the organisations, and their use of the shops. --- Results --- Meta-analysis Reported numbers of the organisations in the UK vary. For example, according to Curran and Williams (2010), there have been approximately 400 such agencies set up in the UK since 1970. However, Defra (2009) note that there are about 1000 such entities in England alone. While LR Solutions and London CRN (2008) state that there were 693 third sector reuse organisations and initiatives in London, divided into six main categories, namely: • Domestic furniture and appliance reuse organisations (16) • Computer and other IT reuse organisations (7) • Charity shops (614) • Other reuse organisations (4) • Internet-based exchange forums (38) • Locally organised swap forums -give or take days ( 14) Despite the discrepancy in numbers, it is generally agreed that most are small and localised, with income of less than £250,000/annum (Dururu, 2014). However, there are around 7% which have an income of over £1m and 20% operate regionally and nationally. For example, half of the principal reuse organisations in London serve one to three boroughs, with only 11% serving seven to ten boroughs (LR Solutions and London CRN, 2008). They have diverse scales of operation, activities and objectives. For example, they deliver public services (HM Treasury, 2005), including waste management and in particular re-use (e.g. Williams et al., 2006;Defra, 2008;Cox et al., 2010), bulky waste services (Alexander and Smaje, 2008;Curran and Williams, 2010), community composting (Slater et al., 2010) and waste minimisation activities (e.g. collecting used furniture and electrical appliances) (Defra, 2009). In 2009, nationally, the sector was diverting around on average 500,000 tonnes of waste from landfill per annum (Defra, 2009). For example, Featherstone (2013) states that reuse operations in London collect around 12,000 tonnes. The types of materials managed by the sector varies, with only 4% of items donated to charity shops ending up in landfill. According to Defra (2005), textiles recycled through charity shops added up to 20% of the tonnages of material handled by other community organisations. By 2013, some 96% of materials (an equivalent of 347,000 tonnes of textiles donated to their shops) were recycled or sold on for reuse (CF and CRAQM, 2013). Approximately 20% of furniture collected at the kerbside is reusable and around 40% of the materials at household waste recycling centres (HWRVs) are reusable (Featherstone, 2013). They also undertake a significant social role. For example, they redistribute the furniture and electrical appliances to vulnerable households, thus alleviating poverty, and combating social exclusion (Curran and Williams, 2010). Indeed, as illustrated in Fig. 1, poverty alleviation is key factor in their objectives. Featherstone (2013) argues that reuse organisations play a vital role in social housing, by facilitating the sustainable management of housing stock (e.g. by reducing waste costs from voids clearances and supporting residents to recycle and reuse more). In the UK, there is an increasing demand for reuse furniture, with child poverty a pressing problem, with two in five households having no working adult. Thus their benefits to society include (Lloyd, 2012): -The ability to deliver services in response to local demand, particularly with respect to niche materials and/or particular social needs -Making goods and materials available that would otherwise be unaffordable for those on a low income -An emphasis on, and ability to meet, the specific needs of service users and the local community --- Questionnaire survey Over half (55%) of the sample was female (Table 1). There were more females, 64% interviewed in Luton than any other town. However, according to the ONS (2013), the 2011 population census shows that the number of males and females in Luton is almost similar (101,954 and 101,247 respectively). The high percentage of female respondents could be attributed to reluctance to participate by men. The majority of the respondents for the three towns were in the 16-30 years age group followed by the 31-45years age group. Some 50.3% of the population was in some form of employment, with Northampton having the highest part time (P/T) employed (44%) and Milton Keynes the lowest (32%). However, the figures show that there are far less people in full time (F/T) employment than part time (P/T) across the three towns. Luton had the highest number of students (30%). Some 57.7% of the sample had an annual income of less than £20,000. All three towns showed similar levels of income, except in the £30-50,000 range where Northampton had a significantly higher figure than Luton. Over 50% of the individuals in all three towns resided in rented houses, with Luton having the highest rentals at 65%. The most common houses were semi-detached and flats. House ownership was highest in Northampton at 58%. --- Recycling and use of charity shops Eighty-one percent of all the respondents said that they recycled. Table 2 indicates that residents of Northampton were the most likely to use charity shops (80%), followed by Milton Keynes (78%) and Luton (66%). However, on buying or taking items to furniture reuse shops, Luton had the least respondents (48%), Milton Keynes had 62% and Northampton was highest at 80% (Table 2). As shown in Fig. 2, clothes were the most donated item at a combined percentage of 31% for all the three towns, while furniture donation was 6.7%. Other items included books and toys. Over 34% of the respondents said they made monthly donations and 28% donated on an annual basis. Fig. 2: Items donated and bought across the three towns --- Awareness of the existence of furniture reuse shops An overwhelming majority of respondents (84.4%), were aware of the existence of furniture reuse shops in their area and had shopped in them. Residents in Luton had the highest lack of awareness about them (20%). Overall, 34% only came to know of the existence of the shops either by walking or driving by. As demonstrated in 2, about 50% of the individuals stated that they would take their unwanted sofa to a charity, while 40% said they would take it to the tip or throw it away. --- Environmental attitudes and beliefs The main reasons why individuals used the shops were because of the value offered and quality, as demonstrated by these correlation factors being highest (Table 3). There was also some correlation with gender, with women expressing a greater engagement, compared to men. However, this may relate to the larger percentage of women surveyed. Perceptions about helping the environment (41.6%) and also living in close proximity to furniture reuse shops (30%) were also key deciding factors. Alternatively, of those that said they did not buy from the shops, 30% preferred to buy new items. However, they could not unequivocally say whether items from the shops were of good quality or not. Most reported strong beliefs on the positive role of recycling on the environment. An overwhelming 78% thought that their consumption patterns had an impact on the environment and 88% agreed that it was their personal responsibility to look after the environment. Asked what would encourage them to use furniture reuse shops, 81% suggested quality of items, while 63% thought awareness of the existence of a shop within their local area might have an effect on their shopping habits (Table 4). --- 4.Discussion While accurate numbers of VCS organisations working in waste management across the UK, vary, they evidently play a significant role in society. This is evidenced both in terms of their environmental role of collecting, reusing, minimising waste, but significantly also, their social role helping vulnerable households (Defra, 2011;Lloyd, 2012;Seyfang and Haxeltine, 2012;Forrest and Wiek, 2014). Across each of the three towns there was high awareness of furniture reuse shops, and most used them to either buy or sell items. Clothes were found to be the most donated item for all three towns, with just over a third of residents stating that they donated items at least once a month. This confirms the importance of textiles as found in other studies and suggests the key role played by textiles in achieving reuse targets (Defra, 2005;2009;CF and CRAQM, 2013). The socio-economic composition of the population appeared to have had some impact on engagement with the shops. Indeed, most residents across the three towns were in P/T employment, earning less than £20,000/annum, and within the age range of 16 -30 years old. These factors would have had a bearing on disposable income thus affecting lifestyles, as well as behaviour and attitudes towards resource consumption (Dururu, 2014). It's important to note though that use of charity shops was highest in Northampton, where incomes were highest. This perhaps could be related to the higher quality of items in the shops. It would be interesting therefore to extend the study into areas where disposable incomes are higher. An overwhelming majority of the respondents were aware of charity shops in their towns, primarily via either walking or driving by. This would suggest the importance of location to such shops to ensure good public engagement. The perceived value offered in shopping at these stores would also suggest that price is a significant contributing factor in public engagement. Interesting, perceived benefits to the environment were also reported as a key reason why residents used the shops (Dururu, 2014). Presumably this relates to perceived minimisation of waste through reuse and recycling of items, which if they had not been donated/sought/bought from the shops, would have been disposed to landfill. At the same time, it may simply be respondents telling the researchers what they believed they wanted to hear. Nevertheless, the findings suggest that notions of value, quality and environmentalism should form keycomponents in the marketing strategies of these entities. At the same time, the results showed that costs and good quality were key influencing factors, with 30% of the respondents preferring to buy new items. This raises two key issues with regard to continued and future public engagement. First, there exists a dichotomy between price and quality. If the quality of items donated to these entities continues to fall, then regardless of the 'low' price, residents may decide not to engage with them and not use the shops. Second, these organisations need cash flow to sustain operating costs and if there is no one to buy and no items to sell, they will struggle to fund their operating costs and remain viable (Dururu, 2014). Thus while the study suggests that there was generally good awareness of the organisations in the three towns and they were fulfilling a need for individuals seeking value, there are a number of issues that need to be addressed to further improve public engagement. --- Conclusions VCS organisations working in the waste management sector have a key role to play in maintaining the environmental and social fabric of communities and the society. While, there was strong public awareness and engagement with the furniture reuse shops across the three towns, there were also a number of challenges identified that impacted upon public engagement. Key amongst these included overcoming perceptions of the quality of items, value and the location/visibility of shops. It is vital that they not only offer value, but also good quality items. A good location to ensure visibility is evidently also crucial. Greater awareness building and perhaps even a'rebranding' exercise to move away from public perceptions of the organisations offering primarily 'poor' quality items, may very well be required. Faced with competition from entities such as eBay and low cost retailers, these are issues that need to be urgently addressed if the public is to be better engaged and ultimately the long-term viability of these organisations assured. Crucially, outside of their role in waste management, these organisations evidently also play a key role in addressing the social needs of society. Indeed, the meta-analysis illustrated that poverty alleviation was a more important issue than waste management. Indeed, glimpses of this are also seen from the survey in that value was a key contributing factor for why individuals engaged with the organisations. In addition, income levels in the three towns were low, thus the shops were a manifestation of the lifestyle choices of residents. It is possible that the timing of the study, during the economic down turn in the UK may have impacted upon perceptions and public engagement. An understanding of whether this is indeed the case would require a follow up study. Given their environmental and social roles, it is vitally important that the sector remains relevant, in tune with the needs of the public and ultimately therefore, resilient.

Within the context of shifts towards the concepts of resource efficiency and circular economy, voluntary and community sector organisations are increasingly being viewed as agents of change in this process. Using questionnaire surveys across three towns in England, namely Northampton, Milton Keynes and Luton, this study aimed to understand public engagement with these organisations. The findings suggest that there were generally high levels of awareness of the organisations and strong engagement with them. Clothes were the items most donated. Key reasons for engagement included the financial value offered and the perception that it helped the environment. However, potential limitations in future public engagement were also determined and recommendations for addressing these suggested.Recent European Union (EU) and UK Government policy and legislation have sought to encourage a more sustainable approach to the management of resources (EC, 2008; Defra, 2011;Williams et al., 2012). The revised EU Waste Framework Directive (rWFD), (EC, 2008), transposed via the Waste (England and Wales) Regulations 2011, identifies waste as a resource giving greater priority to waste prevention and ''preparation for re-use''. Indeed, for some time, Government has sought to implement policies and to encourage enhanced efficiency and recovery measures (Defra, 2005;2007;2011).

Introduction According to the Swedish preschool curriculum, it is an important task of the preschool to promote gender equity (Swedish National Agency for Education 2006). A Swedish Government Official Report (2006) entitled Gender Equity in Preschool indicates, however, that preschools have difficulties achieving equity goals. Instead of working to counter traditional gender patterns, preschools sometimes reinforce them. According to the report, adults working in preschools treat girls and boys in different ways and express gender-specific expectations of children. Furthermore, the children themselves actively reproduce gender stereotypes. One factor the report considers important from a gender perspective is the physical environment of the preschool. The equipment and the materials regulate what is possible-and not possible-to do in different spaces, as they are imbued with messages. These messages silently convey gender-specific codes (Swedish National Agency for Education 2006). In the present paper, the focus is on preschool children's play activities in the special physical context of nature environments. The analysis is based on data from an ethnographic study in an outdoor preschool, where children spend a large part of their days in a forest. The study uses a gender perspective to analyze the play activities that take place in nature environments. --- Literature Review Gendered Play in Preschool A large number of studies have shown that much of children's preschool play is gendered (Browne 2004;Davies 2003;Hellman 2005;Kampmann 2003;Löfdahl 2002;MacNaughton 1999;2006;Nordberg 2005;Thorell 1998;Thorne 1993). Girls and boys in preschools choose different play themes. Boys choose themes concerning the struggle between good and evil, while girls' play themes are often closely tied to everyday experiences (Browne 2004;Davies 2003;Kampmann 2003;Löfdahl 2002). Furthermore, they prefer different toys (Browne 2004;Nelson and Nilsson 2002;MacNaughton 2006) and play in different rooms (Davies 2003;Paley 1984). They also play in different places when they are outdoors in the preschool yard (Davidsson 2006;Davies 2003;Thorne 1993). From a post-structural perspective, children as well as adults actively take part in the production of gender identities in their everyday lives (Blaise 2005;Browne 2004;Davies 2003;MacNaughton 2006). Language and other forms of expression are imbued with gender discourses. These discourses are connected to different subject positions to which people relate when they take part in discursive practices. At the same time, subjectivities are produced. Gender is seen as constructed in local everyday practices, which implies that gender constructions differ from one setting to another. Settings can be more or less gender-stereotyped and allow few or many possibilities for girls and boys to position themselves (Davies 2003). The construction of gender is not only a question of language-it is also a physical process. In the construction of gender, material resources like clothes and artifacts are important. They carry discursive meanings that are used when we position ourselves as women/girls or men/boys (Davies 2003). In a similar way, Butler (1990) argues that gender is performed and that bodies are important in this process. She uses the concept of the heterosexual matrix (Butler 1990) to explain how gender is shaped in relation to normative heterosexuality. The concept of the heterosexual matrix has been used to analyze gender aspects in small children's everyday lives (e.g., Blaise 2005;Boldt 1996). Blaise (2005) describes episodes that reproduce heteronormativity as well as others that contradict the heterosexual matrix, e.g. when children assume roles of the opposite gender. She uses the term "gender bending" to describe those events (see also Boldt 1996). Connell (2005) has introduced the concept of hegemonic masculinity, defined as the form of masculinity that at a given moment is put forward and constructed as superior to femininity and other forms of masculinity. Other forms of masculinity and femininity are seen as constructed in relation to hegemonic masculinity. The concept has been used to analyze children's play in early childhood research. Blaise considers that "hegemonic masculinity can be thought of as the most desirable and powerful way to be a boy" (2005,21), and her analyses show that girls, boys and adults (including herself) act in ways that reinforce hegemonic masculinity. Early childhood teachers who offer children a non-sexist curriculum often find that their strategies are ineffective. The children stick to stereotyped play even though adults try to create equity (Davies 2003;MacNaughton 2006). Preschool researchers have reported that it is difficult and sometimes painful for children to display behaviors associated with the opposite sex (Davies 2003;MacNaughton 1999;Walkerdine 1990). This can be seen as a result of the hegemonic matrix (Butler 1990) that makes such behavior unintelligible. Davies (2003) states that children born in our society become aware quite early in life that humanity is divided into two kinds of people: men and women. To be comprehended as acceptable members of society, children have to choose the "right" gender and behave in a way considered suitable for that gender. Boys particularly avoid what is considered feminine-for example, girls' toys, actions and places in preschoolwhile girls have more freedom to choose masculine-coded positions and activities (Browne 2004;Jordan 1995;Hellman 2005;Nordberg 2005;<unk>ngg<unk>rd 2005). Not all play activities in preschools are gendered. For example, many toys in Swedish preschools are gender-neutral (Nelson and Svensson 2005). In a study of children's play activities, Löfdahl (2002) reports that both girls and boys participated in 34 percent of her play observations. One problem highlighted by Thorne (1993) is that researchers in educational settings tend to notice genderstereotyped games1 and be blind to activities that deviate from typical gender patterns, and thus fail to notice the variation within the groups "girls" and "boys." Gender is presented as two categories that are uniform and opposite, instead of situated, temporary and flexible discursive constellations. Thus, research itself serves to confirm gender-stereotyped expectations. Interviews with children show that they often have clear opinions about what is appropriate for girls and boys, respectively, to play (Davies 2003;Browne 2004;MacNaughton 2006). Their verbal accounts of play activities in interviews are in fact often more gender stereotyped than their performed play activities (Browne 2004;Davies 2003;Hellman 2005;Nordberg 2005). This circumstance suggests that interviews are insufficient if the aim is to acquire knowledge about gender patterns in children's play. Evaldsson (2000) underlines the importance of conducting ethnographic studies in which girls' and boys' play activities are observed in situ. Such studies enable us to acquire more complex and varied knowledge and to challenge notions of static gender dichotomies. --- Play in Nature Environments Many studies of children's play in nature environments address the values and benefits of such play (Lester and Maudsley 2006). One of the areas that has been studied is physical motor development and associated health benefits as a result of play in natural spaces (Fj<unk>rtoft 2000;2004). Also, mental health aspects of play in green spaces have been in focus (Kellert 2002;Taylor, Kuo and Sullivan 2001). Furthermore, the possibilities for active exploration and experimentation in natural spaces, and thus the promotion of cognitive development, have been investigated (Tranter and Mallone 2004). Imagination and creativity are other valuable abilities that researchers have studied in relation to play in nature environments (Grahn et al. 1997;M<unk>rtensson 2004). Play in natural spaces is thought to engage children's senses and emotions, which makes it motivating (M<unk>rtensson 2004;Sebba 1991) and which provides powerful memories (Chawla 2002). In some studies the character of the physical environment is highlighted (Grahn et al. 1997;Fj<unk>rtoft 2000;2004;M<unk>rtensson 2004). Features in the landscape that stand out as stimulating for children's play are green structures (like trees and bushes), loose objects and a diversity of topography (Fj<unk>rtoft 2000;2004). The concept of "affordances" (Gibson 1979;Heft 1988) is used to discuss the qualities of natural spaces (Fj<unk>rtoft 2000;2004;Kernan 2010;Kyttä 2002;<unk>ngg<unk>rd 2009). Affordances can be seen as the range of functions provided by environmental objects; individuals apprehend those functions in relation to themselves (Gibson 1979;Gibson and Pick 2000;Reed 1996). Heft (1988) has constructed a taxonomy of affordances in outdoor environments. For example, flat surfaces afford running, climbable features like trees afford mastery and looking out from, shelters afford privacy and moldable materials afford construction. Children's play in natural spaces has been categorized as functional play (physical play), construction play (for example building huts) and symbol or fantasy play 2 (Fj<unk>rtoft 2000;2004;<unk>rleman-Hagser 2006). Fj<unk>rtoft (2000;2004) and M<unk>rtensson (2004) conclude that physical play is predominant in their observations, which can be explained as a consequence of the affordances of the natural landscape (Fj<unk>rtoft 2000;2004). M<unk>rtensson (2004) considers that children who play in natural spaces are influenced by the physical aspects of the environment to a large extent since natural environments are flexible and changing. The possibility, 2 In the present paper symbolic, fantasy and pretend play are used interchangeably. to manipulate natural objects as well as changes related to weather and seasons catch children's attention. M<unk>rtensson (2004) describes children's play in natural spaces as a relation between three factors: the physical environment, the social interaction between the children, and the play theme. Even if children are involved in a symbol play their attention often turns towards the physical environment. Several researchers have reported that symbol or fantasy play is common in natural spaces (Grahn et al. 1997;Fj<unk>rtoft 2000;2004;M<unk>rtensson 2004;<unk>rleman-Hagser 2006;Waller 2010) but there is a lack of studies analyzing this kind of play in detail. In an ethnographic study in an outdoor preschool, children's play activities in a forest were observed and videotaped (<unk>ngg<unk>rd 2009). The analysis showed that the physical environment as well as cultural experiences was of importance to the play. The nature environment invited children to play special kinds of games like animal play, and inspired play themes with elements of excitement and adventure. Cultural influences on the play were also obvious; the nature environment was used to symbolize artifacts and places that the children knew from experiences outside the forest. There is very little research on how gender is constructed when children play in nature environments. Fj<unk>rtoft (2000) and M<unk>rtensson (2004) mention that they have observed gender differences, but neither of them has studied gender aspects in depth. In a multi-method study, Waller (2010) observed 3-and 4-year-old children who visited a country park every week. Girls and boys engaged mainly in similar activities, e.g. climbing, running on paths, splashing in mud and water and playing fantasy play. In one group out of six, however, the children played more often in gender-based subgroups and to some extent chose different activities. In an interview study, 106 children between 3 and 7 years of age were asked about their play activities in the forest (<unk>rleman-Hagsér 2006). On a superficial level, no gender differences were visible, but when play themes and positions in the play activities were studied in more detail, gender patterns emerged. --- Children's Play Activities Include Cultural and Natural Resources The paragraphs above presented two different theoretical perspectives on children's play: the post-structural perspective highlights gender as socially constructed (Davies 2003), while ecological theory prioritizes children's play in natural spaces (Gibson 1979;Gibson and Pick 2000;Reed 1996). On a superficial level, the theories seem to be incompatible. However, I argue that they are complementary and that both are needed. The theories have some important similarities: they are both non-determinist and they both perceive humans as agents. Post-structural theory uses the concept of positioning to analyze how agency is carried out in everyday life. In ecological theory, the concept of affordances implies that individuals have the possibility to act-not that their actions are determined (Reed 1996). Within gender studies there has been a "turn to the material" (Alaimo and Hekman 2008). This shift does not mean that insights about gender construction are abandoned; it means only that pre-discursive factors are noticed as well (Lykke 2009). Scholars with scientific backgrounds like Haraway (1991) and Barad (2007) argue that the importance of the material world (including the body) has been underestimated and under-researched. Barad (2007) claims that the material world possesses agency. She uses the concept of "intra-activity" (2007,33) to discuss the interaction between organisms, the material world and discourses. From this perspective, nature, environment and matter are unpredictable agents. In this paper I analyze the intra-action between playing children, the nature environment and discursive factors. The two theoretical perspectives differ in contribution to knowledge and complement each other as tools to understand gender aspects of children's play in natural environments. Post-structural theory provides tools for understanding how children's play activities are imbued with cultural ideas, although the theory lacks tools for understanding how children interact with the physical world. Ecological theory provides tools that are useful for the understanding of children's use of the material world, but its contribution to knowledge about how cultural factors influence children's play is weak. As humans we are physical creatures who relate to our physical context. In particular, small children experience the world with their perceptions and locomotions (Gibson and Pick 2000;Piaget 1968). At the same time, children are social and cultural beings from their birth. Corsaro (1997) describes how children appropriate cultural resources, first in their families and later on in peer groups. As mentioned above, children's outdoor play has been categorized as functional play, constructive play and symbolic play. Piaget (1962) developed a similar classification in which the first two types of games are practice games and symbolic games. A practice game is essentially sensory-motor. It contains actions carried out for pleasure, e.g. jumping over a stream just for fun, not of necessity. Symbolic play implies representations of an absent object and make-believe. Symbol play often includes sensory-motor elements. In practice play, the importance of the physical world is obvious; this play form implies that children experience and manipulate the world in various ways. The material world performs agency when it catches children's attention, makes them surprised, etc. In many of those play activities children's relations to nature are more or less pre-discursive. In symbolic play (or pretend play), physical objects are used to represent other things. The surrounding physical environment is assimilated to fit into the child's symbolic world (Piaget 1962). According to Garvey (1990, 79), the principal resources of pretend play are "features of the social world, and socially learned and transmitted expectations of the way objects, actions and people are related." Play themes are connected to guidelines or implicit rules for the storyline and for the actions of the characters (Garvey 1990). Expressed in post-structuralist terms, play themes can be interpreted as belonging to different discursive play practices with agreements and rules for how the play should be carried out, which storylines they include and which play positions can occur. In relation to symbol play, the concept of affordances shifts slightly: because of their varying characters, natural spaces seem to afford special functions that can be used in different play themes. Further, in symbol play the environment serves as an agent since it invites certain discursive play practices. --- Aims and Research Questions The aim of this paper is to analyze play activities that take place in nature environments from a gender pespective. The research questions that have directed the paper are the following: Which play practices are typical for the studied preschool when the children play in natural spaces on their own? Which affordances in the nature environment are used in these play practices? Which gender positions are available in different forms of play? --- Methods --- Data This paper is part of a larger study with several research questions about how staff and children in an outdoor preschool make use of nature and how nature and its benefits for children are conceived by parents and staff. 3 Using an ethnographic approach, for the present study I carried out participant observations one day a week, on average, from August 2006 to June 2007. The data consist of field notes, video observations (38 hours), informal conversations with children, semistructured interviews with staff members (10 hours) and parents (12 hours), photographs and local documents. In the present paper, mainly field notes, video observations from play situations in nature environments (10 hours) and informal conversations with children are used as the study material, as the aim of the article is to analyze children's play activities. Interviews with adults and other data sources are used only to obtain contextual information and are not accounted for in detail. --- The Preschool The studied preschool is one of around 185 preschools that are conducted in cooperation with Friluftsfrämjandet, an important national organization for outdoor life in Sweden. Preschools such as this have existed since the mid-1980s. 4 These preschools carry out outdoor education, and a large part of the day is spent outdoors. The aim is to give children knowledge about nature and, at the same time, to make them aware of environmental issues and to help them achieve a feeling for nature. This knowledge is mediated through play and pedagogy characterized by exploration (Rantatalo 2000). The preschool, here called the Rainbow, was deliberately chosen from a list of preschools with a similar pedagogy and it was the first preschool that was contacted. All children in the preschool, a total of 36 children, 18 girls and 18 boys, participated in the investigation. 5 The children were between 11<unk>2 and 6 years old. The children were divided into two groups, one for children between 3 and 6 years and the other for children between 1 and 3 years. The preschool was located in an ordinary residential building. The premises were adapted to preschool activities, and the school was as big and well equipped as a "regular" preschool. The preschool was located about 50 meters from the edge of the forest. The preschool was situated in the outskirts of a larger Swedish city in an area with mixed housing types. Most of the children came from middle-class families. Many of the parents were committed to environmental issues. In interviews, a few parents with daughters mentioned that the outdoor profile of the school could promote gender equity, for example by providing girls good opportunities to develop strength and motor skills. The staff in the studied preschool had previously been involved in a gender project along with other preschools in the area. After that project, the staff felt that they had become more reflective about how they treated girls and boys. In the present study, however, it is not the staff's work with gender issues that is in focus, but gender aspects of the children's play activities. --- Ethical Considerations and the Researcher's Role All the parents received written and oral information about the project and were asked to sign consent forms. All children were informed about the project. 6 One ethical dilemma associated with using video observations is that children's integrity may be threatened. At the beginning of my fieldwork, I explained to the children that they could tell me any time they did not want to be observed. On a few occasions one boy told me that he did not want to be videotaped. I also tried to be sensitive to the children's body language to decide whether they felt embarrassed about being observed. I participated in the preschool as a researcher. I explained to the children that I needed their support to gain knowledge about their play activities (cf. Mayall 2000). I tried to avoid being seen as a teacher by children, because it could have reduced my chances to observe play activities that the children felt were less favored by the staff. By posing questions and paying attention to the children's play activities I participated in the production of data. My presence probably had an impact in that the children sometimes tried to catch my attention. On other occasions, they seemed to forget they were being observed through the videocamera, and I do not think their ways of playing were influenced. --- Analysis The children's play activities were documented in different ways. The first weeks in the preschool I observed and wrote field notes. After two weeks I introduced the video camera. The play observations were made in various ways. Sometimes I moved around and registered all play activities that were going on, and on other occasions I followed one play episode from the moment I recognized it until it dissolved (cf. Corsaro 1985). The field notes were typed out immediately after the field work and video observations were transcribed roughly. These transcriptions were used in different ways. In ethnographic research, the analysis process starts from the first day of the investigation and has impact on the choices made for data gathering (Hammersley and Atkinson 1995). During the ongoing field work I used the transcriptions to check that different kinds of play activities in a variety of spaces were observed. I made decisions on how to get a representative sample of play observations. Furthermore, I based my overall analysis of the children's play activities on those transcriptions. All episodes that were about the children's free play in nature environments were marked and coded in relation to the following questions: (1) Which play forms are observed? I used Piaget's (1962) categories of practice game and symbol game. (2) Which play themes and play roles (Garvey 1990) are observed? (3) Which meaning does the play activity seem to have to the children themselves (Corsaro 1997)? ( 4) How is the nature environment, including nature materials, used as a resource in the play activities? The last questions were guided by the concept of affordances (Gibson 1979;Heft 1988). In a second reading, I analyzed the episodes from a gender perspective. (5) Which activities included both boys and girls and which were single-sex activities? (6) Which gender positions (Davies 2003) were available in different forms of play? In the interpretation of the data, all the observations were used but some episodes have been transcribed and analyzed in more detail. 7 The examples presented below represent typical play activities during the observation period. My interpretations were cross-checked in workshops and seminars where I shared the material with members of the project group and other research colleagues. --- Results The Base Places Three or four days a week the groups headed for the forest. Each of the two groups had its own "base place" near the preschool. The base places were carefully chosen to provide environments that were considered appropriately challenging in relation to the children's ages. The 3-to 6-year-olds' place covered approximately 2000 square meters. It contained a hill, trees, a ditch that sometimes was filled with water, and areas where children could play out of sight of adults and other children. The 1-to 3-year-olds' base place was about half as large as the older children's. It consisted of an open plateau with minor differences in ground level, surrounded by trees and bushes and a marsh. There were also stones and two big pits that sometimes were filled with water. --- Four Play Themes The analysis process generated four play themes: war and superhero play, family play, animal play and physical play. The play themes were empirically constructed in relation to the meaning they seemed to have for the playing children, the actions that were carried out, the storylines that they included and the way nature resources were used. They are partly overlapping, e.g., all play themes include physical activity, animal play can include family members, etc. All the themes included both practice play and symbol play but they differ in the extent to which a storyline is central. In the last play theme, physical play, a certain kind of activity (e.g., to jump or to climb trees) is of importance rather than a storyline. Each of the themes is described and analyzed below. I use the concept of affordances (Gibson 1979;Reed 1996) to display how natural resources are used in the special play theme. Each play theme is analyzed from the perspective of the possibilities it provides for girls and boys, respectively, to participate and which gender positions (Davies 2003) they can take within the theme. --- War and Superhero Play The hero theme is common in boys' games (Carlsson-Paige and Levin 1987;Davies 2003;Jordan 1995;Levin 2003;Marsh 2000;Paley 1984). In superhero play children use media figures and the storylines connected to them (Dyson 1997;Jordan 1995;Marsh 2000). Over the years a range of characters like Superman, Batman and X-Men have been used in children's play. Marsh (2000) points out that the need for superheroes is not a new thing for the human race. Superheroes may respond to a need in the human psyche for control over nature and evil (Marsh 2000). It also seems that children need to explore the world in terms of opposed extremes like good/evil or male/female. Superhero stories provide good opportunities for such exploration (Marsh 2000). The superhero theme particularly attracts boys. Jordan (1995) discusses the warrior discourse, where masculinity is described in terms of "the warrior, the knight errant, the superhero" (Jordan 1995, 76). This discourse, according to Jordan, has power over boys and is manifested in the stories they tell, pictures they paint and play they engage in. In the superhero games, there is no place for girls or female positions. Boys' choice to use exclusively male positions and to exclude girls can be interpreted as a way to create a distance to girls and everything that is female, thereby constructing masculinity by marking distance (Connell 2005;Hirdmann 2003;Jordan 1995). In superhero play only one version of masculinity is allowed, the strong, aggressive and powerful personhood (Marsh 2000). This masculinity corresponds to the concept of hegemonic masculinity (Connell 2005). In my observations, five of the boys in the 3-to 6-year-old group often chose to play superhero themes. Girls did not take part in these play activities. One of the boys who participated in the superhero play did not want me to videotape their games so the observations were made from a distance. These boys moved a great deal over the area pretending they were shooting and chasing. Their play was lively and noisy. During the observation period, these boys were very fond of superhero figures from LEGO called Bionicles. 8 These figures and other media figures inspired their play. In one play episode one of the boys pretended to throw bombs on a bridge, a plank where a girl and a boy balanced, unaware of the bombs. In another episode they pretended to be dinosaurs that threw fire balls and opened the ground from which lava flowed. In these activities the affordances of the nature spaces were important. The wild character of the outdoor environment was suitable for war-and superhero play. The 3-to 6-year olds' base place afforded running over vast surfaces in varied terrain, and a hill that served as a vantage point over "enemies." Trees were used in many ways. In one episode a tree was used as a boat with an underwater gun, claws and knives that were used to fight sharks. The boat then was transformed to a house and after that to a spaceship that took off into space. The ground invited the boys to fantasize about underground caves and lava flows. Thickets of bushes afforded places to hide. Loose parts were also important. Logs were used to make bridges over dangerous gaps and sticks and roots were used as weapons like bows, light sabers, machine guns and pistols. The example of superhero play below is from the 1-to 3-year-old group where the three oldest boys played superhero themes during the spring. In the following episode they were playing in a dried-up marsh. A girl, Jenny, (3:1)9 who wanted to join in was refused entry. Mikael (3:8), Fredrik (3:1) andNiclas (3:2 This episode included elements that can be associated with a fighting theme, pirates and guns. Pirates can also be interpreted as heroes, and the same is true of "Lucky," which may refer to Lucky Luke, a lonely cowboy cartoon character who travels around in the Wild West. One trait of this character is that he is fast with his guns, something that helps him get risky commissions (Morris 2004). When Jenny asked if she could join in, she was refused. My interpretation is that Fredrik did not think girls could take part in this kind of play because it was a superhero play. His arguments to deny Jenny entry were related to the superhero theme; first he said that she could not join in "because it is a Lucky's play." He also said that '"we are pirates and you are no pirate." --- War and Superhero Play Example: Pirates in the Marsh The superhero play carried out by the boys in the 3-to 6-year-olds group as well as in the example above followed the script of superhero play described by other researchers (Jordan 1995;Paley 1984). Superheroes were included. The stories and characters were fetched from media and the storylines included dangers, fights and weapons. No girl participated in the games and when a girl (Jenny) wanted to join in she was refused, something that can be interpreted as the boys' effort to create a distance from girls and femininity, constructing masculinity by marking distance (Connell 2005;Hirdmann 2003;Jordan 1995). As theorized, the superhero theme did only provide one kind of masculinity, the strong and powerful character corresponding to hegemonic masculinity (Connell 2005). --- Family Play Family play is a well-known theme among preschool children. This theme includes reproductive enactments inspired by the home sphere like cooking or taking care of babies. The roles typically come in pairs like mommy and daddy or mommy and baby (Garvey 1990). In homes, women typically have power in certain areas that concern housekeeping and children. By acting as mothers in games, girls can exercise power over other children (Walkerdine 1990). On the whole it seems that girls have the power to rule in these kinds of play themes (Löfdahl 2002). Boys who participate in family role play assume subordinate roles (Davies 2005). In preschools family play often is located in the "doll corner," equipped with dolls and other toys connected to housework. The doll corner is generally a place where girls reside (Davies 2003;Paley 1984). Many boys avoid objects and places connected to femininity including the doll corner (Blaise 2005;Davies 2003). In both age groups some of the girls chose to play family themes frequently. In those play episodes they pretended to cook, sleep, go to the supermarket, go and see the neighbors and so on. In family play, nature resources were used to symbolize houses. The space between some bushes, stones or trees were used as natural huts. Branches and stones were used to mark walls, furniture, etc. The small children's "home" was located at a stump that was used to symbolize a stove. Those places were frequently used as homes but the play was also significantly nomadic. The children moved around the area while playing, picking flowers, collecting materials or pretending to go shopping. They used nature materials in various ways. Trees with raindrops were shaken and used to take a shower. Branches were used as clothes hangers where the children hung up their caps before going to bed. Sticks were gathered in piles and used as pretend fires. Sticks were also used as all kinds of household utensils. Moss was used as beds, to sleep on. Leaves, cones, berries and needles were pretend food. A bent pine was used as a car, motorcycle or bus when the children pretended to go to Ikea or McDonald's. --- Figure 3. Girls playing house Figure 4. The motorcycle-pine Sometimes only girls played together and sometimes one or two boys participated. Among the family theme episodes, several practices were traditional and expected in the sense that there were family members, mostly a mother and some children, and that the play actions concerned home and family life, activities such as cooking, eating, sleeping and shopping. However, the observed family play episodes also contain non-traditional elements, as illustrated in the following episode in the 3-to 6-year-old group. --- Family Play Example: Grilling Fish under the Tree Two girls, Ester (4:2) and Filippa (4:2), and one boy, Jonas (4:2), are sitting under a tree. They have been playing by the ditch, fishing up leaves from it for a long while. They pretend that they have a fire where they are grilling fishes, which are represented by the leaves. Ester: Now we stop fishing and sit in front of the fire. Jonas: (with play voice) Ok, now we are going to eat all of it. Ester: Now the food is ready... then I feed you. Jonas: No I don't need that. Filippa: Wait mother, this can be salad (she picks up a green leaf). Jonas: (takes a green leaf and pretends to eat) Finished! Ester: Now we have eaten all of it! Ester was the leader in this episode. She suggested that they should stop fishing and sit in front of the fire, and she decided that the food was ready. She took the position as mother when she initiated the meal and suggested that she would feed Jonas. As mentioned above the mother role is connected to power (Walkerdine 1990). However, it did not seem to be crucial to Ester's influence that she had the mother position. In another episode, she had the father position, and that time as well she was the one who stayed in the home and decided things. In that episode she stayed in the "house," a hut built from branches, pretending to carve, while the "children" were "outdoors" pretending to ride bicycles. Still, it is probably important that she is a girl since girls often rule family play (Löfdahl 2002). The family play example above was traditional in terms of its care theme (cooking and eating) and the play positions that were available (mother and children). In other ways, however, it was non-traditional in senses that can be related to the nature environment and the pedagogical practice in which the children were involved: the food that was cooked consisted of "fishes" that had been caught in the creek and cooked over an open fire. The play episode was enacted in a pretend world that transcended the home environment with which feminine activities are associated. In Sweden fishing is an activity performed by men more often than by women (Statistics Sweden 2004). The fact that the game was played outdoors, in nature environments (and not in a doll corner), and that activities like fishing were included enabled Jonas to participate in this activity without appearing to be a boy who took part in typical girls' play. Similar factors seem to have contributed to making it possible for Ester to take the father's role in the other episode mentioned above. --- Animal Play Preschool children often engage in symbolic play where they pretend to be animals. Corsaro (1985;1997) and Kalliala (2002) noticed a decrease in traditional family role play and an increase in role play involving animal families starting in the mid-1990s. When assuming animal family roles children seem to have more freedom than when they enact traditional family roles. They do not have to enact

This paper concerns gender aspects of children's play in nature environments. In an ethnographic study, children between 1½ and 6 years in a Swedish outdoor preschool were videotaped during time for free play. Four different play themes were particularly popular among the children: war and superhero play, family play, animal play and physical play. Each one of these themes has been analyzed from two perspectives: how nature resources are used and which gender positions they provide. Within the themes, nature's affordances are used in various ways. Similarly, a range of gender positions is evident across the themes. The superhero theme includes exclusively gender-stereotyped masculine play positions, while the family theme includes both traditional gender positions and possibilities for transgressions. Further, animal play as well as physical play provides non-gendered play positions. Natural environments are not gender-coded in themselves and they invite certain play activities where girls and boys play together. Thus, nature spaces seem to offer good opportunities to promote gender equity.

ical practice in which the children were involved: the food that was cooked consisted of "fishes" that had been caught in the creek and cooked over an open fire. The play episode was enacted in a pretend world that transcended the home environment with which feminine activities are associated. In Sweden fishing is an activity performed by men more often than by women (Statistics Sweden 2004). The fact that the game was played outdoors, in nature environments (and not in a doll corner), and that activities like fishing were included enabled Jonas to participate in this activity without appearing to be a boy who took part in typical girls' play. Similar factors seem to have contributed to making it possible for Ester to take the father's role in the other episode mentioned above. --- Animal Play Preschool children often engage in symbolic play where they pretend to be animals. Corsaro (1985;1997) and Kalliala (2002) noticed a decrease in traditional family role play and an increase in role play involving animal families starting in the mid-1990s. When assuming animal family roles children seem to have more freedom than when they enact traditional family roles. They do not have to enact a set of scripts connected to traditional family play; instead they are allowed to move in directions in line with the peer culture in the group (Corsaro and Evaldsson 1998;Kane 1996). Both Corsaro (1985) and Kane (1996) observed that children pretending to be baby animals were more free to move and were more aggressive than pretend-babies in human families (Corsaro 1985;Evaldsson and Corsaro 1998;Kane 1996). Myers (1998) is critical of the tendency to reduce the function of play where children pretend to be animals to represent human roles. Instead he wants to study such play as a way to understand what animals mean to children. He points out that children who pretend to be animals do it on a preverbal level-they imitate animals postures, gestures and noises and they seldom use verbal language. Animal roles give children possibilities to resist heteronormative positions. Blaise (2005) recounts an episode where a girl, Madison, is gender bending, e.g. performs masculinity, when she pretends to be a male dog. In the play episode she saves a family member from a fire. In the role of (male) dog, Madison has the power of being a rescuer without having to position herself as a hegemonic male. She can assume an alternative masculine position that does not include marginalizing others. As a dog she can also have warm and friendly relations with the other family members. In the studied preschool, play episodes that included animals were common. The animals were both "ordinary" animals, such as dogs, cats, birds, spiders and snails, and exotic or dangerous animals, like sharks, crocodiles, wolves, tigers and snakes. There were also media figures like Bambi and Thumper from Disneyworld. The animals were represented in various ways: Sometimes real animals (mostly snails) were used. Animals were also represented by nature material, such as stones or sticks. At other occasions they were "invisible" and represented merely by gestures and talk. Finally, the children often pretended that they were animals such as cats and dogs themselves. In some episodes the children pretended to be zookeepers. When dead animals were found they arranged funerals. The children mentioned that some animals were dangerous, e.g. a tiger and a watchdog-but they were never dangerous to the children: they were their friends. Natural spaces include many affordances for animal play. Special features of the landscape that reminded children of animals associated with natural habitats were used as resources. A dead tree, for example, was considered to be the place where the vultures lived and a marsh was the place for the crocodiles. Loose parts were used to build houses for animals. In one episode a girl and a boy pretended to take care of an invisible injured baby bird and build a nest for it. The water-filled ditch afforded fishing and pretending that there were a seal and a duckling in it. As mentioned, living animals like snails were used as toys, representing family members. Holes in the ground and in trees were used as pretend nests for various animals. Traces of dog paws in the snow led to a play episode where some children tracked elks and lizards. In play activities where children pretended to be animals themselves, they used the terrain to act like wild animals-e.g., to run on paths, hide in bushes and climb trees. In the following sequence where the children pretended to be leopards, both girls and boys participated. Hanna: I want to be a kid too,0 then one of you has to be a mommy (points at Frej, Linus and Kristoffer). Stina: But wait-Frej: (overlapping Stina) I want to be mommy. (Stina looks surprised but pleased. Linus and Kristoffer laugh loudly, Frej smiles towards them.) Linus: And we are two daddies, there are two daddies (laughs). (Several children start to growl.) Hanna: Hurry, a monster! (All the children run away down the hill.) Here Linus, Frej and Kristoffer-the boys who in most of my observations played superhero themes-asked for permission to join a game in which two girls were involved. Hanna was leading; she was the one who gave Linus, Kristoffer and Frej permission to join the game, and she assigned the play positions. Both Linus and Kristoffer chose to be daddies. The girls and Felix chose gender-neutral roles; they wanted to be kids. Although the girls were older than the boys, they did not choose adult positions. One interpretation of this choice is that a kid position gives more freedom to be playful and mischievous than an adult position does (Corsaro 1985;Evaldsson and Corsaro 1998). When Stina, Hanna and Felix had chosen their roles as kids, Hanna said that one of the three boys who wanted to join the play had to be mommy. Frej, who was the last one to choose a role in the game, said that he wanted to be a mommy and in that way was gender bending. In this case it may not have been the wish to play a female role that was his motive, rather a wish to compromise and thereby solve a problem, that a mommy was needed in the game. Directly after Frej accepted being mommy the negotiation about roles was over and the play started-the children went into their roles, growling and running down the hill. Besides the kid position, there were two other gender-neutral positions in the play: "adult" and "monster." None of the children chose these positions. The episode was in some respects reminiscent of traditional family play-there were daddies, a mother and kids. The children seemed to have the idea that there ought to be a daddy, a mommy and kids in the play. In other respects, however, it was different from typical family play. The storyline was not about care and reproduction, but about excitement: being very quick animals that were chased by a monster. Furthermore, there were two daddies, not one. Thus, the rule system regulating traditional family play was in that way transcended. These aspects together made the game more interesting to those boys, who according to my observations generally did not take part in family play, play with girls or assume female roles. These aspects also made it possible for Frej to accept the mother role. --- Physical Play A large part of children's play is physical or related to sensory-motor activity. According to Piaget (1962) practice play is the first and most primordial form of play, also played by animal kids. As a part of practice play children spend a lot of time exploring and manipulating objects in the physical world around them, both toys and other objects. In doing so, they discover the objects' affordances, or how they can be used (Gibson and Pick 2000). As mentioned above, physical play seems to be prevalent when children play in natural environments (Fj<unk>rtoft 2000;2004;M<unk>rtensson 2004;Waller 2010;<unk>rleman-Hagsér 2006), something that agrees well with my observations. The theme "physical play" includes activities where the play forms Piaget (1962) classified as practice games and symbolic games are mixed. The sensory-motor aspect is always central, but there are often symbolic elements involved as well. The theme is different from the other three in the sense that a storyline is not central to the children's play activity. Many of the play activities observed in the forest were organized around some kind of physical activity (such as climbing trees), or material exploration (such as peeling twigs). Some of these activities included tests of strength, e.g., carrying heavy things. In such activities age seemed to be more important than gender. In one episode the three oldest children in the group, two girls (Stina 5:8 and Hanna 5:5) and one boy (Daniel 5:1), were carrying stones. They all agreed that Stina should carry the biggest stone since she was oldest. On another occasion, on a cold winter day when there was ice on the ditch, Hanna, who was a bold girl, jumped until the ice was broken so that her shoes became wet, and she was reprimanded by a teacher. --- Figure 7. Girl and boy climbing a tree The nature environment included many affordances for physical play. The children could run, jump, roll, crawl and dig. Puddles afforded play with water and the soil afforded digging and making goo. In autumn, fallen leaves were gathered in piles. In winter, snow was used in different ways, eg. to build snowmen, snow caves or just to scoop. The following episode has elements of family play, but the central meaning to the children seemed to be the joint action of jumping into a pit. The episode illustrates that girls and boys can play together in this kind of play activity. Here, the boys who were playing pirates in the superhero play example above left the marsh and the pirate play and moved to another place where they pretended to jump into a bathtub. Jenny, the girl who was refused participation in the pirate play, came up to the boys and started jumping without asking for permission. Someone, probably Fredrik or Mikael, said "this is ours," perhaps in order to exclude Jenny. In the next turn, Niclas said that it is "everybody's" and he thereby included Jenny. Niclas even invited Jenny explicitly when he said that it was her turn to jump, something that indicates that he considered this game suitable for both girls and boys. Jenny could join in this game. One explanation for this is that this activity had elements of family play, there was a bathtub, something that belongs to the home area, and it included father and mother positions. The character of family play, contrary to the superhero theme, is considered appropriate for girls engagement. Another and non-contradictory interpretation is that she could join the play because it was about physical activity. As mentioned above, the physical activity of jumping seemed to be the most important element, the meaning of the play. Even if the play had a family theme, the play actions were not those typically enacted in family play such as cooking, eating and sleeping, and the play roles did not seem to have much importance for the play. The "mothers" and the "father" all performed the same thing (to jump) and Jenny could participate without playing a role. The physical character of the game also explains why two boys could choose positions that contradicted heteronormativity when they pretended to be mothers. Niclas, who initiated the play and could have chosen any position, chose to be the mommy. Mikael chose to be a father but Fredrik, the third boy, also chose to be a mother and not a second father. In this episode, hegemonic masculinity did not seem to have an impact. Here, it was not important to separate the genders and produce difference (Hirdmann 2003;Jordan 1995). Gender borders were transcended, and the boys tried out female positions. In addition to the physical character of the play, the boys' ages may have contributed to this non-gender stereotype choice. They were all under four years of age, and can be considered to be less influenced by ideas about what constitutes appropriate masculine play actions than are somewhat older boys (cf. Davies 2003). --- Concluding Discussion Above, I have presented four play themes that were typical for the studied preschool. I have analyzed those play themes in relation to how nature resources are used and to the play positions they offer to girls and boys. In the play activities the natural environments as well as the children's cultural experiences are used as resources. In accordance with Barad's thoughts (2007), play activities can be understood as intra-action between the playing children, the nature environment and discursive factors. In the four themes those agents differ in influence, which is discussed below. One play theme more than the others encouraged gender-stereotyped positions, namely, the war and superhero theme, which represents a typical way of constructing masculinity among boys (Jordan 1995). In these activities, hegemonic masculinity (Connell 2005) was practiced and there was no room for girls or feminine positions. Here, the superhero discourse was strong. The superhero play in the forest was similar to superhero play in other settings (Blaise 2005;Davies 2003;Paley 1984). Media figures like Bionicles were included in special stories that in analogy with toys affected the children's play and restricted their freedom to control the content of the games (Levin 2003). The nature environment fitted well into this play theme but it did not change the play scripts; rather it was assimilated into the superhero discourse. The family play theme on the one hand offered opportunities to produce femininity and to reproduce heteronormativity, as the family play discourse regulated actions and roles. On the other hand, the family play practices in the studied preschool allowed transgression of gender borders and gave both girls and boys opportunities to test positions and actions that are connected to the opposite gender. The impact of outdoor life on family play opened the field for boys to join in. Pretending to fish and to cook over an open fire are actions that are suitable in family play, and at the same time they are acceptable to boys because they are connected to masculinity or at least they are not feminine-coded. In family play, the nature environment represented an agent with affordances that the children used to perform nonstereotyped play actions. Furthermore, the fact that there were no outdoor places designed for family play and no dolls or other toys connected to femininity made it easier for boys to participate without taking the risk of being teased for playing in girls' places or with girls' things. Animal play provided good possibilities for girls and boys to play together. Both girls and boys are interested in animals, and animal themes do not seem to be connected to any particular gender. In animal play, there is freedom to be dangerous and wild, but also to be kind, cute and funny. Taking care of animals is less connected to femininity than is taking care of babies. Even in animal play where the children take family member positions, there is more freedom to make the play exciting and adventurous than in traditional family play, where reproduction of home life has a predominant place. In the animal play scenario excerpted above, it did not seem that the children felt obliged to follow scripts connected to family play roles. Both girls and boys had freedom to choose roles and actions that they found interesting and attractive. In this play theme, discourse had little influence; instead the children were free to change the scripts. Nature had agency since it inspired the children to engage in animal play. The physical play theme also provided good opportunities for girls and boys to play together. Nature elements invited the children to get involved in sensory-motor play. The children balanced, climbed trees, jumped over ditches, slid, and so on (cf. Fj<unk>rtoft 2000Fj<unk>rtoft, 2004;;M<unk>rtensson 2004;Waller 2010;<unk>rleman-Hagsér 2006). In these activities, gender did not seem to be of importance. According to MacNaughton (2006) and <unk>rleman-Hagsér (2006), children themselves consider such activities as sliding and climbing trees to be appropriate for both girls and boys. In motor activities the children's interaction with the physical environment became more important, while play actions and play roles were less important. The nature environment was to a large extent an agent affording children to explore different functions, using their bodies in various ways. Discursive aspects seemed to be absent when the children were absorbed by the physical environment (cf. M<unk>rtensson 2004). The examples above indicate that the character of the nature environment can make it easier for girls and boys to play together and to break free from traditional gender patterns in many (but not all) play practices. The physical environment contributes to this in two important ways. First, it works as a powerful agent (Barad 2007) when children play, through the affordances (Gibson 1979) it offers. It invites children to sensory-motor activities and to explore and manipulate the environment. Secondly, it is relatively "neutral" in relation to (gender) discourses. Nature material and places can indeed be loaded with cultural meanings, among them gender-related ones, something that is illustrated in some of the play episodes above, but they are not gender-coded in the same way as places and artifacts created by human beings. The physical environment in a preschool, including toys and other artifacts, mediates cultural meanings. These are often gender coded and stimulate particular gendered actions (Nelson and Nilsson 2002;Nelson and Svensson 2005;Nordin-Hultman 2004;Paley 1984;Seiter 1993). That is particularly the case for toys that represent something else such as cars or utensils, while toys with their own function, such as balls, are more gender-neutral (Nelson and Svensson 2005). Some toys are more extremely gendered; a Barbie and an Action Man, for example, invite different kinds of play actions and are connected to girls and boys, respectively (Berg and Nelson 2006). Furthermore, children themselves claim that it is impossible for children to play with toys that are seen as meant for the opposite sex (Berg and Nelson 2006;MacNaughton 2006). In the places used by the studied preschool, there were no such physical environments or toys that were reserved for girls or boys. Because nature material does not have specified meanings, it can be used to represent different things and the opportunities for transformation are great (<unk>ngg<unk>rd 2009). This means that the children are not "forced" into gender-stereotyped play actions. Play in nature thus has an opportunity to avoid being shaped by the gender discourses often embedded in manufactured artifacts. To summarize, some of the play activities in the studied preschool provided genderstereotyped positions, especially the superhero play. To a certain degree the family play provided gender-stereotyped positions, but it also contained possibilities of transgression related to the nature environment. The last two play themes, animal play and physical play, provided good possibilities for girls and boys to play together and to try a variety of gendered and non-gendered play positions including gender bending. In those play themes, gender did not seem to be an important category for differentiation. In the last theme nature was an especially powerful agent. Gender construction is a complicated process in which many factors are involved. In the studied preschool, some special conditions beyond the nature environment may have been of importance for counteracting stereotyped gender positions in the children's gender construction. As mentioned above, the teachers had previously been involved in a gender project that they believe had led them to a higher level of reflexivity in pedagogical work. This in turn can have had an impact upon the children's play. Furthermore, some of the children's parents hoped the outdoor education would promote equity. With these factors in mind, I argue that the nature environment made it possible to play in various non-gendered ways. In conclusion, we cannot take for granted that play in a nature environment will counteract stereotyped gender patterns, but for several reasons, such play does seem to offer good opportunities to promote gender equity: • Nature materials and environments are not gender-coded. They have to be interpreted, and meanings can easily be transformed. This implies that material and places are not connected to one of the genders and that they can be used for several purposes. • Nature is a powerful agent; it plays with children when they are invited to sensory-motor activities. • The forest affords play themes such as animal play and physical play that are not exclusively for one of the genders. These play themes make it easier for girls and boys to play together and probe different positions. Eva <unk>ngg<unk>rd, Ph.D., is senior lecturer at Stockholm University, Department of Child and Youth Studies (BUV). Her field of research includes meaning making processes in early childhood settings. In her dissertation study, children's art activities were analyzed as a part of their peer cultures. In her ongoing research, she studies nature and outdoor settings for preschool children and 6-8-year olds, investigating aspects such as how natural resources are used in pedagogical activities as well as children's play activities in natural environments. --- Animal Play Example: Leopards and Monsters Stina (5:8), Hanna (5:5) and Felix (4:9) pretend that they are leopard kids. They are hunted by Linus (4:7), Kristoffer (4:6) and Frej (4:4)

This paper concerns gender aspects of children's play in nature environments. In an ethnographic study, children between 1½ and 6 years in a Swedish outdoor preschool were videotaped during time for free play. Four different play themes were particularly popular among the children: war and superhero play, family play, animal play and physical play. Each one of these themes has been analyzed from two perspectives: how nature resources are used and which gender positions they provide. Within the themes, nature's affordances are used in various ways. Similarly, a range of gender positions is evident across the themes. The superhero theme includes exclusively gender-stereotyped masculine play positions, while the family theme includes both traditional gender positions and possibilities for transgressions. Further, animal play as well as physical play provides non-gendered play positions. Natural environments are not gender-coded in themselves and they invite certain play activities where girls and boys play together. Thus, nature spaces seem to offer good opportunities to promote gender equity.

Introduction Research has demonstrated that emotional and behavioral problems during adolescence are associated with chronic and persistent problems during adulthood. Specifically, elevated symptoms of adolescent depression predict excessive adult drinking, smoking, criminal behavior, and relationship difficulties (Allen et al. 2014;Pine et al. 1999;Wickrama and Wickrama 2010); delinquency during adolescence predicts subsequent substance use and elevated externalizing symptoms and psychiatric disorder in adulthood (Reef et al. 2009(Reef et al., 2011;;Reinke et al. 2012); and an early age at first intercourse predicts the contraction of sexually transmitted infection and engagement in later risky sexual behaviors (Kaestle et al. 2005;Sandfort et al. 2008). Understanding the etiology of adolescent adjustment problems may help efforts to prevent both elevated symptoms during adolescence and the continuation of related problems into adulthood. Both normative (Bongers et al. 2003) and problematic changes in behavior during adolescence may be linked, in part, to pubertal development (Caspi and Moffitt 1991;Ge et al. 2003). Thus, it is important to distinguish between normative patterns of mild increases in risky behavior and emotional and behavioral patterns that are problematic and put adolescents at risk for later psychopathology. Among females, early pubertal timingexperiencing advanced pubertal status compared to peers-has been tied to elevated depressive symptoms, delinquency, and early initiation of sexual behavior during adolescence (Negriff and Susman 2011). Whether or not pubertal timing per se would put adolescents at risk for both proximal and persistent psychopathology is less clear. Given the demonstrated associations with later outcomes, if we can further understand how and why pubertal timing is tied to these outcomes, we may be able to improve our intervention and prevention efforts for adolescent emotional and behavioral problems. Alternatively, we may prevent expensive research efforts aimed at linking pubertal timing and psychopathology that are exploring the wrong processes. As such, we sought to further examine the mechanisms through which pubertal timing influences these outcomes in the current study. Several theories posit mediating mechanisms that account for the associations between the timing of pubertal development and adolescent emotional and behavioral problems. The maturation disparity hypothesis (Ge and Natsuaki 2009) infers that early pubertal timing poses risk because of the discrepancy between advanced physical changes and immature psychosocial capabilities that render early maturers less able to manage the biopsychosocial changes associated with puberty. Heightened social expectations (actual or perceived) from peers and adults due to the older appearance of individuals who reach menarche earlier (e.g., receipt of romantic interest from older individuals and rising responsibilities in school and at home) may act as stressors, increasing risk for depressive symptoms (Resnick et al. 1997) or may act as pathways into romantic relationships with older and/or deviant peer groups that increase risk for engagement in delinquent acts (Haynie 2003;Resnick et al. 1997) and early intercourse (Vanoss Mar<unk>n et al. 2000). This stress and attention may be particularly difficult to navigate for early physiological maturers because they may not have the cognitive and emotional maturity to respond to parental and peer expectations. Consistent with this perspective, (Skoog and Stattin 2014) recently developed an integrated model, which posits that maturation-disparity will only predict problem behaviors in contexts that facilitate interaction with older and more deviant peers. The hormonal influence hypothesis infers that early pubertal timing poses risks because the timing of hormonal changes that occur during puberty influence emotional and behavioral problems throughout adolescence. Recent human research implicates neuroendocrine changes related to cortisol reactivity (Ellis et al. 2012) and pulmonary volume (Whittle et al. 2012) as mediating the link between pubertal timing and adolescent depressive symptoms. Additionally, some animal models provide insight into a possible connection between pubertal timing and subsequent impulsivity, which predicts both adolescent delinquent and sexual behavior. Findings from studies of hamsters suggest that the brains of newborns are highly sensitive to gonadal hormones, and that this sensitivity declines as offspring age (Schulz et al. 2009). If this is comparable for humans, girls who experience gonadarche (most prominently indicated by menarche and breast development) at an earlier age would be exposed to the influence of gonadal hormones when the brain is still more sensitive to gonadal influence. For instance, early-maturing girls would experience greater gonadal influence during the neural development of reward responsivity than during the neural development of executive control (Steinberg 2008), putatively resulting in longstanding influences on impulsive behavior. Although theoretically compelling, the hormonal influence hypothesis has received limited empirical support (Ge and Natsuaki 2009). The psychosocial acceleration theory (Belsky et al. 1991) is a life history theory that posits experiencing psychosocial stressors during early childhood accelerates pubertal timing, and that accelerated pubertal timing influences subsequent patterns of behavior as part of a reproductive strategy (Ellis et al. 2012;Neberich et al. 2008). From this view, a reproductive strategy that maximizes time for reproduction and the number of offspring is strategic if environmental experiences indicate uncertainty in early childhood caretaking. The putative link between pubertal timing and adolescent depression and delinquency is therefore unclear from this theoretical lens because they are not directly tied to reproduction. One review from this perspective posited that both accelerated and decelerated pubertal timing are linked to depressive outcomes (Del Giudice and Ellis 2014), and an empirical article indicated that early menarcheal age did not mediate a link between early psychosocial stressors and delinquency (Belsky et al. 2010). The same empirical article, however, indicated that menarcheal age mediates the link between psychosocial stressors during early childhood and adolescent sexual behavior (Belsky et al. 2010), which can be interpreted as more consistent with the acceleration of reproduction. The maturation-disparity, hormonal influence, and psychosocial acceleration hypotheses posit nuanced mechanisms by which pubertal timing putatively causes emotional and behavioral problems during adolescence. Yet, there are two broad explanations for the associations between menarcheal age and adolescent emotional and behavioral problems (Harden 2014). One possibility, consistent with the aforementioned hypotheses, is that early menarcheal age is an independent risk factor for the development of adolescent emotional and behavioral outcomes (i.e., there is a causal relation). If so, the mechanisms responsible for the association between menarcheal age and adolescent outcomes would be specific to menarcheal age and independent of a female's family background. Alternatively, females from families with an earlier average menarcheal age may "select" into the adolescent outcomes. That is, certain factors that some families share may make members more likely to both have an earlier menarcheal age and to experience any associated outcomes (Mendle et al. 2007). In such a case, the observed association between pubertal timing and the development of emotional and behavioral problems would be spurious. Indeed, some family background characteristics that may be shared by sisters, such as family structure and interparental conflict, predict both timing of menarche (e.g., Ellis et al. 1999) and adolescent emotional and behavioral problems (e.g., Donahue et al. 2010). Furthermore, research indicates substantial contributions of both genetic factors (i.e., heritability estimates) and shared environmental factors to the variability in menarcheal age (Anderson et al. 2007;van den Berg et al. 2006), depressive symptoms (Boomsma et al. 2005;Silberg et al. 1999), delinquent acts (Tuvblad et al. 2006), and early age at first intercourse (Moore et al. 2014). These findings bring about the possibility that genetic factors or environmental factors that make siblings similar could confound the associations between menarcheal age and subsequent problems (Moore et al. 2014). Although these theories refer to pubertal timing in a broad sense, pubertal timing is a multifaceted construct, with several possible indicators. Most research exploring pubertal timing has used menarcheal age (i.e., age at first menstruation) to index pubertal timing (Dorn et al. 2006). Self or parent report of menarcheal age is a useful measure because it is a discrete event that indicates a female has likely experienced the maturation of the hypothalamicpituitary-adrenal axis, and is in the midst of the maturation of the hypothalamic-pituitarygonadal axis (Bordini and Rosenfield 2011;Marshall and Tanner 1969). Consistent with the above theoretical frameworks, many studies have identified that early menarcheal age is associated with adolescent emotional and behavioral problems (see Mendle et al. 2007;Negriff and Susman 2011 for reviews). Few studies, however, have used design features that can test the generalizability of the associations and rule out confounding factors that may account for the identified associations (Harden 2014). The current study, therefore, used statistical analyses and methodological design features to examine the mechanisms by which depressive symptoms, delinquency, and early intercourse are associated with menarcheal age during adolescence by testing (a) whether associations differ across racial and ethnic groups and (b) whether associations remain when controlling for genetic and environmental confounds (i.e., remain within-families) or whether they are attenuated (i.e., between-family processes account for the association). --- Testing Race and Ethnicity as a Moderating Factor In the US, many contextual factors (e.g., cultural distinctions, the experience of systemic discrimination) are systematically related to race and ethnicity (Williams 1999). Therefore, if race and/or ethnicity moderate the predicted associations between menarcheal age and adolescent emotional and behavioral problems in the US, the results would suggest that these associations are modifiable because they would vary by context. There may be several manifestations of different contexts, including cultural values, rites of passage, and perceptions of pubertal changes. The possibility that differences in developmental context influence associations between menarcheal age and adolescent adjustment is captured in the contextual amplification hypothesis, which posits the stressfulness and/or developmental "fit" of a context may exacerbate or attenuate the putative risk of an early menarcheal age (Ge and Natsuaki 2009). One posited context that may influence the association between menarcheal age and emotional and behavioral problems is the parent and child orientation toward the physical changes that accompany pubertal change. Research suggests that changes in BMI are related to pubertal development. Further, research indicates that Black girls have more body satisfaction than White girls, particularly during this developmental period, and that body satisfaction is less associated with mental health for Latina girls (Ge et al. 2001). If body dissatisfaction, for instance, is a mechanism linking menarcheal age to adolescent emotional and behavior problems, then the association between menarcheal age and such problems may vary across race and/or ethnicity. The extant findings exploring whether race/ethnicity moderates associations between menarcheal age and adolescent behavior are inconsistent. Some studies suggest no moderation in the link between menarcheal age and adolescent internalizing (Benjet and Hernández-Guzmán 2002;Carter et al. 2012), but others suggest a weaker menarcheal ageinternalizing link for Black and Latina females in the US (Carter et al. 2009(Carter et al., 2011;;DeRose et al. 2011). Notably, few of these studies explicitly tested race as a moderator. One study found that menarcheal age did not predict externalizing problems among African American youth (DeRose et al. 2011), but a larger study recently found that the link between early menarche and peer deviance and delinquency were similar across racial and ethnic groups (Mrug et al. 2014). Finally, one large study using data from the National Longitudinal Study of Adolescent Health demonstrated that the menarcheal age-sexual initiation link was strongest for Latina females, weaker among Caucasian females, and weakest among African American females (Cavanagh 2004). Findings regarding racial and ethnic differences may be inconsistent for several reasons. First, as some researchers have noted (e.g., DeRose et al. 2011), many studies have included suboptimal sample sizes of non-Caucasian participants, limiting the statistical power to detect potentially small associations. Second, because few studies have explicitly examined race as a moderating factor, methodological differences among studies (e.g., whether menarcheal age was measured prospectively or by retrospective report, the age range during which the outcome was measured, etc.) may have led to inconsistencies in findings. It, therefore, will be important to compare studies that are more methodologically similar. To address these limitations in the literature, the current study tested whether race and ethnicity moderated these associations in a large, nationally representative US sample, as some previous work has examined. --- Testing Within-Family Associations In order to determine whether the associations are consistent with a causal effect or are due to confounding factors, researchers must use methods that can account for putative genetic and environmental confounds. To address this issue, some studies have included variables measuring the early childhood environment and family experiences as covariates in models of menarcheal age predicting adolescent adjustment (e.g., Joinson et al. 2011), but including measured covariates does not rule out unmeasured confounds (see Moore et al. 2014 for a discussion of this). Research designs that compare associations within families can help rule out unmeasured confounding factors (Rodgers et al. 2000;D'Onofrio et al. 2013). Quasi-experimental, multi-level familial designs leverage the natural variations among individuals within a family to control for unmeasured genetic and environmental factors shared among related individuals (D 'Onofrio et al. 2013;Lahey and D'Onofrio 2010;Rutter 2007). If there is a direct link between menarcheal age and adolescent emotional and behavioral problems, the association should persist in a within-family analysis that controls for unmeasured genetic and environmental factors. If, however, selection is occurring, the association would only be present in a between-family analysis, and would be diminished in a within-family analysis. In the current study we utilized two kinds of quasi-experimental family designs: sibling and cousin comparisons. Specifically, we compared the emotional and behavioral outcomes of sisters and female cousins who differed in their menarcheal age, thereby controlling for genetic and environmental factors shared among sisters or female cousins (D 'Onofrio et al. 2013). Each method has benefits and limitations. Sister comparisons account for more confounding factors because sisters have more genetic and environmental similarity than cousins. Cousin comparisons, however, relax key assumptions of the sister comparison (e.g., you cannot compare singleton siblings, but you can compare singleton cousins to cousins with siblings) and can provide either converging or diverging evidence to evaluate the results of a sister comparison. If the mechanisms underlying the associations between menarcheal age and the outcomes found in the population are independent of family background (i.e., all factors that make family members similar), then individuals within the same family who differ in menarcheal age should also differ in the outcomes. This finding would be consistent with the hypothesis that menarcheal age is a causal contributor to adolescent adjustment problems for females. For example, if different sisters reached menarche at different times, then they may have had different expectations from parents and peers at different ages, which would put them at differential risk for emotional and behavioral problems. If the mechanisms are consistent with selection, then genetic and/or environmental factors that are shared by sisters and differ between families would account for the association between menarcheal age and adolescent emotional and behavioral problems. The key mechanisms would therefore be shared by sisters, and the process by which pubertal timing is associated with risk would be something that differs between families. In this case sisters would have the same rates of behavior and emotional problems regardless of their menarcheal ages. Importantly, these designs do not control for unmeasured genetic and environmental factors that differ between sisters that may also explain identified links between menarcheal age and adolescent adjustment problems. Nevertheless, when associations persist even after controlling for unmeasured covariates shared among sisters they are more likely to be consistent with causal inferences. Putative risk factors that fit this description and that are of clinical significance (i.e., demonstrate a substantial effect size) should be more rigorously examined for prevention and intervention efforts (Kraemer et al. 1997). Few studies have used within-family designs to test the association between menarcheal age and adolescent emotional and behavioral outcomes (Harden 2014). We are unaware of any such study of the link between menarcheal age and depressive symptoms. Some studies examining externalizing behaviors have been conducted. Burt et al. (2006) examined timing of menarche and conduct disorder using bivariate twin analyses and found that shared environmental factors that accounted for variation in menarcheal timing were highly correlated with shared environmental factors that accounted for variation in conduct problems at approximately the same age. Rodgers et al. (2015) replicated the results of Burt et al. (2006) using both childhood and adolescent conduct problems in the National Longitudinal Survey of Youth. These results suggest that menarcheal age does not independently predict conduct problems, but that environmental factors shared within families account for the association between the two. Because conduct problems and delinquency are closely related (Woolfenden et al. 2002), this same process may apply to delinquent behaviors during adolescence. Rowe (2002) and Moore et al. (2014) both examined menarcheal age and adolescent sexual behavior in the National Longitudinal Study of Adolescent Health and found that shared genetic factors largely accounted for the observed link between menarcheal age and early intercourse. The existing quasi-experimental studies suggest that factors shared among sisters (genetic and/or environmental) explain the association between pubertal timing and subsequent emotional and behavioral outcomes. This pattern of findings suggests that menarcheal age may not independently contribute to risk for the development of emotional and behavioral patterns during adolescence, which is not consistent with a causal influence interpretation. Yet, these studies were limited in the breadth of adolescent outcomes explored (i.e., none for depressive symptoms or delinquent acts per se) and the study designs (i.e., mostly bivariate twin analyses). The findings from sibling comparison analyses may be more generalizable than those of twin analyses, because siblings are a much more typical type of family relationship than twins. The current study, therefore, extended previous work by examining multiple outcomes using multiple family designs to examine whether our findings would be consistent with previous work. --- The Current Study Although several studies have indicated associations between menarcheal age and depressive symptoms, delinquent acts, and sexual initiation, few studies have utilized nationally representative, prospective longitudinal designs with the ability to compare menarcheal age across racial/ ethnic groups and within families. The current study, therefore, rigorously tested whether menarcheal age independently predicted these outcomes across people of varying backgrounds. We had two main aims. First, we tested whether associations between menarcheal age and adolescent emotional and behavioral problems were similar across broad ethnic and racial categorizations in the US. If menarcheal age consistently predicts outcomes across racial and ethnic groups, findings would suggest that the association is generalizable across a range of sociocultural contexts. Second, we tested whether the association between menarcheal age independently predicted risk for the development of adolescent adjustment problems, including depressive symptoms, delinquency, and early age at first intercourse, when comparing across sisters and female cousins. If menarcheal age predicts the outcomes within-families, our findings would indicate that the association between menarcheal age and adolescent outcomes is independent of genetic and environmental factors shared among families, which would be consistent with a causal model. If menarcheal age is only associated with the outcomes between-families, our finding would be consistent with a selection model, suggesting that the association between menarcheal age and adolescent outcomes is confounded by genetic and/or environmental factors shared. That is, menarcheal age would be an indicator of factors that both increase the likelihood of early menarcheal age and increase the likelihood of experiencing adolescent behavioral problems. --- Methods --- Participants The sample included reports from female participants of the 1979 National Longitudinal Survey of Youth (NLSY79) and the subsequent surveys of the daughters of NLSY79 females (CNLSY) (Bureau of Labor Statistics 2008a, b;Chase-Lansdale et al. 1991). The sample of mothers came from two merged subsamples within the NLSY79 cohort. The first subsample is a nationally representative, household sample of youths (n = 6,111) who were 14-21 years of age on December 31, 1978. The second subsample is an over-sample of Black and Hispanic/Latina youths, also age 14-21 (n = 3,642). All daughters of the women in the initial samples comprise the females in the CNLSY, who were the target individuals for the current study. These daughters have been assessed biennially since 1986 (with year of birth ranging from 1970 to 2008 in the sample used) on various domains including emotional and behavioral adjustment. Because of the wide age range of daughters in the CNLSY sample, participants were in the target study age range (with the measures described below ranging from being assessed at birth to being assessed at age 17) at different times, with some not being old enough to report on the key outcome variables at the most recent measurement wave (n <unk> 396), and others having reported on the outcome variables as early as the 1970s (n <unk> 259). Additionally, the age at which participants were first assessed varies from birth (n <unk> 3,415) to age 12-14 (n <unk> 6). Of a total of 5,627 females included in the full data set, we used data from both mother-reports and self-reports for those daughters in the CNLSY who met our requirements for inclusion on the menarche variable and the critical outcome measures-depressive symptoms (n = 3,069), delinquent acts (n = 3,279), and early age at first intercourse (n = 3,021). --- Primary Measures Menarcheal Age-We constructed the menarcheal age variable using information from mother-reports (n = 2,081), self-reports (n = 795), and/or both mother and self-reports (n = 459). Until daughters were 14 or 15 years of age, mothers were asked whether or not her daughter had experienced her first menstrual period, and if so, both the age (e.g., 11) and month/year (e.g., June, 1998) at which her daughter experienced it. Beginning at age 14 or 15, daughters were asked the same questions about their own menstrual periods, usually if their mothers had not already responded. In cases in which both mothers and daughters responded, their responses were moderately correlated (r =.43 in the analyzed sample). Because individuals were asked both the age and the month/year, we prioritized the use of the month/year measure because it was more precise. Ideally, each participant would have a single report of the month/ year at which she reached menarche. However, there were several ways in which participants diverged from this ideal. Some participants had both mother and self-reports, some had multiple reports from the same rater (n = 190 for mothers and n = 75 for daughters), and some only had a report of age, without a report of month/year (n = 486). To address different patterns of reporting, we averaged mother and self-reports, averaged multiple reports by the same rater, used month/year reports when available, and if not, used the age report +.5 to estimate within-year variability as guided by previous research (Rodgers et al. 2008). Mean menarcheal age for the entire sample (presented in Table 1) was similar to means found in previous research (American Academy of Pediatrics and American College of Obstetricians Gynecologists 2006; Ge et al. 2003;Wu et al. 2002). Though some past studies have analyzed menarcheal age by dividing the sample into timing categories, research suggests that categorization of pubertal timing may conceal relationships with depression and delinquency (Negriff et al. 2008), so we analyzed menarcheal age as a quantitative/continuous variable for our primary analyses. Adolescent Depressive Symptoms-Daughters completed a subset of seven items from the Center for Epidemiological Studies Depression Scale (CESD; Radloff 1977) beginning at 14 or 15 years of age. These items assessed how often in the past week individuals had problems with appetite, concentration, mood, motivation, and sleep (on a Likert scale from 0 to 2 where 0 = rarely, 1 = sometimes, and 2 = most of the time). Cronbach's alpha for the items, calculated from age 15-17 ranged from 0.68 to 0.71, consistent with what has been demonstrated in previous work (Orth et al. 2009). Participants who responded to at least five of seven items for at least one wave of data collection were included in the analyses. The mean of the 5-7 completed items was taken to create a summary score that was used for analyses. Because participants in the CNLSY were assessed biennially, most participants have a score for age 14 or age 15, but some have a score for both ages if the assessment fell at the beginning of 1 year and the end of another. Due to this assessment schedule, we considered age 14-15 as one wave and age 16-17 as a second wave. For each individual we found the mean response score across the full age range from 14 to 17 years to maximize our power to detect an association. For most participants (n = 2,095) this was based on a single score. We chose to assess depressive symptoms beginning at age 14-15 because by this age there is a full differentiation between girls who have reached menarche early and on time, and those who will reach menarche late in relation to the average girl. Adolescent Delinquency-Daughters completed seven items assessing delinquency based on the Self-Reported Delinquency Interview (SRD; Elliott and Huizinga 1983). The SRD has been used in studies examining adolescent delinquency (e.g., Moffitt & Caspi 2001) and predicts criminal convictions in the CNLSY (Lahey et al. 2006). The items were coded for whether each individual did (1) or did not (0) severely injure someone, lie to a parent about something significant, steal from a store, vandalize others' property, get in severe trouble at school, skip school, or run away overnight/stay out overnight without permission. The variable represents the number of times an individual engaged in one of these acts across two assessment waves. Thus, we took the mean number of endorsed SRD items across the ages of 14, 15, 16, and 17 and rounded this mean to the nearest whole number to obtain an approximate measure of the number of delinquent acts in which participants engaged across this age range. Participants with data for at least one assessment wave were included in analyses. The mean number of delinquent acts in which a participant engaged from age 14-17 was 1.4. Cronbach's alpha ranged from 0.55 to 0.67 across age 14-17. Early Age at First Intercourse-At each assessment wave beginning at age 14-15, daughters were asked to self-report whether or not they had ever engaged in sexual intercourse, and if so, how old they were, in years, when they first did. Although we chose to focus on the entire range of the predictor, because we were focusing on problem behaviors as outcomes, we chose to analyze age at first intercourse as a binary variable of "early" or not. Consistent with previous research (Donahue et al. 2013;Zimmer-Gembeck and Helfand 2008), we used age 16 as a cutoff such that all females whose age at first intercourse was younger than 16 years or earlier was considered "early." We therefore created a dichotomous measure for whether or not daughters had engaged in early intercourse. All participants who were at least 18 by the last assessment wave and had responded to this measure by age 17 were included in our analyses. Race/Ethnicity-In the NLSY79 (the mother generation), race/ethnicity was coded as "Latina," "Black," or "Non-Latina, Non-Black" at the initial assessment. The Non-Latina, Non-Black group consisted of all individuals who did not fall within the other two groups, and was predominantly Caucasian. These broad categorical groupings were based on how participants in the mother sample self-identified from a list of over 20 more specific racial/ ethnic categories. Daughters' race/ethnicity was subsequently categorized based on her mother's self-report. --- Analytic Plan Analyses were conducted in Mplus version 7 (Muthén andMuthén 1998-2010). We standardized the outcome measure for depressive symptoms in order to help with the interpretation of the results. We used full information maximum likelihood with robust standard errors (mlr) due to missingness and skewness of the data. We used sampling weights to account for the non-random sampling methods used to collect national data to assure that the parameter estimates were representative of the population. We ran separate multilevel models for each adolescent outcome-depressive symptoms (standardized for interpretation), delinquent acts (in mean number of acts), and early age at first intercourse (as early or not). The outcome for depressive symptoms and delinquent acts was the mean value across age 14 and 17. We chose to use the mean across this developmental period which typically falls within the high school years as the outcome in order to maximize power and include data from as many participants as possible. Because some participants either only completed the assessments at one age across the full age range, and others had not lived through the full risk period, comparing the two age ranges would, in some cases, not be comparing the same people. For all models, variance was estimated at three levelsindividual girls, nested within her mother's current household (all girls who lived with the same mother), nested within her mother's original household (all mothers who lived in the same original NLSY79 household). Females who were the biological children of the same mother were considered sisters. Female offspring of mothers who lived in the same household in the original National Longitudinal Survey of Youth data collection were considered cousins. All models included birth order and age at the last assessment wave as covariates. Our series of four separate analytical models answered four main research questions. In Model 1, we tested whether menarcheal age predicted the outcomes across the population. We tested both linear and curvilinear models because some research indicates that late pubertal timing may be associated with emotional and behavioral problems (e.g., Carter et al. 2012). Menarcheal age was centered at the sample mean for all girls who were not missing on the outcome of interest, and no predictors at the family level were included. In Model 2, we tested whether the association attained in Model 1 was similar across broad racial and ethnic groups using multiple group analyses. We compared a model in which all parameters were constrained to be equal across Black, Latina, and Non-Black, Non-Latina groups to a model in which the estimate for menarcheal age predicting the outcome in question varied freely across groups. We carried out Chi square difference tests; a constrained model that fit the data significantly worse than the full model was evidence for moderation. We also examined the magnitude of the point estimates for each group. In Model 3, we examined the independence of menarcheal age as a risk factor by testing whether the attained association remained when testing among cousins. Menarcheal age was centered at the mean for all female cousins in a family who were not missing on the outcome of interest. The centered menarcheal age score was a measure of how much each individual deviated from the average menarcheal age among cousins within a family. This analysis partially controlled for genetic (6.25-12.5 % for differentially related cousins) and environmental factors shared among cousins. Additionally, the mean menarcheal age for the all cousins was included in the model as a predictor to control for the family-level effect. In Model 4, we further examined the independence of menarcheal age as a risk factor by testing whether the attained association remained when comparing sisters who differed in their menarcheal age. This model did not include estimates for cousin comparisons. Instead, we separately explored comparisons of sisters. Menarcheal age was centered at the mean for all sisters who were not missing on the outcome of interest. The centered menarcheal age score was a measure of how much each individual deviated from the average menarcheal age among sisters within a family. This analysis partially controlled for genetic factors (of which maternal half-siblings share 25 % and maternal full siblings share 50 %) and controlled for all environmental factors shared among sisters (Lahey and D'Onofrio 2010). Therefore, a persistent association above and beyond these shared genetic and environmental factors among sisters provides support for an independent association, consistent with an inference that early menarcheal age is a causal risk factor. In contrast, an attenuated association provides evidence that menarcheal age is a selection factor. The mean menarcheal age for all sisters was included as a predictor in the model to control for the family-level effect. To preserve statistical power for the analyses, the current models did not distinguish between full and half-sisters and did include rare cases of identical twins (who share 100 % of their genes). Finally, we tested a series of sensitivity analyses

Better understanding risk factors for the development of adolescent emotional and behavioral problems can help with intervention and prevention efforts. Previous studies have found that an early menarcheal age predicts several adolescent problems, including depressive symptoms, delinquency, and early age at first intercourse. Few studies, nevertheless, have explicitly tested (a) whether the associations with menarcheal age vary across racial/ethnic groups or (b) whether the sources of the associations are within-families (i.e., consistent with a direct, causal link) or only between-families (i.e., due to selection or confounding factors). The current study analyzed data from a nationally representative US Sample of females (N = 5,637). We examined whether race/ ethnicity moderated the associations between early menarche and several adolescent problems by using multiple-group analyses and we examined the degree to which genetic and environmental

eal age was centered at the mean for all sisters who were not missing on the outcome of interest. The centered menarcheal age score was a measure of how much each individual deviated from the average menarcheal age among sisters within a family. This analysis partially controlled for genetic factors (of which maternal half-siblings share 25 % and maternal full siblings share 50 %) and controlled for all environmental factors shared among sisters (Lahey and D'Onofrio 2010). Therefore, a persistent association above and beyond these shared genetic and environmental factors among sisters provides support for an independent association, consistent with an inference that early menarcheal age is a causal risk factor. In contrast, an attenuated association provides evidence that menarcheal age is a selection factor. The mean menarcheal age for all sisters was included as a predictor in the model to control for the family-level effect. To preserve statistical power for the analyses, the current models did not distinguish between full and half-sisters and did include rare cases of identical twins (who share 100 % of their genes). Finally, we tested a series of sensitivity analyses to examine some of our analytic assumptions. We did not include these within the main analyses because these analyses would be less than optimal for estimating the associations with as much data as possible. We ran four sets of sensitivity analyses. First, we tested whether we would have a similar pattern of findings when using only mother reports of menarche or only daughter reports of menarche in models. Second, due to possible concerns about collapsing reports of adolescent depressive symptoms and adolescent delinquency across a 4-year age range, we tested the associations separately at ages 14-15 and 16-17. Third, because many past studies examining pubertal timing have used categorical measures (e.g., early timing, average timing, and late timing) and because some research suggests that findings may differ when using categorical instead of continuous measures of menarcheal age (Negriff et al. 2008) we included models with menarcheal age as a categorical predictor. Menarcheal ages at least one standard deviation below the mean (i.e., 11 years or younger) were considered "early" and menarcheal ages at least one standard deviation above the mean (i.e., 13.58 years or older) were considered "late". Fourth, because our main analyses included siblings within the same household with different genetic relatedness, we sought to test the analyses in families that only had full siblings. For all analyses, we used linear models when predicting depressive symptoms (measured quantitatively/continuously), negative binomial models when predicting delinquent acts (measured as a count variable), and logistic models when predicting early age at first intercourse (a binary outcome). In the multiple group analysis, we estimated the mean levels of depressive symptoms for each group, as well as thresholds for the count and binary outcome. When predicting delinquency and early age at first intercourse, thresholds at the family level were estimated separately for the three known classes of race/ethnicity. --- Results Descriptive statistics and correlations for menarcheal age, depressive symptoms, delinquent acts, and early age at first intercourse are presented in the Table 1. The average menarcheal age was 12.29, and ranged from age 7.58 to age 17.67. The mean and range of menarcheal age was almost identical across subsamples for specific outcomes (M dep = 12.29, range = 7-17; M del = 12.29, range = 7-17; M int = 12.30, range = 7-17). We found significant, small correlations between menarcheal age and depressive symptoms, delinquent acts, and early age at first intercourse (Cohen 1992). Intraclass correlations indicated that, cousins in the same extended family share 24 % of the variance in menarcheal age, 8 % of the variance in depressive symptoms and 15 % of the variance in delinquency was within extended families. When examining the data as sisters nested within nuclear families, 28 % of the variance in menarcheal age, 10 % of the variance in depressive symptoms, and 15 % of the variance in delinquency was within groups of children that shared the same biological mother. --- Depressive Symptoms Unadjusted linear and nonlinear associations are depicted in Fig. 1. In the linear model, menarcheal age inversely predicted mean depressive symptoms between age 14 and 17 across the population (b = -0.05, p <unk>0.05) (see Table 2). For every 1 year decrease from the mean menarcheal age, there was a 0.05 standard deviation increase in depressive symptoms, indicating that an earlier menarcheal age was associated with more depressive symptoms. In the nonlinear model (Figure 1, Panel C), the quadratic term was significant (b = 0.02, p <unk>0.01). However, the non-linear association (depicted in Fig. 1, Panel A) does not indicate that late menarcheal age is predictive of more depressive symptoms. Further, the fit statistics for the linear (AIC = 8,690.052; BIC = 8,714.171) and nonlinear (AIC = 8,687.058;BIC = 8,717.207) models indicate that model fit of the more parsimonious linear model is comparable to that of the nonlinear model. For reference, we have depicted the modelderived estimates for the linear, quadratic, and categorical models. In the model in which menarcheal age was categorized into early, average, and late, early menarcheal age predicted more depressive symptoms compared to average menarcheal age, but late menarcheal age did not predict depressive symptoms compared to average age. Because we were interested in early menarcheal age, we chose to use the linear model for subsequent analyses. The estimate for menarcheal age predicting adolescent depressive symptoms was -0.03 for Latina girls, -0.05 for Black girls, and -0.05 for Non-Black, Non-Latina girls. Modified Chi square difference tests [<unk> 2 (2) = 3.15, p = 0.21] indicated, however, that the constrained models did not fit significantly worse than the models in which the parameters for menarcheal age varied across groups. We, therefore, ran the subsequent models in the entire sample rather than fitting separate parameters in each racial/ethnic group. The association between menarcheal age and adolescent depressive symptoms was attenuated and not statistically significant when comparing cousins (b = -0.02, p = 0.43) and further attenuated when comparing sisters (b = -0.01, p = 0.68). Thus, menarcheal age did not predict depressive symptoms when comparing cousins and sisters, suggesting that confounding factors account for the association between menarcheal age and depressive symptoms found in the population. Findings from sensitivity analyses (see Table 3 for population estimates and Table 4 for within-family comparisons) were generally consistent with the main findings, such that when (a) using mother-reported menarcheal age, (b) self-reported menarcheal age, (c) early versus other menarcheal age, (d) predicting age 14-15 depressive symptoms only, (d) and predicting among full siblings only, the population estimate was small and significant. The within-family analyses, were, as in the main analysis attenuated and no longer statistically significant. --- Delinquency Menarcheal age also predicted delinquent acts (b = -0.04, p <unk>0.01) in the population (see Table 2). Every 1-year increase from the mean menarcheal age was associated with a 0.04 decrease in mean delinquent acts over the age period. The nonlinear model yielded a nonsignificant quadratic term (b = -0.01, 95 % CI -0.02, 0.01, p = 0.49). As depicted in Fig. 1, Panel B, the linear and nonlinear models provide a similar association except in the tails, which include very few people. The model fit statistics for the linear model (AIC = 10,289.261;BIC = 10,313.645) and the nonlinear model (AIC = 10,290.697; BIC = 10,321.178) provided further evidence that the linear model was superior and should be used for subsequent analyses. The estimate for menarcheal age predicting adolescent delinquency was -0.03 for Latina girls, 0.01 for Black girls, and -0.06 for Non-Black, Non-Latina girls. Modified Chi square difference tests [<unk> 2 (2) = 5.4, p = 0.13] indicated, however, the constrained model did not fit significantly worse than the full model, suggesting that race and ethnicity did not moderate the associations. In the subsequent models, which were fit to the entire sample, the association was attenuated and not significant when comparing cousins (b = 0.01, p = 0.76) and sisters (b = 0.01, p = 0.75). Thus, within extended and immediate families menarcheal age did not predict delinquent acts, which suggest confounding factors account for the population associations. Sensitivity analyses were broadly consistent with these findings (see Table 3 for population estimates and Table 4 for within-family comparisons). Among the sensitivity analyses, only the population estimates yielded significant estimates for menarcheal age predicting engagement in delinquent acts. In some cases (i.e., for self-report only and categorical menarcheal age), nevertheless, the point estimates for the sister comparison analyses were larger than the population estimates. --- Early Age at First Intercourse Menarcheal age predicted early age at first intercourse in the population (see Table 2 and Fig. 1,Panel C). Every year menarcheal age was delayed was associated with a 31 % decrease in the odds of early intercourse (OR 0.69, 95 % CI 0.64, 0.75). In the nonlinear model, the quadratic term was not significant (b = -0.03, 95 % CI -0.06, 0.01, p = 0.19), suggesting that the linear model was a better fit for the data. Moreover, fit statistics for the linear (AIC = 3,680.721; BIC = 3,698.763) and nonlinear (AIC = 3,681.175; BIC = 3,705.231) models also provide evidence that the linear model should be used because it provides similar fit with more parsimony. When comparing across race and ethnicity, odds ratios for menarcheal age predicting early age at first intercourse were 0.78 for Latina girls, 0.74 for Black girls, and 0.62 for Non-Black, Non-Latina girls. Modified Chi square difference tests [<unk> 2 (2) = 5.4, p =.07] indicated that when predicting early age at first intercourse, the constrained model was not significantly different than the model in which the estimate for menarcheal age predicting early age at first intercourse varied across Latina, Black, and Non-Latina, Non-Black girls. Fit indices suggested that the constrained model fit the data equally to the full model (BIC constrained = 18,342.9, BIC full = 18,353.5) or that the models fit the data equally well (AIC constrained = 18,277.8, AIC full = 18,276.6). We, therefore, fit the subsequent models to the entire dataset without constraints. The association persisted at the same magnitude when comparing cousins (OR 0.69, 95 % CI 0.60, 0.80) and comparing sisters (OR 0.69, 95 % CI 0.57, 0.82), suggesting the association exists at the within-family level. The results, therefore, suggest the association between menarcheal age and early age at first intercourse was independent of confounding factors shared by siblings and cousins. Sensitivity analyses were generally consistent with the primary findings (see Tables 3,4). Analyses that included mother-report of menarcheal age only, self-report of menarcheal age only, or categorical menarcheal age yielded a pattern in which the link between menarcheal age and early age at first intercourse persisted in point estimates, but the estimates had large confidence intervals and were no longer statistically significant in the within-family comparisons. In contrast, the series of analyses that only included full siblings resulted in a pattern in which menarcheal age predicted early age at first intercourse both across the population and within families at the same magnitude, which were also statistically significant. --- Discussion Hypotheses from several theoretical orientations-including hypotheses of maturationdisparity, hormonal influence, and psychosocial acceleration-suggest that menarcheal age is part of an etiological pathway for the development of depressive symptoms, delinquent acts, and/ or sexual behavior during adolescence. In contrast, selection or confounding factors that influence menarcheal age and outcomes may actually account for the associations between menarcheal age and emotional and behavioral problems during adolescence seen in the population. We found that menarcheal age predicted offspring depressive symptoms, delinquency, and early age at first intercourse across the population, consistent with previous studies. We also found that race/ethnicity did not moderate any of the associations. Finally, when testing the association within-families, we found that the link between menarcheal age and depressive symptoms and delinquent acts was attenuated and not statistically significant, but the association between menarcheal age and early sexual intercourse remained. Outcome-specific results are described below. --- Depressive Symptoms The association between menarcheal age and adolescent depressive symptoms in the population was quite small. Other studies and reviews have implicated a large role of pubertal timing in the prediction of depressive symptoms (Mendle et al. 2007). Some studies specifically linking menarcheal age and depression nevertheless show small associations (e.g., Carter et al. 2012;Joinson et al. 2011), suggesting that menarcheal age alone may not be a strong predictor of these outcomes. We found that race and ethnicity did not moderate the small association between menarcheal age and adolescent depressive symptoms across the population. The current study replicates a finding from another nationally representative longitudinal study (Carter et al. 2012) in which the association was similar across Black and Caucasian girls. This finding suggests that contexts systematically related to race or ethnicity may not have differential influences on the association between menarcheal age and depressive symptoms. Together, these findings suggest that large, nationally representative samples have greater power to detect small associations in racial and ethnic minority groups. We found that the small association between menarcheal age and depressive symptoms did not persist when comparing female cousins and sisters. These findings are consistent with a selection model and suggest that factors shared among siblings and cousins in an extended family account for the association between early menarcheal age and depressive symptoms. As such, the within-family results (i.e., the comparison of siblings and cousins) are inconsistent with the interpretations associated with the aforementioned theories and previous studies (Negriff and Susman 2011) linking menarcheal age to adolescent depressive symptoms. The current study, therefore, provides evidence for menarcheal age as a risk marker, but not an independent risk factor for the development of depressive symptoms. There are several possible empirical explanations for why the current results are not consistent with previous findings. First, most previous research has not tested the withinfamily association between menarcheal age and adolescent depressive symptoms. The result may mean that factors shared among families (i.e., that differ between families) account for the link, and most previous research has not been able to rule out this possibility. One caveat to these findings for this and other outcomes is that the imprecision with which cousin and sister comparisons were measured (i.e., based on individuals living in the same household rather than biological relatedness alone) may result in more similar estimates for cousin and sister comparisons. This would especially be the case if genetic confounds account for the association. Second, the current analysis does not preclude the possibility that more precise measurement of menarcheal age would have yielded stronger estimates. The magnitude of the estimates, nevertheless, were still very small, indicating that if menarcheal age is an independent risk factor, its contribution to risk for depressive symptoms is likely quite limited. The results from sensitivity analyses were largely consistent with these findings. --- Delinquent Acts The association between menarcheal age and the development of delinquency was also small. We also did not find evidence for race or ethnicity moderating the small association between menarcheal age and delinquent acts, which replicates results from Rodgers et al. (2015). The current finding also replicates the findings of another recent large-scale study that directly tested race and ethnicity as a moderator in finding no statistically significant difference by race and ethnicity for menarcheal age predicting delinquency (Mrug et al. 2014). The association between menarcheal age and delinquency did not, however, persist within families. This finding is consistent with a selection model, and suggests that genetic and environmental factors shared by siblings and cousins account for the observed association between menarcheal age and delinquent acts in the population. For example, (Harden and Mendle 2012) posited that the androgen receptor gene may be part of an array of genes that are similar within families and may influence menarcheal age and engagement in delinquent behavior. Further, our findings may also be consistent with research using bivariate twin analyses that implicate shared environmental factors as explaining the association between menarcheal age and conduct problems (Burt et al. 2006), a construct associated with delinquency. The link between menarcheal age and adolescent delinquent acts was generally consistent across sensitivity analyses. In two sensitivity analyses, the within-family point-estimate for menarcheal age predicting delinquent acts was larger than the population point-estimate. Because the within-family model requires greater statistical power, the larger point-estimate suggests that in a larger sample the link between menarcheal age and delinquent acts may persist within families. The current study, nevertheless, does not provide evidence for a within-family link. --- Early Age at First Intercourse We found a moderate association between menarcheal age and early age at first intercourse across the population; for every 1 year increase from the mean menarcheal age, there was a. 31 decrease in the odds of having engaged in sexual intercourse by age 17. Consistent with findings for depressive symptoms and delinquent acts, we did not find evidence for race or ethnicity as a moderator. Nevertheless, another large-scale longitudinal study found that Caucasian females showed the strongest association between menarcheal age and early age at first intercourse, then Latina females, and then Black females (Cavanagh 2004). Given the conflicting findings between large scale studies, future research should continue to examine race and ethnicity as putative moderators of this association, particularly when compared to peers rather than national averages. Menarcheal age continued to predict early age at first intercourse in within-family analyses, both when comparing siblings and comparing cousins. These findings are consistent with an inference that menarcheal age has a direct effect on intercourse before the age of 16. Although very few studies have utilized genetically informed designs to test the link between menarcheal age and early intercourse, the current findings are counter to those of a recent study conducted in the National Survey of Adolescent Health, which showed that shared genetic factors accounted for the link (Moore et al. 2014). Our estimates from the cousin-comparisons, which account for approximately 25 % of genetic factors, and siblingcomparisons, which account for approximately 50 % of genetic factors, were similar. As such, the findings are not consistent with genetic confounding, although additional studies that explicitly test genetic and environmental confounds are needed. The current findings may be consistent with both the psychosocial acceleration theory and mechanistic hypotheses linking menarcheal age to early age at first intercourse. First, the maturation disparity hypothesis suggests that early maturers are more likely to engage socially with older adolescents, particularly in romantic contexts (Graber and Sontag 2006). This may be one pathway to early intercourse for females who reach menarche early. Second, the hormonal influence hypothesis suggests that the increase in androgen hormones may influence engagement in sexual behavior. Future work should continue to investigate these and other putative mechanisms to determine which processes mediate the association. --- Limitations and Strengths The current findings should be considered in light of some limitations. First, the associations we identified within the population may be interpreted as smaller than those identified in some previous work. This small association may be related to the measurement of menarcheal age in this study which included varying informants (mother, daughter, or both) and varying formats (e.g., age vs. month and year) of reporting menarcheal age. The average mother-reported menarcheal age was earlier than the average self-reported menarcheal age. This was likely because mothers were asked whether their daughters had reached menarche until age 14 or 15, and daughters responded thereafter. Although ideally both reporters would have been asked across all time points, we sought to address this by running sensitivity analyses in which only mother or only self-reports were used. The small association may also be difficult to compare to other studies, and may, in fact, be in the confidence interval of findings from previous studies. A meta-analysis examining associations between pubertal timing more broadly and depression in adolescence found that the overall estimates across studies had large confidence intervals, indicating a wide range of estimates in which the true association lies (Galvao et al. 2014). Second, sibling comparisons make a few key assumptions about how risk factors operate. The experiences of one sibling are assumed to not influence the other siblings (Lahey and D'Onofrio 2010). Further, it is assumed that females with sisters are representative of singletons and females with brothers only, when all of these factors may make home environments distinct for any individual girl. Also, the sister comparison controls for fewer genetic factors than twin comparisons, so analyses that compare twins, siblings, and unrelated individuals would yield stronger internal validity. The current study included a range of genetic relatedness within families (e.g., full and half-sisters), but did not explicitly test differences by genetic relatedness. It is important to note, nevertheless, that we found consistent results when comparing both siblings and cousins, which suggests the results are not due solely to the assumptions/limitations inherent in each design. Third, the study was unable to specify menarche compared to same-age peers, rather to national norms. Some researchers posit the importance of specifically comparing adolescent girls to the individuals within their social networks, which is more salient and meaningful. Fourth, the study was unable to elucidate processes related to pubertal timing and outcomes in boys because our measure of pubertal timing was limited to the female participants in the sample. Finally, we were limited in our measurement of race and ethnicity which was based on the mother's report, precluding the examination of more specific moderation (e.g., no specific ethnicities for Black participants, no knowledge of whether participants were biracial). The current study also had several strengths. The sample used was larger and more diverse than samples used in much of the extant literature. Notably, our findings regarding race and ethnicity for the depressive and delinquent outcomes were consistent with recent large-scale studies with diverse samples in the US. Additionally, we utilized several quasi-experimental family designs that allowed us to control for unmeasured genetic and environmental confounds shared within families. Although most previous research has controlled for measured covariates, our analytical design dramatically increased the genetic and environmental factors for which we controlled when testing whether the association between menarcheal age and adolescent outcomes was causal. Finally, we tested multiple adolescent outcomes within the same study, thereby extending the reach of research using quasiexperimental methods in this area of research. --- Future Directions We see at least two directions for future research. First, a majority of previous work examining the link between pubertal timing and adolescent behavioral patterns has focused on menarcheal age as an index of pubertal timing. The current study suggests that menarcheal age is not a causal risk factor for depressive symptoms or delinquency. Recent work suggests that other indicators, such as the development of secondary sex characteristics, perception of pubertal timing or physical maturation compared to peers, and pubertal tempo, are more proximally related to adolescent emotional and behavior experiences than menarcheal age, particularly because they more explicitly engage social comparisons and expectations (Carter et al. 2009;Halpern et al. 2007;Joinson et al. 2012;Mendle 2014). If other indicators of pubertal timing, perceptions of pubertal timing and tempo are considered, there may again be contextual differences by race/ethnicity. For example, pubertal timing according to the Pubertal Development Scale was linked to depressive symptoms among Caucasian females, but not African American females (Hamlat et al. 2014). Future studies, when possible, should test these different measures in large, longitudinal studies and continue to examine both ethnic moderation and use rigorous methods to rule out alternative explanations. Second, the integrative model of maturation-disparity within a context, proposed by Skoog and Stattin (2014) suggests that problems associated with pubertal timing are short-term and do not endure into adulthood. The proposed mechanisms may differ in whether or not the putatively associated difficulties would be proximal to pubertal change, or whether pubertal timing would predict more longstanding difficulties. From the maturation-disparity framework, for example, challenges (e.g., risky sexual behavior) for early maturing girls may dissipate as they achieve cognitive and emotional maturation. Recent studies that have followed large birth cohorts have indicated that emotional and behavioral problems associated with pubertal timing, including menarcheal age, may diminish as girls age beyond the period of pubertal transition (Copeland et al. 2010;Joinson et al. 2011;Boden et al. 2011). Future work should continue to examine these developmental questions. --- Conclusion Consistent with previous research, we found associations between menarcheal age and three adolescent outcomes-depressive symptoms, delinquency, and age at first intercourse. Adding to the equivocal literature about racial and ethnic differences in these associations, we found that all associations were similar across Latina, Black, and Non-Latina, Non-Black individuals, indicating similar mechanisms explaining the associations across these groups. When further examining these mechanisms, we found that the association between menarcheal age and depressive symptoms and delinquency did not persist within families. This and other recent findings suggest that interventions for the development of depressive symptoms and delinquency during the adolescent period would not benefit from further examination of proposed causal mechanisms linking them to menarcheal age. Instead, intervention and prevention efforts should identify the factors that differ between extended families that are correlated with both menarcheal age and these adolescent problems. In contrast, we found that the association between menarcheal age and early age at first intercourse did persist within families, although other research has suggested genetic confounding may account for the association. This finding suggests that further exploration of putative causal mechanisms linking menarcheal age to early age at first intercourse may provide insight into improvements for intervention efforts, but that further evidence of this possibility is necessary. --- Biographies --- Author Manuscript Vaughan et al. Page 29 Table 2 Unstandardized estimates of AAM predicting adolescent outcomes

Better understanding risk factors for the development of adolescent emotional and behavioral problems can help with intervention and prevention efforts. Previous studies have found that an early menarcheal age predicts several adolescent problems, including depressive symptoms, delinquency, and early age at first intercourse. Few studies, nevertheless, have explicitly tested (a) whether the associations with menarcheal age vary across racial/ethnic groups or (b) whether the sources of the associations are within-families (i.e., consistent with a direct, causal link) or only between-families (i.e., due to selection or confounding factors). The current study analyzed data from a nationally representative US Sample of females (N = 5,637). We examined whether race/ ethnicity moderated the associations between early menarche and several adolescent problems by using multiple-group analyses and we examined the degree to which genetic and environmental

Introduction Suicide is a major public health and mental health challenge. In China, the high suicide rates and unique suicide patterns observed in the 1990s (Phillips et al. 2002a) have been changed in recent years. Based on the Global Burden of Disease study, suicide rate in China has decreased from 20 per 100 000 in 1990 to 12 per 100 000 in 2010 (Yang et al. 2013). Using different data resources and methods, researchers drew similar conclusions (Wang et al. 2014;Zhang et al. 2014;Liu et al. 2015). The pattern of suicide has also changed dramatically. Suicide rates among male have exceeded those among female; the peak of suicide in rural young women has gradually vanished; the rural/urban ratio of suicide rates has been significantly reduced, while suicide rates remain the highest in older adults (Wang et al. 2014;Zhang et al. 2014;Liu et al. 2015). During 2013-2014, it was estimated that the average suicide rate among elderly (65 or above) was 34.5 per 100 000, 6.5-fold higher than the rate of population under 65, and rural elderly were more likely to commit suicide than urban elderly (incidence rate ratio = 1.83) (Zhong et al. 2016). Researches indicated that urbanization and economic development might be the main reasons for these changes (Liu et al. 2015;Sha et al. 2017). However, a decomposing study showed that the positive impact of urbanization on suicide rate had diminished recently, and suicide among older adults might be elevated as China is facing slower economic growth and rapid aging (Sha et al. 2017). Remarkable demographic transition has happened in China in the past three decades. China stepped into an aging society in 1999, and it has 143.9 million older adults now (65 or above) or 10.5% of the whole population (National Bureau of Statistics of China, 2017). Approximately 250 million rural residents (40% of the whole rural population) move to urban areas each year, mostly young and middle-aged migrant workers. Therefore, a large number of rural elderly are left-behind. Traditionally Chinese elderly are taken care of by their children, but this has become difficult because of urbanization, domestic migration, and the deconstruction of extended families. Concerns about the impact of urbanization on rural elderly has raised not only in China but also in other developing and urbanizing countries. Previous studies on the mental health status of left-behind elderly showed inconsistent results. In a study in rural China, authors reported that the migration of rural workforce had significantly degraded the welfare of the left-behind elderly (He and Ye, 2014). Several quantitative studies showed that 41-56% Chinese rural older adults were empty-nester or left-behind, and it was correlated to worse mental health outcomes including loneliness, depression, and anxiety (Wang et al. 2013(Wang et al., 2017)). On the contrary, researches in Thailand and Indonesia reported less negative effects or even positive effects: children working in urban areas can provide better material support for their elderly parents; negative impacts of migration on social support are attenuated by support from kin and neighbors, the advent of communication technologies, and the improvements of transportation; preexisting advantages of families that send migrants (Kreager, 2006;Knodel and Saengtienchai, 2007;Abas et al. 2009). Living arrangements, rather than being left-behind, have been examined in suicide risks studies. Living alone has been shown to be a risk factor of elderly suicide in a study in Australia (De Leo et al. 2013), but the association was not found in another study in Sweden (Rubenowitz et al. 2001). A study in Hong Kong found that living with children was a protective factor for both suicide attempt and completed suicide in older adults (Chiu et al. 2004). However, living arrangements might be less relevant in rural areas. It is common that elderly live alone while they are taken care of by their adult children who live nearby (i.e. in the same village). Thus, it is important to examine directly whether being left-behind is associated with elderly suicide, and if yes, what is the mechanism underlying the association. To understand the characteristics and risk factors of suicide in this population is of key importance for suicide prevention. However, little is known about suicide among older adults in China. Using data from the Integrated National Mortality Surveillance System, Zhong et al. reported suicide rates and geographical distribution of Chinese older adults from 2013 to 2014 (Zhong et al. 2016). A review summarized characteristics of elderly suicides based on several reginal studies in China (Li et al. 2009). There have been two large-scale psychological autopsy studies in mainland China, the earlier one focused on general population was conducted in 2000 by Phillips et al. (Phillips et al. 2002b). The authors further described the characteristics of 304 suicides older than 55 years in the sample (Zhou et al. 2004;Wang et al. 2007). While providing important data about suicide in older adults in China, information from these studies is outdated, and more importantly, the value is limited because of the lack of comparisons. The later psychological autopsy study focused on younger suicides aged 15-34 (Zhang et al. 2010). Other studies on the risk factors of suicide in older adults used suicide attempt (Zhang et al. 2017b) or suicide ideation (Zhang et al. 2017a) as main outcomes. Psychological autopsy is a widely used method to explore the risk factors of completed suicide (Conwell et al. 1996;De Leo et al. 2013) and has been validated previously in China (Zhang et al. 2003). Using 1:1 matched case-control design, this psychological autopsy study aims at examining the relationship of demographic characteristics including being left-behind, mental disorder, depressive symptoms, stressful life events, social support, and completed suicide. More specifically, we hypothesize that being left-behind elevates the risk of suicide, and mental disorder, depressive symptoms, life stress, and social support mediate the relationship between being left-behind and suicide. To the best of our knowledge, this is the first national psychological autopsy study focused on the risk factors of suicide in rural older adults, a rapidly growing vulnerable population in contemporary China. --- Material and methods --- Sample and sampling Multi-stage stratified cluster sampling method was used to select the research sites. In the first stage, based on the GDP per capita of 31 provinces in mainland China, Shandong, Hunan, and Guangxi were chosen from the top 10, 11-20, and 21-31 provinces, respectively. Counties in these provinces were stratified into three strata based on average income. One county in each stratum in Shandong and Hunan provinces and two counties in each stratum in Guangxi province (because the population size of county in Guangxi was smaller) were randomly selected. Therefore, 12 counties from three provinces were chosen. We relied on the death certification system in each county to consecutively collect completed suicides aged 60 or above. All village doctors and local public health professionals involved in death certification were trained briefly and were asked to report all elderly suicide death to local Center for Disease Control and Prevention (CDCs). The manner of death was finally determined by trained investigators after all available and relevant information was collected. Living comparisons were 1:1 matched with the suicide case in age (<unk>3 years old), gender, and living location. Whenever a suicide case was identified, the investigators would list and numerate all older adults that matched in age and gender in the same village. Then one living comparison was randomly selected from the list using a computer program. In a few cases when there were no appropriate living comparisons available, the investigators expanded the search to the nearest villages. --- Procedures of interview This study was conducted during June 2014 to September 2015. Interviewers from the three research sites were trained intensively for 10 days on the determination of manner of death, method of psychological autopsy, interview skills, and administration of study instruments. Interviews with informants of suicide victims were scheduled 2-6 months after death, while interviews with informants of living comparisons were conducted as soon as the participants and their informants were identified. Two informants for each suicide victim and living comparison were identified: generally, the first informant was one next-to-kin who lived with the suicide victim or living comparison, and the second informant was always a friend, a neighbor, or a remote relative. Each informant was interviewed separately by one trained interviewer. The average interview time was 90 min. The study was approved by the IRB of the Central South University, Shandong University, and Guangxi Medical University. The aim and procedure of the research were explained to all participants. Written informed consent must be obtained before interviews were conducted. --- Measures --- Demographic characteristics Demographic characteristics including age, gender, marital status, family income, school education, living arrangement, and Psychological Medicine pesticides stored at home were collected. All adult children of each elderly in both groups were listed, and the living location and frequency of visiting their parents of each adult child were recorded. Being left-behind was defined as during the last 12 months prior to death (for suicides) or investigation (for living comparisons), all adult children had lived out of the original township for at least 10 months, and had visited their parents no more than twice. Suicide behavior and help-seeking behavior before suicide Information about the time, location, and method of suicide was collected. Suicide intent was assessed using the eight-item Beck's Suicide Intent Scale (SIS-8). We also asked if the suicide victim had sought for help from a doctor (and if yes, what kind of doctor) in the last month prior to suicide. --- Mental disorder The Chinese version of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; SCID) was used to generate current diagnoses of mental disorder. Diagnoses were made by psychiatrists in consensus meetings in which all information including SCID interview from both informants and previous medical records was presented. Four categories of diagnoses were included: mood disorders, schizophrenia and other psychotic disorders, alcohol dependence, and anxiety disorders. Because complex general medical conditions and medications were common in older adults, diagnoses including major depressive episode and psychotic disorder not otherwise specified were used if appropriate. Diagnoses of personality disorders or uncommon disorders in Chinese rural elderly (i.e. mental disorder onset in childhood and adolescence, eating disorder, illicit drug abuse, etc.) were not included. Multiple diagnoses were made if appropriate. Depressive symptom, social support, and stressful life events Geriatric depression scale (GDS) was used to assess the depressive symptoms in the last week before death/investigation. The instrument composed of 30 items (possible scores range from 0 to 30), and a higher score indicates severer depressive symptom (Chan, 1996). GDS has been validated in rural Chinese older adults in a previous study (He et al. 2008). The severity of depressive symptom can be categorized into three groups based on the GDS score: no or mild depression 0-10, moderate depression 11-20, and severe depression >20. Social support in the last week before death/investigation was measured by the 23-item Duke Social Support Index (DSSI, possible scores range from 11 to 45), and a higher score indicates higher social support. DSSI has been used in a previous psychological autopsy study in China and showed satisfactory reliability and validity (Zhang et al. 2003). Stressful life events in the last 12 months before death or investigation were measured by the Life Events Scale for the Elderly (LESE), which was developed specifically for older adults in China and covered 46 life events (Xiao and Xu, 2008). --- Integration of information from different sources Answers from the two informants may differ, therefore need to be integrated. For the demographic characteristics and suicide behavior, we relied on the information provided by the first informant. For each item of GDS, DSSI, and LESE, answers that were hypothetically correlated to elevated suicide risk were used. The rationale for this practice is that a targeting behavior may exist when one of the two informants has observed it. For instance, positive answer of an item of GDS was used when one of the two informants reported positive; similarly, higher scores of LESE and lower scores of DSSI were used. --- Statistical method Descriptive analysis, <unk> 2 tests, t tests, and rank-order tests were used to describe and compare the demographic characteristics, mental disorder, depressive symptoms, life events, and social support of suicides and comparisons. Marital status was dichotomized into stable and unstable: the former included currently married and living together, the latter included never married, divorced, widowed, and separated. Family annual income was categorized into three groups based on the 33 and 66 percentiles: <unk>3600, 3600-10 000, and >10 000. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) derived from the conditioned multivariable logistic regression indicated the associations between risk factors and suicide: social support was dichotomized into two groups based on the median score of DSSI; stressful life events was categorized into three groups based on the 33 and 66 percentiles; the score of GDS was used as a continuous variable to indicate the severity of depressive symptoms. Backward stepwise (likelihood ratio) method was used in the logistic regression. All these analyses were conducted using SPSS 24.0 for Windows. All reported p values were two-sided, and p values <unk>0.05 were considered statistically significant. The theoretical model was estimated with structural equation model. We speculated that being left-behind did not cause suicide directly, but elevated the suicide risk through its effects on life events, depressive symptoms, mental disorder, and social support. Life events not only had a direct effect on suicide, but also had an indirect effect through decreasing social support and increasing depressive symptoms and mental disorder. Depressive symptoms, mental disorder, and social support had direct effects on suicide and were correlated with each other. The <unk> 2 test, goodness-of-fit index (GFI), adjusted goodness-of-fit (AGFI), Tracker-Lewis index (TLI), and root mean square error of approximation (RMSEA) were used to estimate the GIF of the theoretical model. These analyses were performed using AMOS 21.0 for Windows. --- Results --- Demographic characteristics, depressive symptoms, stressful life events, and social support of suicides and comparisons A total of 242 suicide victims and 242 living comparisons were enrolled in this study. As shown in Table 1, 135 (55.8%) of them were male, and the mean (S.D.) age was 74 (8) years old. Compared with living comparison group, suicides were more likely to have unstable marital status, to be unemployed and be left-behind, and to live alone. No statistically significant difference was found in education, income, and storing pesticides at home between suicides and comparisons. Compared with living comparisons, suicides had significantly severer depressive symptoms, more stressful life events, and less social support (all p values <unk>0.001). Most suicides (227, 93.8%) and 86 (35.5%) comparisons had at least moderate depressive symptoms. The median (interquartile ranges) of number of stressful life events in suicides and comparisons were 6 (4-8) and 3.5 (2-7), respectively. The three most common life stresses in 460 Liang Zhou et al. suicides in the last year before death were suffer from chronic disease (191, 78.9%), hospitalization (132, 54.5%), and death of spouse (77, 31.8%). --- Suicide behavior and help-seeking behavior among suicides The most frequently used suicide means in our sample were pesticides (125, 51.7%), followed by hanging (95, 39.3%), drowning (nine, 3.7%), and poisons other than pesticides (eight, 3.3%). Most suicides (212, 87.6%) happened in homes. The mean (S.D.) score of SIS-8 was 6.88 (2.90). One hundred forty-four suicides (59.5%) had sought for help in the last month prior to death. Most commonly utilized health service was physicians other than psychiatrists (103, 42.6%), followed by village doctors (55, 22.7%), traditional Chinese medicine practitioners (nine, 3.7%), and mental health professionals (eight, 3.3%). --- Diagnosis of mental disorders As shown in Table 2, 122 (50.4%) suicides and 12 (5.0%) comparisons met at least one diagnosis of mental disorder. The most common mental disorder in the suicide group was mood disorders (120, 42.1%), followed by psychotic disorders (15, 6.2%), substance use disorder (14, 5.8%), and anxiety disorders (seven, 2.9%). Sixteen suicides and one comparison had two diagnoses. The prevalence of any mental disorder, mood disorders, psychotic disorders, and alcohol dependence was Psychological Medicine significantly higher in suicide than those in comparisons, while the difference of anxiety disorders did not reach statistical significance. --- Risks of elderly suicide: multivariable regression Conditioned multivariable logistic regression was used to determine the risk factors of suicide. Independent variables included in the model were marital status, employment, living alone, being left-behind, social support, stressful life events, depressive symptoms (GDS score was entered as a continuous variable), and diagnosis of mental disorder. Four variables entered the final model: unstable marital status (OR 4.19, 95% CI 1.61-10.92), unemployed (compared with employed, OR 4.43, 95% CI 1.09-17.95), depressive symptoms (OR 1.34, 95% CI 1.21-1.48), and mental disorder (OR 6.28, 95% CI 1.75-22.54) (Table 3). --- Test of the structural equation model Verification analysis of the structural equation model proved that the theoretical model was well validated (Fig. 1). The <unk> 2 test showed a significant probability >0.05 [<unk> 2 (1) = 1.717, p = 0.190]. GIF analysis showed that the model fit was high: GFI = 0.999, AGFI = 0.975, TLI = 0.986, and RMSEA = 0.039. The standardized total effects of predictors on suicide were: depressive symptom 0.615, life events 0.230, mental disorder 0.179, being left-behind 0.136, social support -0.085. --- Discussion Using a strict definition, being left-behind was significantly more prevalent in elderly suicides than in living comparisons (17% v. 10%). Structural equation model showed that being left-behind could elevate the suicide risk through increasing life stresses, depressive symptoms, mental disorder, and decreasing social support. This may explain our result that after controlling for these mediating factors using logistic regression, being left-behind is no longer associated with completed suicide. Emotional and instrumental support from family members, particularly adult children, is the central provider of care for rural elderly because of the deficiency of external support (He and Ye, 2014). Although a study in Thailand showed that parents with children outmigrated received more economic remittance and therefore had less depressive symptoms (Abas et al. 2009), it seems that this is not the case in China. Migrants are generally cheap labor in cities and have limited income. Studies at population level found that urbanization contributed to the decrease of suicide rates in general population (Sha et al. 2017); however, this study indicates that urbanization may increase elderly suicide risk at the individual level. Suicide prevention strategies should be developed for left-behind older adults in rural China, as well as in other developing and urbanizing countries. The prevalence of mental disorders in elderly suicides was 50.4% (122/242), mostly mood disorders (42.1%, 102/242). These results were similar compared with previous studies in China. In a study of 304 suicides older than 55, authors reported that 64.8% suicides had at least one diagnosis of mental disorder, and the most common diagnosis was mood disorder (45.7%) (Zhou et al. 2004). Study in youth suicides in China showed that the prevalence of any DSM-IV mental disorder and depression was 48.0% and 34.9%, respectively (Zhang et al. 2010). The prevalence of mental disorder among elderly suicides in different countries varied from 47% to 96.5%, but depressive disorder was consistently the most common mental disorder (Waern et al. 2002;De Leo et al. 2013;Innamorati et al. 2014). Different methods used to detect and diagnose mental disorders across these studies may contribute to these differences. The absence of diagnosable mental disorder does not indicate that there is no psychological distress. Depressive symptoms are highly prevalent among elderly suicides: most suicides (94%) had at least moderate depressive symptoms, and nearly two-third had severe symptoms. Both mental disorder and depressive symptoms are independent risk factors for elderly suicide after controlling for other risks. The most frequently used suicide means in our sample were pesticides, which is consistent with the previous studies in China (Phillips et al. 2002b;Zhang and Li, 2011). In earlier studies, in older (<unk>55) (Wang et al. 2007) and youth suicides (Zhang and Li, 2011), pesticide was used in 52% and 66% suicides, while hanging was used in 28% and 10.5% suicides, respectively. These differences might reflect the decrease of availability of pesticides in the past decade in rural China: pesticides were stored at home in 75.3% youth suicides (Zhang and Li, 2011). Another possibility is that elderly suicides have stronger suicide intent and are more likely to use violent means such as hanging. Our results have important implications in suicide prevention. Firstly, despite lower than previous studies, pesticide is still the most frequently used suicide means in rural China. Further efforts in restricting the accessibility of pesticides in rural areas are warranted. Secondly, nearly 60% elderly suicides had sought for help in the last month but only 3% had seen a mental health professional. This indicates that training rural physicians in identifying and referring individuals at suicide risk may prevent suicide among rural elderly. Thirdly, mental disorders and depression are important risk factors for suicide among elderly, and these conditions are rarely recognized or treated. To treat mental disorders, particularly depression, is of key importance for the prevention of suicide among elderly. Fourthly, we may buffer the negative impact of being left-behind through providing social support and enhancing social connections, treating mental disorder including depression, and mitigating life stress. Several limitations need to be considered when interpreting the results. Firstly, because of the lack of comprehensive vital reporting system in China, we relied on local public health professionals to identify suicide cases. Misclassification and underreport of suicide is a concern. We trained the personnel who were involved in reporting suicide death, and the manner of death was determined by trained interviewers. By doing so, we identified 242 suicide deaths and the male/female ratio in the sample was 1.26 (135/107), close to previously reported male/ female ratio of 1.4 among Chinese elderly suicides in 2013-2014 (Zhong et al. 2016). Secondly, there are methodological limitations in psychological autopsy studies. The use of proxy informants, the lack of blinding about suicide and comparison, and interviewing informants of suicides 2-6 months after death may have an impact on the reliability of the data. Third, it is important to establish temporal relationship between being leftbehind and the mediating factors that were examined in the structural equation model. Most mediating factors happened during the last 12 months before death or investigation, which means during the period of being left-behind. However, a few of them might have started before being left-behind, for example, persistent financial difficulties, chronic mental illnesses such as schizophrenia. Fig. 1. The relationship between being left-behind and suicide mediated by life events, social support, depressive symptoms, and mental disorder. The mediating effects of life events, social support, depressive symptoms, and mental disorder on the relationship between being left-behind and suicide were examined using structural equation model. <unk> 2 (1) = 1.717, p = 0.190, GFI = 0.999, AGFI = 0.975, TLI = 0.986, and RMSEA = 0.039.

Background. Suicide rate among rural elderly is the highest among all age groups in China, yet little is known about the suicide risks in this rapidly growing vulnerable population. Methods. This matched case-control psychological autopsy study was conducted during June 2014 to September 2015. Consecutive samples of suicides aged 60 or above were identified in three provinces (Shandong, Hunan, and Guangxi) in China. Living comparisons were 1:1 matched with the suicides in age (±3 years old), gender, and living location. Risk factors included demographic characteristics, being left-behind, mental disorder, depressive symptoms, stressful life events, and social support. Results. A total of 242 suicides and 242 comparisons were enrolled: 135 (55.8%) were male, mean (S.D.) age was 74 (8) years. The most frequently used suicide means were pesticides (125, 51.7%) and hanging (95, 39.3%). Independent risks of suicide included unstable marital status [odds ratio (OR) 4.19, 95% confidence interval (CI) 1.61-10.92], unemployed (compared with employed, OR 4.43, 95% CI 1.09-17.95), depressive symptoms (OR 1.34, 95% CI 1.21-1.48), and mental disorder (OR 6.28,). Structural equation model indicated that the association between being left-behind and suicide was mediated by mental disorder, depressive symptoms, stressful life events, and social support. Conclusions. Unstable marital status, unemployed, depressive symptoms, and mental disorder are independent risk factors for suicide in rural elderly. Being left-behind can elevate the suicide risk through increasing life stresses, depressive symptoms, mental disorder, and decreasing social support. Elderly suicide may be prevented by restricting pesticides, training rural physicians, treating mental disorders, mitigating life stress, and enhancing social connection.

Introduction Approximately half (41.7%) of US Black women, including Caribbean women, currently comprising of one of the fastest-growing ethnic groups, have reported physical intimate victimization in their lifetime [1][2][3][4]. Studies show that early childhood exposure to violence within families and the neighborhood context are precursors to intimate partner violence as an adult [5]. Statistics indicate the rate of child abuse among African Americans in the United States is second highest only to American Indian and Alaskan Native [6]. While there is general knowledge surrounding the association between adult intimate partner violence and child abuse, less is known about the role of neighborhood violence context exposure on intimate victimization among US Black women [7]. To inform intervention and preventative practices, research geared to understanding the interconnectedness of violence at the individual and community levels is necessary due to high and rising levels of child abuse and reported cases of violence within the Black population [8][9][10][11]. Child abuse is one of many childhood adversities that can be a precursor for violence in adulthood [12]. Studies suggest the link between child maltreatment and adult intimate partner violence may be influenced by childhood experience and mental disorders [5,13]. However, there is a void in the literature on how social behavior and mental conditions might moderate the relationship between child maltreatment and adult intimate partner violence among US Black women and other understudied populations (i.e., Latinx, Native American, Asian American, Immigrant and Refugees). This study utilized population-based data to explore IPV in association with child maltreatment and neighborhood violence among US Black women with a specific focus on African American and Caribbean Blacks. --- Background Research has long found a connection between a history of exposure to violence and intimate victimization [5,11,[14][15][16]. Studies largely suggest that experiencing or witnessing acts of aggression can influence perpetration or victimization [11,14,17,18]. Social learning theory posits that acts of violence are learned through imitation; and such acts internalized may influence our approach to addressing disputes in interpersonal relationships [19,20]. The framework evaluates behaviors that are normalized and rewarded while examining operant methods that provide explanations on how experiences with child abuse or exposure to violence may be linked to adult victimization [21]. For example, children who are exposed and/or socialized in violent-prone environments may be more accepting of certain behaviors, and therefore, are more likely to resort to such practices during their relationships in later life. The intergenerational transmission hypothesis further contends that violent behavior is learned through modeling and imitation, and such behavior is particularly acquired in the early life course during childhood and through observation of parents and peer relationships [22,23]. Moreover, violence within the home or against children is rooted in the subconscious and intergenerational cycle of violence that perpetuates from one generation to the next [24,25]. --- Child Abuse and Intimate Partner Violence Studies have demonstrated that there is a co-occurrence of child abuse and adult victimization [5,11,14,15,18,26]. Notably, harsh physical treatment and disciplinary measures in childhood have been found to increase the association of violence in adulthood [8,21]. For example, children growing up in violent homes are at risk of becoming victims of IPV [27]. Women in particular, who were raised in violent households, are at greater risk for suffering and becoming victims of intimate partner violence [26]. Although there is a general knowledge about the potential connection between child abuse and intimate partner violence, the understanding among ethnic groups where physical punishment is a method of disciplinary practice used by a parent or caretaker in rearing children, remains limited [28]. Nonetheless, there is some evidence that suggests childhood victimization increases the risk for physical, psychological, and sexual victimization and perpetration into adulthood among Caribbeans [29]. In recent years, more emphasis has been applied to understand the nuance of this problem from a more intersectional perspective [30,31]. However, more inquiries are needed to understand the association between child abuse and intimate partner violence among U.S. Black women, who are more vulnerable to victimization compared to other populations [1]. While considerable progress has been made to understand these issues among Black Americans, there are still considerable gaps that delineate the experiences of Caribbean Americans, a growing sub-population, that has its own experience with violence. --- Childhood Exposure to Violence and Intimate Partner Violence Along with direct acts of child abuse research further recognizes that children's exposure to violence increases the risk for adult perpetration and victimization, as well [5,13,18,32]. Particularly, children who bear witness to, or are exposed to family violence, were found to be at increased risk of battering later in life [5,13,32]. Research has established that early exposure to family violence results in males being 3 to 10 times more prone to partner violence than males without exposure to violence [26]. The connection between children's exposure to violence and adult intimate perpetration and victimization has also been noted by various international studies. For example, women in Jamaica who had witnessed parental or family violence were found more likely to be physically abused by an intimate partner [33]. Gage earlier found that compared to Haitian women who had not observed their father beating their mothers, those who had such experiences reported significantly higher rates of emotional and sexual violence [34]. In Grenada, Jeremiah et. al. explored how the failure to address adverse childhood experiences-such as witnessing abuse among their parents continued to affect adult women that were associated with domestic violence [35]. Despite these findings, we still lack an understanding of the role of cultural norms in the relationship between children's exposure to violence and the risk for adulthood victimization. --- Neighborhood Violence Exposure and Intimate Partner Violence While the literature is relatively new in providing an understanding of the effects of neighborhood violence on intimate partner violence, the association has been mixed [17,18,36]. Reed and colleagues (2009) established that neighborhood violence in addition to perception about intimate partner violence is associated with increased perpetration of IPV among urban African American men [10]. A systematic review further links neighborhood environment and disadvantage with physical and sexual IPV while noting the influence of socio-economic factors (i.e., poverty, unemployment, income, education) [17]. This was supported by an earlier study that linked neighborhood disadvantage to IPV [37]. Conversely, little variation was found in the likelihood of male IPV concerning neighborhood crime in other studies, even though there was an increased likelihood of IPV experiences among women whose partners were involved in male-to-male violence [38]. Raghavan and colleagues additionally found that living in a neighborhood with high levels of social disorder and substance use increased women's exposure to community violence and subsequent IPV in adulthood [7]. --- Mediating and Moderating Effects of Child Maltreatment and Intimate Partner Violence Research suggests that the relationship between later intimate partner violence and child maltreatment including witnessing violence and child abuse, is not always linear and may be influenced by childhood adversities and mental conditions [39,40]. For some children or adolescents, the possibility of developing emotional and psychological problems in response to painful experiences with exposure to violence is not out of the ordinary during this critical stage of development. Studies have found experiences with maltreatment are accompanied by external and antisocial behaviors [5,18,40]. The association between child maltreatment and adult victimization may also be reflective of hostile behaviors often developed by abused children [18,40], particularly if the childhood trauma goes unacknowledged or untreated. Such hostile behavioral patterns, which may be a part of their coping strategy, are poor impulse control that may be present among perpetrators of violence [26]. There is evidence that child maltreatment might further be linked to the use and abuse of alcohol and other substances. Early substance abuse among children and adolescents is common, and often related to aggressive behavior that can continue into adult life [41,42]. Research additionally suggests personality disorders may have some influence on partner violence [40]. Ehresaft et al. found that personality disorder partially mediated the relationship between childhood family violence and adult partner violence [43]. Likewise, a prospective longitudinal study found that early behavior problems were associated with partner violence in adulthood [42]. Conduct disorder, in particular, was found to mediate the relationship between child abuse and partner violence [5,41]. Furthermore, conduct disordered behavior in early childhood and adolescence has been linked to IPV perpetration in later adulthood [44]. Irrespective of previous studies, potential moderators or mediators of intimate partner violence such as substance abuse, anti-social personality disorder, conduct disorder, and oppositional defiant disorder have yet to be fully explored in the relationship among US Black women using national data. --- Goals and Summary of Hypothesis Using a nationally representative sample, the present study sought to add to the body of knowledge by exploring the association between violence exposure and intimate partner violence among US Blacks with a focus on African American and Caribbean Black women. The specific aims of the study were to: (a) examine the relationship between child maltreatment (child abuse or witnessing violence as a child) and adult severe physical intimate partner violence (SPIPV); (b) address the relationship between exposure to neighborhood violence and intimate partner violence; (c) and to evaluate the moderating effects of substance abuse disorder, conduct disorder, anti-social personality disorder and oppositional defiant disorder in association with child abuse and later interpersonal violence. As with previous studies, we expected to find an association between severe intimate partner violence and both child maltreatment and exposure to neighborhood violence. We also expected that the relationship between child maltreatment and intimate partner violence would be moderated by mental disorders. --- Materials and Methods Data from the National Survey of American Life (NSAL), conducted over a three-year period between 2001-2003, were used to address the research aims. The NSAL to date is the most comprehensive study conducted on the mental and physical health of adult US Blacks, and the first nationally representative study of Caribbean Blacks residing in the United States (see Jackson et al. [45]). Multistage probability sampling methods were used to collect the data. Face-to-face interviewing was the primary method of data collection, with a smaller percentage (14%) collected by phone. In total, the sample consisted of 6082 participants: 3570 African American; 1621 Caribbean Black; and 890 non-Hispanic White respondents. African Americans were characterized as those with African ancestry but without Caribbean roots. Caribbean Blacks were those respondents of African descent who were either (a) of West Indian descent, (b) from a Caribbean-area country, or (c) had parents or grandparents who were born in a Caribbean area country [46]. Prior to the data collection process, informed consent was obtained from participants. Interviews on average were 2 h and 20 min in length. The response rate for the entire sample was 72.3 percent. Respondents received an honorarium of $50 for their participation in the study. For this study, approximately 3277 women of African descent were the focus of analysis. Data collection for the NSAL was approved by the University of Michigan's Institutional Review Board. --- Predictor Measures 2.1.1. Control Variables The control variables included age (in years), marital status, employment status, educational level, and poverty. Marital status was separated into married, partnered, separated or divorced, widowed, or never married. Employment status was divided into employed, unemployed, and not in the labor force. Educational level included less than high school, high school graduates, some college, and college-educated. Poverty status is an income-to-poverty ratio consisting of the participants' household income divided by the 2001 US Census poverty threshold for the number of adults and children living in that household. Ratios below 1.00 indicate that the income for the participants' household is below the official poverty threshold, while a ratio of 1.00 or greater indicates income above the poverty level. For example, a ratio of 1.25 indicates that income was 25 percent above the appropriate poverty threshold [47]. Two ethnic groups were examined: African Americans and Caribbean Blacks. Noted earlier, African Americans were persons who self-identified as Black but did not report Caribbean ancestry. By contrast, US Caribbean Blacks were persons who were descendants or had Caribbean roots [46]. US Blacks were inclusive of both ethnic groups. --- Child Maltreatment Child maltreatment is inclusive of two measures: child abuse and witnessing violence as a child. Child abuse was determined by the question, "As a child, were you ever badly beaten up by your parent or the people that raised you?" Response options were "yes" or "no." For witnessing violence, respondents were asked, "When you were a child, did you ever witness serious physical fights at home, like when your father beat up your mother (yes/no)?" These measured were combined for multivariate analysis. --- Neighborhood Violence Various markers of neighborhood violence exposure were used in the study. First, experiences with neighborhood crime were operationalized with the question, "How often are there problems with muggings, burglaries, assaults, or anything like that in your neighborhood?" Measured on Likert scale response options include: very often, fairly often, not too often, hardly ever, and never. The variable was recoded to reflect ever/often vs. never for bivariate analysis. Second, to address experiences with atrocities, respondents were asked, "Did you ever see atrocities or carnage such as mutilated bodies or mass killings (yes/no)?" Third, seen someone badly injured, was determined by the question, "Did you ever see someone being badly injured or killed, or unexpectedly see a dead body (yes/no)?" --- Moderators A modified version of the World Health Organization Composite International Diagnostic Interview (WHO CIDI) defined by the Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) was used to obtain information on respondents that met criteria for substance abuse disorder, antisocial personality disorder, conduct disorder, and oppositional defiant disorder (yes/no) [48]. Substance abuse disorder refers to the presence of either alcohol or drugs, or both. In addition to alcohol, the substances included are cocaine, tranquilizers, stimulants, pain killers, other prescription drugs, such as heroin, opium, glue, LSD, peyote, or any other controlled substance. The criteria for substance abuse do not include drug-related consequences of tolerance, withdrawal, or a pattern of compulsive use, and instead include only the harmful consequences of repeated use. Antisocial personality disorder (APD) is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. The pattern has also been referred to as psychopathy, or sociopathy. Because deceit and manipulation are central features of APD, it may be especially helpful to integrate information acquired from collateral sources. For the diagnosis to be given, the individual must be at least 18 years of age and must have had a history of some symptoms of conduct disorder before age 15. Conduct disorder (CD) involves a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. The specific characteristics of conduct disorder fall into one of four categories: aggression to people or animals, destruction of property, deceitfulness or theft, or serious violation of rules. The symptoms of CD include three or more of the following: deceitfulness, impulsivity, irritability or aggressiveness, reckless disregard for safety, irresponsibility, or lack of remorse. Oppositional defiant disorder (ODD) is a recurrent pattern of negativistic, defiant, disobedient, or hostile behavior toward authority figures that persists for at least 6 months, and is characterized by the frequent occurrence of at least four of the following: losing temper, arguing with adults, actively defying/refusing to comply with the rules of adults, deliberately doing things that will annoy other people, blaming others for his or her own mistakes or misbehavior, being touchy or easily annoyed, being angry and resentful, or being spiteful or vindictive. These behaviors occur more frequently than is typically observed in individuals of comparable age and must lead to significant impairment in functioning. --- Outcome Measure Intimate Partner Violence IPV was operationalized with the question: "Have you ever been badly beaten up by a spouse or romantic partner?" Response options were "yes" and "no." We assessed this single measure's validity by comparing it to the National Comorbidity Study Replication (NCS-R) dichotomously defined Conflict Tactic Scale within the Collaborative Psychiatric Epidemiology Surveys (CPES) [49,50]. Two tests were conducted to assess the measure's validity. The probability of agreement (OR = 4.5, p <unk> 0.001) [51-53], and area under the curve (AUC > 0.6) showed the item to have a fair association across estimates [54]. Five hundred and five (n = 505) Black women in the sample reported severe physical intimate partner violence. --- Analytic Strategy Descriptive statistics and bivariate (chi-square test, t-test) analytic procedures were employed to provide information on the sample distribution and SPIPV in associations with child maltreatment by a parent or caretaker, and neighborhood violent exposure within cohorts (e.g., US Black women, African American, Caribbean Black). Simultaneous multivariate logistic regression analysis was conducted to address the association between child maltreatment and adult intimate partner violence controlling for other factors. Within the analysis, moderating effects were assessed by including interaction terms for child maltreatment and mental disorders (e.g., child maltreatment X substance disorder). For these procedures, adjustments were made for complex sample design. Due to the underlying complex sample design, standard errors were corrected for weighting, clustering, and stratification. Adjustments were made for complex sample design and differential nonresponse. Stata 15.1 analytical software was used to produce statistical results. Significance was set at the 0.05 alpha level. Diagnostic test revealed an acceptable variance inflation factor (VIF), limiting collinearity concerns for the multivariate model. --- Sample Characteristics The average age of women within the sample was forty-three years (m = 42.5) old (see Table 1). A third (32%) of respondents never married. The socio-economic status of participants within the sample was different. Specifically, thirty-six percent of participants had a high school diploma. Almost two-thirds (63.7%) of respondents were employed. Meanwhile, nearly three-quarters (71.6%) of women lived at or above the federal poverty level. Finally, the majority of women in the sample were African American (93.8%). --- Results --- Analysis Examining the Association of Adult IPV, Child Maltreatment and Neighborhood Violent Exposure Variables among US Black Women Illustrated by Table 2 on US Black women in general, the rate at which they experienced child abuse was more than three times the percentage for victims of severe physical intimate partner violence (SPIPV) than non-victims (13.5% vs. 3.9%, p <unk> 0.001). For women who witnessed violence in the household as a child, the percentage of SPIPV was almost two-fold that of non-victims (36.3% vs. 17.6%, p <unk> 0.001). There were significantly higher percentages of SPIPV victims compared to non-victims (36.3% vs. 21.4%, p <unk> 0.001) among respondents who had seen someone injured. Among African American women, similar results were found as those previously noted (see Table 3). The proportion of severe physical intimate partner violence exceeded that of non-victims by three-fold (13.1% vs. 3.9%, p <unk> 0.001) for those who were the victim of child abuse. For respondents that witnessed violence in the household, the rates were significantly higher (36.7% vs. 17.9%, p <unk> 0.001) among those that experienced SPIPV than non-victims of IPV. The same was true for women who had seen someone injured; the percentage was significantly higher (36.0% vs. 20.9%, p <unk> 0.001) for those who experienced severe intimate partner violence than non-victims. The proportion of severe physical intimate partner victims significantly exceeded that of non-victims (22.2% vs. 3.3%, p <unk> 0.001) for Caribbean Black women who reported child abuse (see Table 4). Among those women exposed to neighborhood violence, there was a higher percentage of SPIPV victims than non-victims (94.3% vs. 82.2%, p <unk> 0.05). Although marginally significant, the percentage at which those who witnessed violence in the household were twice that for IPV victims than non-victims of SPIPV (27.8% vs. 12.9%, p = 0.064). --- Multivariate Analysis Examining Associations and Moderating Factors of Intimate Partner Violence among US Black Women Multivariate results show that the odds (AOR = 4.07, p <unk> 0.05 CI 1.11, 14.92, p <unk> 0.05) for severe physical intimate partner violence significantly increased among women who reported child maltreatment (see Table 5). In the absence of child maltreatment, however, there were other influences of severe physical intimate partner violence. First, the odds (AOR = 2.35, CI = 1.33, 4.16, p <unk> 0.01) for SPIPV increased among women who met criteria for conduct disorder. Furthermore, anti-social personality disorder both increased the possibility (AOR = 4.87, CI = 2.28, 10.41, p <unk> 0.001) and probability (AOR = 1.74, CI = 0.942, 3.22, p = 0.076; CI) of SPIPV. Moderating effects were not found between child maltreatment and severe intimate partner violence. The study results also indicate an association between socio-demographic factors and severe physical intimate partner violence. Notably, the odds (AOR = 1.06, CI = 1.03, 1.08, p <unk> 0.001) for severe intimate partner violence increased with age. Compared with married respondents, those separated or divorced were at increased odds (AOR = 2.52, CI = 1.25-5.06, p <unk> 0.01) for SPIPV. Finally, the odds (AOR = 1.77, CI = 1.13, 2.77 p <unk> 0.01) for SPIPV increased among participants living at or below poverty almost by two-fold compared with those living above the poverty threshold. Collectively the independent variables in the model explained 14 percent of the variance in severe intimate partner violence. --- Discussion The results of the study provide theoretical support for social learning theory and the intergenerational transmission model. By and large, the study indicates that child abuse is linked to victimization in adulthood among US Black women, as with other populations [5,33,55]. This was evident in bivariate analysis across cohorts. While there was an association between exposure to violence and severe intimate partner violence, our study revealed that these experiences differ by ethnic groups. For Caribbean Black women, exposure to neighborhood violence was associated with adult victimization. Meanwhile for African Americans, witnessing violence and seeing someone injured was related to severe intimate partner violence. The findings and differences found between ethnic groups are difficult to explain. Quite possibly, this might be influenced by the cultural differences between Caribbean Blacks and African Americans in terms of how violence is defined and interpreted. However, the findings may point to the commonality of social, economic, and environmental conditions facing Blacks in the United States, including sources of stress, which might expose women to subsequent victimization. As evident in this study, racial and ethnic minorities including Caribbean blacks and African Americans face issues of poverty rate which might confine them to neighborhoods with higher criminal activities and violence, less economic resources and opportunities. There is also evidence that immigrant groups may more so face these challenges due to high rates of poverty after arrival and the absence of generational capital that has been accumulated by US Blacks [56]. Even though there was confirmation regarding the association between child maltreatment and severe intimate victimization in multivariate analysis, our study, in general, did not find any support concerning the moderating effects of mental health disorders. Nonetheless, we did find that independent of child maltreatment, the risk for adult intimate partner violence increased among US Black women who met criteria for conduct and anti-personality disorders. Although these results were either partially or fully supported by previous studies [40,[57][58][59], the mechanism by which these factors influence intimate partner violence among US Black women is less clear. The study results further showed that separated or divorced Black women were at an increased risk for intimate victimization. This could reflect the escalation of violence after the women leave or attempt to leave the relationship [60]. It should also be noted that some divorced or separated women may still be in abusive relationships, even though their relationship status had changed. Additionally, this research found that violence among women within this population increased with age. This finding contradicts other research trends that find that exposure to violence generally reduces with age [61]. Finally, women living in poverty were found to be at increased risk for intimate partner violence, which is consistent with previous research [5,[62][63][64][65][66]. Known to many, poverty contributes to stress and increases the possibility of violent explosive encounters in relationships [67]. --- Limitations of the Study We acknowledge that this study has a few limitations. First, cross-sectional data were used for this study, limiting causal inferences about the relationship between intimate partner violence and both child maltreatment and neighborhood violent exposure. As such, it is difficult to determine the temporal ordering of the relationship. Studies using longitudinal data are necessary for clarifying these relationships. Second, the study was retrospective and may be subject to recall bias, especially for those who have experienced victimization in early life. Therefore, memory lapses could cause participants to attribute certain conditions to other traumatic experiences. Third, the data used for this study is over a decade old and may not reflect current events, though the relationship is not likely to change over this period [68]. The data used for the study to our knowledge is the only available national data that allowed for the examination of the study goals, particularly in respect to ethnic groups within the US Black population. Furthermore, a single binary measure was used to address severe physical intimate partner violence. Even so, such a measure has been used in studies of this nature before [54,64]. Moreover, a comparison of the NSAL IPV indicator with the CTS found a fair agreement with the measure [54]. The measure used for this study also allowed for examining the relationship between child maltreatment, violence exposure, and adult victimization among black women. Additionally, only physical intimate partner violence was examined in this study. Other forms (e.g., psychological/emotional/verbal) of abuse were not evaluated due to data limitations. Finally, sample size issues prevented us from independently examining the moderating effects of child abuse and witnessing violence as a child on the mental disorders of women in this study. --- Benefits of the Study Despite the limitations, this study sheds light on the issue of child maltreatment as an important factor in the trajectory of victimized Black women, which has been lacking empirically using data at the national level. The study also addressed the contribution of other disorders on intimate partner violence. This research further provides insights into the significance of the potential role of structural and environmental conditions that are prominent in the lives of US Blacks which might influence victimization. Finally, this research highlights that while similar in some regards, there are differences that exist ethnically and culturally regarding the association of child maltreatment and neighborhood conditions in relation to Black women's experience with intimate partner violence. --- Conclusions The study has implications for prevention and intervention strategies for IPV. More notably, the findings reinforce both the short-and long-term outcomes of child abuse and witnessing violence as a child. Along with the immediate traumatic effects on the health and well-being of children, child maltreatment can contribute to a cycle of violence that has been known to influence intimate partner victimization or perpetration, placing US Black women at risk for poor outcomes. While some ethnic groups continue to endorse physical punishment, it is becoming more apparent that this method of discipline can contribute to a larger problem in later life. Therefore, other forms of non-violent disciplinary measures should be considered at the earliest stage of the life course. Along with child abuse, the study suggests possible exposure to violence resulting from poor social, economic, and environmental conditions circumstances may serve as a precursor for future violence. Hence, there is a need for preventative measures particularly in impoverished areas where individuals are likely to face these realities in their homes and neighborhoods. Likewise, primary, secondary and tertiary prevention of childhood exposure to violence (group and one on one counseling, addressing defiant behavior, engaging in restorative justice, etc.) can be used as a deterrence for adult IPV victimization and perpetration. Finally, additional studies are necessary to better understand the general and mediating effects of conduct and antisocial disorders and their association with intimate partner violence within minority populations. --- Data Availability Statement: The public use NSAL data is archived at the University of Michigan-ICPSR. --- Author Contributions: K.K.L., H.R.S. and R.D.J. contributed to the conceptualization and writing of the manuscript. K.K.L. contributed to the interpretation and analysis of the data. All authors have read and agreed to the published version of the manuscript. Institutional Review Board Statement: Data collection for the NSAL was approved by the University of Michigan's Institutional Review Board. Informed Consent Statement: Secondary data were used for this study. --- Conflicts of Interest: The authors declare no conflict of interest.

Background: Research suggests that intimate partner violence (IPV) is associated with childhood maltreatment and violence exposure within the neighborhood context. This study examined the role of child maltreatment and violence exposure on intimate partner violence, with the moderating effects of mental disorders (IPV) among US Black women. Methods: Data from the National Survey of American Life (NSAL), the largest and most complete sample on the mental health of US Blacks, and the first representative sample of Caribbean Blacks residing in the United States was used to address the study objectives. Descriptive statistics, chi-square test of independence, t-test, and logistic regression procedures were used to analyze the data. Results: Bivariate results indicate an association between child abuse and intimate partner victimization among US Black women. Witnessing violence as a child as well as neighborhood violence exposure was also related to IPV but shown to differ between African American and Caribbean Black women. Multivariate findings confirmed the influence of mental disorders and social conditions on US Black women's risk for IPV. Moderating effects of child maltreatment and mental disorders in association with adult IPV were not found. Conclusions: The study addressed the short and long-term impact of child maltreatment and the contribution to the cycle of intimate violence among US Black women including African American and Caribbean Blacks. The study suggests the need for prevention and intervention efforts to improve structural conditions for at-risk populations and communities predisposed to violence and other negative outcomes. Possibilities for future research are also discussed.

Early years and missionary service A lifelong Methodist, Agnes Crawford Leaycraft was born in New York City to affluent parents who were active in the Methodist Episcopal Church. Her father ran a real estate firm in Manhattan. 9 She attended Barnard College in New York City beginning in 1894 and graduated in 1901 after a course of study that included mostly English classes. 10 She also took at least one introductory anthropology course, which was probably taught by either Franz Boas (known as the father of American anthropology) or Livingston Farrand. In the late 1890s women were not permitted to take advanced anthropology courses at Barnard or Columbia. 11 In 1899 she also became active in the Woman's Foreign Missionary Society of the Methodist Episcopal Church, a foreshadowing of her life's work. 12 As a New York City resident with interest in foreign missions, it is likely that she also attended the famous Ecumenical Conference on Foreign Missions, which took place in Carnegie Hall in 1900 and featured a missionary exhibit of cultures from around the world. 13 This missionary exhibit may have inspired Donohugh's interest in anthropology. One searches in vain for details about Agnes's life in the few years immediately after graduating from Barnard in 1901. We know she met a Philadelphia Methodist attorney, Thomas S. Donohugh, who was discerning a call to missionary service. 14 It is possible that Agnes met Thomas at a 1903 conference held at Silver Bay, New York, sponsored by the YMCA (with significant Methodist participation) for young adults interested in missionary service. Shortly after the conference Thomas applied for missionary service with the Methodist Episcopal Church, and by 1905 he was serving near Delhi, India. He returned to America and married Agnes in June of 1906. 15 They had their first child, Agnes Carol, in New York late in 1907 before returning together to India around 1908 or early 1909. 16 Agnes and Thomas Donohugh served in India for four years, where Thomas focused primarily on education and administrative oversight of Methodist work in the region. Agnes's father raised over $2,000 shortly after they arrived in India for the construction of a boys' school they were running. One of the missionaries Thomas Donohugh had oversight of was the not-yet-famous E. Stanley Jones, who had arrived in India in November of 1907. Three decades later Time magazine would describe Jones as "the world's greatest Christian missionary." 17 The activity of Agnes Donohugh as a missionary is not well-documented. Doubtless much of her energy was spent raising daughter Carol and then son Crawford, born in India in December 1910. 18 But caring for her children was far from all she did. Years later, after graduating from Columbia University, Agnes Donohugh reported to Boas that she and her husband recognized during their service in India how valuable anthropological training was for their ministry. 19 We were among the village people of Northern India, at Meerut, in the United Provinces, and we needed to know something of village organization of family and caste regulations, the great antiquity of certain customs, and the religious practices of the lower castes. It was slow work acquiring the knowledge first-hand when we did not know how much there was to find out. Since studying in the Anthropology Dept. I have made a beginning in such study. 20 The cultural phenomena that most interested Agnes and Thomas were the "mass movements," or "caste movements," of Indians to the Christian faith. In 1913 Thomas Donohugh published one of the first articles on Christian mass movements, which twenty years later were more thoroughly studied by Methodist missionary colleague J. Waskom Pickett in his Christian Mass Movements in India. 21 Agnes's experience as an undergraduate student in her single anthropology course at Barnard College meant she had more training in anthropology to draw from in understanding these caste movements than any American missionary in the world. But as she told Professor Boas years later, she wanted to know more. --- Graduate school and scholarly contributions Agnes and Thomas Donohugh returned to New York City in 1912. Thomas began working with the Methodist Board of Missions in charge of missionary recruitment, and Agnes began graduate work at Columbia University. 22 At the time that she began work toward her MA in anthropology, she may have been one of just two women in the program. Donohugh and Laura Watson Benedict (1861-1932) were also two of just a handful of students in their program with extensive overseas experience. 23 Agnes Donohugh reported that she took "all the courses in anthropology which were offered." 24 Some of these courses were with Boas, but Alexander A. Goldenweiser was her primary adviser. Doubtless because of both Goldenweiser's and Boas's influence, as well as the challenges of travel during World War I, Donohugh chose to focus on the Salish Indians of British Columbia for her 1916 master's thesis, entitled "Knowledge and Interpretation in Salish Culture." Donohugh's thesis made at least two contributions to the discipline of anthropology. First, she called into question the general tendency of evolutionary anthropology to look down upon persons of other cultures, whom "we are pleased to call primitive.... It is clear that early writers on Anthropology, in so far as they dealt with the mental qualities of primitive man, were hampered by the scarcity of accurate information then available concerning the primitive cultures which they characterized." 25 She was a clear Boasian in her thinking and followed Boas in his strong critique of evolutionary anthropology. 26 Donohugh's second contribution to her field was of an epistemological nature. She critiqued, for example, the tendency of scholars to focus excessively on the "peculiarities of magical interpretation of primitive man," instead of seeing such interpretations from "a common sense view." 27 She critiqued previous portrayals of magic as exotic by pointing out Westerners' own unstated but nonetheless real magical inclinations. Changes in weather caused by unusual happenings such as births, deaths, calamities; portents of death in dreams, in the cry of an owl at night, of a coyote at night near a dwelling, of a dog howling, of a cock crowing in the night, all these show the magical intrusion with which we in our own civilization are familiar. We are hardly in a position to use such evidence as proof of a lack of matter-of-fact knowledge and pervasive magic so long as our own nerves tingle almost involuntarily to similar fears or dreads. 28 Throughout her career Donohugh supervised a number of PhD dissertations on issues related to magic and religious belief in other cultures. During Donohugh's tenure at the Kennedy School of Missions, the institution produced half the anthropology dissertations in America that focused on some dimension of magic or religion. 29 The four letters that have been preserved between Donohugh and Professor Boas after she graduated from Columbia suggest that her relationship with Boas was cordial. Boas tended to have better relationships with female students than with male students. 30 Her longest letter-seven handwritten pages-is especially important for three ways Donohugh sought to influence Boas. The main purpose of her letter was to convince Boas to allow her to teach anthropology courses at Columbia University in the Department of Extension Teaching during the 1918-19 academic year. Boas granted her request. The letter also shows how Donohugh tried to change how Boas thought about missionaries' contributions and her own ability to make a contribution as a woman in the field. In arguing for the significance of missionaries' contributions, she explained to Boas that there were twenty-six returned missionaries from China studying at Columbia University and urged that they be taken seriously for the contribution they could make to anthropology. Of course, the question of the preparation of missionaries is one which does not interest you, perhaps, especially in relation to Anthropology. There is this to consider in the matter: that the missionaries are being sent out steadily, year after year; the effort is being made by all the larger agencies to send out better prepared people in each year, and to that end time is being allowed them to get as much specific preparation as is available.... If to this were added, the anthropology of the country, so given that the newcomer would have an introduction to the manners and customs, the background of thinking, the traditions, which would indicate some of the things not to do, and also some of the lines for very profitable study while with the people, this would add to the equipment a valuable item. This may not appeal to you, but since missions seem to be so an established feature, and modern civilization is making such inroads anyhow among primitive populations, I feel very keenly that science could use much which is easily accessible to the missionary on the field in the recording of rapidly disappearing beliefs and customs. But this will not always be done unless those going out know what to look for. We cannot hope these anthropologists as missionaries! But we can train some missionaries in Anthropology. 31 Donohugh was most likely the first missionary Boas ever taught. This letter suggests that she had earned his respect. Donohugh's long letter also challenged Boas in his attitude toward women in anthropology. In making her case that she should be permitted to teach the ethnology course on Africa and China, Donohugh displayed a bold, fighting spirit: My ambition to help in extending interest in Anthropology (not to "popularize" it however!) is perhaps over-reaching the bounds of propriety, but having greatly profited by my own study I am eager to introduce others to it who in their choice of life work can gain very much by including such study, and can also be equipped to make genuine contributions to science. And I hope you do not class me as one of the restless, discontented women, who has enough to do already and ought not to "dabble" in Anthropology. I am not in need of a "job" nor a "hobby," but am genuinely interested in the study of the problems concerning primitive people. I have no "ulterior motives," nothing to conceal, only a desire to become properly qualified to add something to the sum of human knowledge. My ability to do this is yet to be proved, great as is my hope some day to win such recognition. My aim is to complete the requirements for the Ph.D. within the next three years, as early in that time as I can do so. 32 This excerpt notes Donohugh's intention to obtain a PhD in anthropologysomething she never did, even though she helped over a dozen of her students write their dissertations. Agnes Donohugh was no pusillanimous wallflower; she may have rightly discerned that Boas needed to be pushed. Nearly half of the sixty PhD students Boas had supervised by the end of his life, however, were women, which does not mean that in 1918 he was already positively disposed toward women in anthropology. 33 He was moving in that direction, however, even before Donohugh's letter. 34 By 1920 he remarked to an anthropologist colleague that he "had a rather curious experience in graduate work during the last few years. All my best students are women." 35 Since Boas had encountered only a few women graduate students by 1920, Agnes Donohugh was probably one of the persons he had in mind. She may very well have helped to prepare the way for the dozens of women anthropologists who later studied with Boas. Agnes Donohugh did not continue to teach at Columbia University after the 1918-19 academic year, but she continued to make contributions to the field of anthropology through her publications and participation in professional societies. By her own admission, her publication record was not extensive. She was nevertheless a fellow of the Royal Anthropological Institute, the Royal Geographical Society, the Royal African Society, the American Geographical Society, and the American Ethnological Society. She was even a member of the council for the American Anthropological Association. 36 She occasionally presented anthropology papers at professional societies, including the 1931 gathering of the British Association for the Advancement of Science, where she presented the research she did in the Belgian Congo in 1929 assisted by Methodist missionary Priscilla Berry. 37 Upon her return from the Congo, Donohugh evidently also made a modest contribution as an anthropologist in the related field of what is today called African American studies. Donohugh participated in a lecture series at Columbia University's Teacher College entitled "Lectures on Negro Education and Race Relations." She gave the first of ten lectures of the series, held during the winter and spring of 1930. The title of her lecture was "The African Background of American Negro Life." W. E. B. Du Bois was one of the lecturers in this series as well. Four years after the lecture series, Du Bois became the editor-in-chief of an encyclopedia project funded by the Phelps-Stokes Fund, and Agnes Donohugh assisted in preparing for publication the final manuscript, which became Encyclopedia of the Negro, Preparatory Volume. 38 Agnes Donohugh's interest in teaching about African cultures and education in Africa brought her into extensive contact with the Phelps-Stokes Commission, which sought to develop educational institutions on the continent of Africa and in the United States. 39 During the interwar years, the International African Institute-which received financial backing from the Phelps-Stokes Commission-became the single greatest supporter of anthropological research, involving missionaries, anthropologists, and colonial agents. 40 The Rockefeller Foundation provided a substantial part of its funding as well. It is not surprising that both of Agnes Donohugh's journal articles in the field of anthropology were also published by the institute's journal Africa. --- Teaching and missionary training At the Kennedy School for Missions, Donohugh taught a wide array of graduate courses beginning in 1918. In 1926 she was named associate professor of ethnology; in 1936, full professor. Donohugh taught courses such as "General Ethnology," "Ethnology of Africa," and "Ethnology of India and Southern Asia." In later years she taught a two-semester course "North American Indians" and semester-long courses "Psychology of Primitive Peoples," "Primitive Religion in Africa," "African Social and Political Institutions," and "Studies of Tribal Life." 41 Her course outlines reflect a Boasian influence on her teaching in that she tended to focus a great deal of attention on historical anthropology. Perhaps Agnes Donohugh's most creative course, one that was likely not taught at Columbia University or perhaps at any other institution in her day, was entitled simply "The Life of Women." It was first taught in 1925, and she described it as an "analysis of problems of women at home and abroad. The art of living, in primitive and advanced society." 42 In proposing the course to the seminary administration, she mentioned that she had been "gathering material for years." 43 She was an avid supporter of missionary women and advocated for special attention to girls' education in Africa. In 1942, two years before her retirement, Donohugh also tried unsuccessfully to persuade Kennedy School dean Malcolm Pitt to permanently hire another woman, Esther Strong, to teach courses related to social psychology and "inter-cultural relations." 44 Her course outlines at the Kennedy School do not give much indication about how she integrated Christian theological perspectives in her teaching, but an outline for an Africa seminar in 1930 mentions "Points of Attachment for Truth." 45 This wording suggests that she was interested in contextualizing the Christian Gospel for the African context, thus infusing theological content into her teaching of anthropology. Donohugh could be quite adventuresome in her reflections about contextualizing the Gospel in Africa. It is even possible that in the African religious beliefs we might find that the divine attributes split up among a number of spirits or spiritual beings could be assembled under one expanded concept of a Supreme Being. So large a number of the elements already are present in African thought in many regions that transmutation or sublimation of much that is already there could effectively, easily, naturally evolve into a minimum Christian faith. The first thing to do is to recognize the claims, and their values, and then to devise means for using the native social machinery. 46 Her bold pronouncement concerning African traditional religions is especially noteworthy, for Agnes Donohugh spent very little time in Africa during her life-surely far less than a year. She may have benefited, however, from her husband's knowledge of the African context when his mission board role changed to include oversight of African mission. 47 The priority Donohugh placed on teaching, on the crafting of a curriculum, and even on the nurturing of students outside the classroom was an important expression of her vocation. "Dependence upon the giving of courses and the teaching of subjects is inadequate in sound missionary preparation. The individual person is the subject of education, and the objective is an integrated personality, with a well-rounded preparation." 48 Donohugh stayed at the Kennedy School during the week and returned by train to New York only on the weekends, giving her rich opportunities to contribute to her students' "well-rounded preparation." Her presence on Hartford Seminary's campus during the week may also explain why she exerted so much influence on her students' PhD dissertations. Donohugh's most significant academic contribution to the field of anthropology was through her students. Between 1933 and 1946 Donohugh is gratefully acknowledged in eight of the fifteen Kennedy School of Missions dissertations that had an anthropological focus. No other faculty member in these dissertations is mentioned even half as frequently or with greater appreciation than she was. 49 While most students went on to impact primarily their field of missionary service, a few made a significant impact on the field of anthropology. 50 Donohugh's concern at the Kennedy School for the curriculum, for students' personal lives, and for rigorous anthropological research had ramifications for the wider world of Christian mission education. Many sought her advice on this topic. In her own denomination she was an outspoken advocate for anthropological education for missionaries. Thomas Donohugh's work with the Board of Missions of the Methodist Episcopal Church helped her to develop relationships with mission boards, and he also helped to recruit Methodist missionary candidates to the Kennedy School. 51 During her career she served as chairperson of candidate and personnel committees for missionaries serving overseas, which gave her insight into the missionaries' challenges of cultural adjustment. 52 She had an expansive vision for how anthropological training of missionaries might occur outside of formal educational institutions. After meeting fellow Methodist mission leader John R. Mott at the January 1936 Foreign Missions Conference, she wrote to him about funding what today might be called a distance education project in the study of anthropology for missionaries already on the field. Donohugh proposed that, for her sabbatical the following year, she travel to a number of sites in Africa in order to give such training and that, if successful, this training be expanded for the Indian context. She made this request of Mott a few years after the well-funded Laymen's Foreign Missions Inquiry and, in her letter to Mott, expressed some annoyance at its great expense when compared with her proposal. 53 One of Agnes Donohugh's last publications was a study guide for Americans to reflect upon the continent of Africa in light of American and British foreign policy in the midst of World War II. Neither a work of anthropological scholarship nor a project exclusively aimed at missionary training, this work represents Donohugh's effort to influence American public policy through what has been called public diplomacy. 54 Her 16-page study guide was intended to be read alongside a 164-page study by the Committee on Africa, the War, and Peace Aims entitled The Atlantic Charter and Africa from an American Standpoint. 55 The Atlantic Charter was a set of eight points agreed upon by President Roosevelt and Prime Minister Churchill during their secret shipboard meeting on August 14, 1941, in the North Atlantic. The agreement provided direction for the postwar "extension of the sovereignty, self-government and national life of the states and nations of Europe." 56 While the Atlantic Charter was not originally intended to address the African context, the Committee on Africa, the War, and Peace Aims believed that Roosevelt and Churchill's eight points represented a prime opportunity to make its case for a postcolonial Africa. 57 The forty members of the Committee on Africa, the War, and Peace Aims came from a wide array of backgrounds, including missionary representatives Edwin W. Smith, Thomas S. Donohugh, and J. H. Oldham, as well as African American intellectuals W. E. B. Du Bois, Ralph Johnson Bunche, and Charles S. Johnson. Prominent Africans currently residing in the United States were also asked to contribute to the committee's work. One of these persons was Kwame Francis Nkrumah, the future first president of independent Ghana. While it is difficult to know the impact of Agnes Donohugh's study guide, it nonetheless demonstrates the reach of her interests in foreign policy and her commitment to promoting a postcolonial future for African countries. --- Conclusion Agnes Donohugh's contributions to anthropology, Native American studies, African and African American studies, missionary training, mission thought, the inclusion of women in a new academic discipline, and public diplomacy with regard to Africa are as extraordinary as the extent to which she has been forgotten. She was not only one of the first female students of Franz Boas but also his first graduate student with missionary experience. Her faithful diligence in promoting excellence in her students' PhD dissertations is especially noteworthy, given that she promoted her students' work at the expense of completing a PhD of her own. Her work to encourage the anthropological education of missionaries at the Kennedy School, in international conferences, and in Methodist denominational committees is something to reflect upon in an age where missionary anthropological preparation is still too slight. Donohugh's life as a scholar-practitioner in anthropology is instructive for missionaries and mission educators today for the way she chose to influence both her academic field of study and missionary practice. Doing so requires professional risks-including the risk of being forgotten. --- Notes --- Author biography Benjamin L. Hartley is associate professor of Christian Mission and Director of United Methodist Studies at Palmer Theological Seminary, the seminary of Eastern University, in St. David's, Pennsylvania. He is also scholar in residence at George Fox University, Newberg, Oregon.

taught at Hartford Theological Seminary's Kennedy School of Missions between 1918 and 1944, the leading graduate program in mission studies in North America prior to World War II. The first missionary student of Franz Boas at Columbia University, Donohugh influenced the shape of graduate anthropological education for missionaries in America more than anyone else in the interwar period. Donohugh's story provides a window into understanding how anthropology was first used in mission education in America.Just over one hundred years ago, in the spring of 1915, the Kennedy School of Missions at Hartford Theological Seminary, Hartford, Connecticut, offered the first graduatelevel course on ethnology (now more commonly "anthropology") ever to be taught in America to prospective and current missionaries. The Kennedy School was the premier graduate school for missionary training in the United States during and between the world wars. The seminary's leadership identified the need for teaching ethnology to missionaries-in-training as early as 1913, when the school of missions was just two years old. 1 The 1910 Edinburgh Missionary Conference played a role in this curricular innovation. Hartford Seminary president W. Douglas Mackenzie, in preparation for the conference, chaired its Commission V, "The Training of Teachers," which sounded a sobering call for improved anthropological training for missionaries. 2 Unsurprisingly,

Introduction People living with HIV/AIDS (PLWHA) present to the emergency department (ED) significantly more often than their HIV-uninfected counterparts. [1] This increased ED use, however, does not necessarily reflect severity of illness: ED visits among PLWHA, when compared to those without HIV, are no more likely to result in hospitalization. [1] Despite Department of Health and Human Services guidelines recommendation for continuous outpatient HIV follow-up, [2] many PLWHA frequently interface with healthcare systems through the ED. Frequent and repetitive ED use represents excess cost to individuals and society in that most issues can often be addressed in primary care settings at lower premiums. A pattern of healthcare use with increased reliance on the ED may be emblematic of discontinuous primary care rather than more severe medical disease. [3,4] On the other hand, some PLWHA who are engaged in HIV care may use the ED based on the recommendation of their HIV provider, or alternatively, to meet different medical, psychiatric, and social needs particularly during periods of extreme life instability (e.g. in the setting of homelessness or active drug use). [5][6][7] Individuals transitioning from the criminal justice system to communities are a vulnerable segment of society with a disproportionately high prevalence of HIV, [8] substance use disorders [9,10] with associated overdose and death, [11,12] mental illness, [13,14] and victimization. [15] Despite excellent virological control of HIV achieved while incarcerated, many of these benefits are lost upon release for reasons that have not yet been fully elucidated. [16][17][18] Multiple factors contribute to poor postrelease outcomes for HIV-infected prisoners transitioning to the community. [19] One plausible explanation for loss of virological control after release is problems accessing routine healthcare. [20] Among Texas prisoners, only 5% of PLWHA prescribed antiretroviral therapy (ART) filled their prescriptions within 10 days post-release [21] and only 28% enrolled in an HIV clinic within one month. [22] Without access to and engagement in comprehensive care, released prisoners experience high rates of relapse to substance use, [16,17] recidivism to prison or jail, [23] and reduced adherence to ART with loss of viral suppression. [16,17] As the ED is often the safety net provider for those without regular access to primary care services, understanding ED use in this vulnerable population is important for optimizing HIV treatment and other health-related outcomes. The objective of this study was to better understand factors associated with ED use among PLWHA in the year following release from prison. We calculated the 12-month event rate and correlates of ED use among HIV-infected released prisoners on ART. Our primary outcomes of interest were based on the Behavioral Health Model for Vulnerable Populations [24,25] of healthcare utilization and included quantity and type of ED visits. Because we expected that greater social and medical instability immediately following prison release would result in greater reliance on ED care, we additionally examined the time to first ED visit from baseline. --- Methods This is an observational longitudinal study of ED use among a cohort of released prisoners with HIV, prescribed ART and enrolled in a randomized clinical trial of directly administered antiretroviral therapy (DAART) versus self-administered antiretroviral therapy (SAT). All participants provided written informed consent to have their healthcare records reviewed at all designated sites. Ethical approval for all procedures was provided by the Yale University School of Medicine's institutional review board and the Connecticut Department of Correction Research Advisory Committee. The study's analytical plan was based on the Behavioral Health Model [26,27] that has been adapted for Vulnerable Populations. [24] This theoretical construct, depicted in Figure 1, proposes that healthcare utilization, including ED use, are driven by individual predisposing factors, enabling community resources, and need characteristics of populations and systems. Predisposing domains include demographic and social structures; enabling or disabling domains encompass personal, family or community resources; and need domains include perceived and objective measures of health, especially severity of disease. This model of healthcare utilization has been demonstrated to be applicable to homeless populations, [24] including HIV-infected persons released from jails, [28] who are socio-culturally marginalized in similar ways to released prisoners. --- Setting and Selection of Participants The 151 study participants were released prisoners with HIV who were enrolled in a randomized clinical trial of DAART versus SAT between 2004 and 2009; details of the study and procedures are described elsewhere and registered at clinicaltrials.gov (NCT00786396). [29,30] Eligibility criteria included age $18 years, laboratory-confirmed HIV infection, current receipt of ART, and planned return to Hartford or New Haven, Connecticut. Subjects were recruited from Connecticut prisons within 90 days of prison-release; however, community-referrals were allowed if the subject otherwise met eligibility criteria but were within 30 days after release to the community. In Connecti-cut, standard-of-care release procedures for prisoners with HIV involve receipt of a 14-day supply of all medications and standardized referral and appointments for continuity with patients' community-based primary care providers. Of the 279 potential participants screened, 202 were considered eligible, and 154 were ultimately enrolled. [30] Reasons for exclusion were ineligibility (75 were not on ART, had a sentence modification, were no longer interested, or did not return to New Haven or Hartford) or non-enrollment (48 changed city, had a sentence modification, or were no longer interested in participating). [30] After informed consent, study participants were randomized 2:1 to DAART or SAT and followed for 12 months after release; subjects were interviewed and assessed for HIV-1 RNA levels and CD4 counts quarterly. As part of the study, all participants received their ART from the AIDS Drug Assistance Program. Transitional case management additionally provided assistance with Medicaid enrollment and obtaining appointments at local HIV clinics. Adherence support was provided by trained outreach workers for subjects randomized to DAART and buprenorphine was offered if participants met DSM-IV criteria for opioid dependence and requested treatment. [31] Participants continued to receive all other healthcare from their primary providers. In previous randomized controlled trials of HIV-infected drug users, DAART was found to be superior to SAT in terms of HIV biological outcomes. [32]. --- Study Protocol As part of the baseline interview, participants signed a release of medical information for all ED facilities and other sites where they ever received or planned to receive medical care. Medical chart review was then conducted at the end of the 12-month period for enrolled participants at both EDs in New Haven and all three in Hartford to ensure complete coverage of each urban center and fully document the spectrum of ED utilization. The Veteran's Administration (VA) and psychiatric hospitals were not accessed for chart review (although all psychiatric units within EDs were included and are a conduit to psychiatric inpatient care); none of the subjects identified the VA hospital as their primary site of care. Charts were included from the date of prison release for the 12 months post-release. Medical records were reviewed for all enrolled participants, regardless of attrition in the parent study, with ED visits otherwise concurrent with clinical trial participation. Chart reviews were conducted in accordance with methods proposed by Gilbert et al. [33] Using standardized forms, a trained reviewer extracted the following information from ED records, most of which were electronic: time and status of triage and discharge, patient chief complaint on triage, provider diagnoses and associated diagnostic codes, results of urine toxicology tests, whether the ED visit resulted in hospitalization (including psychiatric hospitalization), disposition from the ED, and discharge medications. There were no illegible charts and as much data as possible was recorded for each visit; all visits were included in the final analysis. All chart reviews were performed and reasons for visit coded by one author (JPM), after which 15% of charts were randomly reviewed by a second author (GLL) and discrepancies were resolved by a third author (FLA.). --- Methods of Measurement The primary outcomes of interest were quantity and type of ED visits. Reasons for visit were based on the subjects' triage chief complaints (grouped by involved organ system) and provider diagnoses (all of which fit into the following major exclusive categories: mental illness, trauma, substance abuse, social/access problems, acute/febrile syndromes, or somatic syndromes that, for the purposes of this analysis, included any issues related to acute or chronic pain.). Unless noted, all other measurements were collected as part of the baseline comprehensive assessment. Demographics. Baseline demographic parameters were assessed as part of the previously validated [34] Addiction Severity Index (ASI), 5 th Edition [35] including age, self-reported race/ ethnicity, gender, education, marital status, and annual income. Anticipated housing status was categorized based on the question: ''How would you describe your expected living situation on the day of release?'' Subjects were considered homeless if they answered ''in a shelter'' or ''street or other public place;'' temporarily housed if they reported ''with a family member or friend temporarily,'' ''haven't decided yet,'' ''short term boarding,'' or ''drug treatment program;'' and permanently housed if they answered ''with a family member or friend permanently,'' or ''my own place.'' Surrogates of HIV biological severity. Absolute CD4 count and quantitative HIV-1 RNA levels were measured at baseline and at 3-month follow-up. These two time points were chosen because data was available for the majority of participants and results reflected the initial destabilizing post-release period. CD4 count (cells/mL) was described as continuous and dichotomous (,200 vs. $200) variables; viral suppression was dichotomously defined as having an HIV RNA viral load,400 copies/ml. History of abuse was measured on the ASI by self-report of any emotional, physical or sexual abuse in one's lifetime. These questions have been shown to be a highly sensitive screen for subjects with histories of substance use and post-traumatic stress disorders (sensitivity = 0.91) [36] Abuse was coded as a dichotomous variable indicating lifetime history of any physical or sexual abuse vs. none. Mental illness. Depressive symptoms were measured using the 16-item Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR) (a = 0.86, 0.73-0.92). [37] Scores were described continuously from 0 to 27 to measure depression severity and also classified dichotomously as major depression (score.11) vs. no or mild depression (score #11). Substance use disorders. Alcohol use disorders were measured using the Alcohol Use Disorders Identification Test (AUDIT) (a = 0.83, 0.75-0.97) with hazardous drinking defined as a score of $8 for men and $4 for women. [38,39] Lifetime alcohol and drug use was measured by the ASI and severity was assessed using previously validated continuous alcohol and drug composite sub-scores that range from 0-1 with larger values reflecting greater severity. [35] If the subject initiated buprenorphine, this was recorded as a dichotomous variable. Other health-related factors. Trust in physician was measured continuously using the 11-item Trust in Physician scale (a = 0.90). [40] Each item is scored on a 5-point Likert scale and a summary measure is equal to the unweighted mean of the responses (range 0-100 with higher scores reflecting higher levels of trust.) [41] Social support was measured continuously using the validated 31-item Social Support Scale (range 0-100 with higher scores reflecting greater social support). [42] HIV-associated quality of life was measured using the 36-item Medical Outcomes Study Short Form (SF-36) (a.0.80); [43] physical and mental health-related quality of life sub-scores were calculated separately using norm-based scoring (mean = 50, standard deviation = 10) with higher scores representing perception of better health. --- Statistical Analysis Descriptive statistics were applied to the total cohort, stratified by number of ED visits. Using Kaplan-Meier survival curve estimates with Cox proportional hazard ratios, we looked at time to first ED visit focusing on different social and medical instability factors (gender, study arm, lifetime history of abuse, and housing stability). Statistical significance was determined by log rank tests; individuals without any ED visits were censored. Because of documented associations between histories of physical/sexual abuse with frequent ED visits for somatic complaints or episodic diseases, [44][45][46] a univariate analysis explored associations between lifetime histories of abuse and each of the categories of patients' reasons for visit. To address non-Gaussian distribution of ED count data, Poisson regression was applied in multivariate models to determine the correlates of having any ED visit. Exposure time, defined as up to 12 months from study enrollment, was included as an offset variable. Multiple variables were evaluated for interaction or colinearity and none were found to be statistically significant. Based on the conceptual framework illustrated in Figure 1, we performed separate multivariate analyses of predisposing factors, need factors and enabling/ disabling resources, including age, gender, and ethnicity in each model a priori. A multiple Poisson regression model was then determined by a forward stepwise elimination procedure, including all covariates illustrated in Figure 1 with p,0.05 Akaike's Information Criterion (AIC) and Bayesian Information Criterion (BIC) were used to compare the multivariate models considered. [47,48] Incidence rate ratios with 95% confidence intervals are reported and p-values,0.05 are considered to indicate a significant difference. To evaluate ED visits likely related to lower medical or psychiatric acuity, a multivariate analysis examined any ED use that did not result in hospital admission using Poisson regression and including variables with p,0.05 by forward stepwise selection. All analyses were performed with statistical software STATA version 9.0 (StataCorp, College Station, TX). --- Results --- Participant Characteristics Of the 154 subjects enrolled in the parent trial, 130 were enrolled within 90 days pre-release and 24 were referred from the community within 30 days after release. Three subjects were excluded from the present analysis because they did not complete a full baseline interview or did not allow release of medical information, resulting in 151 evaluable subjects. Table 1 describes baseline characteristics of the total cohort and subjects with varying numbers of ED visits. Reflective of the statewide population of prisoners, [49] subjects were predominantly men (82%) and self-identified as black or Hispanic (87%) with 1162 mean years of education and negligible preceding-year annual legal income (data not shown). Nearly 80% faced homelessness or being temporarily housed upon release. This included 37 participants (25% of the total cohort) who planned to stay in a shelter, one (0.7%) on the street or other public place, 51 (35%) with a family member or friend temporarily, 16 (11%) who were undecided, three (2%) in short term boarding, and nine (6%) in a drug treatment program. At the time of release, the majority of subjects (80%) had achieved viral suppression. --- Emergency Department Utilization During the 12-month post-release period, 85 subjects visited the ED a total of 227 times, as depicted in Table 1. Over half (56%) of the total cohort visited the ED at least once and 15% frequented the ED more than twice per person-year. Principal reasons for visits, differentiating patients' reasons for visit from ED provider diagnoses, are described in Table 2. The majority of visits were for episodic/febrile syndromes, pain, substance misuse issues, trauma or accidents, and decompensated mental illness. None of the univariate associations between abuse and types of ED visits were found to be statistically significant (data not shown). Disposition from the ED included: 53 visits (23%) resulted in hospital admission, of which five involved direct transfers to an inpatient psychiatric unit. Seven subjects were released from the ED back into police custody. Twelve visits were considered incomplete either because the patient left the ED against medical advice or left before being seen by an ED provider. Figure 2 depicts the time from prison release to first ED visit, stratified and statistically different based on anticipated housing status. Kaplan-Meier analysis demonstrates that those who were permanently housed or homeless first visited an ED sooner (median 40 and 35 days, respectively) than did participants who were temporarily housed (mean 107 days, p = 0.014). There were no significant differences in time to first ED visit based on gender, randomization to DAART versus SAT, or history of lifetime abuse (data not shown). --- Correlates of Emergency Department Use Table 3 shows multivariate correlates of any ED use in the year following prison release. The stepwise elimination model, which used various factors from the predisposing, need, and enabling/ disabling domains, was found to be the best fit using AIC and BIC criteria. Participants who used the ED were more likely than non-ED users to be older, white, not married, and experiencing moderate or severe depression. Participants who used the ED expressed lower levels of trust in their physician, had poorer selfperceived physical health, and lower mean lifetime alcohol severity scores. Participants who used the ED were not significantly different from non-ED users in terms of any HIV biological outcomes. Those anticipating being temporarily housed upon release were nearly half as likely as housed subjects to use the ED. Multivariate correlates of the 174 ED visits that did not result in hospital admission are shown in Table 4. Subjects who were white, homeless, and had viral suppression at baseline were all more likely to have had ED visits that did not result in hospital admission. Those with higher lifetime alcohol addiction severity were less likely to have an ED visit not resulting in hospitalization. These subjects also reported poorer self-perceived physical and mental health with less trust in their physician. --- Discussion To our knowledge, this represents the first analysis of ED use among released prisoners with HIV on ART. The period of transition from prison to communities has been shown to be destabilizing, [11,23,50,51] and our empiric study of ED use provides additional evidence of medical, psychiatric, and social vulnerability during this transition period. This study substantially adds to existing published literature by illustrating how ED use is often driven by psychiatric and social instability after prison release, even for individuals with well-controlled HIV. Although our sample was relatively small, our findings are likely applicable to other populations of released prisoners with HIV in the U.S. A recent retrospective study in Rhode Island, for example, found significantly higher rates of psychiatric and substance use-related ED visits by released prisoners overall as compared to a general adult population. [52] Adding to this existing literature about the post-incarceration period, [53] our results further demonstrate the powerful impact of substance use co-morbidities, specifically drug or alcohol relapse, on ED use during this transition period. High prevalence of active substance use is reflected in our finding that 19% of ED visits were primarily for intoxication. Moreover, a significant proportion of visits were for trauma, wounds, accidents, exposure, and homelessness that are often indirectly related to active substance use. [54][55][56] Surprisingly, greater lifetime severity of alcohol use disorders was protective against ED visits, perhaps because individuals with long-term alcohol misuse are either socially isolated or are ''functional'' in spite of their substance use. Our data suggest that active intoxication and drug/alcohol relapse are more important markers of healthcare utilization than lifetime substance use severity. Hazardous drinking was not found to be associated with ED use in univariate or multivariate models. Post-incarceration, individuals may not have had time to relapse to alcohol use at a level of severity equal to that of baseline. While hazardous drinking was not significantly associated with increased ED use, more severe alcohol use disorders (e.g. harmful drinking, alcohol dependence) may be, and is a topic that warrants further exploration in future studies. Overall, in our cohort of released prisoners with HIV, social instability factors are disproportionately represented reasons for visits compared to the general U.S. adult population in the most recent national surveys on ED use. [57] It was somewhat unexpected, therefore, that temporarily housed participants had a significantly longer time to first ED visit than their housed or homeless counterparts and that they were half as likely as housed subjects to visit the ED. In other words, extremes of housing stability (i.e. being either homeless or permanently housed) were associated with ED visits sooner after release from prison. This counterintuitive finding may be related to the fact that the majority of temporarily housed were at least staying with family or friends and therefore experienced less social isolation, which appears to have had a protective effect against ED visits immediately following prison-release. It might appear to be the case that the temporarily housed group, based on our definition, included a disproportionate number of individuals entering drug treatment, but sub-analyses confirm that those entering treatment included only nine subjects and being temporarily housed remained protective even after removing them from the analysis. Regardless of housing stability, HIV-infected released prisoners overall are not dissimilar to other community-based vulnerable populations with HIV in terms of their heavy reliance on EDs for care. One recent study confirmed that ''hard-to-reach'' HIV populations, including the medically indigent, commercial sex workers, active substance users, homeless persons and prisoners, were significantly more likely to have had two or more ED visits in the prior 6 months (19.3% vs. 12.3%) when compared to a random sample of PLWHA. In another study, injection drug users in community settings having access to and utilizing low-threshold health services on a mobile health van reduced ED use, especially for those who were HIV-infected and had underlying psychiatric co-morbidity. [58] Importantly, these ''hard-to-reach'' individuals experienced excessive housing instability, unemployment, prior heroin/cocaine use, and mental illness. [59] In other communitybased samples, recent ED use has also consistently been associated with homelessness and untreated substance use disorders, social and medical co-morbidities faced disproportionately by released prisoners. [5,6,60] As a co-morbid condition, HIV itself may be a less important driver of healthcare utilization: participants in our study with HIV viral suppression at baseline were more likely to have an ED visit following release. This finding did not reach statistical significance in a step-wise multivariate model of ED use, though the study may have been underpowered to detect a difference. Our finding that increased ED use is associated with social access issues, mental illness and active substance use highlights the importance of addressing these factors as released prisoners adjust to community life, often in a destabilizing environment, after imprisonment. Notably for future research, these issues are amenable to interventions that might include provision of permanent housing, treatment for substance use disorders, or linkages to psychiatric care after release. [61] Multiple possible explanations and interventions have been proposed to improve HIV treatment outcomes during the immediate post-release period. [19] Previous research has confirmed that effective treatment of opioid dependence using buprenorphine during the 3-months post-release resulted in stabilized HIV treatment outcomes. [31] Another recent study further demonstrated that retention in buprenorphine treatment was significantly associated with reduced ED use in a cohort of opioid dependent patients accessing mobile healthcare services. [62] Though findings here did not demonstrate an impact of buprenorphine prescription on ED use, this may be explained in part because ED utilization appears to be more of a function of retention on buprenorphine, rather than receipt of a prescription. [62] In this sample, recent data confirm that retention on buprenorphine at 12 months was only 48%, but was associated with viral suppression. [63] Contributors to this low retention rate should be explored in future studies. The extent to which effective treatment of other substance use disorders affects HIV outcomes, however, has yet to be studied. [10] Ideally, such interventions would shift healthcare utilization from repetitive, episodic care provided in an ED and towards continuous primary and preventative care or, alternatively, to facilitate ED provision of a broader array of resources to those patients with highly comorbid social and psychiatric needs. The finding that participants with higher lifetime alcohol use severity were less likely to use the ED overall seems counterintuitive, yet among this group that used the ED, their ED visit was significantly more likely to result in hospitalization. This complements national-level findings that alcohol-related ED visits are four times more likely to result in hospitalization compared to nonalcohol-related ED visits. [54] Overall, 23% of all ED visits in this study resulted in hospital admission, a rate almost double that of the general U.S. emergency patient population. [57] In fact, it is a rate comparable to that reported in studies of frequent ED users with 6-20 annual visits. [64] The decision to admit any patient from the ED to the hospital is certainly multi-factorial and may be based as much on availability of hospital-or community-based resources as on medical acuity. The significantly high rates of hospital admission in this cohort, however, attest to the great social, psychiatric, and medical needs of this patient population resulting in high demands placed on healthcare systems. --- Limitations This study is a comprehensive assessment of ED use by released prisoners with HIV but represents the lower limits of ED use. All participants were on ART and two-thirds were receiving an intensive adherence intervention with DAART. Generalizability is limited by the relatively small population size and by the nature of participants' involvement in the RCT which provided increased attention and oversight. Although participants were concurrently enrolled in a RCT that included transitional case management, case management has not been shown to significantly affect rates of ED or urgent care clinic utilization in other studies of released prisoners with HIV. [65] Participants may have used EDs outside of these two urban centers, and we may therefore have inadvertently missed visits by more geographically and socially transient patients; however, previous studies on ED use in Connecticut [58] suggest that our data are likely to account for the overwhelming majority of ED visits. Subjects re-incarcerated during the study period may have experienced relatively restricted ED utilization, reflective of either decreased active drug use or provision of onsite primary care in a correctional setting. [17,23,51] Data from Texas, however, suggests that just 20% of released prisoners with HIV are re-incarcerated within three years. [23] Baseline assessments of subjects reflect a single time point and may not reflect variations in status over the 12 months of observation. These assessments are what is known as a person transitions to the community and may provide guidance a priori for interventions that might reduce ED use after prison release. In addition, we did not have access to information about participants' concurrent use of primary care, which may have confounded ED use. Last, this study lacks a control group; application of these findings to HIV-uninfected released prisoners or to other geo- graphic regions where drug use patterns of or available support services for released prisoners differ must be interpreted with caution. In spite of these limitations, this study has several important strengths in its design. Subjects' healthcare use was followed for up to one year after prison release regardless of attrition in the parent study. This allowed us to track individuals in the community for whom the only point of contact with the healthcare system was the ED. Second, much of the health services literature relies on selfreported ED use, which may be skewed by social desirability or recall biases. In a population of released prisoners, there is often a prevailing mistrust of the healthcare system that makes selfreport of healthcare utilization even less reliable. In contrast, our study objectively and comprehensively measured ED utilization based on medical chart review at all major EDs in the two urban centers of interest. Future research on this topic should include a control group of HIV-infected released prisoners receiving no intervention to better distinguish the impact of case management and adherence support on healthcare utilization patterns. From a health services perspective, future studies might explore ED use by including PLWHA who do not interface with the criminal justice system or people recently released from prison but not infected with HIV. We would exercise caution about interpreting such a study, however, because of the specific healthcare needs of PLWHA, the public health implications for retaining people in HIV care and on ART, and the unique destabilizing period that occurs during transition from prisons to communities. --- Conclusions In this study of healthcare utilization by PLWHA prescribed ART and recently released from prison, ED use was highly correlated with mental illness, active substance use and extremes of housing stability, but not with HIV-related medical illness. These co-morbid illness and social factors should be addressed by future interventions because, as illustrated by the ED visits described here, substantial need exists. --- Author Contributions Conceived and designed the experiments: FLA JPM. Performed the experiments: JPM JQ. Analyzed the data: JQ. Contributed reagents/ materials/analysis tools: JQ GLL NEC FLA. Wrote the paper: JPM NEC GLL FLA.

Background: Many people living with HIV access healthcare systems through the emergency department (ED), and increased ED use may be indicative of disenfranchisement with primary HIV care, under-managed comorbid disease, or coincide with use of other healthcare resources. The goal of this study was to investigate ED use by HIV-infected prisoners transitioning to communities.We evaluated ED use by 151 HIV-infected released prisoners who were enrolled in a randomized controlled trial of directly administered versus self-administered antiretroviral therapy in Connecticut. Primary outcomes were quantity and type of ED visits and correlates of ED use were evaluated with multivariate models by Poisson regression. Results: In the 12 months post-release, there were 227 unique ED contacts made by 85/151 (56%) subjects. ED visits were primarily for acute febrile syndromes (32.6%) or pain (20.3%), followed by substance use issues (19.4%), trauma (18%), mental illness (11%), and social access issues (4.4%). Compared to those not utilizing the ED, users were more likely to be white, older, and unmarried, with less trust in their physician and poorer perceived physical health but greater social support. In multivariate models, ED use was correlated with moderate to severe depression (IRR = 1.80), being temporarily housed (IRR = 0.54), and alcohol addiction severity (IRR = 0.21) but not any surrogates of HIV severity. Conclusions: EDs are frequent sources of care after prison-release with visits often reflective of social and psychiatric instability. Future interventions should attempt to fill resource gaps, engage released prisoners in continuous HIV care, and address these substantial needs.

INTRODUCTION In mid-July 2020, the Indonesian social media universe was shocked by the upload of a photo on the @joshirwandi Instagram account. The uploaded photo, which until now (December 15, 2021) has received 353,437 likes and 9,279 comments, has received various responses from netizens. Many expressed admirations for the uploaded photo, some felt that the photo had so many irregularities that it made no sense. Even an Indonesian musician, Anji also commented on the photo until it became a polemic. He thought that Covid-19 was not so dangerous, and argued that a photojournalist should not take photos in a hospital if the family cannot see the victim. Some of the singer's follower wrongly accused Irwandi of taking photos with a mannequin, and even called him a "slave" of the World Health Organization (Wijayanti and Mochamad, 2020:263). Wiku Adisasmito, Head of the Expert Team of the Task Force for the Acceleration of Covid-19 Handling, also commented that the person who took the picture of the corpse of a Covid-19 patient (Joshua Irwandi, 2020) was considered unethical. This also included those who spread it to go viral on social media (CNN indonesia, 2020). As is known, the Visual Communication Design Journal, Vol. 7 No. 2 (December 2022): 87-95 viral photo was actually taken to accompany an article in the August 2020 edition of National Geographic magazine. Beyond the debate, Joshua's photo was actually made with the aim of raising public awareness and vigilance about the virus, and to honor the work of medical staff in Indonesia and around the world who were willing to risk their lives (Beard, 2020). Nowadays, photography has become one o the media to convey messages to the audience both personally and a mass communication media. Photographic works are often interpreted more than words. In fact, Ray Bachtiar (Bachtiar, 2011) added that a photograph, any kind of photograph, not only speaks a thousand words, but is also part of a thousand series of events. Seno Gumira Ajidarma suggested that images produced by humans, including photographs, are part of visual literacy (Ajidarma, 2003:26). In short, photographs have become part of a personal way of speaking, expressing thoughts and feelings. Through photographs, the reality which exists in society is then constructed by photographers to convey messages which can raise the potential of social conditions (Artana, 2014). Images or photographs included in the realm of visual rhetoric have a rhetorical or persuasive function (Sa'idin, 2013). Douglas Ehninger (Foss, 2005:141) defined rhetoric as the way in which humans "can influence each other's thinking and behavior through the use of symbols". Visual rhetoric is used to describe the study of visual imagery within the discipline of rhetoric, relating to the study of the use of symbols to communicate (Foss, 2005:141). Visual rhetoric is not only about design or images, but also about the culture and meaning reflected in the visual work. In simple terms, visual rhetoric can be defined as how or why a visual image has meaning. Although the direct response is not visible, indirectly it can be in the form of understanding, views, and actions which affect the way of thinking and persuade the audience. In this context, visual rhetoric theory as one of the theories which aims to persuade the audience plays a key role. Rhetoric is the starting point of speaking in which the action has a purpose to be achieved (e.g. providing information). However, apart from its oral delivery, rhetoric is also capable of being delivered in writing. Therefore, rhetoric has a wider scope. Rhetoric is not only about speaking in front of the public using auditive communication methods but can also use visual and audio visual communication methods (Hendrikus, 1991:14). Not all visual objects are visual rhetoric, there are 3 main requirements so that a visual product can be said to be visual rhetoric according to Foss (Foss, 2005:144), namely: a. --- Symbolic Action Visual rhetoric, like all communication, is a system of signs. In a simple sense, a sign communicates when it is connected to another object. For example, the change of leaves in the fall is connected to a change in temperature, or a stop sign is connected to the act of stopping the car while driving. To qualify as visual rhetoric, an image must transcend its function as a sign, and become symbolic. --- b. Human Intervention Visual rhetoric involves some type of human action. Humans engage in visual rhetoric when they are involved in the process of creating images such as watercolor paintings or taking photographs. This process involves conscious decisions to communicate as well as conscious choices about strategies to make function in areas such as color, shape, medium, and size. Human intervention in visual rhetoric might also assume the form of transforming non-rhetorical visual images into visual rhetoric. For example, a tree does not inherently become visual rhetoric. The tree is interpreted as such only when humans decide to use the tree as rhetoric, such as when the tree is brought into homes to symbolize Christmas. In other words, visual rhetoric requires human action in the creation or interpretation process. --- c. Presence of Audience The visual elements arranged and modified by the rhetorician are not just for self-expression. While that may be the primary motive for the creator of an image, it is also to communicate with the audience. The creator of an image can be the audience of his own image, and the audience itself need not be a rhetorician. A photograph with a rhetorical function is inseparable from the message contained in it which is arranged in such a way. According to Sidhartani (in Pradani and Eli, 2021:146), there are two models in the preparation of messages, namely: "informative message preparation" and "persuasive message preparation". The preparation of informative messages is the preparation of messages which aim to convey information to the public based on facts, while the preparation of persuasive messages is the preparation of messages which require audience reactions to do or (Sidhartani in Pradani and Eli, 2021:146). --- RESEARCH METHOD This research uses a qualitative approach with Sonja K. Foss' visual rhetoric analysis. The qualitative method makes it possible to interpret and describe the message in the photo object using words. Furthermore, this method studies problems in society, whether it concerns procedures, situations, relationships, behavioral attitudes, perspectives, and influences in a community group (Restu in Illahi, 2017:8) while this study used the results of the analysis in the previous study to assist in the process of analyzing visual rhetoric using Sonja K. Foss' theory. --- RESULT AND DISCUSSION --- Covid-19 Photo by Joshua Irwandi A photo by Joshua Irwandi depicting an alleged corpse of a Covid-19 victim has stirred up the social media universe. This had caused pros and cons among netizens. Even one of Indonesia's top artists and the Head of the Expert Team of the Task Force for the Acceleration of Handling Covid-19 commented on this matter. The Pewarta Foto Indonesia (PFI) organization had aired the statement of the Chair of the Task Force. In its Press Release, it stated that as long as those who photographed the Covid-19 bodies were competent journalists, it was considered legal and reasonable because not just anyone could get access and take pictures for editorial purposes in dangerous places (Pewarta Foto Indonesia, 2020). The Chairman of Center PFI, Reno Esnir, added that when taking photos, Joshua had fulfilled all journalistic codes of ethics, including following the required licensing procedures and health protocols (Amanaturrosyidah, 2020). --- The Application of 3 Characteristics of Visual Rhetoric in Joshua Irwandi's Photo The symbol system in symbolic action characteristics is shown through the use of a sign system (Smith, Moriarty, Kenney, and Barbatsis, 2004:144). According to research conducted by Rani Ika Wijayanti and Mochamad Syaefudin (Wijayanti and Mochamad, 2020:267), the photo showed a human body which was a corpse who died from Covid-19 and was placed on a bed. This figure looked stiff and was wrapped in a shroud with plastic covered all over its body. Shroud is a white cloth used to wrap a corpse, especially in Islam and Christianity (Fanti in Wijayanti and Mochamad, 2020:268), the photo showed a human body which was a co. Plastic here also symbolizes eternity because it is not easily decomposed. In the connotation meaning, the coating or wrapping of the dead human body illustrates that they are already bound in the spirit world and can no longer return to the world. All deeds of worship, sins, and all their actions must be accounted for and there is no more opportunity to correct them. In general, funeral arrangements only use shrouds without being wrapped in plastic and coffins. Funeral arrangements by adding plastic and coffins aim to avoid transmission of the virus to others (Permatasari and Isra, 2020). As is known, the Covid-19 virus is a dangerous new virus and has a high risk of being transmitted to other people who are in direct contact with positive Covid patients which can cause death. The addition of plastic and coffins in funeral arrangements is a very new thing, especially with the Indonesian people who are predominantly Muslim, where funeral arrangements do not use coffins because they will be considered as bid'ah. Bid'ah is an act which is done not according to the established example, including adding or reducing provisions. Linguistically, this meaning relates to innovation, renewal, or even heretical doctrine. (Kharisma, Thesis, 2021:44). In the photo taken by Joshua, the body wrapped in plastic looked like a mummy. In its understanding, a mummy is a preserved corpse, due to protection from decomposition by natural or artificial means, so that its initial shape is maintained (Wikipedia, 2018). Historically, mummies originated in Ancient Egypt which was a method of preserving the bodies of kings at that time. Over time, mummies were considered scary because the cause of death of the corpse in the mummy at that time was a mystery and was considered creepy. Human intervention in Joshua's work is presented in the form of a human being who has died from Covid-19 wrapped like a mummy. In addition, there is a proximity factor because this pandemic is still ongoing and around us. Indirectly, this gives an appeal and a frightening effect for some people. Joshua made this photo in a hospital room setting with dim lighting which adds to the gloomy aura of the photo (Wijayanti and Mochamad, 2020:267). The dim lighting is made to give a mood of sadness, gloom, loss, solitude, void, and emptiness. This is a fact because from the beginning people who were confirmed positive for Covid-19 were required to be isolated in a room or hospital room with minimal human interaction. And if they do not survive the treatment process, they will die in solitude and no relatives are allowed to perform rituals to honor the corpse as usual (Wijayanti and Mochamad, 2020:268). This aspect strengthens the presence of audience factor in which Joshua tried to provide visual facts in the form of a stiffly lying corpse left alone without being accompanied by relatives. In this photo, Joshua wanted to express that the Covid-19 virus is very dangerous, as quoted in his photo caption on Instagram: "The image is published here today as a reminder and a warning, of the ever-looming danger. To inform us of the human cost of coronavirus and how world governments have let matters get so far. As we head towards the second wave of the pandemic, people must realize they cannot take this matter lightly." (@joshirwandi, Instagram,2020). --- Elements of Message Compilation in Covid-19 Photo by Joshua Irwandi Photojournalism made by Joshua Irwandi shows how terrible the consequences of the Covid-19 virus are. In the elements of message arrangement, Joshua Irwandi's photo is included in the preparation of persuasive messages using fear appeal and emotional appeal. --- CONCLUSION This Covid-19 victim photo created by Joshua Irwandi sought to raise public awareness of the dangers of the virus. Using a persuasive approach, Joshua made this photo look tense with dim lighting. Making photos using the fear appeal approach aims to give psychological attention to things which are usually feared or have risks which will then be connected to everyday life. The symbols seen in this photo look quite clear, and can be found around us. In addition, this photo looks quite simple, but on the other hand, the messages conveyed through the visual is quite strong, therefore, the photographer's message can be conveyed well. Persuasive visual rhetoric will have an effect on the audience, if the visual symbols presented are familiar and close to the audience, and the issues or themes raised are current events.

Photojournalism by Joshua Irwandi uploaded on social media Instagram caused various responses among netizens. The photo showed the figure of a human body which was the corpse of a person who died from Covid-19 placed on a bed. This figure looked stiff and was wrapped in a shroud with plastic coated all over their body. The purpose of this research is to find out the visual rhetoric and elements of message arrangement in Joshua Irwandi's photo work. This research uses a qualitative approach with Sonja K. Foss' visual rhetoric analysis. The results of the analysis show that persuasive visual rhetoric will have an effect on the audience, if the visual symbols presented are familiar and close to the audience and are currently happening.

Introduction Within the framework of emerging and entrepreneurial organizations which seek to meet or create requirements in market segments for different economic sectors, Social Enterprises (SEs) seek to innovate in business models, offering alternatives to environmental, social, and financial problems [1]. These innovations are obtained from collaborative and shared strategies between social organizations and communities, managing to re-signify the sense of value creation [2] in addition to improving the conditions for shareholders, consumers, and communities involved. SEs are part of a phenomenon that is developing globally, which is gaining recognition and regulation by national governments; in addition, it is being considered as the economic sector that allows the energizing of the 2030 Sustainable Development Agenda, aimed at solving social problems by solution markers or business initiative makers [1][2][3]. As a field of research approach under construction, the area of SE was consolidated in the 1990s, based on a vast academic output nourished with critical aspects of the experiences of both entrepreneurs and the ecosystems in which they operate [4,5]. It can also be grouped and studied to provide similar subjects and experiences [6]. Among these aspects are Knowledge Management Practices (KMPs), which involve elements capable of creating, storing, transferring, and applying knowledge to generate value among the different stakeholders of organizations [7]. They relate to critical variables of market intelligence to develop new products, businesses, and strategic alliances [8] that meet consumers' present and future needs [9]. Concerning the SEs, the KMPs start by strengthening the skills and experiences of the collaborators [10] to improve their agility and efficiency in the decision-making process, increasing their performance and ensuring the achievement of organizational goals [11], and the constant search for new knowledge resources from the various ecosystems [12]. In this sense, it is necessary to characterize the KMPs used by SE initiatives and their contribution to the integral development of the context and the global perspective in which they are generated. The chosen scenario is the city of Medell<unk>n (Colombia), the first Science, Technology, and Innovation District in the country; which has a Public Policy on SEs, from work in sectors such as environment, peace, human rights, education, and the economy, as well as a gender perspective from the integration of entrepreneurs and income towards women. It offers an ecosystem characterized by the active participation of civil society and is decentralized and dynamic, with challenges that include the legal recognition of the business model and the financing, training, and generation of synergies which seek to increase productivity and solve city problems by the promotion of equity and equality of approach to new benefits and better social conditions [13]. The combination of public, private, and community resources has allowed the city's renewal to strengthen social integration, organizational creativity and inclusion of various economic sectors in entrepreneurship processes, generating a positive impact on society [14]. The approach from the specific perspective of the KMPs in this study establishes a contribution to the field of knowledge in SE's thematic and methodological domains. First, although the SE is not conceptually or thematically delimited, current research trends characterize them from ethical, social, and social hybridization aspects [15]. In this sense, the initiatives addressed focus on the mood of their creators, the interest in social trans-formation towards the communities involved, and the appropriate management of intangible capital from the typology of companies that represent them [16]; all this, from the less-referenced market niches in the literature, such as mental health and sports management, to renowned others such as education and the environment. As part of the SE ecosystem of Medell<unk>n, the associated KMPs energize the promotion and creation of products and services aimed at improving social conditions and respect for the environment [17] that result in profitable, efficient, and flexible business opportunities when transmitting benefits to communities; the management of resources and exchange of experiences; and access to collaborative networks in the early stages of organizational maturity [10]. When considering the methodological aspect, using Pearson's bivariate correlation coefficient makes it possible to associate the strength and degree of relationship between variables of interest [18]: measures from specific categories such as Social Entrepreneurship, Knowledge Management Practices, organizational aspects, and development. To this extent, although the upward direction of scientific publications in databases on the independently studied variables is relevant-with a predominance in Europe, where there is a more significant number of associated institutions and researchers-there are few studies that address the tripartite relationship between them [19][20][21]. In this sense, the purpose of the current study is to analyze the effect of the KMPs on the SE and its contribution to the development of products and services that meet social needs without jeopardizing the creation of value for organizations. The text has four sections: the Theoretical Framework of Social Entrepreneurship; Knowledge Management Practices; Organizational Aspects; and Development. Then, we describe the development of a mixed methodology, with a non-experimental design, based on Pearson's bivariate correlation review and a narrative design: 40 SE initiatives of the city of Medell<unk>n were approached for convenience for research; 30 through surveys and the remaining ten from in-depth interviews. Finally, the document presents an analysis of research findings. --- Theoretical Framework --- Social Entrepreneurship SE seeks to articulate own knowledge with new knowledge, to explore opportunities and solutions to social problems [22]. The diversity of studies on SE range over a number of topics that allow them to be grouped. For the KMPs, the subcategories are taken as: suggested taxonomies of enterprises and the typologies of their implementers; the economic model to which they are accepted, a description of the level of maturity of the social enterprise; and entrepreneurship ecosystems. In the case of taxonomies, groupings are included based on general elements, human resources, business strategy and value creation, and challenges faced and innovation [23]. In addition, from the contribution of the SE to rural and community development and urbanization, there are groupings on the social, economic and environmental considerations of social entrepreneurs; financing and crowdfunding patterns; and women entrepreneurs, in addition to the corporate social responsibility carried out by the SE for existing and potential researchers in the field [24]. On the other hand, the typologies of entrepreneurs are based on the existing organizations or aspects of their creators as agents of social change, depending on the nature of their lives, professional experiences, and the scope of their social commitment [25]. Respect for economic models is circular, focused on the reuse of resources during the production process, ensuring the preservation of systemic social and ecological systems [26]. The Social and Solidarity Economy (SSE) promotes the democratization of economic activity, with social revenues beyond the exclusively monetary [27]. The green economy is where eco-entrepreneurs look for business opportunities by using resources and favoring the environment while generating or supporting both profitable and efficient products and services [28]. The maturity of the SE is related to the efficiency of the knowledge management process, the training of entrepreneurs, and the way of managing the associated resources [29], since entrepreneurs must mobilize their individual and social skills to integrate contributions from complementary actors or new capital [30], decreasing risks in the development of a new product or service to expand market share [31]. SE ecosystems correspond to the community of actors that interact and depend on each other to meet their objectives and generate synergies and circles of interrelation, interdependence, and complementarity [32]; taking creativity and innovation as references, these tools guarantee the pragmatism of their operations, given their flexibility and adaptability [33]. They can vary depending on culture, expectations, and institutional pressures [34], given their composition of at least six elements [35]: accessibility to various markets; the talent of human capital and the labor force; diversity in sources of financing; the existence of support mechanisms; cultural support; and a governmental and regulatory framework, which helps to boost SE from financial, innovative, and training aspects [36]. --- Knowledge Management Practices KMPs involve a set of data, information and knowledge which contribute to creating value and competitive advantage in organizations [37], improving their performance and position in highly dynamic markets [38]. In turn, they promote problem-solving and decision-making based on identifying strategic intangible assets [34]; among those that stand out are: technology, identity, brand, reputation, identity, skills, and the experience of employees [39]. Concerning the SE, reviewing the KMPs from specific subcategories such as knowledge transfer, knowledge co-creation, knowledge combination, and value creation is convenient. The first involves building relationships and trust between various stakeholders to develop activities and projects together [34], in addition to the generation, standardization, and compliance of confidentiality agreements that protect intellectual property shared and exploited among various stakeholders. It represents an alternative to favor the creation of sustained competitive advantages between the parties involved [40] through exchanging knowledge in favor of product differentiation [41]. For its part, knowledge co-creation is responsible for evaluating the relationship between consumers and services that organizations offer, as collaborators have to gather, analyze, interpret, and reconfigure the knowledge that is contributed by the consumer [42]. It is essential to provide stakeholders with knowledge, perceptions, and skills on developing new business models [43], expressing the joint construction of knowledge for adequate service provision and the generation of products that respond to the consumer's needs. It involves the use of cognitive and technological factors to foster collective creativity between two or more individuals who may or may not belong to the same stakeholder group [44], responding to changes in global markets that demand work and collective commitment among stakeholders [45]. Something similar happens with the combination of knowledge, where contextual information can be constantly updated to generate innovation spaces and manage risk in organizations [34]; therefore, explicit knowledge becomes a more complex and systemic component for creating new knowledge inside and outside the organization [46]. It involves the articulation of existing resources that shape customer service outcomes, improve performance, and contribute to the overall competitive ability of organizations [47]; therefore, it is essential at an organizational level to design mechanisms to relate experience, skills, and capabilities between stakeholders [8]. In the same vein, the creation of value goes beyond the profits obtained by shareholders and involves the different stakholders, such as customers, suppliers, and employees [48]. Social value can be understood from three perspectives: financial, described as the increase in the wealth of shareholders, which represents an increase in corporate profits or the price of shares; social, which involves a set of practices and activities aimed at strengthening the mission of organizations, without disassociating from the financial perspective of the organization [49]; and politics, since government provisions can produce asymmetric benefits in the economy, where various typologies of organizations face multiple obstacles to the exercise of their economic activity [50]. --- Organizational Aspects Given the organizational nature of the SE, aspects of the administrative and functional structure are required, in this case, from subcategories such as planning processes, access to financing sources, management of tangible and intangible resources, and incorporation of technologies. Planning is one of the differentiating tools of change that seeks to achieve the most excellent organizational efficiency in environments of uncertainty [51]; at the same time, it allows us to efficiently deliver products, components, and materials that are highly useful for businesses, consumers, and society in general [52]. From access to financing sources, decisions can come from own capital or external sources [53]; in this regard, it is necessary to form in entrepreneurs a set of competencies that will help them identify investment risks and opportunities for cooperation with potential partners [54]. In this way, the SE can attract financial resources for the joint development of projects in which shared value is created and different stakeholders benefit [55]. Concerning the management of tangible and intangible resources, these assets can be seen as a system of variables in which different organizational elements of strategic, physical, financial, human, and relational typology interact [47], which allows estimation of the value of a resource in the market to the deal, in addition to its difference, originality, and necessity [56,57]. In the early stages of consolidation, SEs face a set of barriers to acquiring tangible and intangible resources; therefore, the decisions made in this regard will affect the success of the SE in the market [58]. For its part, incorporating technologies in SE provides opportunities and generates competitive advantages since it facilitates greater integration between this type of organization and stakeholders' requirements; in addition, it reduces uncertainty in the ecosystems to which they belong [59]. Currently, there is a new phenomenon called digital or technologybased SE, which is the result of collaboration between different agents such as governments, universities, companies, and communities, whose purpose is focused on the development of intensive initiatives for the development and adoption of innovations that improve social conditions [60]. --- Development The KMPs in SE promote the active participation of organizations and stakeholders in the joint development of products and services [61] which seek to improve communities' quality of life. In this way, the development concept is approached from three subcategories: organizational development, social development, and its relationship with the 2030 Agenda. The first is related to the performance and fulfilment of strategic objectives regarding cash flow, financial planning, and quality of products and services offered to the consumer [62]. It promotes the innovation of products and services, strengthening organizational flexibility to meet the different requirements of the target market [63] and generates both financial performance (focused on improving the return on investment, in-creasing market share and obtaining a better cash flow) and non-financial performance; for its part, non-financial performance involves compliance with consumer specifications, consumer satisfaction, and employee commitment [64]. Similarly, social development, related to the previous category, evidences the empowerment of collaborators and communities in the reduction of social inequality [65]; at the same time, it favors the consolidation of the organizational structure, acquisition of technology and renewal of information systems, access to promoters, and knowledge al-lies. The active involvement of those involved in the SE leads to identifying the priorities, characteristics, roles, and commitment of the participants [66] and promotes interdisciplinary work between various areas of knowledge and expertise [22], in addition to strengthening the consolidation of learning curves between the parties involved [8]. The shared or social value that SEs provide concerning local and regional development can complement the lack of public services, strengthen social capital from volunteering [67], and attend to multiple fronts of the public agenda, while the conditions of institutional and social capital are guaranteed [68]. The KMPs in SE are also related to achieving the 2030 Agenda, especially in developing countries, where they seek to solve their challenges, starting with poverty reduction [24]. However, there is a lack of clarity on how this relationship can occur, given the number of SDGs (17) and the number of targets they group (169), compared to the vast number of types of SE that exist [69]. Faced with this, an alternative lies in directly linking to the breadth of the SE value chain and the number of SDGs they may impact. Based on the above, from the perspective of the KMPs in the SE, the two SDGs that directly point to this are: number eight, which seeks to promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all; in addition to number nine, which aims to build resilient infrastructure, promote inclusive and sustainable industrialization and encourage innovation. From these two objectives, others can be included indirectly, as other studies do [70]; and, in line with the types of value created by SE, these are: objective one, to reduce poverty; objective three, for the achievement of health and well-being; objective 10, for generating equality; objective 12, with which responsible production and consumption are favored; and objective 17, which establishes synergies for the scope of the Agenda as such. Based on the previous conceptual approach to these categories, in addition to previous bibliometric and scientometric reviews carried out by the research team [71], the following study subcategories emerge (see Table 1): --- Materials and Methods The methodology used was mixed, with a descriptive correlational scope to respond to the four fundamental categories: Social Entrepreneurship, Knowledge Management Practices, Organizational Aspects, and Development. The quantitative approach included a non-experimental design, which resorted to a case study with 40 SEs located in the Metropolitan Area of the Aburrá Valley, selected utilizing non-probabilistic sampling for convenience due to the absence of systematized information about formalized SEs in the city. Given this, data from significant initiatives were used. These data were provided by the city's innovation hub, a partner organization, and an SE accelerator. The selected SEs shared the following characteristics: between three and six years of its creation; managerial leadership of its entrepreneurs; small and medium businesses; and cooperative financing and commercialization of their own services and/or products. Through the design and application of an online form, we sought to measure the attitudes of the leaders of the SEs regarding the KMPs in their organizations. The document was divided into four components according to the four categories of study, including initial aspects of characterization of the SE. Through the use of a Likert Scale, a series of statements were proposed, based on the different subcategories mentioned in the theoretical section, so that they were evaluated in this way: 1, "nothing in agreement"; 5, "completely agree" (See Appendices A and B). Based on the conceptual approach of the previous section, in addition to earlier bibliometric and scientometric reviews carried out by the research team [71], the following study subcategories emerged (see Table 1). Subsequently, a statistical analysis of the components was carried out using Pear-son's bivariate linear correlation. This type of correlation allows for the study of the association capacity and linearity between the variables, which vary between -1 and +1, indicating negative and positive relationships [72]. In turn, the strength of the correlation can be classified as weak if it varies between 0.10 and 0.30, moderate when behaving between 0.31 and 0.50, and strong if it reaches values above 0.51 [73]. The following pairs of hypotheses were used to identify the significance of the correlation: H 0 = r ij = 0 vs. H a = r ij <unk> = 0(1) H 0 = <unk> = 0 vs. H a = <unk> <unk> = 0 (2) In verifying the significance of the relationship, an <unk> = 0.05 and a confidence level of 95% were used. In the case of obtaining a p-value <unk> 0.05, the null hypothesis was rejected, obtaining a correlation index significantly different from zero (0). From the qualitative approach, the design was narrative, as it allowed social entrepreneurs to communicate the KMPs in their organizations; at the same time, it led the researchers in the construction of an objective knowledge about the subject of study [74]. Ten SEs were selected for the convenience of the study and under two criteria: the areas of entrepreneurship more prominent in the region, such as environment, education, the orange economy, and mental health; and the databases provided by official organizations, incubators and pulling ventures, both private and mixed. In-depth interviews were applied to the entrepreneurs in each organization, which were processed in the Atlas Ti 23 software; the significant aspects were analyzed from matrices where the four study categories were saturated with their respective subcategories, providing favorable elements to complement the quantitative findings. The articulation of the results of the survey with the interviews was given from triangulation as a mixed method modality. This method emphasizes the corroboration of both types of data from coincidences and equivalences [75]. The two methodologies used complement each other as follows (see Table 2): --- Results A general characterization of the 40 SE initiatives reviewed evidenced a remarkable gender leadership and managerial self-determination, with dedication not only to the attention of vulnerable or marginalized groups or the search for concrete solutions to improve the quality of life of communities, but also to the allocation of resources, efforts, and capital in solving social problems. Although there was a correspondence of the economic activities in which the SEs were enrolled concerning the most outstanding in previous research in the specific context of the city of Medell<unk>n, such as the environment, the Culture of Peace and Human Rights, education, and the orange economy [76,77], other economic sectors were also highlighted as innovative fields, including mental health, the use of artisanal fabrics, the reuse of clothing, gastronomy and the collection of animal excrement. Although the SEs had a trajectory of fewer than six years, they have been strengthening through their legal formalization in the recent period, in addition to the use of training and advisory opportunities provided by higher education institutions and self-financing based on the management of public policies and the trust generated from the bank. From the Social Entrepreneurship category, the variables had a moderate association capacity. However, seven of the twelve proposals addressed the subcategories of the economic model of the SEs, their maturity, and their belonging to ecosystems, and were able to generate shared variability concerning those related to the development category (six correlations in total) and three for each of the other types, respectively (see Table 3). In this order, the entrepreneurs considered it convenient and effective dissemination of the portfolio of products and services to generate a risky bet that favored both the requirements of the market and the stakeholders that are part of the social process (D6, SE3, r D6,SE3 2 = 0.2704; D6, SE11, r D6,SE11 2 = 0.2916). In this task, strategic allies were identified for the development of profitable and environmentally friendly products (D13, SE3, r D13,SE3 2 = 0.3481), where the availability or management of resources before public and private entities was highlighted as an opportunity to turn the organization into an engine that helps the dynamization of the local economy (D10, SE11, r D10,SE11 2 = 0.3481); all this, hand in hand with the use of technology, which, combined with energizing strategies that facilitate and favor an organizational climate, motivates employees to develop creative and innovative products that impact the expectations of consumers (D2, SE2, r D2,SE2 2 = 0.25; D2, SE6, r D2,SE6 2 = 0.3721). The initiatives addressed showed how products and services are created from a solidarity perspective (KMPs1, SE2, r KMPs1,SE2 2 = 0.2704), where efficiency in the use of shared resources is promoted (KMPs13, SE3, r KMPs13,SE3 2 = 0.4356); in addition to designing strategies to constantly enhance the different models and alternatives of value creation (KMPs6, SE5, r KMPs6,SE5 2 = 0.2704). The SE grants autonomy to collaborators to implement tools that improve the exchange and management of information in resource planning and task development (OA6, SE1, r OA6,SE1 2 = 0.2916), acquire resources (OA7, SE7, r OA7,SE7 2 = 0.3249), and offer them visibility in the market (OA5, SE3, r OA5,SE3 2 = 0.3035). For their part, the entrepreneurs' narratives were mainly located in the subcategories of the economic model and the relationship with ecosystems. From the first, they pointed out the need to have a model of solidarity consumption, which would allow reinvestment of the profits in the same venture and benefit other people; especially vulnerable populations that characterize Medell<unk>n, such as children, adolescents, female heads of families, people with disabilities, victims of the armed conflict, and unemployed young people. On the other hand, the skills acquired by the entrepreneurs and their life experiences, for the sake of finding the solution to social problems, allows relationships with other entrepreneurs to develop through networks that feed the ecosystem of the Innovation District, where they share, among others, affinities regarding the motivations that led them to work on their initiatives, thus establishing synergies: personal life situations, even experience outside the country, were considered as a starting point; the direct contact with borderline situations in personal matters, or with the reality resulting from market disparities, led them to exercise their abilities at the service of social interest and want to position their initiative more and more in the socio-economic environment. Although the existence of Public Policy is known, there is a lack of greater appropriation of it and the recognition of its operability based on the effective inclusion of all experiences in any activity generated by it. Entrepreneurs know that Public Policy goes through all their work, but there is no awareness about how it is made effective from their work and all its benefits. The Knowledge Management Practices (KMPs) category indicated moderate and robust association capacity in 7 of the 16 established variables, the most outstanding being those related to value creation from social benefits, the co-creation of knowledge from the interrelationships of collaborators, and the combination of expertise to take advantage of innovation in favor of beneficiaries (see Table 4). The shared variability occurred mainly with other variables of the same category (ten in total) and the three already mentioned in the SE category. In this sense, the accessibility of information in the SE affects the constancy and availability of collaborators to generate solutions based on market demand (KMPs7, KMPs3, r KMPs7,KMPs3 2 = 0.3249). Thus, the use of information exchange mechanisms between stakeholders is required (KMPs6, KMPs3, r GC6,GC3 2 = 0.3025), counting on policies for their motivation and retention, with approaches to social realities, empathy, and collaborative design which favor their willingness to share and implement their knowledge (KMPs9, KMPs5, r KMPs9,KMPs5 2 = 0.2809; KMPs7, KMPs2, r KMPs7,KMPs2 2 = 0.3600). Based on this, it is possible to combine the individual expertise and the knowledge previously acquired by the collaborators with the requirements of the consumer to find solutions to social problems together (KMPs8, KMPs3, r KMPs,KMPs3 2 = 0.3136; KMPs9, KMPs3, r KMPs9,KMPs3 2 = 0.3600; KMPs7, KMPs11, r KMPs11,KMPs3 2 = 0.39699; so that the results obtained allow a percentage of the financial profits to be used for the benefit of the community (KMPs13, KMPs14, r KMPs13,KMPs14 2 = 0.3418), without jeopardizing the financial sustainability of the SE (KMPs13, KMPs3, r KMPs13,KMPs3 2 = 0.3136). The entrepreneurs' narratives also emphasized the creation of value from the understanding of social enterprise, which seeks to make a profit and transform the communities' reality. This is achieved by offering a specific product or service that its producers consider to be a social innovation in light of the Public Policy that the city has set. On the other hand, the co-creation and combination of knowledge were highlighted from the ongoing feedback that should be with the beneficiaries as external customers, along with collaboration with other businesses and the assistance of other experts who can help the SE do its job better. From the Organizational Aspects category, 15 of the 16 variables showed moderate and robust association capacity, especially financing, planning, and the use of technologies (see Table 5). The shared variability occurred significantly with variables of the same category (fifteen in total), six with KMPs and three with SE. In this way, the SEs identify strategies and mechanisms for the acquisition of resources, marketing, personnel, and technologies that allow them to: face the demands of the market and competition (OA7, OA1, r OA7,OA1 2 = 0.2601); take advantage of the remnants of indebtedness, and increase profitability (OA2, OA1, r OA2,OA1 2 = 0.4225); ensure security in data handling and the adoption of sustainable practices (OA13, OA12, r OA13,OA12 2 = 0.2704; OA14, OA9, r OA14,OA9 2 = 0.3481; OA14, OA13, r OA14,OA13 2 = 0.3844); and achieve interinstitutional agreements both for the co-creation in the design of products and the offer of financing sources to debtor clients (OA3, KMPs6, r OA3,KMPs6 2 = 0.2916; OA4, OA3, r OA4,OA3 2 = 0.4096). All this is possible if it gives an optimal organizational climate that favors profitability and permanence in the market (OA8, OA2, r OA8,OA2 2 = 0.2704; OA9, OA8, r OA9,OA8 2 = 0.3364) that promotes the autonomy of employees in the implementation of tools to improve information management (OA6, SE1, r OA6,SE1 2 = 0.2916; OA6, KMPs3, r OA6,KMPs3 2 = 0.25), as is the case with technology, since it facilitates interaction, development and visibility in the environment (OA15, OA5, r OA15,OA5 2 = 0.36; OA15, OA9, r OA15,OA9 2 = 0.2601; OA15, OA14, r OA15,OA14 2 = 0.4490, especially through the website (OA16, OA14, r OA16,OA14 2 = 0.3364; OA16, OA15, r OA16,OA15 2 = 0.3025). In this same sense, the testimonies of the entrepreneurs highlighted the financing, planning, and use of technology. The most relevant was the pursuit of calls and competitions that promote access to new sources of economic resources which focus on projects, whether they have local, national or international coverage, or are private, public, or mixed. This was supported, in order, by their resources, nearby environments, voluntary contributions, bank financing, and their pursuit of financial capital. The constant presentation of this type of space, sponsored by different actions from the city ecosystem, generates installed capacity to respond assertively to the same requirements and take advantage of qualification opportunities by the linked incubators and accelerators. These acquired competencies are exercised in organizations that have teams of stakeholders. However, they are not enough in the face of the division of functions, especially in terms of communication with customers and resource management, so self-management must be resorted to, social networks being a mechanism that has provided multiple solutions. From the Development category, 10 of the 13 variables showed moderate and robust association capacity, particularly organizational development and the SDGs (see Table 6). The shared variability was given with eight variables of the same category, ten with OA, six with SE, and three with KMPs. Based on this, organizations should use tools that allow them to assess the complacency and the degree of acceptance of consumers (D4, OA8, r D4,OA8 2 = 0.2916; D4, D3, r D4,D3 2 = 0.3364), as is the case of the motivation of the collaborator in the performance of its activities as a recognition strategy in the market (D3, KMPs1, r D3,KMPs1 2 = 0.3025; D3, OA8, r D3,OA8 2 = 0.4096; D3, D2, r D3,D2 2 = 0.2916), in addition to the inclusion of technology as a differentiating element in the entire value chain (D1, OA13, r D1,OA13 2 = 0.4489; D1, OA14, r D1,OA14 2 = 0.3481; D1, OA15, r D1,OA15 2 = 0.3481; D1, OA16, r D1,OA16 2 = 0.2601). Likewise, the generation of products has to do with the commitment that organizations acquire when articulating their social function with the SDGs (D11, D6, r D11,D6 2 = 0.5184; D11, D7, r D11,D7 2 = 0.2916) and Local Development plans (D12, OA5, r D12,OA5 2 = 0.2704; D12, D7, r D12,D7 2 = 0.3025; D12, D11, r D12,D11 2 = 0.3481), which allows improvement in the living conditions of the communities from a comprehensive perspective: social, economic, and environmental (D3, OA8, r D13,OA8 2 = 0.2809; D13, OA12, r D13,OA12 2 = 0.2704; D13, D6, r D13,D6 2 = 0.2601). The entrepreneurs' narratives highlighted organizational and social development and its relationship with the SDGs, the former from the customization of products and services in addition to its diversification on different fronts: sales, training beneficiaries, support for other nascent ventures, and creation of corporations. This specificity is supported by the use of life stories or associated situations with which it is intended to seek added value and validate the innovation offered, as in the case of the pandemic caused by COVID-19, which forced entrepreneurs to rethink strategies or create new initiatives in which different recipients of SE participated. The support for a solidarity economy model was related to social development and the existence of the SE Public Policy. This type of management provides a sense of both sorority among women, leaders or collaborators of the ventures, and fraternity among all entrepreneurs; those who, by providing various sectors with opportunities for the achievement of their life projects, obtain their emotional salary, which is fundamental in their motivations. The use of biodegradable materials, and the reuse or restoration of material commodities, even food, were emphasized as examples of sustainable development from the perspective of the SDGs, the SE's ecological consciousness, and their persuading customers. --- Discussion The SE initiatives addressed are inserted into the entrepreneurship ecosystem of the city of Medell<unk>n, taking advantage of its opportunities to generate innovative value regarding the solution of social needs, in addition to achieving synergies that allow sustainability from networking, both local and global, and the search for resources. It is an exploration of differentiating niches of social marketing, even beyond the groupings proposed by previous studies [8,9]. They indicate the dynamism typical of entrepreneurs and the active dissemination provided by the ecosystem; their same mood is in line with the trends evidenced in various international field experiences [78]. It establishes the starting and arrival point of the SE: satisfaction from altruism is the benchmark of the emotional salary of entrepreneurs. At the same time, financial sustainability is sought from the hybrid model that implies this type of organization. The ecosystem's accomplishments and efforts to have the business model recognized legally in the city and country have led to knowledge management insights from the SE. This can be appreciated even more as the initiatives mature and contribute to the scope of the ecosystem's homeostasis. As such, a longer time in the market and sustainability with networking allows for good performance of each particular venture and strengthens the areas of recognition achieved from the ecosystem. The SE is positioned as an organization where the KMPs show their increasingly strong value in the context of the Fourth Industrial Revolution, in which the City District operates. In this framework, the KMPs in the reviewed SE are understood holistically and articulate the four associated subcategories: knowledge transfer, knowledge co-creation, knowledge combination, and value creation; from significant aspects found such as organizational strategies, strategic direction, and communication channels mediated by ICT, they link tacit and explicit knowledge in the guarantee of appropriate development of products and services that create value for all stakeholders. Incorporating knowledge stock with dynamic organizational capabilities in the SE allows for facing the dynamic and changing variations of the markets and social needs [79]. Highlighting knowledge as a valuable resource, rare and difficult to imitate, significantly impacts organizational performance by considering intangible elements such as culture, reputation, and necessary trust in the relationships established between businesses, consumers, and communities [80]. The KMPs incorporate processes of knowledge creation, organization, dissemination, and use, and regulate knowledge processes that remedy existing needs [22], both from Medell<unk>n's ecosystem and, possibly, from other national and foreign ones. Faced with this, the organizational climate, the management of resources, the improvement of the product, and its commercialization motivate the desire of social entrepreneurs to generate effective strategies to stay in the market. All these factors validate the different KMPs used by the SEs, since, when evaluating the generation of sustainable social value shared by its members, they allow the SEs to make decisions conducive to becoming agents of change for the different economic sectors where they are [81]. In this sense, the KMPs, concerning what was conceived as SE, highlight

In the context of the city of Medellín (Colombia), which has been declared a National Science, Technology, and Innovation District, Knowledge Management Practices (KMPs) have been gaining importance because they improve the commercial entrepreneurial ecosystem by articulating tacit and explicit knowledge. The study investigates the role of KMPs in Social Entrepreneurship (SE), and how this relationship generates products and services that meet social needs, with articulation between tacit and explicit knowledge, which start from the experiences of entrepreneurs and join shared interests in ecosystems and public policies of social entrepreneurship. This study employs a non-experimental design based on a survey and a deep interview for 40 SE initiatives; we then developed a Pearson's bivariate correlation review and a narrative design. The results reveal that SE initiatives aimed at novel market niches and management strategies that articulate multiple sectors and social actors that aim for a practical scope of the purposes of entrepreneurship concerning the 2030 Agenda of the United Nations. The findings of this study suggest that KMPs in SE create a series of perspectives that seek to achieve greater competitiveness and sustainability in front of the market, all from innovative proposals of social value articulated with environmental care.

of appropriate development of products and services that create value for all stakeholders. Incorporating knowledge stock with dynamic organizational capabilities in the SE allows for facing the dynamic and changing variations of the markets and social needs [79]. Highlighting knowledge as a valuable resource, rare and difficult to imitate, significantly impacts organizational performance by considering intangible elements such as culture, reputation, and necessary trust in the relationships established between businesses, consumers, and communities [80]. The KMPs incorporate processes of knowledge creation, organization, dissemination, and use, and regulate knowledge processes that remedy existing needs [22], both from Medell<unk>n's ecosystem and, possibly, from other national and foreign ones. Faced with this, the organizational climate, the management of resources, the improvement of the product, and its commercialization motivate the desire of social entrepreneurs to generate effective strategies to stay in the market. All these factors validate the different KMPs used by the SEs, since, when evaluating the generation of sustainable social value shared by its members, they allow the SEs to make decisions conducive to becoming agents of change for the different economic sectors where they are [81]. In this sense, the KMPs, concerning what was conceived as SE, highlight the relevance of intangible resources as the motivation and retention of the collaborator to guarantee the appropriate attention to the requirements of vulnerable populations without putting at risk the financial stability of the organization [82]. In this sense, the experience acquired by the entrepreneurs in the various value chain processes becomes another intangible resource echoed in the ecosystem, to communicate life stories and meaningful experiences that serve not only as motivational factors but also as tacit knowledge that can be incorporated by other emerging filmmakers or assist in designing routes and strategies for the environment and entrepreneurship. The hunt for resources, which operates in a way proportionate to the development of entrepreneurship and its acceptance within the ecosystem, stands out among these talents learned through the expertise of entrepreneurs. Access to local and global calls is more feasible for the initiatives with capital accumulated in this area, which is recognized as a source of income, given the support for this type of business, even from the private sector. Although the SEs focus on developing activities where financial performance is not predominant, the core is on generating solutions to problems of different social sectors that can generate profitability for entrepreneurs and stakeholders while responding to market disparities. In this way, SE can offer unique products and services whose development is supported by the management of intellectual capital (knowledge assets) and cooperation between the organization and stakeholders [83]. This behavior contributes to access to other resources such as physical infrastructure, furniture, entrepreneurship ecosystems, diversification of funding sources, spaces for creativity, and sharing of meaningful experiences. The KMPs improve the development of products and services by articulating organizational work with the communities and social functions of the social enterprise. However, this activity is not carried out in isolation. It requires the generation of trusting relationships with strategic allies that help to make visible the demands of the market and the benefits that the organization has to meet these demands. Under this perspective, developing products and services in SE includes a series of financial, organizational and social interests, which, by working together, improve the living conditions of communities [84]. This type of entrepreneurship faces high uncertainty in developing products and services derived from the structure of business models, the nature of consumers, and the market in which they operate [85]. In response to this, the filmmakers' inventiveness and tenacity were on display, allowing them to endure within the parameters of their goals as a catalyst for sustainability. The KMPs can contribute to a greater extent to the generation of products and services that satisfy social needs on the part of entrepreneurs, to the time that there is a more significant appropriation of the Public Policy adopted in this matter by entrepreneurs and the ecosystem in general. This is merely a follow-up report on the city's observatory of the legislation's implementation of the SE. It shows a lack of conceptuality, even of what the SE is. Eight years after the policy was implemented, which covers the average time of creation and development of the SE participating in the study, there was no evidence of adequate knowledge of it and its opportunities. Although the city ecosystem is being strengthened with KMPs that help to structure the different SEs organizationally, a more active role of Public Policy could boost the achievements obtained-all from participatory evaluation and monitoring processes that allow SEs to be co-creators of new knowledge in entrepreneurship management as impacts achieved according to their own cycle of Public Policy [86]-in addition to continuing to promote the training and advisory processes for entrepreneurs, repeatedly highlighted by them, from a Triple Helix management model [87] that combines the local university and their business career with the District's purposes. The field of knowledge in the construction of the SE finds in the revised KMPs a horizon of favorable understanding, while the organizational character is one of the approaches that characterize the epistemological approach to these practices in recent years. In this regard, the related experiences highlighted the importance of tacit and explicit knowledge management, given by entrepreneurial expertise. Typical of their work, as an engine of the generation of the economic and social value chain, it is, at the same time, the competitive advantage against the market, where it is committed to a solidarity economic model with attention to environmental care. The gender perspective contributes to this, not only as the target audience of the SE but also as a strength in the significant number of female leaders at the forefront of the experiences, which corresponds to similar studies [88,89]. The ecosystem's objectives give women a decisive role in post-pandemic economic reactivation [90]. Because of the ecosystem's strength and the difficulties arising from public policy, it is necessary to strengthen the entrepreneurship sector from synergistic proposals for the same KMPs raised. Numbers eight and nine should also be introduced in addition to number 17, as these aspects help determine the KMPs' influence on the SDGs. --- Conclusions SEs can be considered as emerging organizations that innovate in traditional business models by incorporating solidarity management actions to guarantee the creation of shared value among all stakeholders and improving the living conditions of communities. The context of the city of Medell<unk>n's Science, Technology, and Innovation District reaffirms how this type of organization has a dynamic role in the entrepreneurship ecosystems and the local business fabric, given its function as an articulating agent between the development of products and services, and the appropriate attention to social and market requirements. In addition, the intrinsic relationship between SE and the SDGs promotes economic growth and industrialization, providing to a certain extent the resolution of the challenges of Medell<unk>n and the environments in the national and international development path, to reduce the rates of unemployment and poverty. The topics addressed are novel compared to other organizational models, highlighting aspects such as the search for calls and sources of financing, gender focus, sorority, and generation of employment opportunities in highly vulnerable environments. In turn, the KMPs help by developing products and services in coordination with different stakeholders, where the intangible assets of intellectual capital acquire a leading role in providing appropriate solutions to the needs of the communities without putting at risk the financial stability of the organization. In response to the purpose of the research, the KMPs from subcategories such as transfer, co-creation, combination, and value creation promote the relationship, trust, and exchange of tangible and intangible resources between SEs, consumers and other members of the entrepreneurship ecosystem. This type of behavior increases the differentiation of the products and services offered by optimizing organizational capabilities to permanently update the knowledge necessary to meet the social demands of the market. In this way, to guarantee appropriate knowledge management, it is essential to adopt communication mechanisms and tools between the parties involved, which digital platforms and technological tools can mediate. These communication elements facilitate interaction and make visible the role of SEs as organizations that transform the needs of communities, managing to differentiate themselves from their traditional competitors. Technological factors drive the KMPs in SE for the generation of supply of goods and services that improve the quality of life in the communities. However, this process is not isolated and requires collaborative work between the different actors of the entrepreneurship ecosystem. In the city of Medell<unk>n, this is dynamic more as a consequence of the efforts of enterprises and their KMPs than state policy. However, it requires permanent participatory impact assessment processes that allow the ecosystem to be further enhanced, including the tacit and explicit knowledge generated. With this, a series of articulation strategies of different academic, business, and state actors are contributed to the field of SE study, which offers training and advice in incubation, empowerment, and sustainability of entrepreneurship. The SEs from the KMPs become reference organizations in completing the SDGs by assuring respect for the environment, transforming, and building unique capacities in the areas where they operate. Sustainability in the SE articulately controls the economic, social, and environmental components. Additionally, multidisciplinary research determines social objectives, including many economic model typologies and fields of study pertinent to the circular economy, solidarity economy, and green economy. In correspondence with the consulted literature, the SE can be understood based on the articulation between organization, knowledge management, and development aspects. This behavior is evidenced from the narratives of the entrepreneurs who revealed the need for strengthening the knowledge obtained (tacit or explicit) from actions that would allow them greater projection in the entrepreneurial ecosystem. However, this claim is still incipient from the Public Policy. In addition, entrepreneurs consider that value creation is reflected in obtaining social benefits. These benefits are present in economic sectors estimated by the Innovation District of the Aburrá Valley Metropolitan Area. Difficulties related to the sample size may affect the management results of the Innovation District. In addition, the responses of SEs show shortcomings in the organizational structure and formalization. Both public and private organizations have databases of entrepreneurs and their work; however, they are not unified, systematized, and updated. This behavior limits access to information about the current state of SE. Future research can contribute to strengthening information management processes regarding the SE. Likewise, it is recommended for future research to consider the relationship between SE maturity and local entrepreneurship ecosystems support. Finally, for future research, it is proposed to analyze the appropriation of Public Policy in the city; highlighting the role of the KMPs in the management of the SE and their achievement of integral forms of development. Furthermore, future studies should include the issues of knowledge privacy and security in SE. --- Social entrepreneurship Economic Model --- SE2 The organization adopts principles that seek social benefits and solidarity with the associated workers beyond economic profitability --- SE3 The organization seeks business opportunities in resource use and environmental friendliness, while generating or supporting cost-effective and efficient products and services --- SE4 The organization is based on circular economy principles where all elements of production serve a continuous function and are reused at various times --- SE5 The organization recognizes its value creation processes and seeks to enhance them on an ongoing basis Entrepreneurial maturity --- SE6 The different internal customers of the organization (executives, salespeople, and operators) are trained to dynamize the value chain --- SE7 The organization has several strategies that allow the acquisition of resources and their investment --- SE8 The development of social entrepreneurship depends on the interaction between organizations, training processes, financing systems and legal framework --- SE9 The organization demands from the surrounding ecosystem or environment activities that promote and support innovation processes Ecosystem SE10 The organization is part of a network or association of entrepreneurs at the local, regional or national level --- SE11 The organization has developed initiatives to disseminate the work and social efforts that it has been carrying out --- SE12 Continuous training of internal customers is a necessary strategy for strengthening and projecting the work of the organization --- Code --- Statement Category Subcategory --- KMPs1 The organization actively participates with the consumer in the co-development of new products and services Knowledge management practices Knowledge transfer --- KMPs2 The organization has strategies to integrate participants from different disciplines in order to share knowledge --- KMPs3 The organization implements tools to improve the exchange of information between stakeholders --- KMPs4 The organization has intellectual capital protection policies --- KMPs5 The organization has defined motivation and retention policies for outstanding employees in the creation/improvement of products and services --- Knowledge co-creation KMPs6 Co-creation supports the design of products and/or services to be offered KMPs7 I consider adequate the frequency and availability of employees to develop meetings focused on solving consumer problems --- KMPs8 The members of the organization combine their individual expertise to solve problems together --- KMPs9 In the organization there are tools that allow the articulation of old knowledge with new knowledge generated by employees --- Knowledge combination KMPs10 Seeking information from different internal and external sources helps to expand the organization's knowledge --- KMPs11 The organization has mechanisms that allow it to articulate the skills and experiences of its employees with the requirements of the consumer --- KMPs12 The organization has manuals, brochures or materials that determine the procedures that are developed in different areas of the organization KMPs13 The organization continuously creates social benefits for its consumers --- Value creation --- KMPs14 The organization uses a percentage of its financial profits to contribute to the solution of social problems --- KMPs15 The organization's operations generate wealth or profit for its shareholders and/or owners KMPs16 Government policies contribute to the creation of value in social entrepreneurship --- OA1 The organization establishes a roadmap for investment in marketing, human resources and technological developments Organizational aspects --- Sources of funding OA2 The organization takes advantage of cash balances to avoid unnecessary indebtedness --- OA3 The organization provides its customers with third-party financing to grant them extensions on overdue debts --- OA4 The organization develops inter-institutional agreements with the financial sector to offer its clients credit and financing --- OA5 The organization establishes synergies with strategic partners to evaluate their performance in the development of new products or services Planning processes --- OA6 The organization grants autonomy to its employees in the planning of resources for the optimal development of their activities --- OA7 The organization identifies short-and medium-term challenges to meet market demands --- OA8 The organization defines organizational strategies to promote an optimal organizational environment among its employees --- Code --- Statement Category Subcategory --- OA9 The organization analyzes the competitors and the market to define competitive strategies that allow it to optimize its resources --- Organizational aspects Management of tangible and intangible resources --- OA10 The organization establishes quality control techniques for tangible and intangible products to measure and monitor processes in progress --- OA11 The organization enhances the competencies and skills of its employees to develop new ideas that enable it to carry out its activities --- OA12 The organization has pleasant physical spaces for the well-being of its employees --- OA13 The organization has the technological infrastructure to ensure the security and management of its data --- Incorporation of technologies OA14 The organization identifies efficient technological developments oriented towards the adoption of sustainability practices --- OA15 The organization considers that ICT plays an important role in its development and interaction with the environment --- OA16 The organization has a website as a growth strategy to commercialize its products and/or services --- D1 The organization employs financial control tools that help it improve its return on investment --- Development Organizational development --- D2 The organization's employees are motivated to perform their daily activities --- D3 The organization uses tools to assess consumer satisfaction D4 Compared to its competitors, the organization has a higher rate of success in launching new products or services --- D5 The organization provides autonomy to employees for the development of their functions --- D6 The organization aligns its business goals with social needs and requirements Social development --- D7 The organization identifies social needs to develop new products or services --- D8 The organization includes women and/or other minority person(s) as part of its work --- D9 The organization generates different opportunities for community participation to generate collective benefits. --- D10 The organization manages its resources in accordance with government regulations Relationship with the 2030 Agenda --- D11 The organization is aware of the Sustainable Development Goals and articulates its work with them --- D12 The organization relates its operations to the Development Plan of the municipality where it is located D13 Environment and sustainability are a priority in the organization's performance --- Data Availability Statement: Data is unavailable due to privacy or ethical restrictions. --- Conflicts of Interest: The authors declare no conflict of interest. --- Code --- Statement Category Subcategory --- SE1 The organization is managed based on guidelines for renewal of resources, and social, economic, and ecological conservation --- Appendix A. Survey A series of statements will be presented below. you should rate each statement based on the following measurement scale: 5 (Completely agree), 4 (Somewhat agree), 3 (Neither agree nor disagree), 2 (Somewhat Disagree) and 1 (Nothing in agreement). --- Appendix B. Deep Interview Questions

In the context of the city of Medellín (Colombia), which has been declared a National Science, Technology, and Innovation District, Knowledge Management Practices (KMPs) have been gaining importance because they improve the commercial entrepreneurial ecosystem by articulating tacit and explicit knowledge. The study investigates the role of KMPs in Social Entrepreneurship (SE), and how this relationship generates products and services that meet social needs, with articulation between tacit and explicit knowledge, which start from the experiences of entrepreneurs and join shared interests in ecosystems and public policies of social entrepreneurship. This study employs a non-experimental design based on a survey and a deep interview for 40 SE initiatives; we then developed a Pearson's bivariate correlation review and a narrative design. The results reveal that SE initiatives aimed at novel market niches and management strategies that articulate multiple sectors and social actors that aim for a practical scope of the purposes of entrepreneurship concerning the 2030 Agenda of the United Nations. The findings of this study suggest that KMPs in SE create a series of perspectives that seek to achieve greater competitiveness and sustainability in front of the market, all from innovative proposals of social value articulated with environmental care.

YÜKSEK E<unk>T<unk>ML<unk> <unk>GÜCÜ G<unk>Ü: YEN<unk> ZELANDA <unk>RNEK <unk>NCELEMES<unk> --- <unk>z Yeni Zelanda'da araşt<unk>rma ve e<unk>itim olanaklar<unk> çok yüksektir. Ülke, çok çeşitli dünya standartlar<unk>nda programlara sahip uluslararas<unk> popülerlikte e<unk>itim kurumlar<unk>na sahiptir. Yeni Zelanda'n<unk>n e<unk>itim sisteminin cazibesi, denizaş<unk>r<unk> --- Introduction The best possible allocation or use of the resources available is essential to a nation's economic progress. Natural resources, capital assets (such as land, money, and equipment), and human capital assets are some of these resources (Stiglitz et al., 2018). Population migration behaviour in the context of human resource development (HRD) is motivated by strategies to overcome obstacles or a lack of necessary resources needed to advance knowledge and skills, which can then become assets to increase one's income potential and competitiveness in the job market (Diao et al., 2018). Additionally, there are two primary methods to raise a person's quality of living: by raising their educational level and by shifting their regional economic conditions through migration (Blunch and Laderchi, 2015). Urbanization, or the growing migration of people, especially from rural to urban regions, is a result of Indonesia's industrialisation and urban area growth. Urbanization, or the movement of people from rural areas to cities, is one kind of population migration that is motivated by the desire for a higher quality of life. Urbanization is a result of the social, economic, and living conditions in rural and urban regions that differ from one another, particularly in Indonesia's industrial zones. Industrialization significantly impacts how the job structure has changed in the setting of activities (Ateş, 2008). Successful industrialisation can then drive the growth of urbanization. Rural industrialization is viewed as a transformation of the local economic structure defined by a movement in employment from the agriculture to the industrial sectors (Faggian and McCann, 2009). Rural economic sectors are transformed into urban economic activity as a result of the industrialization of rural regions (Engbersen, G. and Okólski, 2012). Individual migration decisions, according to Lee (1996), are influenced by both push and pull influences. Push factors are associated with regional disparities in economic development and infrastructure. For instance, relative to rising unemployment rates, income gaps across regions, deplorable economic conditions in the place of origin, and educational levels, high population density results in few work options. On the other hand, pull factors are linked to the migration of workers from areas with poor economic development to those with strong economic growth. This includes the existence of numerous amenities in the destination location that increase worker productivity, as well as the availability of more employment possibilities, higher earnings, good environmental conditions, and favourable environmental conditions. Therefore, the pull factors for those with higher education are things like work prospects, a decent infrastructure, earnings, and a higher standard of living. The development of human resources and economic expansion in migration destination regions depend heavily on the accumulation of human capital contributed by highly educated migrant workers (Ciriaci, 2009). By giving the local people and economy more purchasing power, the presence of highly educated migrant workers promotes economic growth. Furthermore, the presence of highly educated migrants contributes to local population knowledge growth, human capital expansion, and improved availability and accessibility of social services (Goujon and Samir, 2008). Furthermore, an area with a high concentration of human capital may be better protected when it faces perilous economic circumstances (Corcoran et al., 2010). The destination regions are negatively impacted by the flood of highly educated migrants. The downsides of the influx of highly educated migrants are less obvious than the upsides, but at least certain demographic groups in the destination regions might possibly lose out as a result of the highly educated migrants moving into their neighbourhoods. The entry of highly educated workers, which would increase the supply of labour and at the same time the demand for essential needs, could have negative effects on the local economy. These highly educated workers would increase the supply of labour and at the same time the demand for essential needs. Furthermore, the regional variety that, if not well handled, can result in disputes and mistrust between population groups will be impacted by the presence of highly educated migrant workers from different sociocultural backgrounds than the local population. The appearance of migrants exhibits unpredictable migratory patterns, flexibility, and brief, circular, or repeated motions (Li et al., 2012). Migrations from highly educated or skilled backgrounds are directly related to such territorial movements. Migrants migrate with the intention of acquiring assets, such as educational qualifications and a variety of job experiences, which improve their capacity to relocate to other places offering greater economic prospects. Furthermore, the regional variety that, if not well handled, can result in disputes and mistrust between population groups will be impacted by the presence of highly educated migrant workers from different sociocultural backgrounds than the local population. The appearance of migrants exhibits unpredictable migratory patterns, flexibility, and brief, circular, or repeated motions (Li et al., 2012). Migrations from highly educated or skilled backgrounds are directly related to such territorial movements. Migrants migrate with the intention of acquiring assets, such as educational qualifications and a variety of job experiences, which improve their capacity to relocate to other places offering greater economic prospects. One such example is New Zealand. Historically a country that welcomed immigrants, it quickly shifted the emphasis of its immigration policy to a general-and/or occupational skills concept as the arguments for a growing need for "skilled" workers started to take shape. Despite worries about a "brain drain" caused by skilled workers leaving the country, the arguments frequently referred to the positive distributional effects of "skilled" immigration and the notion that people with in-demand skills adapt quickly to domestic labour market conditions and are more likely to significantly contribute to economic growth. In the 20 years leading up to 2022, employment in New Zealand has grown by 50%. Two factors contributed to this: first, the working-age population increased by 36% (i.e., there were more people of working age); and second, a higher percentage of persons of working age were employed (69% vs. 63% in 2002). Population increase and labour force utilisation were both influenced by several reasons (Alimi et al., 2022). --- HIGH-EDUCATED WORKERS' PULL FACTORS FOR NEW ZEALAND Due to a number of strong pull factors, New Zealand has become a desirable location for highly educated employees. First off, the great quality of life and work-life balance in the nation are a major draw for professionals. New Zealand provides an unmatched lifestyle because of its stunning natural scenery, energetic cities, and a strong focus on leisure time activities. Initiatives for work-life balance, such as flexible scheduling and friendly culture, also help to better integrate personal and professional lives. Second, there are numerous job prospects in important industries thanks to New Zealand's vibrant and varied economy. One of the main industries that draw highly educated employees is the healthcare and medical sector, followed by engineering and technology, information technology and digital innovation, education and academics, and research and development. For professionals looking for employment opportunities, New Zealand is a desirable location since these industries not only provide exciting and fulfilling careers but also opportunities for growth and progress. The chances for research and education in New Zealand are very wellrated. Internationally famous educational institutions with a wide range of topnotch programs are located in the nation. The attraction of New Zealand's educational system is further increased by scholarships and funding options for overseas students. High-educated people seeking to advance their academic and professional goals are drawn to the stimulating research environment created by collaborative research initiatives, alliances with industry, and access to state-of-the-art facilities and resources. High-educated employees find New Zealand attractive because of its well-known reputation for having a kind and inclusive culture. The nation encourages multiculturalism and variety, creating a setting that encourages cooperation, innovation, and creativity. New Zealand is an appealing option for professionals looking for stability and a good level of life because of the robust social welfare system, universal healthcare, and safety that all contribute to a sense of security and well-being for both people and their families. --- COMPREHENSIVE ANALYSIS OF THE SIGNIFICANCE AND INNOVATIONS IN THE IMPACT OF AN EDUCATED WORKFORCE ON ECONOMIC GROWTH The different ways in which education promotes economic prosperity have been thoroughly examined in relation to the effect of a well-educated workforce on economic growth. Education is a key factor in economic growth because it gives people the opportunity to pursue high-paying careers and raise worker productivity as a whole (Borjas, 2015). An educated workforce has positive effects on both people and companies as well as the economy as a whole. Studies have demonstrated that investing in education has financial benefits since greater levels of education are linked to better salaries for people (Sjaastad, 1962;Borjas, 2015). Furthermore, a highly educated workforce fosters innovation in the work industry, resulting in higher productivity and economic expansion. Businesses understand the value of having educated employees and may decide to move to places where the workforce is more educated, highlighting the economic relevance of education (Farooq and Bakhadirov, 2022). Because education leads to higher gross domestic product and better productivity, states with a larger percentage of educated employees are more likely to enjoy economic growth (Hewitt andWield,1992, Mithas andKrishnan, 2008). The relationship between education and income shows that states may grow their economies over time by hiring more educated employees, underscoring the need to prioritize education spending to boost economic competitiveness (Kruk et al., 2018). A well-educated workforce is vital for economic growth and development since spending on education boosts state economies and draws high-wage firms. The idea that education is essential for promoting economic success at both the individual and social levels is supported by a thorough review of how an educated workforce affects economic growth (Blundell et al., 1999;Raghupathi and Raghupathi, 2020). Researchers employed a quantitative approach as their research strategy. Explanatory research, also known as descriptive or hypothesis-based research, is the method used in this study. The information gathered for this study was obtained from the Central Statistics Agency and includes information on the movement of a highly educated workforce into 57 industrial districts and municipality regions in New Zealand. The same source also provided information on issues including minimum salaries, economic growth, and employment rates that influence the movement of highly qualified workers to industrial districts and municipal regions. Cross-sectional and time-series data are combined to form panel data. Using repeated observations on a certain issue across a variety of time periods, this panel data is utilized to uncover key factors. This approach is used to comprehend how a factor, such as migration, the minimum wage, economic development, and so on, periodically affects a particular issue. Multiple linear regression is a development of panel data regression. The parameters of a regression model can be predicted using either technique. The following describes the form of the regression model to be utilized in this investigation, which is based on a generic model modified with several simplifications (Gujarati,2004). HSM it = <unk> 0 + <unk> 1 MWC it + <unk> 2 EG it + <unk> 3 EOR it + e it (1) Data transformation using the natural logarithm will be carried out because the data in this study have different units, including the high-skilled labour migration (HSM) measured in individuals, the Minimum Wage of Cities (MWC) measured in New Zealand Dollars, the Economic Growth (EG) measured in percentage (%), and the Employment Opportunity Rate (EOR) measured in percentage (%). To prevent bias in the logarithmic transformation, this is done. The following describes the logarithmic model applied in this study: In(HSM) it = <unk> 0 + <unk> 1 In(MWC) it + <unk> 2 EG it + <unk> 3 EOR it + e it (2) The panel data regression model is estimated using the following method: 1. First, the Common Effect Model (CEM) Combining time series with cross-sectional data is the easiest way to use the panel data model. This methodology may estimate the panel data model using the Ordinary Least Square (OLS) strategy or the least squares method. To model panel data, a linear model with the following general form can be used: HSM it = <unk> 0 + <unk> 1 MWC it + <unk> 2 EG it + <unk> 3 EOR it + e it (3) 2. FEM, or Fixed Effect Model A fixed effect model is a method for estimating panel data by capturing intercept differences using dummy variables. The Fixed Effect Model (FEM) is represented in the following way: Random Effect Model (REM) HSM it = <unk> 1 + <unk> 2 D 2i + <unk> 3 D 3i +... +<unk> n D ni + <unk> 1 MWC it + <unk> 2 EG it + <unk> 3 EOR it + e it (4) 3. Random Effect Model (REM) The distinctive effects of every person are taken into account as part of the error component, which is random and independent of the observed independent variables, in contrast to the Fixed Effect Model (FEM). The Random Effects Model's (REM) equation is as follows: HSM it = <unk> 0 + <unk> 1 MWC it + <unk> 2 EG it + <unk> 3 EOR it + e it (5) Conducting descriptive statistics comes before any data processing. Descriptive statistics can be used to learn more about the characteristics of each independent variable, including migration values and all other independent variables that are thought to significantly affect changes in the migration of highly skilled workers to industrial districts in New Zealand from 2018 to 2022. The following table shows the descriptive statistics utilized, which include the maximum, minimum, mean, and standard deviation of each variable: Examine the data to see if they fit a normal distribution. For this, the mean and standard deviation of the data were calculated. The calculated value of 57 industrial areas and municipal districts is 83.514, and the calculated value of standard deviation is 2.617. The Shapiro-Wilk test was used to confirm normality assumptions. The Shapiro-Wilk statistic is 0.99, and since p=0.192>0.05, the data are observed to be normally distributed. Auckland is the most popular destination for immigrants, whereas Nelson is the least popular. The highest real salaries in 2020 and 2021 will be $87,022 and $89,799, respectively. From 2018 to 2021, the lowest real salaries were $68,183 and $70,838 per year, respectively. Since the 1970s, the percentage of New Zealanders who are working age who are in the labour force has climbed to about 66 percent. This surge is mostly attributable to significant increases in both the proportion of women working and the number of part-time employments. High labour force growth will undoubtedly boost production if those who join the workforce do so and find employment. The topic of whether labor force expansion boosts output per capita is more debatable. On the one hand, extra labour may experience diminishing returns when added to a base of finite other productive resources, lowering the average level of production per person. However, a bigger labor force could boost production per capita through economies of scale or by allowing workers to "learn by doing" while they are employed. Overall, the most important factor affecting the impact on productivity per person is likely the additional labourers' workplace abilities. --- Model Analysis The empirical approach is panel data analysis. It is possible to conduct analysis using a data collection that combines cross-sectional and time-series data using panel data analysis (Baltagi, 2005). It is suitable to employ the panel data analysis approach for the analysis since the study's data come in both cross-section and time-series form. Due to its benefits, panel data analysis is quite helpful. First, a significant number of observation values will be available in the cross-section and time-series data forms. The estimations will therefore be more trustworthy. Additionally, the cross-section and size of independent variables vary. As a result, multicollinearity issues are less likely. LNHSMit = <unk>0 + <unk>1<unk>LNMWCit + <unk>2<unk>LNEGit + <unk>3<unk>LNEOR uit + uit (6) uit = <unk>i + vit (7) The econometric model utilized for panel regression estimation is shown in Equation ( 6). I stands for nations in equation ( 6), and t stands for time. High-skilled labor migration is represented by the dependent variable (LNHSM). The independent variables included in the analysis are (LNMWC) the Minimum Wage of Cities, (LEG) the Economic Growth, and (LEOR) the Employment Opportunity Rate, which is an independent variable that affects the migration of highly trained workers. In equation ( 7), it stands for the error terms, while uit represents the unobservable individual impact. I define specific effects that are not time-dependent and are not taken into account in regression (Baltagi, 2005). Equation ( 6) is calculated using a fixed-effects, random-effects, or pooled regression technique. To choose amongst these techniques, the Hausman, Breusch-Pagan, and F tests are run. Finally, diagnostic tests including heteroscedasticity, autocorrelation, and multicollinearity are carried out. These statistical issues allow for the employment of robust estimators. Aside from the migrant stock, three variables thought to influence high-skilled labour migration were investigated in this study. The research is based on 57 industrial districts and municipality areas in New Zealand with varying income levels, where these factors better safeguard their social and economic assets and may provide migrants with a more viable job market with a higher educational level. As a result, higher education is also in the spotlight in terms of wealth, pay, and work opportunities. As a result, New Zealand's economic expansion is predicted to have a beneficial impact on high-skilled labour migration flows. All data utilized is from the years 2018-2022. Highskilled labour migrant statistics for these time periods and on a yearly basis are available in the United Nations and World Bank statistical databases. Regression that is spurious is the result of analyzing non-stationary series. Thus, the series has to be stable for the studies to produce meaningful and trustworthy conclusions in terms of both economics and statistics. The stationarity of the series that will be utilized to make the model estimates is examined before beginning. In choosing the unit root test for the investigation of the series' stationarity, the cross-section dependence problem of the series is taken into consideration. In the panel data analysis, the cross-sectional dependence-where all units in the same cross-section are correlated-is a key issue (Baltagi, 2005). The second-generation unit root test is utilized when a cross-sectional dependence issue exists in the series. Table 2 shows the outcomes of the Pesaran CD test, which examines the cross-sectional dependence problem, and the CADF (Cross Sectionally Augmented Dickey-Fuller) and CIPS (Cross-Sectionally Augmented IPS) unit root test, which examines the stationary of series. Numerous tests are used to examine crosssectional dependence, including the Breusch-Pagan LM, Pesaran scaled LM, Bias-corrected scaled LM, and Pesaran CD test (Pesaran, 2007). When the panel data set is N>T, Pesaran CD test produces accurate findings. All variables have a cross-section dependence issue, as shown by the Pesaran CD test findings. In order to identify stationary of series, Pesaran's (2007) CADF unit root test and the CIPS unit root test are utilized. The LNHRS is stationary at level, according to the findings of the CADF test, whereas the other variables are stationary at the first difference. Taking the difference has resulted in the series becoming stagnant. The findings of the diagnostic tests are displayed in Table 3. First, it is determined if the model to be estimated is appropriate for the fixed effect, random effect, and pooled regression models. First, the Hausman test was successful. The alternative hypothesis in this test is that there is a connection between the unique mistakes and the model's regressors, contrary to the null hypothesis, which states that there is no link. The null hypothesis is disproven using the Hausman test. So, instead of using the random-effects model, use the fixed-effects model instead. The F test results contradict the null hypothesis. The fixed-effects model is thus recommended over the pooled regression approach. As a consequence, the econometric model in equation ( 6) was estimated while taking into consideration the fixed effects. To identify statistical issues with estimates, certain tests have been run. The findings of the Pesaran CD and Friedman R tests show that cross-section dependence is a concern in estimates. The Modified Wald test indicates that the model's estimations are heteroskedastic. The statistical values for the modified Bhargava Durbin-Watson and Baltagi-Wu LBI tests are computed as 0.46 and 0.68, respectively. It has been determined that there is an autocorrelation issue with the estimations as the statistical values are less than two. Aside from the migrant stock, three variables thought to influence highskilled labor migration were investigated in this study. The research is based on 57 industrial districts and municipality areas in New Zealand with varying income levels, where these factors better safeguard their social and economic assets and may provide migrants a more viable job market with a higher educational level. As a result, higher education is also in the spotlight in terms of wealth, pay, and work opportunities. As a result, New Zealand's economic expansion is predicted to have a beneficial impact on high-skilled labor migration flows. Eviews is used to do panel data regression analysis on the independent and dependent variables. The estimation results of the above three different models are shown in Table 4. It can be seen that in Model II, except EOR, one of the variables has a statistically significant effect (5% level) on the number of high-skilled migrant workers, and the AIC value indicates the applicability of the Model II specification, which is included together with EOR in MWC and In EG. The signs of the parameter estimates are as expected. Diagnostic metrics indicate that the error terms for all models are not autocorrelated and have constant variance. According to the results obtained, it can be said that the higher the urban minimum wage, the higher the economic growth rate, and the higher the employment opportunity rate, the more highly skilled migrant workers will come to the countryside. It turns out that variables representing institutional quality and stability have parallel effects on expectations and the existing theoretical and empirical literature. As expected, based on New Zealand's higher economic growth, the country appears likely to attract more highly skilled migrant workers. It can also be concluded that increased democratization, demand for more workers in the labor market, and improved living standards will lead to more high-quality migrant workers entering the country. Considering that the regression equation is more sensitive to its components, the immigration variables in different specification models generally retain a significant positive effect, which can be interpreted as an indicator of the robustness of the relationship between education and immigration. Following is the equation for the Common Effect Model (CEM) method's regression result on the panel data: LOGHSM it = 16.1425 + 0.4278MWC it + 0.00647EG it -0.2105EOR it + e it (8) For panel data utilizing the Fixed Effect Model (FEM) approach, the regression result equation is as follows: LOGHSM it = 0.10247 + 0.51736MWC it + 0.00541EG it + 0.00841EOR it + e it (9) Using the Random Effect Model (REM) approach, the following equation represents the regression result: LOGHSM it = 4.4879 + 0.5107MWC it + 0.00412EG it -0.02871EOR it + e it (10) The next stage is to run tests to choose one of these three models after studying the three different sorts of models. Eviews is used to do panel data regression analysis on the independent and dependent variables. These are the outcomes for each model. Following is the equation for the Common Effect Model (CEM) method's regression result on the panel data: LOGHSM it = 16.1425 + 0.4278MWC it + 0.00647EG it -0.2105EOR it + e it (11) For panel data utilizing the Fixed Effect Model (FEM) approach, the regression result equation is as follows: LOGHSM it = 0.10247 + 0.51736MWC it + 0.00541EG it + 0.00841EOR it + e it (12) Using the Random Effect Model (REM) approach, the following equation represents the regression result: LOGHSM it = 4.4879 + 0.5107MWC it + 0.00412EG it -0.02871EOR it + e it (13) The next stage is to run tests to choose one of these three models after studying the three different sorts of models. --- Selecting a Model The following assumptions are tested using the Chow Test to evaluate whether the common effect model or the fixed effect model is more suitable: H 0 = OLS pooled common effect model H 1 = LSDV fixed effect model grounds for decision If the probability > ( <unk> = 0,05), H=0 is acceptable. H=1 is true if the probability is (<unk> = 0.05). The null hypothesis is rejected since both the cross-section F and crosssection Chi-Square probability are 0.0000, which is less than <unk> = 0.05. As a result, it suggests that the Fixed Effect Model (FEM), which is the best model, is relevant in assessing the panel data. In order to choose between a random effect and a fixed effect model, the following hypotheses are tested using the Hausman test: H0 = The model error does not depend on any of the independent variables. (Fixed Effect Model) H1 = The model error and one or more independent variables are related. rationale for the decision If the probability><unk>, which denotes that a random effect model was utilized, H 0 is acceptable. If the probability <unk>, suggesting that a random effect model was utilized, then H 1 is acceptable. The P-value is less than <unk> = 0.05 because the probability value for Cross-Section Random is 0.0049, supporting the null hypothesis. Therefore, it shows that the Fixed Effect Model (FEM) is the optimal model to utilize for the research. --- Determining the Best Panel Regression Model's Interpretation Fixed Effect Model (FEM) is the top panel regression model (Gujarati, 2004). The constant has a positive value of 0.10247, as shown by the linear regression findings on the panel data above. Accordingly, if the Minimum Wage of Cities, Economic Growth, and Employment Opportunity Rate remain unchanged, the inflow migration of highly educated workers to industrial locations in Cities will grow by 0.10247 percent. Minimum Wage City Coefficient (MWC) is 0.51736. Accordingly, if all other variables remain constant, a 1 percent rise in the minimum wage in a district or city will result in a roughly 0.51736 percent increase in the average inflow of highly educated personnel to such places. The economic growth coefficient (EG) is 0.00541. This suggests that, assuming all other factors remain constant, a 1 percent rise in economic growth will result in an increase in the average inflow of highly educated workers to industrial regions and cities of around 0.00541 percent. The Employment Opportunity Rate (EOR) coefficient is equal to 0.00841. --- Results Based on the results of the studies, it has been concluded that the minimum wage of cities has a beneficial and significant influence on the migration of highly educated people to industrial areas in Indonesia. This result is supported by Everett S. Lee's migration theory, which holds that one of the factors luring individuals to move is the presence of higher salaries at the destinations. This supports Ricardo's wage theory, according to which highly skilled workers are less affected by minimum wages because of their in-demand skills. They could prefer seeking for work in locations with higher minimum pay if their country of origin has lower minimum wages, in particular. A positive relationship between worker salaries and education level was discovered by the Central Statistics Agency (BPS). With higher levels of schooling comes higher incomes. Higher education degree holders often make more money than other types of workers. Conversely, those with merely a high school graduation or fewer frequently earn less money. The typical worker's monthly salary decreased slightly from around NZD 2.76 million in 2020 to NZD 2.74 million in 2021. But when salaries are compared according to education level, those with more advanced degrees frequently make more money, amounting to NZD 3.99 million per month. It was also less than the previous year, 2020, when it was over NZD 4.1 million each month. The lowest wage, or almost NZD 1.65 million per month, was still provided to persons with only a primary education. This is unchanged from the prior year. For individuals with a high school certificate or a vocational degree, the average monthly pay varies from NZD 2.62 million to NZD 2.69 million. The complete populace should make an attempt to locate honorable careers with higher pay. In this regard, the involvement of the government is essential. This is consistent with the International Labor Organization's (ILO) mission to advance just working conditions for individuals to sustain their families. The trials' findings indicate that economic growth has a positive and significant impact on highly educated people's decisions to relocate to industrial areas in Indonesia. This result is supported by Lee's migration theory, which contends that fast economic expansion attracts highly educated workers to a location, particularly cities or neighborhoods with industrial zones. The idea holds that a region's robust economic development promotes the construction of businesses and industries that require highly educated workers, such as engineers, doctors, and lawyers, among others. This research's findings are further supported by the Ravenstein theory, which holds that a new location's quick economic development stimulates the migration of highly educated workers there. This is so because the wages and career prospects there are more attractive. This agrees with the "Spillover Effect" justifications put out by Vernon Ruttan, Michael Porter, and Paul Romer. This theory holds that having educated residents may increase local output and innovation, which can indirectly have a positive impact on the local economy. The spillover effect can manifest itself in the economic environment in a number of different ways, including in relation to technology, innovation, knowledge, skills, and social impact. For example, firms close by can benefit from the technology and knowledge developed by a region's cutting-edge and thriving sector. This can increase the productivity and caliber of local workers and encourage the growth of related economic sectors. Strong economic growth is strongly tied to the influx of highly educated migrant workers, which raises the quality of the labor force and increases productivity and efficiency in sectors that require highly educated employees. Foreign companies looking for highly educated workers are increasingly preferring to invest in countries with a large pool of labor. The Wellington region has continued to provide the largest contributions to the growth of New Zealand's gross domestic product (GDP) in terms of manufacturing. Sometimes immigrants from locations with more advanced technology bring with them more advanced knowledge and technology. In the aforementioned areas or territories, this can help to increase innovation and productivity in certain industries. It supports the growth of higher-quality human resources there and produces spillover effects, which can increase output and economic growth. This is also in line with the idea of virtuous cycles, which holds that a developing industrial sector may be able to create a virtuous cycle in which job possibilities and economic advancement have a mutually beneficial relationship. Strong economic expansion may attract investment and create new jobs, which in turn raises the population's purchasing power and accelerates economic growth. --- Conclusion In light of the research findings using panel data regression on the factors influencing the migration of highly educated workers to industrial areas in New Zeland: 1. High-skilled workers in New Zealand frequently move to industrial areas where the minimum wage is greater. 2. It has been demonstrated that economic growth attracts highly educated employees to New Zealand's industrial zones. 3. Due to Indonesia's employment rate, high-skilled workers do not seem to be moving to the country's industrial areas. In order to give more detailed findings, the researcher suggests many areas for more investigation, including: Involving industry, labor unions, municipal governments, and research institutions as decision-making stakeholders is the first step. Constructive discussions and exchanges can help to clarify the viewpoints of various parties about minimum wage increases and help to establish a balance between worker protection and company sustainability. The second phase is to include sustainability principles in the design of industrial zones to ensure sustainable economic growth. Ecosystem protection, natural resource management, and consideration of environmental implications may be useful in maintaining a balance between economic growth and environmental sustainability. Third, expanding employment opportunities outside of urban centers and industrial areas to deter people from relocating. Increasing investment in non-manufacturing sectors including tourism, agriculture, fishing, and other service industries as well as the unorganized sector and improving infrastructure and accessibility may all help achieve this. Peer Review: Independent double-blind Author Contributions: <unk>a<unk>atay Tunçsiper: 100% Funding and Acknowledgement: No support was received for the study.

Research and education opportunities in New Zealand are very high. The country has educational institutions of international popularity with a wide variety of world-class programs. The appeal of New Zealand's education system is further enhanced by scholarships and funding options for overseas students. Highly educated individuals seeking to advance their academic and professional goals are invited to the stimulating research environment created by collaborative research initiatives, alliances with industry, and access to cutting-edge facilities and resources. Because of these attractive factors, New Zealand has become a desirable destination for highly educated workers. First of all, the country's high quality of life and work-life balance is a major attraction for professionals. New Zealand offers a unique lifestyle due to its stunning natural scenery, energetic cities and strong focus on leisure activities. The aim of this study is to examine the phenomenon of highly educated workers migrating, sometimes called brain gain or brain drain, in relation to New Zealand. It examines the pull factors from their home country, the pull factors that attract highly educated people to New Zealand, and the effects of this migration on both their homeland and New Zealand. The research also looks at the idea of brain gain through return migration and how overseas students impact the local labour market. Government actions and initiatives aimed at retaining highly educated workers and maximizing the advantages of migration are also covered. By assessing these factors, the research provides insight into the dynamics of highly educated worker migration in New Zealand.

lived alone (n = 6, 50%). Caregivers of participants (n = 5; M = 63 years old, SD = 11) were predominantly Hispanic, Latino, or of Spanish origin (n = 3, 60%), female (n = 4, 80%), and lived with a partner (n = 4, 80%). Four central themes emerged: social isolation, emotional concerns, transportation loss, and care loss. Data showed decreases in social support and increases in loneliness. Results suggest programs like PACE greatly benefit older adults. Future directions may include developing community-based interventions to address service needs and social isolation concerns in Wyoming. Abstract citation ID: igad104.2738 --- THE MODERATING ROLE OF SOCIAL SUPPORT IN THE RELATION BETWEEN FUNCTIONAL LIMITATIONS AND DEPRESSIVE SYMPTOMS Junyub Lim, and Giyeon Kim, Chung-Ang University, Seoul, Republic of Korea Background and Objectives: Prior research has demonstrated that social support from friends and neighbors can effectively reduce depressive symptoms. However, few studies have investigated how the characteristics of these relationships can alleviate depressive symptoms among older adults with functional limitations. Therefore, the present study aims to investigate the moderating effects of characteristics of friends and neighbors relationships on the link between functional limitations and depressive symptoms among Korean older adults. Methods: The data used for analyses were obtained from the 2020 Survey of Living Conditions and Welfare Needs of Korean Older Persons, a nationally representative survey. The sample included a total of 9,985 individuals who were 65 years of age or older residing in Korea. Results: Results from the moderator analyses revealed that the link between functional limitations and depressive symptoms was influenced by both the number of close friends and neighbors (b = -0.085, p <unk>.01) and the level of satisfaction with relationships with friends and communities (b = 2.052, p <unk>.05). Discussion: Satisfaction with relationships with friends and communities may act as a protective factor that mitigates the impact of functional limitations on depressive symptoms. In particular, for older adults with functional limitations, having a larger network of friends and neighbors network is expected to help reduce the risk of depressive symptoms. Abstract citation ID: igad104.2739 --- UNDERSTANDING LONELINESS PATTERNS AMONG WIDOWED OLDER ADULTS OVER TIME AND THE PROTECTIVE EFFECT OF SOCIAL SUPPORT Gina Lee, and Daniel Russell, Iowa State University, Ames, Iowa, United States The present study aimed to investigate loneliness among widowed and non-widowed older adults. Additionally, the study sought to identify classes with different loneliness patterns among widowed older adults over time and to determine social resources that impact loneliness patterns after spousal loss. Data from the Health and Retirement Study were utilized to compare loneliness levels between widowed (n = 137) and non-widowed (n = 2,361). Those who were married at T1 (2008/2010), widowed at T2 (2012/2014), and remained widowed at T3 (2016/2018) were defined as widowed. T-tests were conducted to compare loneliness between the two groups, revealing that widowed individuals reported significantly higher levels of loneliness at T2 only. Using growth mixture models, three distinct loneliness patterns were identified among widowed individuals: Group 1, displaying mid-level loneliness at T1 and increasing over time (n=32); Group 2, exhibiting the lowest loneliness at T1 and leveling off (n=88); and Group 3, experiencing the highest loneliness at T1 and decreasing over time (n=17). Finally, analysis of variance tests were conducted to determine whether social support and engagement as measured at T1 differed among the three identified groups. Results indicated that social support from friends and children was significantly higher among group 2 compared to the other two groups. This study provides evidence of the protective effect of social support before widowhood on the psychological well-being of older adults after spousal loss. The findings may have implications for the development of interventions aimed at supporting widowed older adults during this difficult period of transition. As individuals age, social connection becomes increasingly important, and social media has the potential to facilitate social connections. This study aimed to investigate the relationship between age and well-being, focusing on the mediating role of social media use. While previous research has found social connection to be an important predictor of well-being, the specific implications of social media use for social connection on various aspects of well-being remain unclear. To explore this relationship, the study used publicly available data from the Midlife in the United States (MIDUS) study wave 3 and refresher 1, with a sample of 6871 participants (M = 56.80 yrs, SD = 14.58 yrs). Results showed that social media use played a significant mediating role in well-being, specifically in loneliness (b = 0.001, p=0.003), positive affect (b = -0.002, p<unk> 0.001), and eudaimonic well-being (b = -0.020, p<unk> 0.001). However, the indirect pathway from age to well-being through social media use was negative. That is, as individuals aged, they tended to use social media less frequently, which in turn was associated with worse well-being outcomes. These findings add to the expanding body of research on the complicated relationship between social media use and well-being, emphasizing the significance of focused interventions to encourage social media use for social connection in middle-aged adult populations. The study has implications for health professionals working with middle-aged adults, underlining the importance of considering social media use as a potential method of enhancing well-being. --- SESSION 7620 (POSTER) --- ALZHEIMER'S DISEASE AND DEMENTIA (HS) Abstract citation ID: igad104.2741 --- A CONCEPT ANALYSIS OF SHARED DECISION MAKING FOR OLDER PATIENTS WITH DEMENTIA IN ACUTE CARE HOSPITALS Taeko Saito 1, and Harue Masaki 2, 1. Chiba University, Inzai, Chiba, Japan, 2. Chiba University, Chiba, Chiba, Japan Background: Dementia patients often have comorbidities like Diabetes Mellitus, kidney disease, and cardiovascular disease that require patient decision-making about care, despite the challenges in judgment that stem from dementia. The study aimed to determine what Shared Decision-making is for older patients with dementia in acute care hospitals. Methods: The study used the Hybrid Model of concept analysis method. This comprises a theoretical phase, a fieldwork phase, and an analytical phase. In the initial phase, the concept is selected. The fieldwork phase collects qualitative data to further analyze the selected concept. The third phase analyzes the empirical observations and writes up the findings. We searched Pub-Med, CINAHL, and PsycINFO for the keywords: "shared decision-making" and "patients with dementia." Results: We identified 14 articles that gave rise to over 100 codes. We defined shared decision-making for older patients with dementia in acute care hospitals as "The older person with dementia can be involved in collaborative activities in the care network, including delegation of authority as active decision-making. Open-minded communication based on person-centered care can be the foundation for considering feasible options. Clarify the role of family caregivers and identify decision-making participants in the care network to view the best alternative for the patient's subsequent life". Conclusions: We developed a working definition of shared decision-making for patients with dementia. We clarified critical elements of the decision-making process, like based as person-centered care, open-minded communication, and collaborative decision-making activities between the person and the care network members, including delegation of authority. Abstract citation ID: igad104.2742 --- ANALYSIS OF CONVERSATIONAL ENTRAINMENT AMONG OLDER PERSONS WITH ADRD AND UNIMPAIRED ADULTS Christine Williams 1, Joseph McKinley 1, Charles Cooper 1, Nurgun Erdol 1, and Christopher Beetle 2, 1. Florida Atlantic University,Boca Raton,Florida,United States,2. Florida Atlantic university,Boca Raton,Florida,United States Social isolation threatens the health of older adults, particularly those with Alzheimer's disease and related dementias (ADRD). Our research uses measures of behavioral coordination to quantify the entrainment of an individual's behavior to the collective dynamics of a group to which they belong, aiming to identify useful strategies to reduce social isolation for persons with ADRD in therapeutic group contexts. The present study is based on data collected during 27,

This study aimed to identify subtypes of Social Network Service (SNS) use that affect self-esteem by applying a person-centered approach. The study also aimed to compare the SNS use subtypes and their associations with self-esteem between young and middle-aged adults in Korea. The sample included 2,572 young adults (18-44 years old) and 1,790 middle-aged adults (45-64 years old) drawn from the Korea Media Panel, a nationally representative dataset. Self-esteem was measured by the sum of ten questions from Rosenberg's Self-Esteem Scale. Four indicators of SNS use (e.g., "How often do you check other people's posts (feed)?") were used to perform a 3-step Latent Profile Analysis, which accounts for classification errors. The results of the Latent Profile Analysis showed 5 and 4 subtypes of SNS use for young and middle-aged adults, respectively, depending on the frequency of active and passive usage. Overlapping subtypes include 'passive-low', 'active-low', 'moderate', and 'high-active' users. Young adults had one distinct subtype with a very high frequency of passive usage (checking others' posts and liking them) but a very low frequency of active usage (sharing content with others). The results also revealed that those with more frequent use in both active and passive use showed the lowest self-esteem in both young and middle-aged groups. This study supports previous findings suggesting that frequent SNS use has negative impacts on self-esteem, even for middle-aged adults. Based on these results, digital literacy programs for middle-aged adults should cover healthy ways to use SNS.

INTRODUCTION Despite significant improvements in the control of leprosy in recent decades, the disease persists as a public health problem in many countries in the world, including Brazil 29. Leprosy is a Neglected Tropical Disease (NTD) with unequal occurrence, mainly in socioeconomically disadvantaged and marginalized populations in tropical countries 11. Approximately 233,000 new leprosy cases were recorded in the world in 2013. The Americas recorded about 17% all cases, with 92% of these from Brazil. The overall case detection rate in the country was 15.4 new cases per 100,000 inhabitants 29. The distribution of the disease is heterogeneous in Brazil, with new cases concentrated in the poorest regions of the country (North, Midwest and Northeast) 1,24. Despite advances in the control of leprosy at the national level in recent years, the detection rates are still high in these regions 1. The State of Tocantins, located in the North region of the country, ranked second in the Brazilian States in terms of new cases per 100,000 inhabitants (60.9) and ranked first in those aged 15 years or less (19.7) in 2013 16,a. This epidemiological situation indicates a relationship of the endemic process of the disease with the habitation of new regions, as Tocantins is a State with a large area of agricultural borders. Migratory movements and population growth leading to deforestation seem to promote an increased incidence of the disease 18. Additionally, the high values of the indicators may reflect the social vulnerability of the disease, which also favors transmission and endemicity of the bacillus 7,14. The understanding of the different determinants and conditions of the disease in that territory can support local programs to control the disease. The objective of this study was to identify socioeconomic, demographic, operational, and health service-related factors associated with the occurrence of leprosy in a hyperendemic State in North Brazil. --- METHODS This study is part of a major project of the Universidade Federal do Ceará called INTEGRAHANS -Norte/Nordeste. The project is an integrated approach on epidemiological, clinical, psychosocial, and operational patterns of leprosy in the States of Tocantins, Rondônia, and Bahia. Tocantins is located in the North region of Brazil (Figure). It is the most recent State in the country (founded in 1988) and part of the Brazilian Amazon region, with a predominantly savannah (Cerrado) vegetation. It has a territorial extension of 277,622 km 2 and an estimated population of 1.5 million in 2014. It is divided into eight health regions. The urbanization rate of the State increased from 40.0% in 1980 to 79.0% in 2010. Sociodemographic data point to a significant improvement of the living conditions of the population in the last two decades. The Municipal Human Development Index (MHDI) increased from 0.369, in 1991, to 0.699, in 2010. The proportion of extreme poverty was reduced from 31.8%, in 1991, to 10.2%, in 2010. Income inequality pointed by the Gini index ranged from 0.63, in 1991, to 0.60, in 2010. Average per capita income increased by 140.8% in the last two decades, from R$243.58, in 1991, to R$586.62, in 2010 (income adjusted for inflation). The proportion of poverty, i.e., individuals with income per capita of less than R$140.00 (August 2010 figures), deceased from 59.1%, in 1991, to 22.2%, in 2010. The illiteracy rate of persons aged 15 years or more decreased from 31.4%, in 1991, to 13.1%, in 2010. There was a significant growth of households with running water and sanitation, increasing from 29.0%, in 1991, to 94.3%, in 2010. The proportion of the population with waste collection in the urban area of the municipalities, increased from 77.3%, in 1991, to 97.0%, in 2010 b. We calculated the smoothed detection rates (per 100,000 inhabitants) as outcome using the empirical Bayesian method. Smoothing was adopted to reduce the fluctuations of crude rates associated with the small areas, using the information of the neighboring municipalities 3. --- The data of leprosy cases The independent variables included the demographic and socioeconomic characteristics of the municipalities, as well as the variables related to the government program of income transfer and health services. In reference to a national study 7, the following characteristics of the municipalities were obtained from the 2010 Census: Municipal Human Development Index (MHDI), illiteracy rate, proportion of low-income population (half minimum wage/nominal household monthly income per capita <unk> R$255.00), proportion of population living in extreme poverty (nominal household monthly income per capita <unk> R$70.00), average household monthly income per capita, urbanization rate, gender ratio, unemployment rate, Gini index, income ratio (income ratio of the richest 20.0% and the poorest 20.0%), income ratio of the poorest 20.0% (income ratio of the 20.0% with better and 20.0% with worse income among the poor), proportion of households with two or more persons per bedroom, proportion of households with inadequate sanitation (no connection to the network of water supply, sanitation, or had no access to waste collection), proportion of immigrants with permanent residency in the municipality during the past 10 years, proportion of households with running water and bathroom, proportion of households with waste collection b. Continuous variables were categorized into approximate quartiles. However, for the variable "proportion of cases with grade 2 disability among new cases assessed", we used the categories for the parameters of interpretation of this indicator: low (<unk> 5.0%), average (5.0% to <unk> 10.0%), and high (<unk> 10.0%), as recommended by the Ministry of Health. The distributions of the values of the smoothed detection rates of leprosy, according to the characteristics of the municipalities, were described based on the values of the medians, minimum, and maximum. We analyzed the association between the smoothed detection rates with socioeconomic, demographic, income transfer, and health service conditions in the municipalities of the State of Tocantins. The distribution of the detection rates in the period showed asymmetry to the right (positive asymmetric distribution of 1.089 and with extreme values, Kurtosis = 2.242). Therefore, we decided to use the hierarchical log-linear model with negative binomial response in the analytical step to identify which parameters significantly determine the variation of the number of cases of the disease by municipality. The test of significance of the parameters of the rates was carried out by Wald statistic, and we estimated the Incidence Rate Ratio (IRR) of the risk factors for the disease with their respective 95% confidence intervals (95%CI). We estimated the Pearson correlation coefficient to avoid multicolinearity in the multivariate regression analysis. For the multivariate model, we selected the variables that, in the bivariate regression, were related with the outcome at a level of significance of up to 10.0%, and in accordance with the best quantitative or qualitative fit. We adapted the hierarchical theoretical model proposed by Victora et al. 28 to identify the factors associated with the detection rates of new cases of leprosy. The independent variables were separated into proximal (income transfer program and health services) and distal levels (demographic and socioeconomic factors). We started hierarchical modeling by introducing all first-level (distal) variables at once. The significant variables in the analysis of the first level (p <unk> 0.05) remained in the model and were part of the adjustment of the next level (proximal) 28. We used the backward elimination method and Wald statistic in each of the hierarchical levels for the construction of the final models. The corrected Akaike criterion was used to select the best model. The residues for the log-linear negative binomial model were examined using the probability distribution 22 to assess the quality of the fit of the model. --- RESULTS The average annual smoothed detection rate in the period was 84.6 cases/100,000 inhabitants. The values ranged between 21.9 and 250.5 cases/100,000 inhabitants by municipality. In the bivariate analysis, IRR was significantly higher for the municipalities with the lowest (<unk> 25.1%) proportion of the population covered by the BFP compared with the highest proportion of coverage (25.1% to 33.9% and greater than 33.9%). Of the variables on income, only the income ratio of the poorest 20.0% presented significant IRR for municipalities with inequality above 3.4%. The IRR of the disease was higher for municipalities with detection of early cases, i.e., <unk> 5.0% of cases with grade 2 disability. The municipalities with the highest concentration of immigrants with permanent residency in the last 10 years had the highest IRR (1.32; 95%CI 1.10-1.59) (Table 1). Socioeconomic and demographic variables, such as the proportion of households with two or more persons per bedroom, per capita income of up to half wage per household, and others, were significantly lower for leprosy (p <unk> 0.05). The detection rates of these variables showed the highest median in the most vulnerable groups (Table 1). In multivariate analysis, IRR was significantly higher in the municipalities with higher proportion of households with waste collection and higher proportion of immigrants (Table 2). Increased coverage of the BFP was significantly associated with a reduced leprosy detection rate. This effect was maintained after controlling for sociodemographic and income variables. The municipalities with the highest unemployment rates per household in the population aged 16 years or more presented lower IRR (Table 2). --- DISCUSSION This study indicates a significantly positive impact of public social policies in reducing the detection of leprosy incidence in municipalities in the State of Tocantins. The IRR was significantly higher in municipalities with higher ratio of income of the poorest 20.0%, better Municipal Human Development Index (MHDI), higher proportion of immigrants, and higher proportion of households with waste collection. There was a significant reduction of the IRR with increased coverage of BFP. Social inequities determine the persistence and the difficulties of controlling NTD, causing higher vulnerability and risk for these diseases 11. Poverty is one of the determining factors for the occurrence and transmission of leprosy 7,13,14. In this study, the variables related to poverty were clearly associated with the high incidence. On the other hand, social interventions can have an impact on the transmission of leprosy with poverty alleviation of a more vulnerable part of the population 20. Examples are the policy measures to mitigate poverty, such as the BFP. Corroborating with a recent study 20,25, our data showed, in the final model, a significant reduction of the indicators of leprosy in the municipalities that had better coverage of the BFP. The BFP reached approximately 29.0% of the population of Tocantins in 2010, evidencing a scenario of poverty. Under certain conditions, the transfer of income to poor and extremely poor families can significantly increase food consumption, reduce food insecurity, improve nutritional conditions, and increase school enrollment and frequency 9,15,27, as well as reduce barriers to access health services, especially to primary health care units. The municipalities with populations living in poor socioeconomic conditions, high unemployment rates, probably benefited most from the BFP, as shown by a significantly lower risk for leprosy. Our and other studies suggest that interventions focused on the improvement of socioeconomic conditions may contribute to reducing the incidence of the disease 7,10,12,20. On the other hand, in the bivariate analysis, the leprosy incidence was significantly higher in the most miserable population (higher ratio of income of the poorest 20.0%), i.e., the group of persons that are probably not part of the income transfer program with consequent difficulty to access health services. This condition leads to food shortage, proven as a socioeconomic risk factor for the clinical manifestation of the disease in different endemic areas 8,14. Food insecurity is a result of the deprivation of basic rights, such as being alive and without disease, and being well nourished 21. In the State of Tocantins, 97.8% of the municipalities are small-and medium-sized (up to 50,000 inhabitants). According to data from the 2010 Census, these municipalities have a higher incidence of poverty. The average per capita income in the households of the most populous municipalities was more than twice as higher as that observed in municipalities with up to 50,000 inhabitants. Almost 50.0% of the population of these small municipalities lived with an average household per capita income of up to half minimum wage, while 24.2% lived with up to 1/4 of the minimum wage, and another 13.4% of the population lived with up to R$70.00. In large-sized municipalities, a quarter of the population lived with half minimum wage b. These smaller municipalities usually have a lower population density, better coverage of the BFP and FHS, and more migrants with consequent impact on the reduction of the leprosy incidence, or even a lack of trained professionals for the diagnosis. No association was found between the leprosy incidence with urbanization rate and household density. This is due to general low household density and few populous municipalities, which are only 2.1% of the municipalities. However, there is no consensus in the literature on the association between leprosy and population density. On one hand, the endemic process of the disease can be associated with high population density, in which contact is greater 5,12. However, on the other hand, there is no systematic evidence of this association 6,20. Incidence was significantly higher in municipalities with higher availability of potable water and bathroom, waste collection, and better MHDI. These variables have higher representation https://doi.org/10.1590/S1518-8787.2017051006655 in areas of greater population density, more intensive movement of persons, and development, defining the predilection character of the disease 17. Of the 139 municipalities in the State, 10 had high MHDI (> 0.7), such as Palmas, Aragua<unk>na, Gurup<unk>, Para<unk>so do Tocantins, Porto Nacional, Colinas do Tocantins, Guara<unk>, Dianópolis, Alvorada, and Pedro Afonso. These municipalities had a population equivalent to 46.4% of the total of the State a,b. In fact, intra-or interregional economic growth is not translated into significant improvements in the conditions of health of a population. The situation of health cannot be explained by the total wealth of a given territory, but by the way in which it is distributed, i.e., by social inequality 26. The economic growth occurred in the 1970s with the installation of highway BR 153, in the 1980s with the creation of the State, and in the 1990s with the establishment of the capital and the expansion of farming activities consequently lead to the population growth of the State and improved MHDI f. In addition to the social problems of the resident population, these changes led to increased social problems because of the overload of the existing infrastructure, suffering from increasing demands from surrounding regions in relation to social welfare, commercial, and financial activities. In this context, the increased distribution of leprosy was related to the extension of the habitation of the the territory 17. Migration was another aspect associated with increased cases of leprosy in the municipalities of the State in both bivariate and multivariate analyses. In 2010, 31.5% of the population of the State consisted of immigrants, and Palmas (the capital) had a proportion of 48.1%, Aragua<unk>na of 37.1%, and Gurupi of 32.4% immigrants b. The migratory movements may increase the incidence of disease when susceptible migrants move to areas of high endemicity and infected migrants move to non-endemic areas, especially among the poor, who are disproportionately affected 4,18. Migratory populations are generally more vulnerable to infectious diseases, such as leprosy. In the 1980s and 1990s, the higher number of migrants came from the endemic States of Maranh<unk>o, Goiás, Pará, and Piau<unk> g. Most migrants moved from socio-economically deprived regions of high leprosy-endemicity which border the State of Tocantins 2,17,18. Migrants usually have greater difficulty accessing health services and more commonly suffer from late diagnosis, poor housing and living conditions, and are unemployed, which define migration as an indicator of poverty and reproduction and distribution of the disease 18,19. The fact that leprosy can be significantly higher for migrants can hinder control measures. Although there was an increased detection rate in the bivariate analysis associated with a higher proportion of the population covered by the FHS and also higher proportion of contacts examined, this difference was not statistically significant. These actions are essential, but not sufficient for the control of the disease in a territory marked by misery and poverty 10,16,18. On the other hand, the 139 municipalities had average coverage of the FHS above 60.0% during the 12 years of the study. There was no low coverage of the FHS to mark a possible difference 16, as in other scenarios 7,20,23. The increased detection of cases was associated with lower proportion of cases with grade 2 disability in the bivariate analysis. This contributes to the decrease of hidden prevalence with early diagnosis and control of the disease in municipalities with better population covered by the FHS and with trained professionals. The observation of municipalities is fundamental for the study of the social reproduction of the disease, in which economic and cultural relations of the groups are materialized in the society. The analysis of data on leprosy in different regions is important to describe different specificities and vulnerabilities. These findings differ in some aspects from ecological studies at the national level and from other States, where the detection of cases was directly associated with municipalities with higher percentage of poverty and social inequality 5,7,12,13. The interpretation of the results should consider the limitations arising from the use of secondary data, which may show inconsistency in relation to the quantity and quality of the information. Potential detection errors may have overestimated the different incidences between minor and major municipalities. To minimize this limitation and correct extreme values and quiet areas, we smoothed the detection rates using the empirical Bayesian estimator 3. Despite the mentioned limitations, the results show internal consistency and coherence with existing knowledge about leprosy and are considered representative. The activities of control programs need to focus on municipalities of greater social vulnerability (high number of socioeconomically disadvantaged populations and migrants), with intersectoral investments for the improvement of the living conditions of the population. The good coverage of the FHS and in-service training ensure the discovery of cases, but it is not enough for an effective control. Social determinants of the disease have also to be considered. --- Conflict of Interest: The authors declare no conflict of interest.

To identify the socioeconomic, demographic, operational, and health service-related factors associated with the occurrence of leprosy in a hyperendemic State in North Brazil.This is an ecological study based on secondary data from the Sistema de Informações de Agravos de Notificação in municipalities of the State of Tocantins from 2001 to 2012. Units of analysis were the 139 municipalities of the State. Negative binomial log linear regression models were used to estimate incidence rate ratios.In bivariate analysis, the incidence rate ratios were significantly higher for municipalities with higher income ratio of the poorest 20.0% (1.47; 95%CI 1.19-1.81) and better Municipal Human Development Index (1.53; 95%CI 1.14-2.06). In multivariate analysis, the incidence rate ratios were significantly higher in municipalities with higher proportion of immigrants (1.31; 95%CI 1.11-1.55) and higher proportion of households with waste collection (1.37; 95%CI 1.11-1.69). There was a significant reduction in the incidence rate ratio with increased coverage of the Bolsa Família Program (0.98; 95%CI 0.96-0.99).Control programs need to focus on activities in municipalities of greater social vulnerability with intersectoral investment for the improvement of the living conditions of the population.

Understanding Youth Violence through a Developmental Asset Framework Fortunately, violence prevention can be achieved through public health etiologic research to identify factors that increase or decrease risk for violence. To inform the factors that can be targeted for primary prevention efforts (that is, efforts to stop violence before it starts) we use a developmental, social-ecological approach to investigate factors across individual, relationship, and community levels (Bronfenbrenner, 1977;Dahlberg & Krug, 2002;Gorman-Smith, Tolan, & Henry, 2000). This approach emphasizes the importance of relationships among social settings and acknowledges that contexts and propensity for violence change over adolescence (Loeber & Hay, 1997). For many years prevention researchers examined factors that increase the likelihood of violence (risk factors). More recently there has been a greater emphasis on positive youth development (Catalano, Hawkins, Berglund, Pollard, & Arthur, 2002); specifically, on the skills, competencies, relationships, and opportunities that help youth to overcome challenges and successfully transition through developmental stages into adulthood, termed "assets" by Oman and colleagues (2010). When a factor directly decreases the likelihood of violence (a direct protective effect) or when a factor decreases the likelihood of violence in the presence of risk (a buffering protective effect; Lösel & Farrington, 2012), it can be considered to be an asset. Understanding when and under what conditions some factors can moderate the detrimental effects of others leading to resilience is critical to the development of prevention efforts (Fergus & Zimmerman, 2005). Identification of social processes that serve as assets is particularly important as such factors are modifiable and can be promoted within prevention efforts, perhaps more easily than reducing structural risks that exist in a community. --- Family Structure, Parenting Practices, and Family Processes Family structure and the relationships formed between caregivers and their children early in life influence whether youth can negotiate relationships successfully with others, or resort to violent behavior. Youth living in single-parent households are significantly more likely to engage in fighting and weapon carrying and experience violent injuries (Oman, Vesely, & Aspy, 2005;Orpinas, Murray, & Kelder, 1999). Monitoring and supervision (the degree to which parents supervise their children's behavior, know where their children are throughout the day and evening, and know their children's friends) reduces risk for physical fighting and weapon carrying (Luster & Oh, 2001;Orpinas et al., 1999). The mechanisms of influence underlying these practices include the promotion of youths' self-control, facilitation of anger control skills, and reduction of frequency with which youth affiliate with violent peers (Cantillon, 2006;Griffin et al., 1999;Henry, Tolan, & Gorman-Smith, 2001), as seen through the effects of family behavioral and therapeutic intervention approaches. Through participation in Multisystemic Therapy (MST), parents enhance their parental monitoring, supervision, and discipline skills; these changes are associated with youth's decreased association with delinquent peers, as well as perpetration of serious offending (e.g., Huey, Henggeler, Brondino, & Pickrel et al., 2000). Family communication also reduces propensity for fighting and weapon carrying (Aspy et al., 2004;Resnick, Ireland, and Borowsky, 2004), and when improved through family strengthening interventions, such as in the Iowa Strengthening Families Program, it can result in reductions in youths' aggressive behavior (Spoth, Redmond, & Shin, 2000). Youth who experience consistently good family management practices or improvements in positive family management practices over time are less likely to engage in violence over the course of adolescence (Herrenkohl, Hill, Hawkins, Chung, & Nagin, al., 2006;Henry, Tolan, & Gorman-Smith, 2001). The effects of high quality parenting on violent behavior begin in middle childhood (Brody et al., 2003), and can interrupt the progression of violence, particularly for youth who hold high aggressive beliefs in childhood (Andreas & Watson, 2009;Brendgen, Vitaro, Tremblay, & Lavoie, 2001). --- Neighborhood Structural Characteristics and Social Processes Neighborhood structural characteristics such as concentrated disadvantage, typically defined by low socio-economic status, single-mother households, residential instability, unemployment, and low rates of home ownership, have emerged as some of the most reliable predictors of violence, including homicide (Leventhal & Brooks-Gunn, 2000;Sampson, Morenoff, & Gannon-Rowley, 2002;Fagan & Davies, 2004). In the Community Survey of the Project on Human Development in Chicago Neighborhoods (Morenoff, Sampson, & Raudenbush, al., 2001), a one standard deviation increase in concentrated disadvantage was associated with a 40% increase in the homicide rate per police data, and a 25% increase per vital statistics data. Researchers have long recognized that the effects of neighborhood structural factors on violence might best be explained by the social processes that accompany these structural conditions, such as social ties, collective efficacy, institutional resources, and routine activities (see Leventhal & Brooks-Gunn, 2000;Sampson et al., 2002 for reviews). Social disorganization theory suggests that neighborhood characteristics such as poverty and residential instability weaken the social controls that residents have over youth, thereby increasing rates of crime (Shaw and McKay, 1942;1969). Collective efficacy, a combination of social cohesion and trust among members of a neighborhood along with informal social control, mediates the relationship between residential instability and concentrated disadvantage and violence, including homicide and self-reports of violent crime and victimization (Sampson et al., 1997;Morenoff et al., 2001). The critical mechanism underlying this effect goes beyond strong social ties between neighbors: Social ties assist in fostering social control, but it is the expectations, willingness, and working trust among residents to take action and intervene in problem situations to stem social disorder that predicts the occurrence of violence. Inferior city services such as poor police and fire protection and trash removal may signal a lack of value in public safety and civility in residents, and contribute to social and physical disorder (e.g., abandoned buildings and drug and gang activity), affecting levels of violence in turn. Residents perceive urban decay, such as vacant housing, trash mismanagement, and inadequate street lighting as having a direct impact on youth violence rates by offering opportunity for illicit drug selling and hiding firearms, thereby increasing opportunities for offending and leading to a devaluing of people in the neighborhood (Yonas, O'Campo, Burke, & Gielen, 2007). Youth have been found to be more likely to carry a weapon in public housing spaces and disordered areas characterized by higher levels of neighborhood violence and where illicit drugs are sold; however, effects of disorder have varied across studies or have disappeared once other community factors have been taken into account (Patchin, Huebner, McCluskey, Varano, & Bynum, 2006;Luster & Oh, 2001;Watkins, 2008). Perceived neighborhood risk (including presence of gangs and danger of getting in trouble in the neighborhood) has also been associated with higher levels of risk taking behavior, and in turn, physical aggression (Griffin et al., 1999). --- Advancing Knowledge on Family and Neighborhood Processes and Youth --- Violence: The Current Study Gaps in knowledge about neighborhood-level assets result from an insufficient utilization of transactional models to investigate how neighborhood processes interact with individual characteristics and family-level processes. Prior research that has investigated neighborhood factors has often been risk-focused, cross-sectional, examining only temporal relationships, in isolated domains of influence, using only self-report instruments and census data, with small samples. Hence, our understanding of whether and how neighborhood matters over the course of adolescence in the context of individual and family characteristics is in its infancy, especially compared to our understanding of individual, peer, and family effects on violence. Also, previous research has often focused on only one type of violence-related behavior, such as physical fighting or weapon-carrying, but not both, limiting our understanding of how families and neighborhoods may have similar or differential effects on multiple forms of violence. Some youth engage only in physical fighting, others carry weapons, and some are involved in both (Spano & Bolland, 2010). Fighting and weapon carrying have been found to have some risk factors and assets in common, but not others (e.g., Aspy et al., 2004;Duke, Pettingell, McMorris, & Borowsky, 2010). For example, Aspy and colleagues (2004) found that assets such as family communication and friends that stay out of trouble influenced fighting and weapon carrying similarly, while good grades and ability to communicate thoughts and feelings to others uniquely contributed to a lower likelihood of weapon carrying, but not fighting. Thus, understanding which factors influence multiple forms of violence allows for the targeting of primary prevention strategies toward the factors that can have the greatest population-level impact on violence. The current study fills in these gaps by assessing family and neighborhood structures as well as social processes, employing a longitudinal study design, and utilizing objective measures of neighborhood factors with self-reports and census data in a large diverse sample. Longitudinal models advance cross-sectional studies and allow for an understanding of what predicts violence and how processes may differ over time and across developmental periods (Fergus & Zimmerman, 2005). Examining both family and neighborhood processes in the same model enables investigation of interaction effects to determine possible moderating, protective influences (Fergus & Zimmerman, 2005;Leventhal & Brooks-Gunn, 2000;Roosa, Jones, Tein, & Cree, 2003). Innovative measurement strategies such as systematic observations allows for a less biased test of the association between neighborhood factors and violence. We examine the predictive influence of parenting practices, family processes, and neighborhood processes on fighting and weapon carrying over the course of adolescence, controlling for structural characteristics of families and communities to isolate the effects of social processes. We hypothesize that supportive family and neighborhood social processes decrease the likelihood of violence over time, whereas neighborhood concerns and disorganization increase the likelihood of violence over time. We also explore whether family assets interact with, or moderate, neighborhood risks. We investigate these hypotheses in an analysis of data from the Youth Asset Study (YAS), funded by the CDC to prospectively investigate relationships among neighborhood factors, youth assets, and sexual and related risk behaviors (e.g., violence). Five waves of data were collected annually from youth and parent participants beginning with the baseline survey conducted in 2003/2004 and concluding in 2007/2008. The project was approved and reviewed annually by the IRB at the University of Oklahoma Health Sciences Center. --- Method Sampling and Data Collection Census tracts in the Oklahoma City metropolitan area were stratified by income and race/ ethnicity using 2000 census data, and twenty census tracts were randomly selected using a multi-stage process to recruit a diverse community-based study population in regard to race/ ethnicity and socioeconomic status. Door-to-door canvassing of every household located in the selected census tracts was conducted to obtain the baseline sample of one youth and one parent or guardian from each household (Oman et al., 2009). Random selection was used to select a youth for the study if the residence contained more than one eligible and willing youth. If there was more than one eligible and willing youth, each youth was assigned a number based on age (e.g., youngest youth assigned a 1, next oldest youth assigned a 2, etc.) and a laptop computer was used to randomly generate a number that matched a youth's number. Fathers were always selected to participate if both parents were willing to participate in the study because fewer fathers typically participate in this type of research. Only 20% of the parent sample was fathers despite this strategy (Oman et al., 2009). Inclusion criteria for the study were that the youth had to be 12 to 17 years of age and living with a parent or guardian. Also, the participants had to speak English or Spanish, have the mental competence to respond to interviewer questions and complete the survey, and have no plans to move from the study area within the next two years. Baseline data were collected from the youth and their parents using Computer-Assisted Personal/Self-Interviewing (CAPI/CASI) procedures conducted in their homes by twoperson interviewing teams. However, youth completed the risk behavior items themselves in private using computers equipped with wav sound files and headphones to minimize any potential reading problems. These data collection methods were repeated for waves 2 to 5 except for those participants who had moved more than a 2-hour drive from the metropolitan area. Telephone interviews were conducted with these individuals and the youth completed the sensitive questions via a questionnaire administered over the internet. A total of 1,111 youth/parent pairs participated in the study with a response rate of 61% (Oman et al., 2009). Ninety-four percent of the participants were retained over the course of the study and 89% (986 of the 1,111 of the youth) had complete data from all 5 waves of the study. A total of 1,093 youth/parent pairs were included in the analysis, excluding 15 youth who only completed a baseline survey and three youth who did not complete two consecutive waves of the survey. --- Measures Demographics and family/neighborhood structure-Demographic variables assessed included youth age at baseline, youth gender, youth race/ethnicity, family structure, parent-reported poverty status, and parent education. Race/ethnicity was self-reported by the youth and was coded as non-Hispanic white, Hispanic, non-Hispanic black, and non-Hispanic other. Family structure was assessed at each interview from the youth report. At baseline the response options were one-or two-parent household; at subsequent waves, the youth could respond "independent" if they had lived alone for at least 6 months. If a youth consistently reported one-parent household the time constant family structure variable was coded as 'one parent'; if youth consistently reported two-parent household, the variable was coded 'two parent'; for youth who either reported both one and two parent over waves 1 to 4 or reported 'independent' before the age of 18, the variable was coded 'inconsistent.' Parents reported their total family income and the number of people supported by their income. Each year, youth were classified as being above or below the federal poverty thresholds (FPT) (e.g., $20,614 for a family of four in 2006) (U.S. Census Bureau, 2011). Youths were coded as ever below the federal poverty limit if in waves 1 to 4 they were below the FPT at least once. The interviewed parent reported their highest level of education as well as the education level of the child's other parent on a seven-point scale ranging from (1) never went to school to (7) college graduate from a four-year college or university or more. The highest level obtained by either parent (or for one parent if education data for the other parent were missing) was used in the analysis. Neighborhood structural disadvantage and residential stability were calculated using 2000 Census data, similar to previous data-based approaches that have examined factor loadings and association with violent behavior (e.g., Fang, Rosenfeld, Dahlberg, and Florence, in press). Neighborhood structural disadvantage is a standardized and weighted index combining four census tract level variables: percentage of single-headed households, percentage of poor persons, percentage of households with public assistance, and percentage of unemployed. Residential stability is the standardized and weighted index combining two census tract level variables: percentage of owner-occupied households occupied and percentage of individuals who had lived in the same household since 1995. Parenting practice and family process assets-Parenting practices and family process assets were assessed via youth interview data. The parental monitoring asset was used as an indicator of parenting practices. Family processes were defined by three separate asset constructs: quality of the youths' relationship with their mother, quality of the youths' relationship with their father, and the amount and quality of youth and parent communication. The parenting practices and family process asset constructs were conceived, developed, and coded based on literature reviews and our previous research involving youth assets and youth risk behavior research (Kegler et al., 2005;Oman et al., 2002;Oman et al., 2010). Each asset construct was assessed using four items. The items representing each construct were summed and divided by four to create a score ranging from one (lower quality) to four (higher quality). A score of three or higher for any construct meant that youth responded, "usually/almost always," or "agree/strongly agree" to indicate the presence of a family asset process: having a positive relationship with a parent, having positive communication with a parent, or being monitored by their mother, father, or both parents. The Cronbach's alphas for the parenting practices and family process asset constructs ranged from.74 to.92. (Oman et al., 2010). Neighborhood social processes-Five neighborhood social process variables were measured via data from the parent interviews. All of the variables were multi-item constructs that were created by summing the responses to the items that represented each construct and dividing by the number of items. Sense of community was assessed using the Psychological Sense of Community (PSOC) scale (McMillan & Chavis, 1986). The PSOC scale included seven items such as "People in this neighborhood get along with each other." Possible responses ranged from one (strongly disagree) to four (strongly agree). Cronbach's alpha for the PSOC scale was.84. Informal social control is one component of social control and defined as informal mechanisms by which residents themselves achieve public order, including actions such as keeping watch over the neighborhood and actively monitoring community youth; It was assessed with five items such as, "How likely is it that your neighbors will become involved if children are skipping school and hanging out on the street corner?" (Sampson, Raudenbush, & Earls, 1997) Responses for the scale ranged from one (very unlikely) to four (very likely). The Cronbach's alpha was.82. Neighborhood support was assessed with five items such as, "About how often do you and people in your neighborhood watch over each other's property?" (Buka, Brennan, Rich-Edwards, Raudenbush, & Earls, 2003) Responses ranged from one (almost never) to four (almost always). The Cronbach's alpha was.77. Finally, neighborhood concerns related to crime and safety and to services were assessed. Neighborhood crime and safety was assessed with five items such as, "There is crime and violence in your neighborhood" (Aronson & O'Campo, 1997). The Cronbach's alpha was. 87 (Kegler et al., 2005). Neighborhood services was assessed with four items such as, "There is poor police protection in your neighborhood." Three items were created for the study and the fourth was adapted from previous research (Aronson & O'Campo, 1997). The Cronbach's alpha was.69 (Kegler et al., 2005). Possible responses for the neighborhood concern questions ranged from one (strongly agree) to four (strongly disagree). These responses were reverse scored for analyses so that higher values reflected greater neighborhood concerns. Neighborhood disorder-A modified version of the Broken Windows survey was used as an objective measurement of the neighborhoods involved in the study (Cohen et al., 2000;Wilson & Kelling, 1982). Trained raters conducted annual windshield tours of each census tract included in the study using the Broken Windows survey to rate the neighborhoods' environment according to the condition of the dwellings, and the amount of trash, graffiti, and abandoned cars. The Broken Windows survey score ranged from to 0 (neighborhood in better condition) to 12 (neighborhood in poorer condition). The Spearman correlation coefficient for the test-retest reliability of the Broken Windows survey was.83 and the intraclass correlation was 0.80. Youth violence-Physical fighting and weapon carrying were assessed using items adapted from the Youth Risk Behavior Surveillance System (CDC, 2010). Fighting was assessed via the item "During the past 12 months, how many times were you in a physical fight?" Possible responses included 0 (times); 1; 2 or 3; 4 or 5; 6 or 7; 8 or 9; 10 or 11; and 12 or more times. Weapon carrying was assessed via the question "During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club?" Possible responses included 0 (days); 1; 2 or 3; 4 or 5; and 6 or more days. For analytic purposes fighting and weapon carrying were recoded into dichotomous outcomes: yes (one or more fights or one or more days carrying a weapon) or no (no fights or zero days carrying a weapon). This approach is common in epidemiological research in violence prevention and criminology, and can be considered appropriate when results are not likely to be affected by dichotomous splits, the variable is not truly continuous, the variable is skewed with sparse data across the response categories greater than zero, there is an interest in simplifying presentation of interactions to highlight meaningful findings with odds ratios, and when investigators are interested in primary prevention of violence comparing youth who participate to those who do not participate in the behavior (Farrington & Loeber, 2000). --- Analytic Approach Youth were followed over the course of the five-wave study to determine if they engaged in violent behavior one, two, three, or four years after baseline. Demographic variables were controlled for in all analyses. Youth age, gender, race/ethnicity, family structure, ever below the federal poverty level, neighborhood structural disadvantage, and neighborhood residential instability were time constant covariates; education was included as a timevarying factor. These factors were controlled in the analyses because previous research indicates they are associated with youth violence (Blum et al., 2000;Oman et al., 2005;Orpinas et al., 1999) and to isolate the effects of family and neighborhood social processes. Family and neighborhood assets and risks were analyzed as time-varying and lagged (e.g., asset/risk wave 1 with outcome wave 2). Marginal models using a Generalized Estimating Equation (GEE) approach were used to determine the effects of the family and neighborhood assets and risk on the youth violence outcome (fighting or weapon carrying) while controlling for the influence of the demographic variables as well as the effects of family and neighborhood structure. The GEE approach constructs marginal or "populationaverage" models. The estimated effect from the marginal model describes how the average rates (odds) of the outcome would increase in the study population for young people who possessed the covariates of interest. Our analytical goals and scientific interests were to identify factors for public health planning and draw inferences about the population; therefore we conducted a marginal model. In marginal models, the mean response and covariance are modeled separately which ensures that the interpretation of the regression coefficients does not rely on the assumed model of the covariance among the responses. The result is a less complex model than alternatives (e.g., subject-specific, mixed effects models). All two-way interactions between the assets/risks and the demographic variables were separately evaluated in a GEE model in the presence of all the factors controlled in the analysis. A diagonal working covariance matrix was used as recommended by Pepe and Anderson (1994) when covariates vary over time. SAS version 9.2 was used to perform all statistical analysis. An alpha of 0.05 was used for main effects, interaction terms, and planned contrasts. First, for each outcome, ten initial models (one for each of the Parenting Practices, Family Processes, Neighborhood Social Processes, and Neighborhood Conditions variables listed in Table 1) were constructed controlling for the potential confounders youth age, gender, race/ethnicity, family structure, ever below the federal poverty level, parental education, neighborhood structural disadvantage, and neighborhood residential instability, regardless of p-value. These analyses demonstrated the relationship between each variable and the outcome controlling for potential confounders. Then, for each outcome, a final model was calculated that included all potential confounders (regardless of p-value) and Parenting Practices, Family Processes, Neighborhood Social Processes, and Neighborhood Conditions variables that remained significant (alpha = 0.05) in the presence of the other variables. In the final model, interactions between family assets and neighborhood process variables were assessed using an alpha of 0.05. All available data were used for the analyses; given the small percentage and pattern of missing data, missing data were not imputed. --- Results --- Descriptive Results The demographic data for the 1,093 youth and parents included in the analysis at wave one/ baseline were: youth mean age = 14.3 years (SD = 1.59); 53% female; 40% non-Hispanic white, 28% Hispanic, 23% non-Hispanic black, and 9% non-Hispanic other; and parent education: 16% both parents less than a high school degree, 56% at least one parent with high school degree, 28% at least one parent with college degree. Thirty five percent of youth had reported household income ever below the federal poverty level. For family structure, 58% lived in two-parent households, 22% in one-parent households, and 21% in inconsistent households. Both the Neighborhood Indexes (Structural Disadvantage and Residential Stability) had a mean of 0 and a standard deviation of one because they were standardized. To illustrate the degree of neighborhood disadvantage and stability in the sample members' neighborhoods as measured by Census data, the mean percent of single-headed households was 13%, poor persons 20%, households with public assistance 7%, unemployed 8%, owner-occupied households 61%, and same house in 1995, 50%. Descriptive statistics for all waves for the primary analytic variables are presented in Table 1. Although a majority of the youth indicated they had the parental monitoring and relationship with mother assets, fewer youth had the family communication and relationship with father assets. The percentage of youth reporting having the family communication asset increased over the four waves of the study whereas the percentage of youth reporting they had the parental monitoring decreased. Neighborhood process scores were remarkably stable over the waves of data collection (Table 1). Examination of the means also suggest that the parents' perceptions of both of the neighborhood concerns factors as well as neighborhood support were somewhat low (indicating less concern and support) whereas informal social control and psychological sense of community were perceived by the parents as relatively stronger neighborhood processes. Youth fighting was moderately prevalent but decreased over waves two to five of the study. In contrast, weapon carrying was a rare behavior that was fairly constant over time. --- Initial Models Parenting practice and family processes assets-All four parenting practices and family process assets were significantly and prospectively associated with the physical fighting outcome (Table 2). Youth who possessed any one of the four assets were significantly less likely to be involved in a physical fight in subsequent years of the study (Adjusted Odds Ratios (AOR) range = 0.55 to 0.77). Two of the parenting practices and family process assets were prospectively associated with weapon carrying (Table 3). Youth with positive family communication or the parental monitoring asset were significantly less likely to carry a weapon in subsequent years of the study (AORs = 0.67 and 0.47, respectively). Two significant interactions were found. The relationship with mother asset was prospectively associated with a lower likelihood of weapon carrying for Hispanic and white youth (AORs= 0.51 and 0.40, respectively). The relationship with father asset was prospectively associated with a lower likelihood of weapon carrying for youth who were 14-15 and 16-17 years at baseline interview (AORs = 0.52 and 0.57, respectively). Neighborhood social processes and neighborhood disorder-Informal social control was prospectively associated with youth fighting (Table 2). Youth living in neighborhoods with higher levels of informal social control were significantly less likely to engage in a fight in subsequent years of the study (AOR= 0.80). One significant interaction was found. Higher levels of neighborhood social support were prospectively related to less fighting only for youth living in one-parent households (AOR= 0.65). Two of the neighborhood variables were associated with youth weapon carrying (Table 3). Youth living in neighborhoods with higher levels of informal social control were significantly less likely to carry a weapon in subsequent years (AOR= 0.83) and youth living in neighborhoods with stronger concerns about services were significantly more likely to carry a weapon (AOR = 1.14). Two significant interactions were found. Higher levels of neighborhood social support were prospectively associated with less weapon carrying only for youth living in one-parent households (AOR=0.59). Only white youth living in neighborhoods with strong concerns about crime and safety were significantly more likely to carry a weapon (AOR=1.45). --- Final Models The relationship with father and parental monitoring family assets and the informal social control variable were each prospectively associated with a lower likelihood of physical fighting after adjusting for the demographic variables, family structure, neighborhood structure, and the other significant variables. Higher levels of neighborhood support continued to predict a lower likelihood of physical fighting for youth in one parent households only (Table 2). The relationship with father and parental monitoring assets were each prospectively associated with a lower likelihood of weapon carrying after adjusting for the demographic variables, family structure, neighborhood structure, and the other significant variables. The relationship with mother asset was significant in the final model only for Blacks (higher likelihood of weapon carrying) and Hispanics and whites (lower likelihood of weapon carrying). Also in the final model, a significant relationship between strong concerns about crime and safety and a higher likelihood of weapon carrying was found for white youth only (Table 3). --- Discussion The results support the proposition that family and neighborhood social processes predict youth violence across adolescence, even after controlling for structural factors such as single-parent household and concentrated disadvantage. Family and neighborhood assets and risks are not just concurrent with violence; they are predictive of violence over time. Strong parental relationships and effective monitoring reduces the likelihood that youth will fight or carry a weapon. Youth who had strong relationships with their father or were effectively monitored were 32% and 42% less likely, respectively, to be involved in a fight in subsequent years of the study. This highlights the protective influence of the involvement of fathers, and parents' understanding of where their children are, who their children are with, and what activities they are engaging in. Given the nature of the self-report youth measures, however, monitoring and supervision may be a proxy for the honesty between youth and their parents. Although family communication was predictive in the initial models, this variable was less influential once parental relationships were included in the analysis. The warm relationship between a parent and child might account for the positive communication effects. Unexpectedly different neighborhood processes were predictive of fighting and weapon carrying. For each unit increase in willingness of neighborhood residents to stem social disorder, there was a 17% decrease in the likelihood of youth engaging in physical fighting over time. For youth in one-parent households, for each unit increase in neighborhood support, there was a 27% decrease in the likelihood of fighting. It appears that keeping watch over the neighborhood and actively monitoring community youth can stem the more visible forms of violence. In contrast, concerns about neighborhood crime and safety were predictive of weapon-carrying. For each unit increase in concerns about neighborhood crime and safety, non-Hispanic white youth were about 1.6 times more likely to carry a weapon. It is plausible that white youth are more likely to carry weapons in unsafe environments because of fears of victimization and a perceived need for self-defense. It is yet unclear, however, why this tendency might differ for youth of different racial backgrounds. Family social processes did not consistently interact with or moderate the effect of neighborhood social processes on violence. Family processes may affect youth similarly regardless of neighborhood processes and conditions, and neighborhood social processes may also affect youth independently. An exception was that neighborhood social support was more important for youth in one-parent households. Supportive neighbors might provide supplemental monitoring and supervision over youth, providing additional protection when single parents are unable. Interestingly, relationship with mother may affect youth of different ethnicities in alternative ways. Positive relationships between mothers and black youth increased the likelihood of weapon-carrying, while positive relationships between mothers and Hispanic and white youth decreased the likelihood of weapon carrying. While this type of finding has emerged in previous literature (Walker, Maxson, & Newcomb, 2007), our data have limited ability to uncover the explanation. Silverman and Dinitz (1974) hypothesized, and found some support for the hypothesis, that African American boys may become "compulsively masculine" to reject feminine identification with their mother, and place a greater value in tough behaviors, including risky behavior such as weapon-carrying. Alternatively, one could predict that youth with close relationships with their mothers may have a desire to be more protective, and thus carry weapons to increase perceptions of safety. Future research is needed to uncover the psychological processes underlying the finding; qualitative research may be particularly helpful in this regard. It is important to acknowledge the limitations of the current study, including methodological challenges in assessing neighborhood effects (Sampson et al., 2002). Census tracts were used to define concentrated disadvantage and residential instability. However, self-reports of neighborhood characteristics were not constrained or defined by census tracts; the extent to which residents' perceptions of their neighborhood boundaries coincide with the boundaries defined by census tracts is unknown. The data on neighborhood structural characteristics originated from the 2000 Census, while self-report data were collected 2003-2008. Neighborhood structural characteristics could have substantially changed during this time period (yet, the self-report data on neighborhood social processes showed stability over time, limiting concerns about neighborhood change in structural characteristics). Although our study included an observational measure of Census tracts concurrent with self-report, the observations of neighborhood disorder were not found to be predictive of youth violence. We may have underestimated the effects of neighborhood social processes given the small number of cases per neighborhood/census tract (an average of 2.4 youth per census block). Because of intra-neighborhood variability in social processes and variability in reporter perceptions, it would be beneficial to have multiple reporters within a neighborhood to improve reliability and validity. This study sampled only from one city, potentially limiting the range of structural characteristics and social processes available for study; having an adequate range is important for adequate estimation (Leventhal & Brooks-Gunn, 2000). Also, the use of longitudinal data allowed for prediction of violence subsequent to the presence of risk and protective factors; yet, causation cannot necessarily be inferred. This analysis did not include an investigation of other factors at the relationship and community levels, such as peer influence and school bonding that have been found to be associated with fighting and weapon carrying behavior; such factors can work interactively with family and community social processes to protect youth from violence perpetration (e.g., Brookmeyer, Fanti, & Henrich, 2006;Chung & Steinberg, 2006). This investigation identified etiological processes that can inform the primary prevention of violent behavior, stopping violence before it starts at the population level. We focused on identifying factors that prospectively influence whether youth do or do not engage in fighting or weapon carrying, across all levels of severity, because all levels of violence are of concern. Even low levels of violence can lead youth on a trajectory of chronic and serious offending (Loeber & Hay, 1997). Few researchers have directly attempted to differentiate the risk factors that predict different patterns and trajectories of violence (e.g., factors that predict low level intermittent offending vs. chronic and serious offending; Dahlberg & Simon, 2006). Future research might address how family and community assets and risk factors interactively affect trajectories of violence; that is, whether certain factors individually or in constellation predict consistent low level aggression compared to chronic, serious, and escalating violence. Other opportunities include studying how family and neighborhood processes interact with initiation of violent behavior at different ages (e.g., early starters compared to late starters), and how the interaction of family and neighborhood processes may differ for boys and girls as they mature. Despite these limitations and needs for

Using a developmental, social-ecological approach to understand the etiology of health risk behavior and inform primary prevention efforts, we assess the predictive effects of family and neighborhood social processes on youth physical fighting and weapon carrying. Specifically, we focus on relationships among youth and their parents, family communication, and parental monitoring, as well as sense of community and neighborhood informal social control, support, concerns, and disorder. This study advances knowledge through its investigation of family and neighborhood structural factors and social processes together, employment of longitudinal models that estimate effects over adolescent development, and use of self-report and observational measures. Data from 1,093 youth/parent pairs were analyzed from the Youth Assets Study using a Generalized Estimating Equation (GEE) approach; family and neighborhood assets and risks were analyzed as time-varying and lagged. Similar family assets affected physical fighting and weapon carrying, whereas different neighborhood social processes influenced the two forms of youth violence. Study findings have implications for the primary prevention of youth violence, including the use of family-based approaches that build relationships and parental monitoring skills, and community-level change approaches that promote informal social control and reduce neighborhood concerns about safety.

processes that can inform the primary prevention of violent behavior, stopping violence before it starts at the population level. We focused on identifying factors that prospectively influence whether youth do or do not engage in fighting or weapon carrying, across all levels of severity, because all levels of violence are of concern. Even low levels of violence can lead youth on a trajectory of chronic and serious offending (Loeber & Hay, 1997). Few researchers have directly attempted to differentiate the risk factors that predict different patterns and trajectories of violence (e.g., factors that predict low level intermittent offending vs. chronic and serious offending; Dahlberg & Simon, 2006). Future research might address how family and community assets and risk factors interactively affect trajectories of violence; that is, whether certain factors individually or in constellation predict consistent low level aggression compared to chronic, serious, and escalating violence. Other opportunities include studying how family and neighborhood processes interact with initiation of violent behavior at different ages (e.g., early starters compared to late starters), and how the interaction of family and neighborhood processes may differ for boys and girls as they mature. Despite these limitations and needs for future research, the current study highlights that both neighborhood and family social processes have a prospective influence on violence. Primary and secondary prevention strategies that support family processes are available, such as the Strengthening Families Program for Parents and Youth 10-14 and Multi-Dimensional Treatment Foster Care (Spoth, Redmond, & Shin, 2000;Chamberlain et al., 2008;Eddy, Whaley, & Chamberlain, 2004). Further, by changing neighborhood social processes early in adolescence, it is plausible that trajectories of violence could be influenced. Unfortunately, there is a relative dearth of evidence-based strategies that support social processes at the neighborhood level. For the greatest impacts on violence to be achieved, we must further our efforts to develop and test community-level change strategies in addition to family-based interventions. Such change strategies might be successful in not only preventing youth violence at a population level, but also other youth risk behavior. By changing the ways in which neighborhood residents interact, providing supervision of youth, and intervening when troublesome behavior is identified, we may realize multiple health benefits for youth and the entire community. Sense of community 2,3 1068 3.16 (0.59) 1042 3.17 (0.55) 1021 3.17 (0.56) 1001 3.17 (0.54) Neighborhood support 2,3 1074 2.13 (0.67) 1043 2.12 (0.66) 1024 2.12 (0.62) 1014 2.07 (0. Mean reflects the percent of youth with that asset, or who reported physical fighting or weapon carrying. Distributions across Waves 2 to 5 are as follows: Fighting: 0 times = 65%; 1 time = 15%; 2 or 3 times = 13%; 4 or 5 times = 4%; 6 or 7 times = 1%; 8 or 9 times <unk> 1%; 10 or 11 times = <unk> 1%; 12 or more times = 1%. Weapon carrying: 0 days = 85%; 1 day = 4%; 2 or 3 days = 4%; 4 or 5 days = 1%; and 6 or more days = 5%. 2 Range of scale is from 1 to 4. --- Author Manuscript Haegerich et al. --- Author Manuscript

Using a developmental, social-ecological approach to understand the etiology of health risk behavior and inform primary prevention efforts, we assess the predictive effects of family and neighborhood social processes on youth physical fighting and weapon carrying. Specifically, we focus on relationships among youth and their parents, family communication, and parental monitoring, as well as sense of community and neighborhood informal social control, support, concerns, and disorder. This study advances knowledge through its investigation of family and neighborhood structural factors and social processes together, employment of longitudinal models that estimate effects over adolescent development, and use of self-report and observational measures. Data from 1,093 youth/parent pairs were analyzed from the Youth Assets Study using a Generalized Estimating Equation (GEE) approach; family and neighborhood assets and risks were analyzed as time-varying and lagged. Similar family assets affected physical fighting and weapon carrying, whereas different neighborhood social processes influenced the two forms of youth violence. Study findings have implications for the primary prevention of youth violence, including the use of family-based approaches that build relationships and parental monitoring skills, and community-level change approaches that promote informal social control and reduce neighborhood concerns about safety.

Introduction Sexuality is an exciting word often discussed behind closed doors or open from the familiar people to state politicians. Sex and sexuality are two different things. Sex-related to biological problems in women and men. While sexuality is comprehensive, its scope is not only on the natural aspect alone. Before we talk more about sexuality, it's good for us to understand the keywords regarding the problem of sexuality, namely the terms sex, sexual, and sexuality. 1 The concept of sexuality will differ according to place and time because it is a concept and social construction of values and sex-related behavior. 2 This difference is not only in the meaning of intercultural sexuality but also in that culture alone-according to Saptari, quoted from Truongh because sexuality discourse regulates the three dimensions of human life, first, including the biological dimension, involving sexual activity a bodily pleasure or obtaining descendants. Second is the social extent that includes relationships between individuals who have legal sex or invalid (according to the size of the community concerned). Third, the subjective dimension is related to individual consciousness against sexual self or group. With such broad boundaries, sexuality becomes a discourse concerning gender behavior and a set of ideas that form a norm. The two are related to each other. 3 Sexual intercourse is a form of implementation of taste love between two people where attraction and the five senses play a role. Therefore, in sex, it is not just a tool genitals and erogenous areas that play a role, but also psychological and emotional aspects. A sexual relationship considered normal is a relationship that is heterosexual, which is associated with norms, religion, culture, and knowledge. A sense of love accompanies a harmonious human being. So that a sak<unk>nah, mawaddah, warahmah will always be created expected by every married couple while still alive until death later. Suppose the husband and wife both carry out their responsibilities. In that case, there will be peace and tranquility in the heart, so married life is perfect by executing a marriage contract between a man and a bride 1 The word "sex" can mean a different gender character (biological gender), and it can also be about everything about the genital organs as well as related to flirting and relationships body (coitus). The word sexual is about behavior, similarities, or emotions combined with stimulation of the genital organs of the erogenous region; This is called the process of reproduction. Whereas "sexuality" is the capacity to have or seek relationship intercourse, it can also mean characters interested in a point of view sexual. Sexuality is about how a person experiences, experiences, and expresses oneself as a creature sexual. In other words, how a person thinks, feels, and acts are based on his position as a creature sexual. Everything that has to do with sex (no relation to sex) is covered. Sex is only one aspect, but in general, sexuality is always connected with sex (copulation). Stevi Jackson and Sue Scott, Feminism And Sexuality: A Reader (New York: Colombia University Press, 1993), 62.; Ahmad Maulidizen and Ashilah Raihanah, "The Technique of Determining Ijtihad and Its Application in Life: Analysis of Istihsan, Maslahah Mursalah, 'Urf and Syar'u Man Qablana," Al-Ahkam: Jurnal Ilmu Syariah dan Hukum 4, no. 1 (2019): 50. 2 Agus Dwiyanto and Muhadjir, Seksualitas, Kesehatan Reproduksi Dan Ketimpangan Jender (Jakarta: Pustaka Sinar Harapan, 1996), 260. 3 Thanh-Dam Truongh, Seks, Uang Dan Kekuasaan: Pariwisata Dan Pelacuran Di Asia Tenggara (Jakarta: LP3ES, 1992), xxiii; Muhammad Amin, "Hadis Tentang Dilaknat Perempuan Yang Menolak Panggilan Suaminya," Fitrah: Jurnal Kajian Ilmu-Ilmu Keislaman 5, no. 1 (2019): 115-136. performed by his guardian. There is a relationship between husband and wife, and the rights and obligations of each arise reciprocally. Internal rights marriage divides into three, namely the right of joint, the wife's request becomes the duty of the husband, and the rights of the husband become the duty of the wife. 4 The issue of sexuality is discussed ambiguously in the Muslim world often addressed with great appreciation, but the same is also very closed and conservative in time. This situation appears due to two religious-patterns in Islam, namely the ideal-Islamic spiritual pattern and Islam-history. The ideal Islamic design appreciates sexuality as nature man. Sex is a gift from God that must fulfill the desired sex as long as humans need it, and it's only at a wedding. The ideal Islam requires relationship equality, justice, and benefit. While gender-biased ideologies often influence Islam's history. So, sex is seen as something terrible, even the opposite of spirituality. The Husband is given authority or some right in acting Nusy<unk>z the Wife. The first action that the husband can take against his Wife is to advise her and regularly take her to sleep together. Sleeping together is a symbol still the harmony of a household. When this first action does not bring results, it can take a second act to separate the bed. The second, wife still does not want to change either. If this alternative path is the wife unconscious through advice and bed separation, then the husband is allowed to perform the third act, which is to hit her, considering that he is the owner of the rights. 5 Wives who perform nusy<unk>z in the Compilation of Islamic Law defined as an attitude when the Wife does not perform its obligation is the primary obligation of devotion to the born and the inner to the husband, and he must organize and organize daily household needs as best as possible. 6 4 Abd Rahman Ghazali, Fiqih Munakahat (Bogor: Kencana, 2003), 155. Sexual intercourse is a sexual activity which does not only involve one actor but also involves another party as a partner. Sexual relations have certain rules in order not to harm either party. Most people assume that sexual relations are always loaded with pleasure. But according to Lucienne Lanson, based on survey results in the 1980s, of a female who has sexual intercourse, 22-75% usually always have an orgasm, 30-45% sometimes or rarely, and 5-22% never once I'm having an orgasm. Umi Khusnul Khatimah, "Hubungan Seksual Suami Isteri Dalam Perspektif Gender Dan Hukum Islam," Jurnal Ahkam 13, no. 2 (2013): 235-246. 5 Sayid Muhammad Husain Fadhlullah, Dunia Wanita Dalam Islam (Jakarta: Lentera, 2000), 74. Dispensation of husband hitting wife who Nusy<unk>z is just an educational effort, but you can't hurt your wife. La Jamaa, "Kekerasan Dalam Rumah Tangga Perspektif Fikih," Jurnal Ahkam 13, no. 1 (2013): 65-80; Eki Resa Firiski, "Pemaksaan Hubungan Seksual Suami Istri Perspektif Maqashid Shariah," Shaksiyah Burhaniyah: Jurnal Penelitian Hukum Islam 6, no. 1 (2021): 49-72. 6 Kementerian Agama Republik Indonesia, Kompilasi Hukum Islam, 1st ed. (Bandung: Fokus Media, 2015), 30. Signs of Nusy<unk>z wife include; (a) She is not quick to answer her husband based on not habits, (b) Unreal or unclear respect for her husband, and (c) No one comes to the husband except with boredom, tiredness, or a frown. Im<unk>m Naw<unk>w<unk>, Al-Jam'u Syarah Muhazab, 17th ed. (Beirut: D<unk>r al-Fikr, n.d.), 127. Nusy<unk>z can occur in word forms and actions. Nusy<unk>z words can occur if a wife does not speak politely to her husband, such as swearing at her husband or Therefore, this article aims to explain sexuality in the Qur'an and its implications for family harmony in Pekanbaru. Expected discussion of sexuality in writing can offset the patriarchal discourse that views sexuality as the opposite of spirituality and is considered taboo. Besides too to show that in the Qur'an, Islam views sexuality as an essential part of human relations which is humanistic, calm, and full of human empathy. This research is field research with a qualitative approach, which explains sexuality in the Qur'an and its implications for family harmony in Pekanbaru. The research data collection method uses interview, observation, documentation, and various articles and books. It was then analyzed using the content analysis method with a descriptive and scientific analysis of a premium message. --- Result and Discussion --- Sexuality Relatioshp in the Qur'an Talking about sexuality in the Qur'an must carefully consider the problem; this is crucial. The Qur'an does not explicitly explain sexuality. But also, do not avoid this conversation. Talking about sexuality in the Qur'an is more likely to sexual relations as husband and wife than sex as an individual right. Thus, the discussion of marriage as an institutionalization of social-sexual relations provides a complete explanation compared to sex as everyone's right. 7 There are two missions the Qur'an talks about sexuality. First, this speaks to counter the history of past sexuality. The past in question is the times before responding rudely to her husband's polite talk to her. At the same time, Nusy<unk>z in words on behalf of the husband to his wife is to insult his wife or scold his wife who has performed her duties as a wife. Nusy<unk>z in the form of deeds, on the part of the wife, for example, unwilling to carry out what was ordered by her husband within certain limits as a wife's duty, outhouse without her husband's permission, does not want to serve her husband while he not in a state of illness. While Nusy<unk>z from the party, the husband is disregarding his wife's rights over himself, like, not giving alimony to the wife or splurging on other women, or considering quiet or inferior to his wife. Ahmad Ropei, "Nusy<unk>z Sebagai Konflik Keluarga Dan Solusinya (Studi Pandangan Syaikh Nawawi Al-Bantani Dalam Kitab 'Uq<unk>d Al-Lujayn)," Al-Hakam: The Indonesian Journal of Islamic Family Law and Gender Issues 1, no. 1 (2021): 1-15; Tutik Hamidah, "Akar Kekerasan Terhadap Perempuan Dalam Fiqh Al-Nisa," Jurnal al-Harakah 3, no. 1 (2001): 59-66. 7 Sexuality issues that are alluded to by the Qur'an, among others, include things like marriage, divorce, treatment of husband and wife in home life stairs (mu'<unk>syarah bi al-ma'r<unk>f), 'iddah, and issues related to sexual perversion such as the story of the people of Luth who are practicing homosexuality. This matter shows that as a holy book, the Qur'an is a book that responds to human problems. In the context of Islamic teachings, the principle of mu'<unk>syarah bi al-ma'r<unk>f (good and voluntary relationship), which emphasizes equality, forms the basis of the marital relationship. So, it is clear that rape in the household is not allowed. M Abi Mahrus Ubaidillah and Ahmad Fauzi, "Larangan Pemaksaan Hubungan Seksual Oleh Suami Terhadap Istri," Minhaj: Jurnal Ilmu Syariah 1, no. 1 (2020): 1-17; Ahmad Maulidizen and Eka Pratiwi, "The Concept of Qat'I Dalalah: Definition, Laws and Perceived Conflict," Khatulistiwa: Journal of Islamic Studies 10, no. 1 (2020): 115-131. Wahidin: Sexuality Relationship in Rokan Hulu Riau with the Al-Quran Approach | 1113 the arrival of Islam (J<unk>hiliyah). Against the times in this pre-Islamic era, it seems that the Qur'an has a despicable view. According to Islam, sexuality pre-Islamic is a model of sexuality that does not allow orderly and uncivilized. Pre-Islamic sexuality is synonymous with promiscuity and out of control. Besides, sexuality at that time also reflected the unequal relations between men and women. 8 Second, this talk is also meant to make rules from patterns of nonreligious sexuality towards a practice of sexuality that is religion (based on shariah). All actions in the name of internal sex Islam cannot take place without gaining legitimacy. Here are the boundaries and rules that must begin to appear for someone who wants sex. For example, in the case of polygamy, in which was a man could marry as many as maybe a girl, with the emergence of Islam, a man is given a maximum limit of four wives. 9 The essential thing in the Qur'anic concept of sex/sexuality is that the Qur'an does not make claims that demean women and sex, even against misogynistic 10 traditions. This can be seen in the Qur'an: "And of His signs is that He created for you from yourselves mates that you may find tranquillity in them; and He placed between you affection and mercy. Indeed in that are signs for a people who give thought" [al-R<unk>m 30: 21]. 8 Before the advent of Islam, society jahiliyyah practice marriage with hundreds or even thousands of wives. Various types of marriage were the practice of sexual behavior during this ignorance period, so it was banned. Shapes The prohibited marriages are: 1) Al-Maqt marriage is marrying the father's ex-wife the deceased, 2) Nikah al-Syighar namely the exchange of daughters without dowry, 3) Nikah al-Istibdha, namely marriage with placing women as heretics or merchandise, 4) Nikah al-Rahth, i.e., marriage for sexual gratification without limit on the number of wives, 5) Nikah al-Badal or the practice of exchanging wives, and 6) Nikah al-Bagh<unk>y<unk> or living together without marriage (free sex). Neng Hannah, "Seksulitas Dalam Al-Qur'an, Had<unk>th Dan Fiqh: Mengimbangi Wacana Patriarki," Wawasan: Jurnal Ilmiah Agama dan Sosial Budaya 2, no. 1 (2017): 45-60; Sobari Bin Sutarip, "Memahami Hadits Tentang La'nat Malaikat Terhadap Istri Yang Menolak Ajakan Suami," Jurnal Indo-Islamika 8, no. 1 (2018): 1-11. 9 The Qur'an talks more about human sexual characteristics and behavior than human sexuality (identity sex which is a social construction). The Qur'an's view of the two views is that men and women have the same sexual characteristics (the idea of sexual equality). The Qur'an supports views that do not distinguish sexuality because it does not attach to a particular type of identity, drive, or predisposition to sexual behavior to one gender. For example, The Qur'an does not support the idea that the depravity and passivity of women's sexual and male sexuality are all evil and deviating. Halim Barkat, Dunia Arab, ed. Muhammad Zakki (Bandung: Nusa Media, 2012); Asma Barlas, Cara Qur'an Membebaskan Perempuan (Jakarta: Serambi, 20013), 267;Dina Nuryani, "Kewajiban Istri Terhadap Suami Dalam Perspektif Hadis," Jurnal Holistic 6, no. 2 (2020): 170-206. 10 The existence of inequality in gender arouses feminists to demand the rights that have been hidden for so long. Discussion about how Feminism was born starts with an explanation of how society looks at women until the emergence of self-awareness from a group of people (who act as agents of change) to the existence of injustice (not egalitarian) to women in the perspective that society. There is inhumane treatment of women, or rampant hatred of women gave rise to the term new, misogynistic. Ade Marhamah, "Hadits Misoginis Perspektif Gender Dan Feminisme," At-Tibyan: Journal of Qur'an and Hadis Studies 2, no. 2 (2019): 16-34. This verse is forward to answer how Islam gives its appreciation to sexuality. There are several goals to be achieved from marriage. First, as a way for humans to channel their libido desires to obtain sexual pleasure/satisfaction. Second, it is a human endeavor to preserve human life. Marriage, in this meaning, contains the function of procreation at the same time reproduction. Third, become a human vehicle and find a place of serenity and beauty. Through marriage, anxiety and the difficulty of the human heart to find its channel. 11 This verse is important for two reasons other. First, it shows that it's different from the dualistic tradition. The Qur'an does not position sexuality as the opposite of spirituality. Instead, he views sexuality as a sign of God's mercy and grace to man. The Qur'an also does not link sex with animal behavior or mere physical action. So, the Qur'an is not declared that sexual instinct is humanity's greatest weakness. In contrast, the Qur'an views sex "as a means" God to create a relationship between men and women characterized by togetherness, peace, love, and affection Dear. Second, this verse, like many others, emphasizes that men and women have identical/similar characteristics, including sexual traits. Both of them are an integral part of the whole human nature (fitrah). Even the similarity/similarity of human (sexual) characteristics make Suk<unk>n reciprocity meaningful and possible. 12 There is no Qur'anic distinction between male and female sexual characteristics; it is also evident from his concept of the pairing of men and women in various issues that show the equivalence/similarity of the two. For example, the Qur'an states: "Evil words are for evil men, and evil men are [subjected] to evil words. And good words are for good men, and good men are [an object] of good words. Those [good people] are declared innocent of what the slanderers say. For them is forgiveness and noble provision" [al-N<unk>r 24: 26]. 11 Husein Muhammad, "Islam, Seksualitas Dan Budaya," Swara Rahima 20, no. 12 (2012): 23-24. Barlas explains al-R<unk>m 30: 21 are as follows: Frequent Suk<unk>n translated with love means deep intimacy caused by sexual fulfillment and mental peace. Its use in the Qur'an is considered essential for two reasons: first, it shows that Islam demands that sexual relations/marriage are based on taste, mutual love, harmony, and satisfaction, a view that when viewed from the time the revelation of the Qur'an is something that very revolutionary. By emphasizing the attitude of giving and receiving satisfaction in sexual intercourse, The Qur'an confirms that men and women both have a drive and sexual needs and the right to fulfill them. Second, by defining sex in the sense that it implies sexual pleasure and satisfaction, the Qur'an also emphasizes that sex does not only aim to increase the number of offspring Sex is also an activity that is fun and purposeful to create Suk<unk>n. Barlas, Cara Qur'an Membebaskan Perempuan, 48; Hannah, "Seksulitas Dalam Al-Qur'an, Had<unk>th Dan Fiqh: Mengimbangi Wacana Patriarki," 50. 12 This is Maududi's opinion quoted by Karena Lebacqz, "Sexuality: A Reader," in Sexuality: A Reader, ed. Riffat Hassan (Claveland: The Pilgrim Press, 1999), 351; Ahmad Maulidizen, "The Urgency of Islamic Law Sources Knowledge Masadir Al-Ahkam Al-Mukhtalaf Fiha: Istisab, Sadd Al-Dzariah and Qaul Al-Sahabi," Jurnal Hukum Islam 18, no. 2 (2018): 49-68. This verse challenges the views of Muslims about women as dilapidated figures sexually on the one hand and attribution innocence (usually defined as virginity) only to women on the other side. However, the Qur'an does not only emphasize the chastity of women alone, as described above. More far, according to the Qur'an, virtue and honor are based on behavior, not on identity or gender, and that is why the Qur'an applies the concept of purity equal to men and women. This is stated in the verse "The fornicator does not marry except a [female] fornicator or polytheist, and none marries her except a fornicator or a polytheist, and that has been made unlawful to the believers" [al-N<unk>r 24:3]. One's sexual morality or virtue is related to behavior, not characteristics or gender. Further, holiness does not mean abstaining from sexual activity, but not engaging in certain types of sexual behavior (adultery and prostitution), maintaining honor, avoiding which encourages cheating, etc. Even in the Qur'an, the requirements for refrain from marriage, permissibility to marry, and marriage life are all meant to keep honor and avoid sexual behavior despicable, uncontrolled or irresponsible by men and women. According to the Qur'an, virtue is the fruit of conduct, and because moral and sexual choices that a person makes are not the result of their characteristics, identity, religion, or social class. Furthermore, one of the verses of the Koran that popularly used as a reference about relationships sex: "Your wives are a place of sowing of seed for you, so come to your place of cultivation however you wish and put forth [righteousness] for yourselves. And fear Allah and know that you will meet Him. And give good tidings to the believers" [al-Baqarah 2: 223]. 13 Such interpretation and understanding generally develop in the middle public. This understanding stretches wide from the camel age to the nuclear age, from West to East. It could be anything forms of discrimination, subordination, and slander on women's sexuality which has been operating through religious teachings, such as the teachings of female circumcision and the requirement of a wife to fulfill her husband's sexual desires, sourced from understanding and interpretation to this verse. Even though understanding and this interpretation have no basis of performance valid except as a bias from the solid patriarchal culture and mindset that surrounds commentators and audiences from the past to time. 14 More than that, the depiction of women as a field in the context of a society in Medina at that time hinted at the high value of women. Farming is limited and rarely used in Medina. Not infrequently, several tribes fight for a place fertile for farming. Because the matter is so high, you can sacrifice that even lives to get it. Different things with the Indonesian context, where the fields are of expected value. So that the metaphor of women as a field is an illustration of how tall the value of a woman that must preserve, care for, and respect the struggle getting it is not easy. 15 For an explanation of the relationship husband and wife sexual refers to "It has been made permissible for you the night preceding fasting to go to your wives [for sexual relations]. They are clothing for you and you are clothing for them. Allah knows that you used to deceive yourselves, so He accepted your repentance and forgave you. So now, have relations with them and seek that which Allah has decreed for you. And eat and drink until the white thread of dawn becomes distinct to you from the black thread [of night]. Then complete the fast until the sunset. And do not have relations with them as long as you are staying for worship in the mosques. These are the limits [set by] Allah, so do not approach them. Thus does Allah make clear His ordinances to the people that they may become righteous" [al-Baqarah 2:187]. 16 14 Marzuki Wahid, "Mendaulatkan Seksualitas Perempuan," Swara Rahima 5, no. 2 (2009): 38. When viewed from the cause of its descent (asb<unk>b al-nuz<unk>l), the verse above does not corner women or even put women in an honorable position. According to Masdar F Masudi, this verse relates to some men's preferences who like to fuck their wives through the anus. Islam prohibits the practice by reminding the wife with her womb (field) for men to plant seeds for his descendants. So don't plant the source was not in place (anus). Apart from being not in the area, the act from a health perspective is also not safe. So clear, verse message it's not for treating girls arbitrarily, as if this verse explained the technique just playing sex. Masdar F Masudi, Islam Dan Hak-Hak Reproduksi Perempuan (Bandung: Mizan, 2000), 121. 15 Furthermore, the verse above also gives understanding that the wife is "like a field" that is ready to work at any time when the husband willed. This verse contains understanding as a form of prudence while maintaining the correct quality of seeds and planting method, so it doesn't seem forced. So there must be an interaction between both which is expected to make the land fertile and productive. Thus, a husband is responsible for the "field" that God has entrusted to him. The fields need to be well cared for by hoeing, watering, fertilizing, and love to stay fertile. Husband relationship wife in a marriage is worship, but that doesn't mean women's sexual rights are abolished. It's this dimension of worship that brings substance to the sincerity of each party without coercion against a partner. Andi Dermawan, "Marital Rape In Perspective Law of the Qur'an," ed. Mochammad Sodik, 1st ed. (Yogyakarta: PSW IAIN Sunan Kalijaga, 2004); Ahmad Munif Suratmaputra, "Reinterpretasi Hadis-Hadis Perempuan," Jurnal Misykat 1, no. 2 (2016): 27-42. 16 Ibn Jar<unk>r al-Thab<unk>r<unk>, the great teacher of the expert Tafsir, put forward two interpretations of this verse. First, this verse is a metaphor for the meaning of the interactive union Therefore, understanding the verses of The Qur'an can't stop at the textonly but must include reading the socio-cultural context when and where the text is formed. Reading the Qur'an about sexuality without reading the cultural constructs of the Arabian Peninsula society at that time will only eliminate the emancipatory mission implied in every meaning. The position of women in the verses of the Koran is revealed to be in the assumption that they are wrong, even to the point of believing that women are source creatures slander, weak, inherited evil, not have intellectual abilities, and empty of spirituality; therefore, women "are not equal to men." Consequently, women are considered not capable and unfit to assume public roles and all things that have access to public areas. Women, it is enough to only take care of, not regulate, things that are in the mere domestic area. 17 of two bodies. Second, quoting the commentator Ibn Qat<unk>dah, this verse means that each partner gives each other peace of mind. The relationship between husband and wife sex in the Qur'an that this verse describes is equal and complementary, and they need each other as partners to channel their sexual desires. 'Ab<unk> Ja'far Muhammad Ibn Jar<unk>r Al-Thab<unk>r<unk>, J<unk>mi' Al-Bay<unk>n F<unk> Tafs<unk>r Al-Qur'An, 3rd ed., n.d., 489. We must position the Qur'an proportionally, as a rule (norms and values) universal, based on justice, benefit, and elevate the dignity and degree of humanity. This positioning is necessary carried out, mainly in understanding the verses related to sexuality and gender relations. The Qur'an was revealed in the 7 th century AD in the region of Arabia, which, sociologically, its people have cultural constructs and perceptions discriminatory about women. The order that applied to the people of the peninsula Arabia when the Qur'an came down was system patriarchy or fatherhood. This culture is built on the structure of male domination as a center of power. Females, in their culture, are positioned and treated in such a low and despicable way. Traditions that can note from their culture towards women are female infanticide, sexual abuse of (slaves) women, the abolition of inheritance rights for women, dzihar, unlimited polygamy, divorcing women like men etc. 17 In such a socio-cultural background, the Qur'an was revealed as an answer, an objection, and an alternative value to rebuild a just cultural order. True, what Fazlur told Rahman that the Qur'an is a response God conveyed through His Messenger to respond to the sociomoral situation at the time of the Prophet Muhammad. The Qur'an and the origins of society Islam emerged in the rays of history and dealt with a historical, social background. The Qur'an is a response to the situation, and much of its content consists of moral, religious, and social statements in response to the problem specifics addressed to him in real situations. Strictly speaking, The Qur'an admits that there are anatomical differences and biology between female sexuality and male sexuality. The Qur'an also acknowledged that the sex organs function in the same way, reflecting the limited differences well by the culture. The Qur'an does not try to erase that anatomical and biological difference; it does not eliminate the significance of the difference that is supernatural. But neither does the Koran have made rules that culturally make sex differences can be treated in a discriminatory, subordinating, and dominant over the other. Because such cultural provisions (if any) will be contrary to the scale of the function of the Koran, universal, cross-cultural, transcend the boundaries of space and time. Ashgar Ali Engineer, Hak-Hak Perempuan Dalam Islam, ed. Farid Wajidi and Cici Farkha Assegaf (Yogyakarta: Yayasan Bentang Budaya, 1994), 55. --- The Wife's Awareness Level about Nusy<unk>z Law of Rokan Hulu Riau According to Mr. Drs. Juki's, wife's level of awareness in Rokan Hulu Riau is fragile because most of them have graduated from public schools, not female students, so there are still many wives who do not understand the rights and obligations of husband and wife. Therefore, in marriage, there must be a prewedding for the bride and groom so that they know the rights and obligations of husband and wife, so that they aim to marry for worship and carry out the Sunnah of the Prophet Muhammad in pairs and refers to Article 1 of 1974 Law that "Marriage is an inner and outer bond between a man and a woman as husband and wife with the aim of forming a family or a happy and eternal household based on the Yang Divinity Almighty." Many mothers don't know what Nusy<unk>z is, so the level of public awareness about Nusy<unk>z is still weak. A wife must know the importance of serving her husband when the husband wants to have sex with his wife, but they underestimate it because husbands understand this situation. After all, they refuse when they are tired, come home from work physically exhausted, and have to take the children to study and put them to sleep so that they sleep soundly. They have to iron her husband's work uniform for the morning because the uniform instead is only limited. They thought that this would not cause the husband divorces his wife, will understand when rejecting it because, in this modern era, it's not enough just a husband who works when the child is still a toddler or a child who needs money high for the school because the child is prioritized over him alone. With his wife being a career woman, even if it's just a laborer, the factory can all increase the needs of his wife and children to daily needs, including buying clothes, culinary outside, and taking a walk at every school event, especially for children who are still toddlers very high costs for necessities such as milk, diapers and the price for someone who takes care of her child. If her husband's background is from Santri, he can get it to make his wife aware that serving her husband is the wife's obligation, especially financial obligations. Unlike with kitchen obligations, it all can be bought outside when the wife is lazy to prepare a meal for her husband, but if it's not financial can be represented outside, it must be his wife who serves him; it's dangerous. If the husband eats out, it can be a sin, and it's not like eating and buying out, huh, okay. By word of mouth, some of them know about the law refusing to have intercourse with a husband is unlawful, and Allah has cursed him until the morning until her husband is happy because his wife has prohibited having sex. However, if the wife was exhausted because he came home from work and had to take care of his When he was young, he needed his mother's milk, so his wife always refused him. Because having sex, it must have a body that is relaxed, healthy, and strong to serve her husband. Worried when helping her husband, the body is not healthy and can affect children's breast milk. When you have children under one year, you have nothing desire to serve your husband because it works and at the same time Wahidin:

Sexuality is a person who uses thoughts, feelings and acts based on his position as a sexual being. The concept of sexuality will differ according to place and time, because it is a social concept and construction of values and behaviors related to sex. This article aims to explain Sexuality and Family Harmonization in Rokan Hulu Riau with the Al-Quran Approach. This research is field research with a qualitative approach, which explains sexuality in the Qur'an and its implications for family harmony in Pekanbaru. The research data collection method uses interviews, observation, documentation, and various articles and books. It was then analyzed using the content analysis method with a descriptive and scientific analysis of a premium message.. The result of this research is that sexuality in Islam is shaped by cultural and religious values. Religious values color the formation of views about what is allowed to be done or not, various imperatives, and attitudes that are developed in relation to gender roles. The view of sexuality in Islam is humanist because it is full of human empathy. Meanwhile, the implications of sexuality on family harmony in Rokan Hulu Riau include; a). Reduced satisfaction with marriage; b). The husband's self-esteem becomes low in the eyes of the wife; c). Husband feels inferior; d). The husband silences his wife; e). The husband is easily angry with his wife; f). Husband left the house temporarily; g). Cheating husband; and h) Divorce.

, especially financial obligations. Unlike with kitchen obligations, it all can be bought outside when the wife is lazy to prepare a meal for her husband, but if it's not financial can be represented outside, it must be his wife who serves him; it's dangerous. If the husband eats out, it can be a sin, and it's not like eating and buying out, huh, okay. By word of mouth, some of them know about the law refusing to have intercourse with a husband is unlawful, and Allah has cursed him until the morning until her husband is happy because his wife has prohibited having sex. However, if the wife was exhausted because he came home from work and had to take care of his When he was young, he needed his mother's milk, so his wife always refused him. Because having sex, it must have a body that is relaxed, healthy, and strong to serve her husband. Worried when helping her husband, the body is not healthy and can affect children's breast milk. When you have children under one year, you have nothing desire to serve your husband because it works and at the same time Wahidin: Sexuality Relationship in Rokan Hulu Riau with the Al-Quran Approach | 1119 come home from work have to look after the child, want to rest, and when a child sleeps with his mother, so the mother wants to follow her child sleep soundly. --- Factors Wife Refuses to Have Sex in Rokan Hulu Riau There are times when a wife refuses to serve her husband in bed. It could be that you feel disappointed, upset, sad, wondering why and maybe a little emotion. At the beginning of a marriage, the couple is still passionate about the relationship. But as time goes by, there will be times when the wife or husband feels reluctant to make love, and it is not a top priority; (1)Busy Work, 18 (2)Tired; 19 18 Wives who work in the office, in the factory, or at home both have a busy schedulefor example, taking care of the business office, taking care of work in the factory, taking care of housework, cooking, preparing for the needs of children, preparing for the needs of the husband, and so on. Therefore, thoughts and attention to affectionate things in bed are far from their daily lives. Let alone stealing time for a short rest besides sleeping night alone is also tricky for them. Especially when the iron is piled up at night, the wife is reluctant to sleep in the room first, primarily to serve her husband to have sex. Interview with Mrs. Arnasih, Thursday, January 20, 2022, at 13.00 19 Due to busy work as in the previous explanation, wife become exhausted and no longer have the energy. Therefore, wife become unwilling to serve their husbands because they are tired, both physically as well as emotions. Especially if they don't have time to rest, relax or do me time to replenish the energy that has been wasted on work. Pay attention to the meaning of a woman's sharp gaze to a man when you ask him to have sex, maybe it is rejection stares because your wife is too tired. This fatigue that does not make the wife to serve her husband have sex. Interview with Mrs. Anita Sumita, Thursday, January 20, 2022, at 13.00 (3)Stress; 20 (4)Sick; 21 (5)Quarrel; 22 (6)Boredom; 23 (7)Menstruation or Breastfeeding; 24 (8) Lack of Emotional Connection; 25 (9) Husband Not 20 Becomes one of the causes of disease in the body, and stress can also trigger a wife to no longer be a passionately serve her husband. The stress experienced by the wife may arise because of busywork, taking care of her children and husband, or even because of conflict with family and friends. You need to discuss with him this one factor so that their burden is a little uplifted and happier and know how to meet a woman's, disappointed heart. Because when the wife is in a state of stress forced to have sex, it is feared that the wife will hurt her husband. Therefore, the husband must understand and wait his wife is in a relaxed state so that they can make each other happy each other during sex. Interview with Mrs. Heristina, Thursday, January 20, 2022, at 13.00 21 The sure factor that the wife does not want to make love to her husband is because they are not fit and sick. This makes them not have more energy to serve you. Because helping husband must be physically fit, fine, and feel both happy with each other. It's not only the wife who is sick not to have sex, and even the wife must understand when the husband is sick because to make out in an unhappy state doesn't have to be related intimate, affectionately make a happy husband. Interview with Mrs. Arnasih, Sunday, Friday 21, 2022, at 13.00 22 Quarrels, resentment, and anger are triggers that don't have more warmth in bed between husband and wife. Especially if the wife's character is a person who likes to remember her husband's mistakes in the past, or it could be that this fight is the reason women refuse to have sex, so you need a way to meet a woman's heart who is angry. Therefore, avoid quarrels by not speaking harshly, remaining calm in dealing with problems, and communicating well between husband and wife. When the wife has offended her husband's words, then a wife is not easy to be good to her husband, not even just a biological need; even the wife's kitchen needs are reluctant to be fulfilled it. Interview Mrs. Soraya, Sunday, Friday 21, 2022, at 13.00 23 Boredom is one factor that affects a wife who refuses to serve her husband. That's all the routine in domestic life, and husband and wife cause a sense of boredom also affects the wife is not enthusiastic about serving her husband. Don't until this saturation becomes the reason married women cheat. The husband must be creative to surprise his wife, for example, by inviting his wife for a vacation to the top by renting a villa or a beach stay at the hotel. Therefore, the wife is happy because the husband can make the wife happy. The wife will make her husband pleased because every household must have an excellent outside atmosphere to make the wife happy with her new atmosphere. Interview Mrs. Soraya, Friday, January 21, 2022, at 13.00 24 Besides being sick, the unavoidable factor is when the wife I'm on my period, so this is a good time not suitable for love. In addition, during Breastfeeding, women are too reluctant to make love because they are in hormone production prolactin which reduces sexual desire. As for when the wife is in menstruation, then the husband must understand the position of his wife, that Intimacy is forbidden during menstruation, but the wife must understand, there are parts of the body that are allowed for husbands to make love with their wife, that is, from the top of the head to the navel of the wife. Interview with Mrs. Nia Aulia, Sunday, January 23, 2022, at 13.00 25 One of the reasons the wife doesn't want to serve her husband is a lack of emotional connection to her husband. When together, husband and wife are physically close to each other. However, not necessarily are your feelings and emotions connected. Connection Physical also requires an emotional connection to feel Satisfaction is not only outward but also inner. Inner satisfaction will be more durable and long-lasting because it can be remembered. It could be that your husbands don't show their romantic side and are full of love for their wives, so they feel lazy to serve you. Women are creatures of feeling and touch. They are right in his heart. Interview with Mrs. Faizah, Sunday, January 23, 2022, at 13.00 Wahidin: Sexuality Relationship in Rokan Hulu Riau with the Al-Quran Approach | 1121 Romantic; 26 (10) Unsatisfactory husband; 27 (11) Haven't had sex in a long time; 28 (12) Having sex too often; 29 and (13) Husband Doesn't Give Kitchen Money. 30 --- Sexuality Relationship in Rokan Hulu Riau with the Al-Quran Approach Women's business (gait) is quite broad, including various fields, especially those related to himself, which is harmonized with Islam in terms of creed, morals, and problems that do not deviate from what has been outlined or established by Islam. Muslim women must strengthen one's relationship with Allah and purify their minds and time from the remnants of western thought influence. In social life, the wife has a balanced position with the husband where the wife can also carry out any work as a source of family welfare, as long as it is 26 The relationship between husband and wife is also a psychological problem, not just physical, especially for women who emphasize feelings more than logic. There are times wife feels her husband is not romantic and rarely communicates intimately in everyday household life. Therefore, wife becomes unwilling to serve her husband at home. So, therefore, I know how to be a romantic man and express the most romantic. All wives want to have a romantic husband because every time you have sex, your husband must make out first with his wife so that when the husband wants to have sex, the wife will be carried away not refuse the desire of her husband. Interview with Mrs. Fitri Khoirunisa, Sunday, January 23, 2022, at 13.00 27 Sad indeed, but the reality if the wife is reluctant to serve her husband because the husband is flawed in bed. Women have longer orgasms than men, while men often don't care whether their partner has climaxed, and the men enter the ending first. In addition, the husband who immediately falls asleep after making love can also be a factor that affects the psychological wife. You can show a romantic, caring, and protective side by talking romantically, giving hugs, and how to attract women with a look in the eye or a thank you to the wife after making love. 28 Lack of attention in daily touch can also affect the wife's reluctance to have sex with her husband. This can be why the husband no longer has an attraction to his wife. It's good before having sex in bed. The husband always shows intimacy, for example, kissing in the morning, touching hands, massaging the wife's neck, and other forms of attention such as a unique way of expressing love. So that the wife does not feel you approach them just for bed needs. Because a wife when her husband is around not only to serve husbands, but wives need love affectionate love outside the room. Interview with Mrs. Rani Kherunisa, Sunday, January 23, 2022, at 13.00 29 The intensity of having sex that is too routine or too frequent is one of your partner's problems. Especially if the activity is not balanced with continuous innovation, such as place, manner, order, position, and other factors, it's good for husband and wife to discuss what to do in improvisation so that the feeling of being together is more turbulent. Can also make the atmosphere of the room more romantic with add candles, music, and other ways of expressing feelings of romantic. Interview with Mrs. Hilda Saptarani, Sunday, January 23, 2022, at 13.00 30 According to Mrs. Eni, Not providing a living for the wife, then the wife is reluctant to serve her husband because the wife feels aggrieved; the wife performs her husband, while her husband does not provide a living to his wife, thus making the wife help her husband in bed. If there is money, the wife wants to help her husband in bed. It's good to find the right time to take your wife's relationship, which is the most relaxing time for him. Besides that, it is also necessary to approach that you as a husband are still very attracted to him so that his wife's passion can increase. This is necessary because women have a period of longer sexual arousal when compared to men. So that when the process of intercourse is too fast, the wife can be brutal to get stimulated at the same speed. Interview with Mrs. Eni Suryani, Sunday, January 23, 2022, at 13.00 not prohibited by law. No contrary to public order and not contrary to public morality. As long as it doesn't change and disturb, it will be The purpose of marriage itself is like creating a small family that is happy, prosperous, devoted to God, productive, independent, and can build themselves and the environment. 31 Viewed from family life as a whole, the mother acting as a housewife navigating the ark of the house stairs, therefore, plays a vital role in creating a good family climate, which can provide conditions for the creation of an educational situation in the family. In this crucial position, the mother has a varied role, depending on which relation we see it, which is already is a general opinion concerning the implementation of her role as queen of the household, first and foremost is concerning household governance, food governance, and the conduct of clothing and apparel. 32 According to Mrs. Sri Nurhayati, who has become a career woman since graduating high school to have a child aged six years, he said that refusing this intimate relationship when the wife comes home from work is past the isya limit. Then the husband understands that when the wife refuses, it will be. Still, if the husband invites him on Saturday and Sunday holidays, then the wife is reluctant to serve him, then the angry husband does not speak to him his wife as long as the wife is obedient to meet the needs of affection her husband. Therefore, every holiday, the wife never refuses unless she is in a sick body condition that is not allowed to serve her husband in bed. When in touch intimate wife in a tired state after coming home from work will cause the body to feel sick, so the next day, the wife is not able to carry out work activities because basic needs are increasingly expensive; that's where Mrs. Sri forced to keep working help the husband's economy, and don't want to choose to be a housewife who only relies on receiving salary husband only. Depending on the husband's salary, every time he wants to buy, needs will cause trivial disputes. Ibu Sri Nurhayati prefers to be a career woman rather than receive her husband's compensation at home. 33 She is refusing to have sex unintentionally. It's just that when she comes home from work late at night. The husband must understand the wife's condition by helping the needs household. Besides, the cost of school for children is very high, so if relying on the husband's income, it is feared not fulfilled. Unable to save, the husband's expression Ramnah Mr. Mulyadi when the wife is still firm to earning money, and the husband is pleased with her. The job is very diligent by the wife, and when the husband asks to have sex, the wife's body is tired after work after eight o'clock, then the husband understands it very well when the wife comes home before sunset. There is a sanction for the wife not being given shopping money, and on holiday, their wife refuses. then the husband provides a sanction not to go home until his wife wants to obey her husband's wishes. 34 According to Mrs. Winda, she is 25 years old and lives in the village. The peacock stated that he refused to have this intimate relationship during working hours go home at sunset because they had a baby. The husband also understands it when the wife is tired to help his family's economy because, in this modern era, needs are costly. Therefore, husband supports his wife to work for the sake of the children. The husband succumbs to their needs, even if they only get their share on holidays, as long as the need for food is fixed every day must provide by the wife. 35 Mrs. Suryani, 25 years old, stated that she refuses this relationship when the wife's condition is not healthy due to illness. The child's disease affects the wife not to want to serve her husband because the wife's concern for the child is very close, so the wife does not want to fulfill her biological needs. The very fussy child at night must be carried and hugged until sleeping soundly. My husband understands it, but if can still serve daily food needs, children can still do it entrusted to his grandmother, not like the case at night, not maybe he could leave it to his grandmother. His grandmother automatically rested. And the husband understands it all because the safety of the children is more important than her husband's biological needs. 36 Mrs. FitriyAni, who is 28 years old, stated not only factory employees, a teacher often refuses, not only him, some of his other friends are the same reject it because there is an age that makes the wife not serve her husband. The wife refuses because when the wife is tired of taking care of the children and their own 34 Interview with Mr. Mulyadi, Wednesday 26 January 2022 35 Especially when the wife comes home from work at night, automatically the wife's condition is less stable, physically tired, which is impossible to serve her husband, sometimes disturbed at night, children like wake up crying want to suckle his mother's milk, that's why the wife makes agreed that when on the night shift only certain parts of the body poster, except on holidays without the husband asking the wife to offer her husband for the ration every night when for a week the husband can't get allocations from his wife. When having children under three years have sex, Intimacy is very lazy to do because every time my wife comes home from work must prepare food for her husband and must meet the needs of the baby; therefore, the husband understands it when on workdays, If it's a holiday, must serve the husband all his needs Not only basic needs, physical conditions are also mandatory for the wife to suit his needs. Interview with Mrs. Winda Fitria, Wednesday 26 January 2022 36 Interview with Mrs. Suryani, Wednesday 26 January 2022 home, not only the child having a 4-year-old and a small one-year-old child is hassled. Therefore, the husband must understand his wife's condition, who was tired of taking care of the children and the house. And if the husband does not meet the needs of his child, the wife gets irritated. Children's needs are not enough. How does a wife want to meet her husband's needs? That's all career only as an honorary teacher. Bitter than employees, a factory that pays quite a lot. 37 The wife's refusal to have sex with her husband has a significant impact, including; 1. Feelings of Inferiority. What's wrong with me? That must be the first thing that pops into your husband's mind, rather than thinking about what's wrong with his partner. And because, in general, men are more interested in the physical, the feelings of inferiority felt by men will focus more on their physical shortcomings. Isn't it cool already? Is it inappropriate? Or does it smell even less material? In men who are married and have experienced more significant income than their wives, it usually has a substantial effect on self-confidence. And this will automatically be the first reason for confusion when there is a refusal to make love to the wife. --- Depression (Psychic). The feeling experienced repeatedly will be stressful. And if it continues, it will cause depression. Feelings of depression, in particular, men will feel related to their physical appearance as if they were deemed unfit for use, even for their wife. Not to mention awareness or women's ignorance of the magnitude of men's desires towards sex, it is not impossible to arouse suspicion. That if not from him, where does the husband get fulfillment? the need is when the wife often refuses 3. Physical Complaints. It's the same with men, and women have desires and the need to have sex. If it is restrained, medically will cause a feeling of discomfort. From illness head to one the -respiratory diseases such as influenza, cough, or asthma often result from a lack of fulfillment of affection needs. A day or two can be detained; however, after a long time, it can hurt 4. Behavioral Complaints. Discomfort, feelings of rejection, and low self-esteem will also result in behavioral complaints. Starting from just grumpy, sensitive, upset to overflowing emotions that are not in place and tend to be excessive. For example, easy to cry or irritable, or nagging. Of course, if you have children, you will impact attitudes towards children. The impact on the husband is already evident. If this woman works, it will even affect behavior in colleagues and implications for performance work. If the husband has behavioral complaints, he will be grumpy, forcing his wife to want to fulfill her needs biologically and going away from home for a while until his heart can calm down. For example, he is easily angry and nagging, so the husband does not give shopping money until his wife obeys her husband. The Impact on husband due to refusal to intercourse, as follows: (1) If the wife refuses, the husband silences him. The husband silences him so that the wife knows that Serving her husband is obligatory; (2) Don't go home. The husband doesn't come home until his wife wants to serve the husband to have sex; (3) Cut the monthly ration to the wife. The husband cuts the monthly allocation to the wife, with the reason so that the wife does not repeat the mistake. In addition, the implication of the wife rejecting sexual intercourse among others: (1) Decreased satisfaction with marriage; 38 (2) Husband's self-esteem becomes low in the eyes of his wife; 39 (3) Husband feels inferior; 40 (4) The husband silences the wife; 41 (5) 38 Physical intimacy is like the glue in marriage. This moment will make the husband and wife more connected and emotional. The frequency of sex that is allowed to decrease can cause a decrease in satisfaction with the marital bond. This conclusion follows the study in the Journal of Family Psychology. This is because orgasm causes the release of the hormone oxytocin to the brain to suggest a "bond." Oxytocin produces trust and closeness and even helps couples judge each other more positively. As for his dissatisfaction, it was caused by his wife's condition is pregnancy. In this condition, the wife's body is fragile, so make the wife feels unmotivated to serve her husband and does not feel the pleasure of sex. 39 Lack of sexual routine can also damage relationships with yourself. "From a medical point of view, a decrease the frequency of intercourse will not affect the neurotransmitter or medical illness. The emotions we feel when we face these situations make up the judgments we give ourselves become low," so that the husband feels ashamed to ask his wife a second time because his wife had rejected it. Supposedly, if the husband wants to have sex, the wife must meet their biological needs so that the husband's selfconfidence is always there. Rejection will make the husband inferior in front of his wife. The husband thinks that his wife is not happily married to her husband, even though that's not the reason the wife rejects it. Still, the husband's thoughts must be different if the wife refuses his biological needs. Therefore, the wife should not often refuse the natural needs of her husband so that her husband does not feel inferior when her husband wants her physical needs. In marriage, they must give and complement each other so that marriage becomes sak<unk>nah mawaddah and warrahmah who have blessed Allah because marriage is the pleasure of the husband. Therefore, the wife must comply with her biological needs, except in conditions of illness and menstruation. Even in a state of fatigue, the wife must continue to serve even though not every day, at least twice a week. 40 When a husband or wife worries about sex life, they often blame themselves alone. "If allowed to drag on, it can affect self-confidence and desire to have sex.". Enjoy sex with your partner in marriage so that self-confidence is restored and emotional bonds are built well. Often the wife refuses when the husband wants to have sex, then the husband feels inferior and can't satisfy his inner livelihood. So in a week, the wife is obliged to provide an inner living to her husband at least twice a week. So that the husband feels confident in front of his wife. 41 This implication is because the wife refuses to work on holidays. The husband can't understand it, so he silences his wife until the wife invites herself to be good. The husband does not give shopping money as long as the wife still doesn't obey her husband. According to Fitri Yeni's mother, this implication is because homework activities are done, and the children are asleep. The wife is still refused, so the husband silences him and locks him up in the side room Husband is easily angry with the wife; 42 (6) Husband leaves home temporarily; 43 (7) Cheating Husband 44 and (8) The Occurrence of Divorce. 45 --- Conclusion Cultural and religious values shape sexuality in Islam. Religious values color the formation of views about what can be done or not, various musts, and attitudes about gender roles. Sexuality in Islam is so humanistic and cool because it is full of empathy for humanity. The implications of the wife's rejection of the invitation to have sex with the husband to the marriage bond are as follows: a). Reduced satisfaction with the wedding. b). The husband's self-esteem becomes low in the eyes of the wife. c). Husband feels inferior. d). Husband silences wife. e). The husband is easily angry with his wife. f). Husband left home in the meantime. g). Cheating husband. h). There was a divorce. --- Bibliografi Al-Thab<unk>r<unk>, 'Ab<unk> Ja'far Muhammad Ibn Jar<unk>r. J<unk>mi' Al-Bay<unk>n F<unk> Tafs<unk>r Al-Qur'An. 3rd ed., n.d. until the wife invites him to have sex. As a family psychologist, Anna Surti Ariani, said that a wife refuses to have sex with her husband, which can trigger problems in a marital relationship. One of them can lead to a wrong perception where the Wife's refusal can be biological or offensive to his masculinity. However, he also emphasized that he could solve this problem with two-way communication by opening a chat directly open. But what you need to remember is that rejection needs to be done subtly. 42 A wife who refuses to have sex is very influential on the husband's attitude. The impact is that the husband is grumpy and has a rough/stern tone towards his wife, so the household does not make harmonious. When the child listens to the fight, parents cause traumatized children to get married because Their parents are often noisy. 43 When the husband wants to have sex, the wife doesn't want to serve him, so if he's left there are nothing changes. Then for a while, the husband is not at home with his wife, so the wife feels guilty about her attitude. The husband will not go home unless the wife meets him and apologizes to her husband to not repeat the incident that disappointed her husband. However, if there are problems and the child is sick, I understand that condition; except for a sick child and homework is done, there is no reason for the wife to refuse it. 44 There are implications for the husband if his wishes are rejected by the husband his wife, then the husband will be more inclined to seek pleasure with women outside (cheating), there are even husbands who ask their wives to allow their husbands to remarry, so that when the husband asks for sex to the wife who First, the husband still has a second wife. 45 The refusal to have sex because the husband is too late at night to arrive home causes the wife to be lazy to serve her husband. The occurrence of divorce is one because the husband never wants to divorce his wife through a religious court; it's enough to abuse the wife verbally. The cost of divorce in court is costly, time and material, so the husband is lazy to process it. This divorce is a warning so that his wife doesn't repeat her mistake and can meet her husband's biological needs. This natural relationship is very influential for the harmony of a society in a sak<unk>nah, mawaddah, and warrahmah household. If the wife does not meet their bodily needs, then the husband has the right not to provide for his wife and divorce her because a Man marry so that someone can take care of their daily lives as long as the husband's position is at home.

Sexuality is a person who uses thoughts, feelings and acts based on his position as a sexual being. The concept of sexuality will differ according to place and time, because it is a social concept and construction of values and behaviors related to sex. This article aims to explain Sexuality and Family Harmonization in Rokan Hulu Riau with the Al-Quran Approach. This research is field research with a qualitative approach, which explains sexuality in the Qur'an and its implications for family harmony in Pekanbaru. The research data collection method uses interviews, observation, documentation, and various articles and books. It was then analyzed using the content analysis method with a descriptive and scientific analysis of a premium message.. The result of this research is that sexuality in Islam is shaped by cultural and religious values. Religious values color the formation of views about what is allowed to be done or not, various imperatives, and attitudes that are developed in relation to gender roles. The view of sexuality in Islam is humanist because it is full of human empathy. Meanwhile, the implications of sexuality on family harmony in Rokan Hulu Riau include; a). Reduced satisfaction with marriage; b). The husband's self-esteem becomes low in the eyes of the wife; c). Husband feels inferior; d). The husband silences his wife; e). The husband is easily angry with his wife; f). Husband left the house temporarily; g). Cheating husband; and h) Divorce.

Introduction Sedentary behavior and physical inactivity are significant contributors to obesity in the United States. The Centers for Disease Control and Prevention reports that 36.5% of U.S. adults and 17% of youth have obesity [1]. Engaging in daily physical activity (PA), such as recreational sports and leisure activities including biking, jogging, and dog walking, can help combat obesity. Dog walking is a unique outlet for PA, considering that one-third of U.S. households are dog owners [2]. One of the first research studies that reported the health benefits of pet ownership was published out of the University of Cambridge over 25 years ago [3]. Since that time, nearly two dozen empirical studies examining the relationship between dog walking and PA have been published in the U.S. However, this entire body of research has focused on adults, with the exception of two studies that explored this relationship among adolescents 12 years of age and older, and one study among children 4-10 years of age [4][5][6]. Among these two U.S.-based studies in adolescents, it was found that dog ownership was associated with more PA among adolescents by way of walking or playing with the dog [4,5]. Likewise, in the one and only U.S.-based study in younger children, a higher level of child-dog attachment was found to be associated with a higher level of PA [6]. Research on adolescent PA and dog ownership performed outside the U.S. has reported mixed results. Specifically, in metropolitan Perth and nonmetropolitan regions in Western Australia, observational conclusions revealed that adolescents who walked or played with their dog spent an average of one hour per week on each activity and were significantly more likely to meet national PA recommendations when compared to adolescents who did not engage in these activities [7]. Yet, in the United Kingdom, no evidence was found to support a relationship between objectively measured adolescent PA, specifically dog walking, and dog ownership [8]. Other research on preadolescent PA and dog ownership performed outside the U.S. has reported more positive than negative results. When a preadolescent population of youth was observed in Melbourne, Australia, researchers detected an association between dog ownership and an increase in PA amounting to an additional 29 min per week among girls 5-6 years old and 59 more minutes in girls 10-12 years old [9]. Another cross-sectional Australian study observed similar positive associations between dog ownership and PA among children 10-12 years old [10]. Dog-owning children 9-10 years old from the Liverpool SportsLinx Project engaged in dog walking several times a week more compared to children without a dog [11]. Another study conducted in the United Kingdom found that children 9-10 years of age with a dog spent more time engaging in light and vigorous PA and recorded higher levels of PA counts per minute with by ActiGraph GT1M activity monitors than those without dogs [12]. This study also revealed that dog ownership was 22% more common in White European households than all other ethnicities included in the study [12]. The dog walkers among a population of 10-12-year-old children in Perth, Australia were more independently mobile and walked or played in the neighborhood, street, and yard at a significantly higher frequency when compared to the non-dog walkers, even though dog walk status was not found to be significantly associated with overall PA, walking, or pedometer steps [13]. Furthermore, subsequent analyses of the children 9-10 years old from the previously mentioned Liverpool SportsLinx Project failed to find evidence that children who live or walk with dogs are fitter or less likely to be obese than children who do not live or walk with dogs [14]. Dog ownership and walking has also been demonstrated to increase independent mobility and decrease anxiety levels in children. Given the research gaps that exist on youth dog ownership and youth dog walking as it correlates to youth PA, it is essential to understand the influence of built environment variables. One U.S.-based study, referenced previously, indicated that adolescents who lived in objectively walkable neighborhoods (e.g., lower perceived traffic safety, higher street connectivity, and less mixed use) were more likely to walk their dog [4]. This finding suggests that dog ownership and one's perceived and objectively measured built environment may influence youth PA. With the majority of literature investigating the relationship between dog ownership and youth PA occurring outside of the U.S., there is a need to further analyze this association within the U.S., particularly among a sample of diverse preadolescent youth. Our study addressed this research gap and examined the influence of family dog ownership and parental built environment perceptions on PA behaviors among Washington, D.C. metropolitan (DMV) children. --- Materials and Methods --- Design and Sample The Built Environment and Active Play (BEAP) Study questionnaire was mailed in September-December 2014 using a stratified sampling strategy to 2000 parents of children (7-12 years) living within nine DMV counties and cities (Washington, DC (District of Columbia); Fairfax County, Virginia (VA); Arlington County, VA; Loudon County, VA; Fairfax City, VA; Alexandria City, VA; Montgomery County, Maryland (MD); Prince George's County, MD; and Frederick County, MD). The BEAP Study area map has been previously published [15]. All participants received the BEAP Study questionnaire, a $10 gift card, and a postage-paid self-addressed envelope with return instructions. If participants preferred to complete an online version of the questionnaire via Qualtrics.com, a secure and encrypted web address and unique access code were provided. Reminder and/or thank you post cards were mailed to the participants seven days after the initial mailing. Adapted from the Neighborhood Impact on Kids project survey, the BEAP Study questionnaire, a confidential study instrument, underwent several iterations of reliability and validity testing [15][16][17]. Within the questionnaire, several topic areas of questions such as child active play, active transportation, home and neighborhood built environment features, dog ownership, parental rules, demographics, and pre-existing health conditions were captured. An initial response rate of 10% was obtained, however, approximately 50 incomplete questionnaires were omitted from analysis. The final sample included 144 children. Implicit informed consent was obtained through the return of the completed questionnaire. The Institutional Review Board at The University of Maryland at College Park approved the study protocol (UMCP, 774586-1). --- Built Environment Variables Home was defined as the "home in which you and your child live" as well as the confirmed address to which the BEAP Study questionnaire was mail delivered. The questionnaire further defined home neighborhood as the area "within walking distance" or a "10-15 min walk from your home". The three statement requests that were used to assess parental perceptions of the home neighborhood built environment and walkability were as follows: (1) "Please mark the answer that best applies to you and your child's neighborhood"; (2) "My child can walk or bike to the closest local park or playground (alone or with someone) because:... "; and (3) "It is difficult for my child to be active in our home neighborhood because:... ". These three statement requests contained 44 subpart-responses in the form of statements or justifications (e.g., because there are sidewalks; because other children walk or bike) based on a four-point Likert scale of agreement, which were dichotomized and collapsed into "agree" and "disagree" responses. Additionally, parents were asked "Have you been the victim of a crime in your neighborhood?" and "Do you know someone who has been the victim of a crime in your neighborhood?", which both elicited yes/no responses. A final question was included, "About how long would it take you to walk from your/your child's home to each of the nearest places listed below?" This question contained 17 subpart-destinations (e.g., indoor recreation or exercise facility) with responses ranging from 1-5, 6-10, 11-20, 21-30, and over 30 min that were then dichotomized into "1-10 min" and "over 10 min". --- Dog Ownership Variables Three questions were presented regarding family dog ownership, children walking the family dog, and children playing with the family dog. Parents were asked the binary question "Is there a dog in your home/child's home?" If the parents responded yes to this question, they were then asked "How many days per week did your child spend walking your dog last week (including with a parent)?" and "How many days per week did your child spend playing outside with your dog last week (not including walking)?" These last two questions contained responses ranging from 1, 2, 3, 4, 5, 6, and 7 days. --- Statistical Analysis The Chi-square (<unk> 2 ) Test of Independence was used to determine the independence or relationship of variables (H o = There is no relationship between the two categorical variables). Hence, the differences in parental perceived built environment measures between children with and without family dogs were examined. Statistical analyses were carried out using STATA/MP 14.1 (College Station, TX, USA). --- Results The average age of the 144 children included in the BEAP Study population was 9.7 years (SD = 1.6). White children accounted for about half of the study population (56.3%), with African American (23.7%) and Asian American (10.4%) following as the highest represented groups. Based on parent-reported weights and heights, 25% of the children were classified as either overweight or obese. Approximately half (53%) of the participants were reported to live in households with an annual income greater than $100,000, but 14.7% of the subjects lived in households with an annual income less than $50,000. Among our study population, nearly 30% of the children lived in a household where there was also a family dog present, and of those children, all of them had parents with some college education or more (Table 1). The majority of dog owners were White (69.1%), compared to African American (14.3%), Other (9.5%), Asian American (7.1%), and Hispanic/Latino (4.7%) dog owners. Only 13% and 5.6% of the children walked and played outside with the dog daily, respectively (Figures 1 and2), and among these children, all of them were in first through fourth grades. Chi-square (<unk> 2 ) analysis was used to determine the differences in home built environment measures by dog ownership (Table 2). The majority of dog owners lived in single family homes (72.1%), compared to only 4.7% of dog owners residing in apartments. However, the majority of families that did not own a dog also lived in single family homes (61.4%). The distribution of front yard and back yard space is almost equal when comparing dog ownership. There were no statistically significant differences in home built environment features between families with dogs and families without dogs. Chi-square (<unk> 2 ) analysis was used to determine the differences in home built environment measures by dog ownership (Table 2). The majority of dog owners lived in single family homes (72.1%), compared to only 4.7% of dog owners residing in apartments. However, the majority of families that did not own a dog also lived in single family homes (61.4%). The distribution of front Differences in parental perceived built environment measures by dog ownership were also examined (Table 3). A significantly greater proportion (p-value <unk> 0.05) of parents who owned dogs recognized and observed some home built environment measures that were PA-promoting for their children. Specifically, more parents who owned dogs agreed (strongly agree + agree) with built environment statements representing positive perceptions of some built environment features (e.g., neighborhood esthetics, safety, walkability infrastructure, and distance) as compared to the parents of children without dogs. For example, a greater proportion of dog owner parents (83.3%) agreed with the built environment measure representing their neighborhood walkability and safety, which stated that "The speed of traffic on most streets is usually 30 mph or less" compared to non-dog owner parents (67.7%). Additionally, no dog-owning parents thought that it was difficult for their child to be active in their home neighborhood because of crime, compared to parents who did not own dogs (10.0%). While statistical significance was not achieved, only 9.5% reported that it was likely their child "could be taken or hurt by a stranger" in their neighborhood as compared to the perceptions of 22.8% of non-dog owners. which stated that "The speed of traffic on most streets is usually 30 mph or less" compared to non-dog owner parents (67.7%). Additionally, no dog-owning parents thought that it was difficult for their child to be active in their home neighborhood because of crime, compared to parents who did not own dogs (10.0%). While statistical significance was not achieved, only 9.5% reported that it was likely their child "could be taken or hurt by a stranger" in their neighborhood as compared to the perceptions of 22.8% of non-dog owners. recognized and observed some home built environment measures that were PA-promoting for their children. Specifically, more parents who owned dogs agreed (strongly agree + agree) with built environment statements representing positive perceptions of some built environment features (e.g., neighborhood esthetics, safety, walkability infrastructure, and distance) as compared to the parents of children without dogs. For example, a greater proportion of dog owner parents (83.3%) agreed with the built environment measure representing their neighborhood walkability and safety, which stated that "The speed of traffic on most streets is usually 30 mph or less" compared to non-dog owner parents (67.7%). Additionally, no dog-owning parents thought that it was difficult for their child to be active in their home neighborhood because of crime, compared to parents who did not own dogs (10.0%). While statistical significance was not achieved, only 9.5% reported that it was likely their child "could be taken or hurt by a stranger" in their neighborhood as compared to the perceptions of 22.8% of non-dog owners. yard and back yard space is almost equal when comparing dog ownership. There were no statistically significant differences in home built environment features between families with dogs and families without dogs. Differences in parental perceived built environment measures by dog ownership were also examined (Table 3). A significantly greater proportion (p-value <unk> 0.05) of parents who owned dogs recognized and observed some home built environment measures that were PA-promoting for their children. Specifically, more parents who owned dogs agreed (strongly agree + agree) with built environment statements representing positive perceptions of some built environment features (e.g., neighborhood esthetics, safety, walkability infrastructure, and distance) as compared to the parents of children without dogs. For example, a greater proportion of dog owner parents (83.3%) agreed with the built environment measure representing their neighborhood walkability and safety, which stated that "The speed of traffic on most streets is usually 30 mph or less" compared to non-dog owner parents (67.7%). Additionally, no dog-owning parents thought that it was difficult for their child to be active in their home neighborhood because of crime, compared to parents who did not own dogs (10.0%). While statistical significance was not achieved, only 9.5% reported that it was likely their child "could be taken or hurt by a stranger" in their neighborhood as compared to the perceptions of 22.8% of non-dog owners. al perceived built environment measures by dog ownership were also ificantly greater proportion (p-value <unk> 0.05) of parents who owned dogs ome home built environment measures that were PA-promoting for their e parents who owned dogs agreed (strongly agree + agree) with built epresenting positive perceptions of some built environment features ics, safety, walkability infrastructure, and distance) as compared to the t dogs. For example, a greater proportion of dog owner parents (83.3%) onment measure representing their neighborhood walkability and safety, eed of traffic on most streets is usually 30 mph or less" compared to.7%). Additionally, no dog-owning parents thought that it was difficult in their home neighborhood because of crime, compared to parents who While statistical significance was not achieved, only 9.5% reported that it ld be taken or hurt by a stranger" in their neighborhood as compared to non-dog owners. When parents were asked to estimate the time it would take for them to walk from their home to the nearest destinations, there was no statistically significant difference of parental perception between dog owners and non-dog owners (Table 4). However, there were a few destinations that were found to be moderately different. It was found that there were less parents of children with dogs (9.5%) who perceived the distance to a fast food restaurant as a 10-min or less walk from their home, compared to the parents of children without dogs (26.0%). More dog owners (65.9%) perceived biking/hiking/walking trails and paths were a 10-min or less walk from their home, compared to non-dog owners (50.0%). Additionally, more dog owners (69.8%) compared to non-dog owners (57.3%) perceived public open space within a 10-min walk from their house. --- Discussion Our results suggest that dog ownership may provide more positive parental perceptions of the neighborhood built environment, which supports children's outdoor PA through dog walking and playing. Unlike older adolescents or children outside of the U.S. who may experience more independent mobility, we found that parental perceptions of the built environment appear to influence their children's dog-related PA. Dog-owning parents had fewer perceived safety risks for their child being active in the neighborhood. This may be due to the fact that there is a higher intimacy level within the neighborhood because there is a higher degree of neighborhood engagement with dog walking and playing multiple times per day. Sense of place, including place attachment and place meaning, has been shown to shape the way individuals perceive their neighborhood and this can vary significantly among different individuals within the same neighborhood [18]. Activities, such as dog walking, foster neighborhood bond and intimacy, which ultimately increases place attachment and place meaning in a favorable manner. Parents may also believe that a dog can provide protection for their child and therefore they are less concerned with their child being hurt by a stranger. This may especially be true depending on the dog breed, as was found in the Liverpool SportsLinx Project. In this project, 9-10-year-old children who owned Pit Bulls as opposed to other non-Pit Bull breeds of dogs were more likely to report friends walking with their dog [11]. A general consensus has been reported that larger, louder, and darker dogs, such as Pit Bulls and Dobermans, would be helpful with house and neighborhood security because of their easily recognized physical appearance and reputation as attack-and guard-dogs [19]. Our results suggest that parents and children with dogs may visit different locations compared to those without dogs. For example, since public playgrounds are not appropriate places for dogs, dog owners may prefer open spaces where dogs can run off-leash. This was demonstrated in our research, where more dog owners perceived biking/hiking/walking trails and paths to be a 10-min or less walk from their home compared to non-dog owners. There has been a challenge in establishing a causal influence of dog ownership on PA in adults, and this certainly has not been established in adolescents or children. While longitudinal studies in adults have suggested that dog owners become more active, the effect in children remains unknown partly because this research has not been fully explored. Consistent with U.S. households, 30% of our study population owned dogs and among this sample, all of the parents with the exception of one received some college education or more. Therefore, this more educated population may have underestimated the potential influence of dog ownership on PA since this sample of parents may appreciate the importance of PA for their children, regardless of dog ownership. Furthermore, nearly 70% of our study population who owned dogs was White, which was similar to previous findings in other research [4,5,12]. While non-Whites are much less likely to own pets compared to Whites, the human-dog companionship has also been shown to vary by race and ethnicity [20,21]. Among the exceptionally limited research exploring the relationship between ethnic diversity and companion animals, it has been found that various groups of non-Whites were afraid of dogs, disliked the hygienic mannerisms of dogs, or used their dog for personal safety [20,21]. Therefore, the motivation for dog ownership may not be founded in reasons of companionship, which may limit the PA interactions of walking or playing for adults and children. As a strength of this study, to date, this is the first U.S.-based study to explore the relationship of dog ownership and PA among a racially and ethnically diverse population of younger children. A prior U.S.-based study in younger children that did report increased PA with dog ownership consisted of over 97% White children [6]. However, the current study consisted of less than 60% White children. In our research, it was found that parental perceptions of the built environment could have a meaningful impact on children's dog-related PA. However, additional research is needed to understand the social and cultural influences of this impact. As with many studies, this study encountered a few limitations. Specifically, the questionnaire relied on family dog ownership as the primary measure. It is possible that children could walk or play regularly with other dogs in the neighborhood, but this would not be accounted for since the family would not own that dog. The age and type of dog could also impact the daily walking and playing habits for children, as these factors influence the dog's energy levels and frequency of needing outside relief. Furthermore, only outdoor playing was assessed and data on indoor dog playing was not captured in this study. Another important limitation of this study is that the questionnaire only collected data on how many days per week the child walked or played with the dog and it did not ask about the minutes or intensity of the PA. Therefore, dog ownership contribution to daily PA accumulation could not be objectively or subjectively estimated. Additionally, since cross-sectional studies only provide a snap-shot in time, youth PA patterns prior to and during dog ownership could not be established. Again, additional research in this area of study, which would collect both objective and subjective PA, is warranted since dog walking or playing could provide an integral outlet for increasing youth PA. --- Conclusions This study suggests that dog ownership may positively influence parental perceptions of the neighborhood built environment. This is important because this positive perception may facilitate their children's outdoor PA through dog walking and playing. --- Conflicts of Interest: The authors declare no conflict of interest.

Sedentary behavior and physical inactivity are significant contributors to youth obesity in the United States. Neighborhood dog walking is an outlet for physical activity (PA). Therefore, understanding the relationship between built environment, dog ownership, and youth PA is essential. This study examined the influence of dog ownership and parental built environment perceptions on children's PA in the Washington, D.C. area. In 2014, questionnaires were mailed to 2000 parents to assess family dog ownership; children's outdoor dog walking or playing; and parental perceived built environment measures. Chi-square analyses examined differences in parental perceived built environment measures between children with and without family dogs. The sample included 144 children (50% female; average-age 9.7 years; 56.3% White; 23.7% African-American; 10.4% Asian-American; 29.9% owned dog). Only 13% and 5.6% of the children walked or played outdoors with the dog daily, respectively. A significantly greater proportion (p-value < 0.05) of parents who owned dogs recognized and observed some home built environment measures (e.g., traffic speed on most streets is 30 mph or less) that were PA -promoting for their children. Findings suggest that dog ownership may provide more positive parental perceptions of the neighborhood built environment, which supports children's outdoor PA through dog walking and playing.

Introduction Oral health disparities are a significant public health concern, particularly among tribal populations [1]. These disparities are influenced by a range of factors, including limited access to dental care, cultural beliefs, poverty, and lack of oral health education. Addressing these disparities requires a multifaceted approach that takes into account the unique needs and circumstances of the tribal population [2]. In this context, a combined implementation of focus group discussion (FGD), mobile technology networking (MTN), and creating a supportive environment is an effective strategy that can improve oral health outcomes among the tribal population. By identifying the population and their oral health needs, developing an oral health promotion program, implementing the program through a community-based approach, and creating a supportive environment, this strategy can help participants adopt healthy oral hygiene habits and adhere to oral health recommendations [3]. This approach has the potential to improve the oral health of tribal populations and reduce the oral health disparities that exist within these communities [4]. Regular evaluation of the program is also essential to ensure its effectiveness and sustainability. Literature has data on the oral health status of various tribal communities in India [5][6][7]. But none exist on the Gond tribes in the Raisin district area. These represent a sect who are isolated from the hustles of city life. Health education interaction done at a single point and by a Socratic approach cannot effectively retain the learned behavior. FGD is a form of research methodology that brings together a group of people to respond to questions in a moderated environment. It will give them a chance to put forth their views and problems and help bring in suitable solutions. This form of discussion is totally different from that of mass education, wherein the health educator only speaks and there is minimal or literally no interaction at all. Mobile phones are extensively used even in remote areas of community dwellings. Presenting short messages in mobiles on a regular basis will further reinforce what was discussed during FGD. Making "healthier choices the easier choices" is the baseline of creating supportive ecology in health. In our context, it was achieved by educating the tribals about appropriate use of indigenous oral hygiene aids. Generally, changes in oral health bought after interactive sessions are subjectively measured, which always has a hidden element of bias. This study is the first of its kind that assesses oral health changes brought about by the combined implementation objectively by reliable quantitative indices, thus eliminating any errors. Hence, the present study was undertaken to answer the research question "Is there an improvement in gingival and oral hygiene status after implementing the combined model of FGD, mobile networking, and creating a supportive environment using indigenous oral hygiene aids in a tribal population?" --- Materials And Methods The study design was a community-led trial using a convergent parallel mixed method model. Ethical clearance to conduct the study was obtained from the Institutional Ethical Committee of People's College of Dental Sciences and Research Centre, Bhopal (EC-202111). Informed consent from all 100 tribal volunteers was taken after explaining the study details. Confidentiality of every subject was maintained. --- Sample size and technique A convenient sampling technique was employed to recruit the study participants. Random recruitment was difficult in our study as we needed participants who were willing to actively participate and respond in a group. Convenience sampling is a non-probability sampling technique commonly used in pilot studies and exploratory research. The researcher selects participants based on their convenience or proximity to the research setting. A total of 100 tribal volunteers were chosen for the study. The study population was recruited from village habitats of tribes in Raisin district, Madhya Pradesh. A set of 10 FGD teams were made, with 10 in each group. The samples were conveniently chosen after checking for their eligibility criteria. --- Eligibility criteria Participants between 18 and 45 years of age of both genders who remained in their tribal habitats throughout life were recruited. The respondents were chosen only when they were willing to participate in FGDs and engage with MTN. Three examiners who were calibrated for codes and criteria of the indices conducted the clinical examination. The Kappa score showed an inter-examiner reliability of 0.87 and an intra-examiner reliability of 0.91 suggesting good agreement in scoring the codes. --- Method of intervention It included both quantitative and qualitative aspects. Clinical examinations for the gingival status made up for the quantitative evaluation while FGD was categorized as the qualitative assessment. Data collection was conducted in three phases. The first phase included the evaluation of the gingival status of all included participants through gingival indices. The second phase constituted regular and systematic FGDs and mobile networking. FGD was conducted by the examiners who performed clinical evaluation. In the last phase, gingival health status was re-evaluated. --- Quantitative phase or oral health status examination or first phase Gingival and oral hygiene status outcomes were measured using the gingival index [8] and oral hygiene index-simplified [9]. The gingival index was scored as "0 = normal gingiva", "1 = mild inflammation", "2 = moderate inflammation", and "3 = severe inflammation". Oral hygiene index-simplified was scored as "0 -1.2 = Good", "1.3 -3.0 = Fair", and "3.1 -6.0 = Poor". --- Qualitative phase or second phase Participants were categorized into groups of 10. Groups were arranged to include similar gender and age ranges for better discussion. The facilitator conducted the discussion in the local language to ensure that the participants were comfortable and could express their opinions freely. FGD aimed at topics such as oral health habits, oral health education, access to dental care, community oral health, oral health, and overall, health, oral health, and technology. These questions and concepts guided a productive discussion on oral health in a focus group setting. The themes or topics of FGD were put forth to all groups and open discussion was encouraged for a session of 45 -60 minutes. Discussions were done regularly at monthly intervals for a period of three months. A social media platform (WhatsApp) group was also formed of all the participants. Subsequently, videos related to oral health and appropriate oral hygiene practices were shown and shared with all via mobile phones. Following the FGD session, demonstration of appropriate use of indigenous oral hygiene aids such as datun sticks and plain mouth water rinsing were taught by the authors. The collected data were analyzed using IBM SPSS Statistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States). Oral hygiene levels and gingivitis before and after intervention were measured by applying the paired 't'-test at p <unk>0.05. --- Results All 100 study participants completed the intervention. FGD was conducted twice in the three-month span. The mean age of the participants was 36.04 + 10.11 years. A clear female predilection (77 females versus 23 males) was noted. The majority of them were into agricultural farming (87%) followed by poultry and craft work. It was observed during the study that participants were enthusiastic and keenly interacted with the facilitator. Table 1 enlists the various sections of FGD, the questions in each section, and the themes deduced from the discussion; 93.8% of the sample felt that oral health was not related to general health suggesting poor dental health awareness. Oral hygiene practices in the family did not differ between its members. Neither technology was not thought to improve oral health nor the significance of diet was known to the study respondents. The tribal population was clueless about mental health awareness and its relation to oral health. Each theme of FGD was elaborately discussed, and the main deduction was noted down. FGD identified that oral health awareness was compromised in the tribal sect evaluated. Overall, tribals were not well aware of oral health and the factors associated with it. --- Themes Deductions Oral hygiene habits Half of the population used twigs and neem sticks to clean their teeth. A negligible portion used a toothbrush and paste. Oral health education Oral hygiene practices were learnt from family members in all the participants. Though mobile phones were used commonly, they did not influence their knowledge or practice of oral hygiene Access to dental care There was no access to dental care in their habitats. Distance and cost were the major reasons for avoidance of dental treatment. Community oral health The importance of oral health was not considered at par with general health by 93.8% of the tribal population. --- Challenges to oral health Elderly members complained of compromised mastication and nutrition due to edentulousness. Young adults and females were more concerned about aesthetics. --- Oral health and technology None of them thought technology could be used to improve oral health. Oral health and diet None in the target population were aware of the role of diet in improving oral health. --- Role of mental health in oral health Role of sound mind in maintaining their oral health was first heard from the facilitator of FGD. --- TABLE 1: Themes and deductions of FGD --- FGD: Focus group discussion Table 2 presents the findings of oral hygiene practices in tribal samples. Fifty-four percent of the population used neem sticks and datun to clean their teeth and only 21 % used toothpaste. Charcoal was also used in 13%. This suggests that oral hygiene practices of the tribals were subpar. Thirty-seven percent of the study sample brushed lesser than once daily, while a majority (56.0%) brushed once a day, thus highlighting the lack of appropriate oral hygiene practices. --- Discussion The present study was conducted on 100 Gond tribal volunteers of the Raisin district and is the first of its kind. It was noted that 54% of the sample used neem twigs for oral hygiene maintenance suggesting decreased accessibility to oral health care products. Knowledge levels regarding dental health were also lesser with only 21% of the population using toothpaste. A definite improvement in gingival health was noted with the decrease in both oral hygiene index-simplified and gingival index scores suggesting the effectiveness of the combined intervention strategy. FGD aimed to understand the oral health knowledge, attitudes, beliefs, and practices of the population. FGD was facilitated in the local language to ensure that participants were comfortable and could express their opinions freely. A volunteer from their habitat during FGD helped us to easily integrate the program into the community. The use of MTN was integrated into the program to ensure that the participants received ongoing support and reminders. Practices such as appropriate use of datun sticks and mouth rinsing with water after every meal remains crucial to sustaining oral health promotion. By creating a supportive environment, participants are more likely to adopt healthy oral hygiene habits and adhere to oral health recommendations. The findings from this study might help in the development of an oral health promotion program that addresses the specific needs of the population. Our study reported that greater than half of the population used neem sticks and twigs to clean their teeth. The study by Asif et al. reported similar findings with only 22% of Koya tribes and 30.80% of Lambada tribes using toothpaste and a good number using sand and charcoal [7]. Similar outcomes were observed in the rural population of the Gambia in West Africa by Jordan, where a large proportion of people utilized chew sticks (50.6%) and toothbrushes (34.6%) [10]. In contrast, Naheeda et al. observed that the majority of the population used a toothbrush and toothpaste and brushed their teeth once per day in their study conducted among tribals of the Khammam district [11]. Considering the economic constraints of this population, a simple toothbrush and paste were also difficult to afford by most of them. For those who were already using a toothbrush and paste, they were strongly encouraged to follow the same. The sect of the population who could absolutely not afford was taught the rightful usage of neem sticks and datun. OHI -S ratings reduced from "Fair (1.4964 + 0.2657)" to "Good (0.95874 + 0.08994)", which was significant at p=0.000. The positive change in oral health bought by the combined strategy can be well appreciated. As the study design in itself is novel, we could only compare our pre-FGD with existing literature. Pre-FGD scores of OHI-S were in accordance with the study by Asif et al. who also reported "Fair score" for Koya and Lambada tribes [7]. This is also in concordance with tribals residing in Telangana [12]. Kumar et al. showed 57.0% of their study respondents showed poor oral hygiene. The oral health disparities of the tribal population can be attributed to various factors such as limited access to dental services, lack of oral health education, poverty, and cultural beliefs [13]. Seeking prompt dental treatment and proper oral hygiene practices enhances oral health. Improving oral health can have a significant positive impact on oral health-related quality of life [14]. While the combined implementation is an effective strategy to address oral health disparities among tribal populations, there are some limitations to this approach. One limitation is the availability of resources to implement the program. The implementation of this approach requires significant financial, material, and human resources, which may not be available in all settings. Additionally, the program's sustainability may be affected if these resources are not sustained in the long term. Another limitation is the language barrier. The approach requires conducting the FGD and providing oral health education in the local language, which may be challenging if there is no standard written language or if the language is not widely spoken. This limitation can be overcome by employing interpreters or utilizing bilingual staff. The approach may also be limited by cultural beliefs and practices that may influence oral health behaviors. Some cultures may not prioritize oral health, or traditional practices may contradict modern oral health recommendations. Addressing these cultural beliefs and practices requires sensitivity and cultural competency on the part of the program implementers. Though the combined implementation is an effective strategy to address oral health disparities among tribal populations, it is essential to consider these limitations and tailor the program to the specific needs and circumstances of the population. The utilization of FGD allowed us to gain in-depth insights into the oral health challenges faced by the tribal population. It provided a platform for open discussions, allowing community members to express their concerns, beliefs, and knowledge regarding oral health. The FGD sessions helped us understand the specific needs and priorities of the community. The integration of MTN played a pivotal role in enhancing access to oral health information and services. MTN has the advantage of reaching a larger population, even those in remote areas. It also provides educational materials, oral hygiene tips, and appointment reminders, empowering individuals to take charge of their oral health. In fact, it can act as a facilitated communication between healthcare providers and community members, enabling timely consultations and referrals. Creating a supportive environment can indeed be a crucial aspect of an intervention aimed at addressing oral health disparities in a tribal population. A supportive environment plays a significant role in promoting positive oral health behaviors and outcomes. Based on the current literature and the experience of implementing the research, several recommendations can be made for future efforts in this area. • In order to identify service gaps and enhance the efficacy of the strategy, it is crucial to frequently examine the oral health needs of indigenous groups. Periodic surveys, focus groups, and community-based participatory research are effective ways to accomplish this. • There is a need to expand relationships between public health organizations, tribal administrations, and academic institutions in order to increase the resources available for putting the strategy into practice. • Further research on the use of mobile technologies is warranted, especially in terms of reaching out to tribal populations that have little access to oral health care. This can involve the use of mobile applications for oral health education and support, text message reminders, and telehealth services [15]. • In order to make oral health promotion programs more acceptable to these tribals and culturally suitable, it is necessary to incorporate traditional knowledge and practices. This can be done by carefully collaborating with local community leaders and healers to incorporate ancient practices into current oral health recommendations. --- Conclusions Our combined approach of FGD, MTN, and creating a supportive environment yielded promising results. We observed improved gingival health among the intervened tribal population. Furthermore, there was a notable reduction in oral health disparities, as evidenced by improved oral health outcomes among the tribal population. However, it is important to acknowledge that addressing oral health disparities is an ongoing process, and there are still challenges to overcome. Sustaining the interventions and ensuring their longterm impact will require continued support from healthcare providers, policymakers, and community stakeholders. Additionally, further research is needed to evaluate the long-term effectiveness and costeffectiveness of the interventions, as well as to explore other potential factors contributing to oral health disparities in the tribal population. --- Additional Information Disclosures Human subjects: Consent was obtained or waived by all participants in this study. People's College of Dental Sciences and Research Centre, Bhopal issued approval EC-202111. The Institutional Ethical Committee in its complete perspective and is of the conscientious opinion that the above study can be conducted without any legal, moral, or ethical encumbrances. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Background and objective: Oral health disparities generally exist among tribal populations, prompting creative solutions to tackle these challenges. By using a combined implementation strategy of including focus group discussion (FGD), mobile technology networking (MTN), and creating a supportive environment, this study aims to assess and bring positive changes in oral health in these populations. Methods: The current study employed a mixed-method approach on a sample of 100 tribal volunteers. Qualitative assessment included FGD conducted regularly for three months based on themes such as oral hygiene habits, access to oral health, technology in oral health, the relationship of oral health to general health, and the role of diet in oral health. Quantitative evaluation included recording of the oral hygiene index-simplified and gingival index to measure gingival status. Messages on oral health were routinely posted to mobile phones to reinforce oral health education. Appropriate use of indigenous oral hygiene aids (neem and datun) was also taught during the discussion session. Clinical examinations were compared before and after FGD. Data were analyzed using IBM SPSS Statistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States). A paired 't' test was used to find significant differences in gingival status at p<0.05. Results: The FGD sessions deduced observations such as limited access to dental care, inadequate oral hygiene practices such as usage of neem sticks and twigs, and lack of oral health awareness. The implementation of MTN facilitated the dissemination of oral health information and enhanced communication between community members and healthcare providers. The gingival index score significantly improved from pre-FGD to post-FGD with a mean difference of 0.41700 significant at p=0.000. Oral hygiene of the target population shifted from "Fair" oral hygiene status to "Good" oral hygiene status.The combined implementation of FGD, MTN, and creation of a supportive environment demonstrated promising results in addressing oral health disparities among the tribal population. The interventions led to improved gingival status and better utilization of oral hygiene practices. These findings highlight the importance of tailored interventions, community engagement, and mobile technology in addressing oral health disparities in tribal populations. Ongoing support, sustainability, and further research are necessary to ensure the long-term impact and effectiveness of these interventions.

INTRODUCTION Rationale There are an estimated 281 million international migrants in the world, constituting 3.6% of the global population. 1 Of these, approximately 13% are forced migrants, including refugees and asylum seekers who often face significant hardships during migration and when settled in their host country. 2 The remainder are economic migrants who often choose to migrate to reunite with family or for better job prospects, but they may also experience marginalisation due to poverty, social isolation, and discrimination. 1 Between 2000 and 2022, the international migrant population increased by 108 million, and although the majority of international migrants originate from low-income and middle-income countries --- STRENGTHS AND LIMITATIONS OF THIS STUDY Open access (LMICs), increasing numbers hope to settle in high-income countries (HICs). 1 HICs are not always well adapted to care for the needs of marginalised migrants, and many HICs struggle to adapt to this changing migration landscape. 1 Women constitute approximately half of the international migrant population. 2 Women who migrate and who are pregnant or postpartum can face significant barriers to accessing maternity care, putting them at increased risk of poor mental and physical health. [3][4][5][6] They may experience poor social support in their host country, an inability to access to healthcare and language barriers. 5 7 Forced migrant women who are pregnant or postpartum experience additional challenges including premigration stressors such as the trauma of war, transition stressors including dangerous migration journeys and gender-based violence, and postmigration stressors such as poor access to legal entitlements, discrimination and sociocultural barriers in obstetric care. 7 8 They are also more likely to have poor access to antenatal care and experience higher rates of perinatal mortality, miscarriage, and stillbirth than non-refugee women. 9 HICs often have some of the resources needed to support marginalised pregnant and postpartum migrant women, but often struggle to provide optimum care. 8 To our knowledge, no previous review has sought to quantitatively synthesise the literature on the most effective interventions to improve perinatal outcomes for migrant women in HICs. Balaam et al conducted a systematic review in 2020 which aimed to identify social support interventions for asylum-seeking and refugee women in Europe. 10 The findings were qualitatively synthesised and women valued peer support and interventions that addressed their needs in a holistic way. 10 The UK National Institute of Health and Care Research commissioned a systematic review to explore interventions to improve maternity care for migrant women in the UK in 2017. 11 The review included only UK studies and identified just four interventions. These included peer support and specialist maternity care interventions, but they were not robustly evaluated, so it was difficult to draw conclusions on their effectiveness. 11 Objectives This systematic review aims to identify the most effective interventions to improve perinatal outcomes for migrant women in HICs by quantitatively synthesising the literature. The primary objective will be to determine what interventions exist to improve perinatal outcomes for migrant women in HICs. The secondary objective will be to explore the effectiveness of these interventions by exploring the impact on perinatal outcomes. The main outcomes of interest will be rates of preterm birth, birth weight, and number of antenatal or postnatal appointments attended. --- METHODS AND ANALYSIS Registration and protocol adherence This systematic review will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered on PROSPERO: CRD42022380678 on 9 December 2022. --- Definitions For the purposes of this review, migrant women will be defined as being aged 16 years or older and who were born outside their host country. Eligible maternity care interventions are any hospital-based or community-based initiatives offered in the antenatal, perinatal, or postnatal period up to 1-year postpartum. The perinatal period is defined as pregnancy and up to 1-year postpartum. --- Eligibility criteria and patient, intervention, comparison and outcome framework Patient, intervention, comparison and outcome framework <unk> Population: Perinatal migrant women (those who were not born in their host country) aged 16 years or older and living in HICs (defined as being in the World Bank high-income economy category). 12 <unk> Intervention: Any hospital-or community-based activity undertaken with the aim of improving perinatal outcomes and delivered during the antenatal period and up to 1-year postpartum. <unk> Control: Usual care if data are available. <unk> Outcome: The main outcomes of interest will be rates of preterm birth, birth weight and number of antenatal or postnatal appointments attended as these are crucial measures of quality of maternity care in accordance with the WHO guidelines for Quality of Care for Pregnant Women and Newborns. 13 Improvements in perinatal outcomes (rates of miscarriage, preterm birth, stillbirth, birth weight, mode of delivery, APGAR score, maternal/neonatal critical care admission, breastfeeding initiation and duration, maternal/neonatal death, perinatal mental illness); number of antenatal or postnatal appointments attended or change in maternal well-being as assessed by validated mental illness or well-being screening scales, as well as any other outcomes retrieved from included studies. --- Inclusion and exclusion criteria Observational, quasi-experimental, and experimental intervention studies published from inception will be included. Abstracts, non-empirical research, opinion or editorial pieces will be excluded. If duplicate reports or publications of the same data are retrieved, the less complete or recent version will be excluded if the same data are reported. Studies including only a qualitative outcome assessment will be excluded. Interventions that were not specifically designed or adapted for migrant women in the perinatal period will be excluded. This is to ensure our results are focused on interventions that could be directly implemented for migrant women and have a direct impact on their outcomes. Additionally, we felt this ensures the systematic review is focused and won't return an unmanageable number of results. --- Open access Patient and public involvement Migrant women who are residing in the UK helped with the review's inception and design, and will also help with data extraction, analysis, and interpretation. They will also help with disseminating the work through co-authorship on peer-reviewed manuscripts and presentations at conferences. Forward citation searching will be employed on all included articles, and the reference lists of all included articles will also be searched. No language restrictions will be employed. If studies are published in a language other than English, one of the research team who is fluent in that language will assess for likely relevance and extract the data, if appropriate. The article will also be translated using Google Translate and a second reviewer will review its relevance and extract the data, if appropriate. If none of the research team are fluent in the language, we will pay UCL's graduate linguistics programme to translate the article. The Boolean operators 'AND' and 'OR' will be employed to combine the descriptors. An experienced medical librarian helped to develop the search strategy and it has been adapted for each database. A search strategy is provided in online supplemental appendix 1. EndNote will be used to collect and manage studies retrieved. 14 Covidence will be used for deduplication and for study selection. 15 Data extraction (selection and coding) Two independent reviewers will screen the titles and abstracts of all the citations for relevance. Full text manuscripts for relevant articles will be obtained. Full texts will be independently assessed for eligibility using a checklist of the inclusion and exclusion criteria by two independent reviewers. Studies meeting the inclusion criteria will be selected for inclusion in the review. All excluded articles from the full text screening will be retained with reason for exclusion noted. Disagreements between reviewers will be discussed and agreement sought from a third reviewer if necessary. If data are not accessible from the paper, the authors will be contacted. All extracted data will be recorded on the piloted data extraction form by two separate reviewers and cross-checked. The main data fields will be: Quality assessment and risk of bias Two reviewers will perform the critical appraisal independently and this will be independently cross-checked. The Quality Assessment Tool for Quantitative Studies will be used to assess rigour for each included study. 16 This was chosen as it has been developed and validated to assess both observational and experimental studies and shows reliability and validity. It assesses selection bias, study design, confounders, blinding, data collection, withdrawals, intervention integrity and statistical analysis. --- Search To assess time-related biases, we will include components of the Risk of Bias in Non-Randomised Studies of Interventions tool. 17 If meta-analysis is conducted, publication bias will be assessed using a funnel plot. --- Data synthesis Study characteristics including outcomes, for example, raw proportions, mean scores and ORs/risk ratios will be extracted and presented in tabular form. Narrative synthesis will be conducted according to Cochrane guidance and will include the creation of categories of interventions based on included papers, for example, specialist midwifery services, interpreting services and use of a doula. 18 19 If appropriate, heterogeneity between studies will be explored using the I 2 statistic. Random effects meta-analysis will be conducted with 95% CIs to allow for expected heterogeneity between different study populations, if appropriate. If possible, pooled estimates of OR/risk ratios with 95% CIs will be calculated to explore outcomes among migrant women compared with usual care. Subgroup analyses according to migration status (economic and forced) and study context (hospital based or community based) will be conducted, if appropriate. Sensitivity analysis according to study quality and method of recruitment will be undertaken. If meta-analysis is not possible due to a lack of standardised outcome data, alternative quantitative methods will be used following the Cochrane Handbook for Systematic Reviews of Interventions guidance. 19 The handbook details several approaches, but it is likely a Harvest Plot will be most appropriate. A Harvest Plot provides a visual extension of vote counting by categorising studies based on their effect (eg, 'beneficial effect' or 'detrimental effect'). 20 Vote counting is recommended when there are inconsistent effect measures across studies. Traditional vote counting methods using statistical significance, magnitude of effect or subjective rules have been shown to be misleading. 19 Instead, we will create a standardised binary metric, --- Open access 'beneficial' or 'detrimental' based on direction of effect for each intervention according to outcome category (eg, birth weight, stillbirth rates or antenatal appointment attendance). 19 We will calculate the proportion of beneficial studies, 95% CI (binomial exact calculation) and p value (binomial probability test) to demonstrate if there is any evidence of an effect. We will present the findings on a Harvest Plot, which will take the form of a'supermatrix' which visually displays the vote counting results for each intervention. 19 All statistical analyses will be conducted using R Studio. 21 Meta-biases such as publication bias across studies will not be assessed. --- Confidence in cumulative evidence Confidence in the strength of evidence found will be assessed using the overall assessment outlined in the Quality Assessment Tool for Quantitative Studies checklist. 16 This will be done by two reviewers and possible disagreement will be assessed by third reviewer. --- ETHICS AND DISSEMINATION Ethical approval is not required for this study as no primary data are being collected. We intend to publish the results in a peer-reviewed open access publication and present results at national and international conferences. The findings will inform the work of the Lancet Migration European Regional Hub. --- DISCUSSION This systematic review will provide a comprehensive overview of interventions being used to improve perinatal outcomes for migrant women in HICs. It will make a systematic assessment of the most effective interventions, which will help to inform policy and clinical decisionmaking across these regions. The findings can also be used by researchers planning or adapting maternity care interventions for migrant women in HICs, as well as to guide resource allocation decisions by funders and healthcare managers. Potential limitations include the retrieval of low-quality studies with poor evaluation of outcomes which will inhibit our ability to robustly assess the evidence of effectiveness of these interventions. Attempts to retrieve all available literature have been used such as involving a medical librarian in the development of our search strategy to ensure a broad and sensitive selection of search terms and searching multiple databases and additional supplementary and grey literature sources, however, it is possible that some relevant studies/ data may be missed. The certainty of evidence may also be limited by few studies including quantitative outcome assessments of interventions. Additionally, we are only including studies conducted in HICs which means we may miss effective interventions which were developed and tested in LMICs. Studies including antenatal interventions and subsequent perinatal outcomes can be affected by time-related biases if women are recruited at various points throughout their pregnancy, that is, person-time of observation is not properly accounted for in the design or analysis of a study. 22 We are unable to adjust for these biases in quantitatively synthesising our findings, but will consider the implications of this in our conclusions. We are taking a coproduction approach to the planning, conducting and interpretation of this work by ensuring migrant women who have given birth or been pregnant in their host country are involved throughout. We will also be assessing if included studies have taken a coproduction approach at any point in intervention development, implementation or evaluation to gain an understanding of the prevalence of coproduction in this field. We will identify gaps in the evidence to guide future research priorities. --- Twitter Kerrie Stevenson @drkstevenson, Hannah Rayment-Jones @HannahTLGG and Robert W Aldridge @rob_aldridge Contributors KS, KO, FAS, MK and RWA conceived of the review. KS, KO, SE, WGH, HR-J, MM, MM-C, GF, SL, FAS, MK and RWA developed the approach and protocol. KS developed the search strategy. KS wrote the first draft of the protocol, and all authors were invited to comment. KS is the guarantor of the review. All authors approved the final version of the protocol. Competing interests None declared. Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details. --- Patient consent for publication Not applicable. Provenance and peer review Not commissioned; externally peer reviewed. Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Introduction Women who are migrants and who are pregnant or postpartum are at high risk of poorer perinatal outcomes compared with host country populations due to experiencing numerous additional stressors including social exclusion and language barriers. High-income countries (HICs) host many migrants, including forced migrants who may face additional challenges in the peripartum period. Although HICs' maternity care systems are often well developed, they are not routinely tailored to the needs of migrant women. The primary objective will be to determine what interventions exist to improve perinatal outcomes for migrant women in HICs. The secondary objective will be to explore the effectiveness of these interventions by exploring the impact on perinatal outcomes. The main outcomes of interest will be rates of preterm birth, birth weight, and number of antenatal or postnatal appointments attended. Methods and analysis This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocols guidelines. EMBASE, EMCARE, MEDLINE and PsycINFO, CENTRAL, Scopus, CINAHL Plus, and Web of Science, as well as grey literature sources will be searched from inception up to December 2022. We will include randomised controlled trials, quasiexperimental and interventional studies of interventions, which aim to improve perinatal outcomes in any HIC. There will be no language restrictions. We will exclude studies presenting only qualitative outcomes and those including mixed populations of migrant and non-migrant women. Screening and data extraction will be completed by two independent reviewers and risk of bias will be assessed using the Quality Assessment Tool for Quantitative Studies. If a collection of suitably comparable outcomes is retrieved, we will perform meta-analysis applying a random effects model. Presentation of results will comply with guidelines in the Cochrane Handbook of Systematic Reviews of Interventions and the PRISMA statement. Ethics and dissemination Ethical approval is not required. Results will be submitted for peer-reviewed publication and presented at national and international conferences. The findings will inform the work of the Lancet Migration European Hub. PROSPERO registration number CRD42022380678. ⇒ We will employ rigorous methodology in accordance with the Cochrane Handbook of Systematic Reviews and report in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol statement. ⇒ We aim to assess if included studies employed coproduction methods at any point in intervention development or analysis. ⇒ The search strategy was developed with an experienced medical librarian and adapted for each database searched. ⇒ No language restrictions will be employed, and we are doing an extensive and systematic grey literature search which is often omitted in similar reviews. ⇒ The certainty of evidence may be limited by the number of studies available and because some studies may be of low quality without a quantitative outcome assessment.

Background With the shifting demographic towards an ageing population in Western societies, nursing homes will continue to be an essential service provided to individuals for the foreseeable future. In Norway and many other European countries, elder care is recognized as a public responsibility. Norwegian municipalities provide long-term care in nursing homes to more than 41 000 people, i.e. one-fifth of the population over 80 years old [1]. Most nursing home residents have advanced chronic illnesses and multiple diagnoses with as many as 80 % suffering from dementia [2]. For long-term residents, the nursing home provides a complete service, including advanced health care, housing and social care [3]. End-of-life care is increasingly the responsibility of nursing homes, and over 45 % of all deaths occur in nursing homes [1]. The many functions of the nursing home and the diversity of the residents' needs, varying from palliative care to social stimulation, add complexity to nursing care [4]. Therefore, to develop high-quality nursing home services that are suited for the future, nursing home organizations must adapt to these complexities. According to Donabedian (1980), quality of care can be divided into at least two interrelating aspects: technical care, defined as the application of the science and technology of health science to the management of health problems; and interpersonal processes, specifically, the psychosocial interaction between client and practitioner. Technical care quality can be defined as the extent to which the care provided maximizes the health benefits without increasing risk, a valuation that must be shared by the patient and the practitioner [5]. Three quality domains should be considered when judging total quality: structure quality, comprising quality of the structural factors that affect the performance of care; process quality, or the quality of the direct care that the staff provides; and outcome quality, encompassing the impact for the patient or health care service outcome for the population. A variety of factors affect the processes and structure quality, which again indirectly provide the results for the individual patient, or the outcome of the service offered [6]. Quality in the interpersonal domain is measured by the degree of adherence to socially accepted values, which are reinforced by the ethical principles of health professions, and expectations of individual patients [5]. Client -nurse interaction is a major aspect in nursing [7], and variables related to client-nurse interactions include: the actors (client and nurse), social context for contact, process of interaction, and client health outcomes [7,8]. Residents in nursing homes develop longterm relationships with nurses that require a unique approach to the interpersonal aspects of nursing. It has been found that the nurse-patient interaction is a vital resource for promoting physical, emotional, functional, social and spiritual well-being among nursing home patients [9]. In nursing homes the nursing care should take a holistic view [10][11][12], and person-centred care means to adopt the resident's perspective resulting in a recognition of the resident's and the family's values [13]. High quality in dementia care means to help the resident to maintain a sense of personal worth, an ability to control his or her personal life, social confidence and hope in a situation where his or her dependence on others is prominent and increasing [14,15]. The interpersonal relationship is regarded as an essential factor in person-centred care and interpersonal skills are considered part of nurses' professional competence and a prerequisite for person-centred processes resulting in high quality of care [16,17]. Hobbs (2009) conducted a dimensional analysis of the concept 'patient-centred care', and the central organizing perspective was that care quality is strongly connected to patient-nurse interaction, and nurses' competences to alleviate the patient's vulnerabilities [18]. Patient-centredness is a highly appreciated value stated in laws and regulations internationally. For instance, the Norwegian regulation for quality of nursing care in health and social services [19] states that the regulation has as its purpose to 'assure that users of health and social services have their basic needs met, acknowledging the individual's right to self-determination, value of selfhood and individual life style' (p1). Laws regulating patients' rights also underpin the right to participate in decisions regarding their own health as a central principle [20]. Another example is the National Minimum Standards for Care Homes for Older People (UK, England) which has a section related to shared decision-making, choice and control over one's own life (Standard 14-Autonomy and Choice) [21,22]. Most studies of nursing homes have dealt with the quality of medical care and the clinical conditions of the residents [23][24][25]. However, nursing homes have many additional functions for the long-term resident including as a home, the main social environment and a complete health care service. Since the nursing home could be understood as a community for those who live, visit and work there [26], it might be useful to study the nursing home's organizational culture. Researchers have held varying conceptions of culture, and they have drawn from both organization theory and social anthropology [27]. In addition, there is little agreement among scholars as to what the terms organization and culture mean, and how each can be observed or measured [28]. Organizational culture is defined as a set of values, beliefs, norms, customs, rules, and codes that lead people to define themselves as a distinct group with a sense of commonality [29]. Whereas 'corporate culture' is defined as a value-infused institution, complete with artefacts, symbolic codes of behaviour, rituals and specialized language commonly held by all it employees [28]. The corporate culture has as a set of social practices within the organization that brings people together. Norms and values are learned as part of the cultural conditioning, and they shape the way people view the world and how they interact with one another [28]. Communication and interaction reinforces the process, and the culture is regarded as the social and normative 'glue' that holds an organization together [30]. Although organizations, such as nursing homes, are embedded within a wider cultural context, they are also culture-producing phenomena [27]. The corporate culture affects each employee in the nursing home and, in turn, the employee takes an active part in re-creating the corporate culture through networking with other employees. Nursing homes are often seen as having strong corporate cultures with limited interaction with the communal society outside the organization [31,32]. Nursing home residents are often perceived as passive receivers of care, thus, mainly employees and the organization itself are presumed to produce the culture [28]. Organizational culture can be understood as either something that an organization has, more specific a corporate culture as an internal variable, or something an organization is, conceptualizing culture as a root metaphor [28]. Culture as an internal variable builds on the assumption that corporate cultures are dynamic and evolving. Culture is understood as an internal organizational variable that can be shaped in particular ways to change or improve the organization [27,28]. In the present study, the focus is on development of nursing home organizations. Quality improvements in the nursing homes' culture could be seen as a means to achieve quality of care and quality of life for nursing home residents [33]. Interventions are often directed at the organization's corporate culture and aim at questioning the espoused values and underlying assumptions under which employees operate [28]. According to Smircich (1983), the conception of an organization as a culture includes an examination of symbolic aspects of social practices within the organization. Therefore, to study the culture, symbolic artefacts and codes by which the participants themselves make sense of their experience and how this relates to their behaviours are observed and interpreted. This study aimed to describe the nursing homes as corporate cultures from the staff's perspective, and includes how cognitively competent residents describe quality of care. An additional aim was to acquire a better understanding of this link in order to create better nursing homes for the future. --- Methods This study is part of a larger study aiming at exploring the most important dimensions of quality of care in nursing homes by describing the perspectives of residents, family and staff [34]. In the present study, two data collection approaches were employed: 1) an ethnographic design using participating observation; and 2) in-depth interviews with residents. A systematic approach to everyday life in the natural setting of nursing homes was used to illuminate the specific research questions, carefully interpreted to draw valid meaning from these data. The purpose was to describe what happens, how the people involved see and talk about their own actions and those of others, the contexts in which the action takes place, and what follows from it [35]. The findings from resident and family interviews have been published previously [4,36,37]. However, in the present article, materials from resident interviews have been used in view of the findings achieved from field notes. The reason for this new approach was that the resident interviews represented only cognitively competent residents, whereas the observations included all residents, both cognitively competent and cognitively impaired, as well as the nursing homes' organization and corporate cultures. --- Setting and study participants A purposive sample [38] of four municipal public nursing homes in Norway with long-term care residents was included. Research indicates that there are differences between small-, medium-and large-sized nursing homes and in urban and rural areas [39,40]. Therefore, a sample of nursing homes that reflects these features was selected. For the purpose of this study, the four nursing homes were given pseudonyms, namely Residence, Hospital, Shelter and Village. The four nursing homes had mixed populations in regard to medical diagnoses, physical and cognitive functioning, ages and gender. --- Data collection The data were collected in 2008 by participant observation, informal conversations and discussions with staff, document studies in the four nursing homes, and in addition in-depth interviews with the residents. The researcher first contacted the management of each nursing home and received permission to do the study. The staff, residents and relatives were informed about the study and information pamphlets were distributed. Information notices were placed on front doors, notice boards and in a ring binder in each nursing home's staff room. There were opportunities for asking for clarification at all times when the observers were present, or anyone could ask to see the ring binder for more information. The author of this paper (researcher) and a research assistant entered the units, wearing health workers' clothing, and participated in daily activities related to nursing care and practical tasks in the nursing home. Both observers are registered nurses (RNs) and postgraduate specialists. The two observers were present simultaneously at each of the nursing homes for 4 or 5 days and, on average for 5 h per day in the morning or afternoon/ evening. The total observation time was 195 h with 44 to 52 h spent in each nursing home. An observational guide was used by both observers, see Fig. 1. Consent from the residents and staff members was continuously collected orally by asking permission to observe and assuring that the resident being observed did not object to the observation. If there were any indications such as signs of discomfort among the residents or negative statements from the resident or a family member that were perceived as doubt of consent, the observers left the room and no notes were taken. Observations focused on organizational structure, practical tasks and activities on the ward, which persons were present in the nursing home and communication. In addition, time and place were described through sensory impressions: smells, sounds, general atmosphere (milieu) and aesthetics. The observers' own reflections were recorded both during the field study and afterwards, representing the main material for analysis. Thus, field notes used in this study encompassed actual situations of everyday life in the nursing homes, the observers' impressions of what happened and the initial interpretation of these situations. After the observation period, 15 residents in all, nine women ages 75-92 and six men ages 80-90, representing all four nursing homes, were recruited for in-depth interviews. Inclusion criteria were being age 65 or older, not being cognitively impaired, and being a resident of the nursing home for 1 month or longer. The clinical nurses were asked to give the researcher a list of residents they regarded as having the ability to give consent to participate in an interview, as well as the physical and mental capacity to be interviewed. The researcher contacted the residents consecutively, handed out the cover letter and read it aloud when requested. The residents consented orally to participation, and residents who were able to write signed a written consent form. To acquire an information-rich description of the informants' experiences, a narrative approach was used, with questions such as "Tell me how your day is" or "Tell me about when you moved into the nursing home" to encourage the informant to freely talk about his or her life in the nursing home, both positive and negative experiences. The author of this article conducted all interviews. The interviews were tape-recorded, and the interviewer also took notes that described the setting and summarized the general impression of the interview (Additional file 1). --- Analysis The ethnographic approach require that data analysis take place in the same time frame as data collection and involve an iterative process [35]. The field notes and notes on the informal conversations with staff were first coded into meaningful entities. Then, all data were sorted into main categories, ensuring association and exclusiveness. Resident interviews were transcribed verbatim, retaining frequent repetitions, pauses, and emotional expressions [41]. The transcripts were first read through while listening to the tape recording, and a matrix of the first general themes was constructed. The analysis then moved into meaning condensation and coding. Meaningful entities in the transcripts were identified, and the text or expressions of the interviewees were sorted into more specific categories. Finally, by comparing and contrasting the content in each category, meaning categorization was achieved [41]. --- Study rigour The credibility of the study depends on both a rigorous method in data collection and analysis, and the credibility of the researcher [42]. Reflexivity is an aspect of all social research, and this reflexivity provides the basis for a reconstructed logic of inquiry and produces justified accounts of the social world [35]. Since some features of culture are not visible to those who are part of the culture, research in one's own field is challenging. Our presuppositions may limit the achievement of full understanding of the nursing home's culture, thus threatening the credibility of the findings [43]. Reflexivity involves a process of examining both oneself as a researcher and one's relationship to the research context. Personal reflexivity refers to how our values, beliefs and presuppositions influence our understanding of the Fig. 1 Observational guide nursing home's culture. For instance, during observation of nursing home practice, our own work experience from nursing homes might be used as a reference. Reflexivity encompasses to make the familiar unfamiliar by taking an outside perspective. On the other hand, our experience as nurses and familiarity with nursing home services can be used deliberately to trigger further exploration of the environment in the actual nursing home being observed, thus enhancing the richness of data acquired [44]. Contextual reflexivity involves attempts to identify the foundations of knowledge and the implications of findings of the study. For example, knowledge acquired from previous research may influence the focal point of observations; thereby determine what to lay emphasis on and what to take no notice of. To strengthen the study's analytical rigour in the area of dependability and confirmability, the researcher and the research assistant met throughout the process to review the data, reflect on interpretations and discuss the findings [41]. --- Ethical considerations The study was approved by the Regional Committee for Medical and Health Research Ethics, Health Region Mid-Norway (ref. no 4.2008.190). During the observation study, the observers aimed at informing the staff, the residents, the residents' next-of-kin and visitors about the study's aim and data collection methods to clarify the observers' roles at all times. Consent was obtained from all participants by asking both the carer and the resident for permission to observe in each situation where the researchers participated in care activities. The staff and the resident could refuse to be observed, and the residents' families were requested to speak on behalf of those who were not competent to consent. However, in order not to disturb the daily activities and normal life in the nursing home, the researchers tried to blend in as nurses. This could have led to misunderstandings about our roles, even if we repeated the information occasionally. For the in-depth interviews, informants gave oral or written consent. There were no instances where family members gave consent on behalf of or in addition to the residents. In all reports and published material, the anonymity of individuals was ensured by avoiding identifiable characteristics in narrative descriptions. --- Results Figure 2 gives a description of each nursing home, focusing on how each one organized the service, ward size, architecture and food services. These descriptions were used together with the field notes, expressing similarities and differences between each nursing home. After the initial analysis of the descriptions of the nursing homes, field notes, and researchers' reflection notes, different or convergent patterns of regular structure and interaction in the nursing homes were found, describing the nursing home's corporate culture. Further, an approach that described the nursing home organizations as 'personalities' was used. Three factors, conformity, group trait and distinctiveness, which have been used for describing the formation of human personality [45] but also organizational cultures [46], emerged, and this formed three statements for analyzing the nursing home's 'personality', see Table 1. The three statements were: 'Every nursing home is like all other nursing homes.' (Conformity) 'Every nursing home is like some other nursing homes.' (Trait) 'Every nursing home is like no other nursing home.' (Distinctiveness) From the analysis of the resident interviews, two main categories of what residents viewed as important for high quality of care and considered as having met their needs and expectations emerged: 'The nursing home as my home' and 'Interpersonal care quality'. See Table 2 for an overview of categories and subcategories. Further overview of the analysis process and findings from the resident interviews are provided in previously published articles by the author et al. [4,36]. --- Every nursing home is like all other nursing homes This statement described how nursing home organizations developed their services according to a perception of what nursing home residents in general need and expect. In the field study, we observed that all nursing homes had organized the day in a similar way with routines for daily activities such as meals, and caring procedures such as washing. The nursing homes were also structured with similar interior designs for patient rooms, common rooms and nurses' offices, with standard institutional furniture (see Fig. 2). The nursing homes were staffed with RNs on a 24-hour basis, which indicated the need for advanced health care among the residents. The communication in the nursing homes was characterized by professional terminology used between the staff and friendly professional nurse -patient communication. Family members or visitors were often regarded as guests and not as part of the nursing home community. Extracts from the field notes illustrate conformity aspects of the nursing homes: A typical Norwegian nursing home, spacious common areas made as homelike as possible. Bright colours on the walls and floor. White curtains and large oceanview windows. Numerous plants and flowers. Solid chairs for everyone and plenty of space for people who Each floor is divided into three units, of which one is the sheltered unit. There are 12, 9 and 8 residents, respectively, in each of the units. On the day shifts the units are attended by three, two and two staff members, respectively, all of whom are licensed practical nurses, assisting nurses or sometimes registered nurses. On the evening shifts there are two, two and one workers, respectively, and there are two on night shifts on each floor. There are two registered nurses on the day shift, one on the evening shift and one on call during the night. (From Shelter, recorded by researcher/author) The staff members discuss how they divide the work between themselves or consult each other whenever they are uncertain about something. The discussions take place in the staff room, corridors or in the living room. Mostly, the conversations concern which resident has been attended to, how their needs should be addressed, observations or division of labour. The staff members talk to the patients and the patients respond as far as they are able to. A number of them depend on the staff to initiate communication. (From Village, recorded by researcher/author) This illustrated the conformity of nursing homes in general. The nursing homes had common structures such as staffing, similar organization of nursing home services and a standardized environment (see also Table 1). Nursing home culture in all four nursing homes included common norms for basic care and professional communication between staff and between staff and residents. These typical characteristics of nursing homes in general were in line with some of the common needs of the residents. The residents stated that routines and a certain rhythm of the day were important to their feeling safe and taken care of. One of the interviewed residents in Hospital said: 'I feel well here. I feel safe. I get food in the morning and get help to be dressed up'. On the other hand, there were fewer opportunities to maintain their personal habits if they did not correspond to the institutions routines. The conformity of the nursing homes was regarded as quite rigid with little or no possibility to change or participate in development. The following citation is from one of the resident interviews at Residence: Interviewer: If there is something that you would prefer to work differentlywould you know how to do this? Is it possible for you to make any changes to things? Resident: No. No, I'm not able to -I haven't thought about this. I don't think so. I think it's not possible to do this. I can't think of any ways to make things work differently. Thus, for some residents, the activities offered in the nursing homes suited them fine, but for others or at other times, there were no activities that were meaningful for them. This was expressed by a resident at Shelter who said: 'No, no, I do not participate in those [activities]'. --- Every nursing home is like some other nursing homes This statement expressed organizational and cultural types in the sense of organizational or cultural assumptions being present in some of the nursing homes but not in all. The nursing home type represented a corporate culture among staff at all levels and in incorporated visions or statements describing the nursing home. The four nursing homes were different in some aspects, but at the same time had characteristics that are common for other nursing homes that we and some of the staff had experienced previously. These characteristics formed four typologies:'residency oriented','medical oriented','safeguard oriented' or 'family oriented'. The focus of care was present throughout the organization, in the daily activities, communication, artefacts, espoused values and underlying assumptions, as interpreted by the observers. Four field notes from the different nursing homes expressed this: The definition of the residency oriented nursing home found in the present study was a main focus on providing housing and custodial care. This type of nursing home was characterized by similar rooms, little privacy and meals served in an institutional manner. Residents experienced the nursing home as a home important for quality of care, but this was difficult to achieve in the residency oriented nursing home. --- Medical oriented (Hospital): In the stairs leading up to the ward there is a glass cupboard with old medical equipment. One gets the feeling of being in a hospital. The combination of homely antiques and medical equipment leaves an ambiguous impression. It is hard to tell if the nursing home wish to promote an image of a health institution or a home for the elderly. The staff members seem quite focused on routines and are anxious to complete their tasks. Still, I get a feeling that they are concerned about the individual needs of the patients and that they show a high level of compassion. The staff meetings emphasize physical and psychosocial problems, such as pain, difficult breathing, defecation, problems in getting up from bed, not feeling well, the amount of food eaten, anxiety. Social conditions are given little attention. There is no mention of whether the patients talk to each other, where they spend their time or with whom they socialize. (Recorded by the researcher/author) I get the impression that a number of the staff members are competent professionals, but that the system, physical environment and organization restrict creativity and the possibility of offering more intimate, individual-oriented care. After spending a week here I have not managed to get a complete overview of the ward. (Recorded by the research assistant) From two of the in-depth interviews with residents: Interviewer: Do you feel lonely here? Resident: No, I wouldn't go that far. Still, at times, when nobody comes by to have a chat or somethingit may become lonely. Interviewer: What would happen if you get poorer health? Resident: 'I get bedbound; I guess'. The findings defined the medical oriented type of nursing home as organized mainly with a focus on the residents' medical problems and needs. The care seemed to be professional at an individual level. However, some of the residents had doubts about the nursing home's ability to provide adequate help if their functions declined. This satisfied the residents' experiences of medical care quality but was an obstacle to the feeling of 'athomeness'. --- Safeguard oriented (Shelter): The nursing home is located in a small municipality. This is a small community where everyone knows each other, and for this reason the staff members may find it easier to communicate with the residents within topics of interest for the patients. A number of patients are able to groom on their own, and only need assistance for things like combing their hair and tidying their rooms. The staff members contribute to create a relaxing atmosphere in spite of disturbing behaviour in one of the patients. The staff members discuss everyday matters with the residents, like children, family members and places where they used to live. There are also discussions about things that bother the patients, like pain, disease and poor walking function. The staff seem to know the patients well and the conversations run smoothly. The doctor is available at the nursing home 12 h a week while a junior doctor is present 7 h a week. At the doctor's visit, the group leaders (certified nurse assistants) meet the doctors and keep track of the patients who need medical attention or matters linked to medication or similar things. The doctor wears a white doctor's coat when attending to the patients. (Recorded by the researcher/author) The nurses are conscious not to exaggerate their assistance and want the patients to carry out their daily tasks as far as possible. (Recorded by the research assistant) 'I have an alarm, a string I pull... they (staff ) come running [to help]' (quote from a resident in the indepth interview) Integration into the local society, individual care and a focus on a home-like environment defined the safeguard oriented nursing home. This aligned with what residents experienced as important for quality of care, both the nursing home as a home and interpersonal quality. With access to help at short notice, the residents felt safe in the nursing home. --- Family oriented (Village): All residents have single rooms with bathrooms. The rooms were located on either side of the living room/kitchen with a small corridor in the middle. The staff room is not located in the central area. There is an outdoor view from all rooms. During one of our days at the ward the staff members serve cake in the living room. On another day the activity coordinators organize a party for the residents in the assembly hall. The tables are laid, cakes are served and a pensioner's band play dance music. It looks like an enjoyable activity in which many of the residents take part. A number of the residents are on first name terms with the staff members and call out their names whenever they need assistance. The employees eat their lunch in the living room. Three residents who happen to be in the living room have a conversation with the staff members. It is a comfortable setting with sounds and smells that we associate with an ordinary home. The staff members claim that they have become a closely knit group as they have worked together for many years. During this time they have seen many directors come and go. They feel they can run the affairs on their own. (Recorded by the researcher/author) The ward is modern, cosily furnished and with attractive colours. The small number of patients makes it a comfortable place to be. I get the impression that the staff are doing a good job and that their relations to the patients and family members are cordial. A nurse states that the ward becomes like a family and that emotional bonds develop between the staff and patients. (Recorded by the research assistant) 'I feel that they are fond of me, they often give me a hug' (quote from a resident in the in-depth interview) The family oriented nursing home was, in this study, defined as being flexible according to each resident's needs, with an individual orientation. The professional care was associated with family-style care. The residents emphasized that aspects of 'at-homeness' and interpersonal quality could be fulfilled in this type of nursing home. --- Every nursing home is like no other nursing home The distinctness or uniqueness of each nursing home's 'personality' was expressed in this statement. Certain patterns of structure, cultural assumptions and interactions in the nursing homes were observed to be different in each nursing home and formed a distinction among them. This distinctiveness emerged as individual organizational and corporate cultural features of each nursing home, based on historical or environmental adaptation over time. This observation note was made: The absence of visible management caused that those who had worked at the ward for some time had gained a certain informal power, enabling their views and attitudes to influence the activities. There was not a lack of official routines or planning tools at the ward, though the absence of control and management made it necessary for each staff member to identify the relevant regulations, and the implementation of these became the responsibility of the individual serviceprovider (From Residence, recorded by the researcher/ author) The uniqueness of the nursing home seemed to fluctuate depending on the stability of staff or residents. For instance, the physical plant for Village had been relocated several times, but most of the staff and residents remained the same. The staff felt they were like a family, with the same level of commitment to each other even if they had moved into a new building and new place. The appointment of a new nurse disturbed the environment, especially in the way communication between the staff and residents was accomplished. This could be illustrated by one of the field notes from this nursing home: I talked with many of the nursing assistants who seem quite reflective, and they are concerned about providing good services to the residents. It seems like they are not satisfied with the nurse [refers to the new nurse], which makes it a bit difficult to be present there. (From Village, recorded by the research assistant) The residents in Village had complex needs, and many of them were referred to this nursing home because of their special needs for individual care. The residents who experienced a high quality of care in Village with these unique features had lived there for a long time, or their special needs could be met in such a nursing home, as one resident explained in the in-depth interview: Many of the nursing home residents are like me. We are really comfortable. I couldn't have been in a better place. The environment was... it was a different attitude, you see, when I arrived here. I felt that it was something entirely [different]. But as I said, I wash on my own. I don't require much, but when I need something they always make themselves available. I feel they really care for me. Quality of care seemed to be dependent on whether the nursing home could adapt and form uniqueness in the organization that closed the gap between the services offered and the needs and expectations of the residents. For instance, in Shelter many of the residents had fewer medical needs but had moved to the nursing home because they could not stay at home due to lack of home health services. This nursing home had organized small groups of residents led by certified nursing assistants (CNAs) who had worked there a long time and knew the residents well. Likewise, one resident with extensive medical needs living in Hospital felt that 'the service was as good as it could be' (quote from in-depth interview with the resident), even though his feeling of 'at-homeness' was not present. Village had organized the care with primary nurses or contact persons (CNAs) who were responsible for each resident's total care-physical, psychological, social and spiritual. The primary nurse developed care plans and normally cared for his or her resident almost like a family member. It seemed to be a good system for individually adjusted care. However, new care staff who were still not aware of the norms in the culture threatened the understanding of what was important for quality of care from the staff's point of view and as experienced by residents. --- Discussion This ethnographic study showed that the nursing homes had relatively stable corporate cultures described as 'personalities' with some characteristics that were common to all nursing homes (conformity) and typical traits that were present in some nursing homes forming four typologies; residency oriented, medical oriented, safeguard oriented or family oriented. Further, the nursing homes had developed some 'personality' characteristics that were like no other nursing home (distinctiveness). Nursing home residents experienced 'at-homeness' ('the nursing home as a home') and 'interpersonal important for quality of care. Part of each nursing home's 'personality' encompassed conformity expressed as 'Every nursing home is like all other nursing homes'. Even though residents accepted standardized care and some residents were comfortable with common routines in the nursing homes, it is necessary to point out that residents should not be responsible for creating a healthy environment for themselves by adapting to existing organizational culture. Designing nursing homes as conforming organizations might be the reason why, in the same nursing home, residents perceived the day as busy or boring, meaningful or devastating. Standardized care illuminated a corporate culture where nursing home residents are seen as merely subject to the culture rather than part of the nursing home culture. Institutional rules, procedures, and environment, and a high degree of conformity to corporate culture can be obstacles to achieving quality of care [4,31,32]. However, an area for discussion could be to what degree the 'personality' can be changed to close the gap between nursing home corporate culture and residents' perception of what is important for quality of care. A study found that residents are customized to organizational practices and feel they have little possibility of challenging these practices [47]. In addition, it is important to recognize the basic human right to be treated equally, although, in some instances this means treating residents differently based on differences in their needs and preferences. The distinction between 'equality' and'sameness' is important to recognize in nursing home organizations to prevent a service that provides only standardized care, regarding this as the most fair and valued health care service [48]. The statement 'Every nursing home is like some other nursing homes' highlights a part of each nursing home's trait, and this created four specific typologies. To some extent, each specific trait of the nursing homes' corporate culture seemed to be in line with their residents' experience of quality of care, whether it was 'the nursing home as my home' or 'interpersonal quality'. Quality of care experiences from the residents' perspectives required an assurance that their priorities could be met and that the interpersonal interactions corresponded to their values. However, holding onto a specific nursing home corporate culture based on the historical composition of residents might be obstacles to organizational development. Being open to change when the characteristics of the resident group changes is important to develop trait characteristics that align with residents' needs and expectations. As presented in this article, the nursing home community or a nursing home's 'personality' is formed by all stakeholders including the residents, their relatives and the staff, and structures such as the physical environment. This means that it is important to foster a balanced relationship among all parties. Respect for the residents as individuals with different needs is the essential attribute in a personalized model of care [13,17,49,50]. Relationship-centred care is suggested to enhance the development of a shared understanding of all residents', staff's and family members' needs and values, and a feeling of all being included as members of the nursing home community [51][52][53]. Being recognized as an individual is a crucial aspect of life in a nursing home, contributing to meaningfulness in which one's humanity is preserved [14,54]. Quality improvement actions in nursing homes should be based on an approach where individual needs and expectations are assessed and care is individually adjusted [23,55]. In the in-depth interviews residents underpinned the importance of seeing each resident as an individual person. Observations made in the field study confirmed that quality of care was dependent on the nursing home's uniqueness, expressed in the statement 'Every nursing home is like no other nursing home'. This was in line with the current residents' values. The findings in the present study showed that a corporate culture that emphasized safety or creating a family-

Background: Internationally, there are concerns about the quality of care in nursing homes. The concept of 'corporate culture' as an internal variable could be seen as the means to improve quality of care and quality of life for the residents. The aim of this article was to describe the nursing home culture from the staff's perspective and to include how the residents describe quality of care. Methods: An ethnographic design was employed. A purposive sample of four municipal public nursing homes in Norway with long-term care residents was included in the study. Data were collected by participant observation including informal conversation with the staff, and in-depth interviews with 15 residents using a narrative approach. Results: The main findings were that organizational cultures could be seen as relatively stable corporate cultures described as 'personalities' with characteristics that were common for all nursing homes (conformity) and typical traits that were present in some nursing homes, but that they were also like no other nursing home (distinctiveness). Conformity ('Every nursing home is like all other nursing homes') meant that nursing home organizations formed their services according to a perception of what residents in general need and expect. Trait ('Every nursing home is like some other nursing homes') expressed typologies of nursing homes: residency, medical, safeguard or family orientation. The distinctness of each nursing home ('Every nursing home is like no other nursing home') was expressed in unique features of the nursing home; the characteristics of the nursing home involved certain patterns of structure, cultural assumptions and interactions that were unique in each nursing home. Nursing home residents experienced quality of care as 'The nursing home as my home' and 'Interpersonal care quality'. The resident group in the different types of nursing homes were unique, and the experience of quality of care seemed to depend on whether their unique needs and expectations were met or not.In order to create a sustainable nursing home service the service needs to be characterized by learning and openness to change and must actually implement practices that respond to the resident and his or her family's values.

to foster a balanced relationship among all parties. Respect for the residents as individuals with different needs is the essential attribute in a personalized model of care [13,17,49,50]. Relationship-centred care is suggested to enhance the development of a shared understanding of all residents', staff's and family members' needs and values, and a feeling of all being included as members of the nursing home community [51][52][53]. Being recognized as an individual is a crucial aspect of life in a nursing home, contributing to meaningfulness in which one's humanity is preserved [14,54]. Quality improvement actions in nursing homes should be based on an approach where individual needs and expectations are assessed and care is individually adjusted [23,55]. In the in-depth interviews residents underpinned the importance of seeing each resident as an individual person. Observations made in the field study confirmed that quality of care was dependent on the nursing home's uniqueness, expressed in the statement 'Every nursing home is like no other nursing home'. This was in line with the current residents' values. The findings in the present study showed that a corporate culture that emphasized safety or creating a family-type nursing home could foster such values. Nursing homes with fewer residents in each ward or organizing the nursing home into smaller groups could facilitate a closer relationship between staff and residents. However, changes in the staff such as employing new care staff led to difficulties accepting alternative practices. New employees might not be familiar with the specific norms and values in the corporate culture. The differences between the formation of the 'personality' in Residence, Hospital, Shelter and Village respectively, also point out that nursing homes as organizations consist of clinical units that can be viewed as clinical microsystems [56]. The idea of clinical microsystems is that they are the basic building blocks of interaction where care is provided and quality is achieved or not. A corporate culture that supports quality of care is where each team member's individual and complementary skills and abilities are used together, supporting a well-functioning microsystem [57,58]. However, a key question is whether corporate culture as an internal variable can be manipulated to influence the nursing home's performance or outcomes for its residents [28]. Believing that change in an organization's culture is achieved by taking control of staff members' behaviours tends to be overly optimistic, partly because there are likely to be multiple subcultures and countercultures competing to define the nature of situations [28]. Culture change is a continuous learning process, not a one-time event [59]. For change to happen, all staff members and the management must recognize the organization's own problems and must share the values of a new culture [12,33,60]. If all employees understand the reasons for change and decision-making is moved to the clinical microsystem, it is more likely that changes in behaviours leading to better outcomes for the residents will occur [16,61,62]. Stable and sometimes rigid corporate cultures were, in some instances, obstacles to delivering nursing home services that corresponded to the residents' experiences of what was important for quality of care. However, the corporate culture of nursing homes with unique distinctiveness that had adjusted to their present nursing home residents' needs and expectations seemed to have succeeded most in terms of quality of care. Nursing homes are a complex phenomenon where both supportive care and curative services compete for the time and energy of the staff. At the same time, adjusting the health service in nursing homes to suit both the individual resident and the organization is challenged by varying and often progressively complex needs of the residents [4,[63][64][65]. Being a long-term resident in a nursing home implies a focus on privacy, the living place and space, as well as the availability of stable caregivers safeguarding the health service [66]. The strength of the present study is the rigorously methodological approach aiming at covering both the staff's and residents' perspectives. However, the significance of management effects was beyond the scope of this study, and this should be explored further. A limitation of the study might be that only four nursing homes were observed during a relatively short period of time. Variations and organizational events that occur infrequently could therefore have been missed. On the other hand, in informal conversations with staff, this was highlighted, leading to a better understanding on the part of the observers about what happened was random or part of the nursing home corporate culture. The researchers' subjective observations and interpretations may have caused bias in the findings. However, we were aware of this problem and tried to reflect upon this to enhance a fair description of the nursing homes and the expressions of the residents [67]. Because the observers are nurses, and since the present research was conducted in a cultural context that we had experienced as professionals in other settings, the observations and field notes may have been influenced by our professional knowledge. Thus, significant observations could have been missed as parts of everyday life in the nursing homes were taken for granted. The researcher and research assistant discussed this concern both during the observations and at the end of the observation period in each nursing home to uncover such presumptions. Extended field notes and observers' impressions are provided in the article to make it possible for readers to align the findings to their own practice [35]. --- Conclusion Population projections and predicting the needs of residents in nursing homes in a 10 to 20 years perspective is a complex task, and is associated with unanticipated factors. We know the most about the demographic situation in the future but less about the needs, expectations and preferences of older people in 2030. This study provides a greater understanding of organizational and cultural factors that influence residents' perceived quality of care in nursing homes. It is crucial that the organizations are flexible and willing to prepare for cultural changes in order to close the gap between the nursing home's corporate culture and residents' experience of quality of care as 'the nursing home as my home' and 'interpersonal quality'. Moreover, it is important that health organizations learn from their clinical practice and that rigid 'personalities' consisting of conforming structures, traits and distinctions found in the present study are prevented from becoming cemented in the organization. A sustainable nursing home service needs to be characterized by learning, openness to change and actually implementing practices that respond to the resident and his or her family's values. --- Additional file Additional file 1: Interview guide for the interviews of residents in nursing homes. (DOC 28 kb) Abbreviations RN: Registered nurse; CNA: Certified nurse assistant. --- Competing interests There are no competing interests. Author's contributions SN planned the study, was responsible for acquisition of data, did the analyses of data and drafted the manuscript. Author's information Sigrid Nakrem, RN PhD in public health. Position as associate professor at S<unk>r-Tr<unk>ndelag University College.

Background: Internationally, there are concerns about the quality of care in nursing homes. The concept of 'corporate culture' as an internal variable could be seen as the means to improve quality of care and quality of life for the residents. The aim of this article was to describe the nursing home culture from the staff's perspective and to include how the residents describe quality of care. Methods: An ethnographic design was employed. A purposive sample of four municipal public nursing homes in Norway with long-term care residents was included in the study. Data were collected by participant observation including informal conversation with the staff, and in-depth interviews with 15 residents using a narrative approach. Results: The main findings were that organizational cultures could be seen as relatively stable corporate cultures described as 'personalities' with characteristics that were common for all nursing homes (conformity) and typical traits that were present in some nursing homes, but that they were also like no other nursing home (distinctiveness). Conformity ('Every nursing home is like all other nursing homes') meant that nursing home organizations formed their services according to a perception of what residents in general need and expect. Trait ('Every nursing home is like some other nursing homes') expressed typologies of nursing homes: residency, medical, safeguard or family orientation. The distinctness of each nursing home ('Every nursing home is like no other nursing home') was expressed in unique features of the nursing home; the characteristics of the nursing home involved certain patterns of structure, cultural assumptions and interactions that were unique in each nursing home. Nursing home residents experienced quality of care as 'The nursing home as my home' and 'Interpersonal care quality'. The resident group in the different types of nursing homes were unique, and the experience of quality of care seemed to depend on whether their unique needs and expectations were met or not.In order to create a sustainable nursing home service the service needs to be characterized by learning and openness to change and must actually implement practices that respond to the resident and his or her family's values.

threat. Hence, the information collected in this dataset can enable the study of how e.g. different governmental responses 12 influence the way in which people perceive epidemic risk. In fact, within game theory, risk perception has been found to particularly influence epidemics' peaks 15. This is relevant as epidemic peaks, such as the first COVID-19 infection wave, can have a disastrous impact on healthcare capacity, and, therefore, on the unfolding of the epidemic itself. The rationale for the selection of multiple threats was twofold: global relevance and local impacts in the surveyed countries. Besides the COVID-19 pandemic, the climate crisis remains a major global threat. Thus, we survey perceptions about climate change to put quantitative results into perspective (e.g. how do concerns about epidemics compare with those about climate change?). This is particularly relevant because of the high number of young people who took part in the Fridays for Future strikes in both Italy 16 and Sweden 17 in the period prior to the pandemic (late 2019 -early 2020). Such a large participation is evidence of a strong concern for the global climate crisis and raises questions of intergenerational risk perception that can be further investigated with this dataset. The other threats included in the survey encompass those that have impacted one or both countries with different levels of severity and frequency over the last decade. Catastrophic wildfires 18 and a deadly terrorist attack 19 recently occurred in Sweden, while many fatalities or economic losses have been caused by earthquakes, floods and droughts in Italy over the past decade 20. We also included economic crises and domestic violence as they are potential (indirect) effects of the COVID-19 pandemic and governmental responses. The inclusion of these additional threats has the potential to support future studies aiming to e.g. unravel how experience, media coverage, trust, inequality or social capital shape public perceptions of risk. --- Methods To provide exhaustive information on the survey to facilitate reproducibility, we follow the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) 21. --- Survey design. The survey was designed following previous studies 8,22,23. It covers people's perceptions on five main factors: likelihood of the phenomenon to occur, potential impact of the phenomenon, preparedness to face the phenomenon, knowledge around the phenomenon, and experience with the phenomenon. The questions used to investigate these factors are listed in Table 1. Each question was asked in relation to epidemics, floods, droughts, wildfires, earthquakes, terror attacks, domestic violence, economic crises, and climate change. In addition to the questions in Table 1, the respondents were also asked to provide socio-demographic information, including their age, gender, maximum level of education achieved, income, type of employment (if any), and political orientation. The survey contained a total of 77 items, as the age and gender of respondents was known in advance. The full survey form can be found in the supplementary material and in the dataset repository 24. Survey administration. The survey was targeted to individuals living in Italy and in Sweden. The two samples were drawn from two existing survey panels, one in Italy and one in Sweden. Both panels were set up by Kantar Sifo 25, one of Sweden's major marketing research companies, and they include around 100,000 individuals in each country. Each panel consists of randomly recruited individuals, from 16 years and up, and is representative of the country's population. The participants are gradually replaced, and the panel is filled with new respondents to prevent the participants from becoming experts or too accustomed to the survey methodology. Panelist collect points for each survey they agree to fill in, and the points can then be turned into various types of rewards (e.g. movie tickets, or gift cards). On a scale from 1, "No damage" to 5, "Severe damage", or "I don't know" --- Preparedness Of the respondent How prepared do you think you are to face the following phenomena*? On a scale from 1, "Not at all prepared" to 5, "Highly prepared", or "I don't know" Of the authorities in the country How prepared do you think the responsible authorities in [country**] are to face the following phenomena? On a scale from 1, "Not at all prepared" to 5, "Highly prepared", or "I don't know" --- Knowledge Of the respondent How knowledgeable are you about the following phenomena? On a scale from 1, "Not at all knowledgeable" to 5, "Highly knowledgeable", or "I don't know" Of the authorities in the country Concerning this specific survey, the panelists were contacted via e-mail, and if they did not respond the first time, up to two reminders were sent during the survey period (5-19 August 2020). In the email, panelists were informed on the estimated length of the survey (around 12 minutes) and were directed to the Privacy Policy, where they could also find information on data storage. To avoid potential biases, information about the investigator and the purpose of the study were not communicated to the panelists. The link to the online survey was sent via e-mail, and only to panelists who accepted to fill in the survey (closed survey). Each question in the form allowed for "I do not know" or "I' d rather not say" options. At the end of the survey, respondents could go back to previous questions to check or edit their answers. Each respondent could fill in the survey only once. As for the response rate, 27% of contacted panelists eventually completed the survey. The completion rate, i.e. the ratio of panelists who finished and submitted the survey and panelists who agreed to participate, was 86.2% in Italy and 89.5% in Sweden. All questionnaires that were submitted are included in the dataset, regardless of their completeness). All responses were automatically captured by the software. The survey was administered only to adults, i.e. over 18 years. The respondents did not have the option of choosing the language, which was Italian for respondents in Italy, and Swedish for respondents in Sweden. The two samples are representative of the two countries' population in terms of age and gender. --- Ethical approval. The research protocol for this study was approved by the Italian Research Ethics and Bioethics Committee (protocol 0043071/2019) and the Swedish Ethical Review Authority (Dnr 2019-03242). All procedures performed in the study were in accordance with the ethical standards set by the European Union under Horizon 2020 (EU General Data Protection Regulation and FAIR Data Management). Participants were advised that participation is voluntary and that the outcomes are anonymous. The research protocol did not encompass collection of privacy-sensitive and personally identifiable information (PII) data. Informed consent was obtained from all participants involved in the study. --- Data records The dataset resulting from the online survey comes in a CSV format and is stored open access on Zenodo 24. Each row represents one respondent and each column represents a variable (i.e. one column for each survey question for each phenomenon, and one column for each socio-demographic variable). The cell value represents the answer that the respondent gave to the question. For instance, if the answer had to be given on a scale from 1 (minimum) to 5 (maximum), then the cell value is either 1, 2, 3, 4, 5, or the respective code in case the respondent did not select any option or selected "I do not know"/"I' d rather not say". The dataset comes with a metadata file (.xlsx) that provides detailed information on the variables and the coding of the answers. The survey forms in Italian and in Swedish are stored in the same repository, along with the English translation. A total of 2,033 respondents completed the survey in Italy, and 2,121 in Sweden. The dataset is divided into two samples, representing the two countries. Each sample is then divided into two subsamples, one representing the capital's region (Rome -Lazio, N = 1,007; Stockholm -Stockholm county, N = 1,036), and one representing the rest of the country. The distribution of the two samples -50% from the capital's region and 50% from the rest of the country -allows for additional studies on the spatial distribution of risk perception. For instance, the risk of terror attacks might be perceived differently in capital cities, compared to the rest of the country. The sample collected in Italy is slightly younger (M = 49.16, SD = 13.70, min = 18, max = 79), 47% of respondents are males and 53% are females. In comparison, the one collected in Sweden is slightly older (M = 49.78, SD = 15.75, min = 19, max = 79), 52% of respondents are males and 48% are females. Figure 1 shows the spatial distribution of the respondents in the two countries, which is representative of the country's population. Thus, there are more respondents in the most populous regions. Response rates to each of the questions, per country, are listed in Table S1. --- Technical Validation Before conducting the survey, we assessed its feasibility and validity 26. The survey questions were designed by the authors of this paper, who have previous experience with survey design on risk perception and preparedness 8,[27][28][29]. The survey questions were designed on the basis of published studies 8,22,23, so that results could be comparable with prior surveys and face validity of the survey could be ensured (i.e. whether the questions appear reasonable to acquire the necessary data). As those who designed the survey are primarily experts in the field of natural hazards, the survey went through a round of pre-testing to ensure its internal validity, i.e. making sure that the questions posed serve the purpose of the survey and that there is no potential for misunderstandings (as some concepts may be obvious to the researcher, but not to the respondent). The preliminary survey was thus administered to a total of 12 lay people in Italy and 6 lay people in Sweden, and the respondents were asked whether the questions were clear and how they interpreted them. This step ensured that the respondents interpreted the questions as expected. The final survey form was then reviewed by Kantar Sifo 25, which then was appointed to undertake data collection. The use of an external professional research firm ensured the validity and reliability of the survey thanks to several levels of quality control before, during, and after data collection. The potential for human error when it comes to data entry is expected to be minimal, as responses to the survey were automatically collected in the dataset through the online survey system. As a matter of fact, we did not find any systematic problem due to response-bias connected to the type of phenomenon, or any other variable, as shown in Table S1. Errors in survey response can be assumed to be random, and not correlated with any demographic or personal characteristics. --- Usage Notes This dataset provides a plethora of opportunities to explore multiple facets related to numerous public perceptions of risk, for both natural hazards and man-made threats. It also provides insights into public trust in national authorities, preparedness to face different types of threats, and levels of risk awareness. Moreover, the contrasting nature of the Swedish and Italian contexts, which was recently highlighted by the different response to the first wave of the COVID-19 pandemic, allows for insightful comparative studies. We present a non-exhaustive list of scientific questions that can be addressed with the help of this dataset: • How prepared to face an epidemic do citizens feel in the two countries? How much knowledge of the epidemic threat do they believe they have? • What are the most concerning threats for the citizens in the two countries? How is public perception influenced by perceived individual and authorities' knowledge? • How are people's concerns affected by their experience? These questions can shed light on potential discrepancies between perceived and actual risk, especially given the spatial distribution of the samples (Fig. 1). • How much do citizens in the two countries trust the responsible authorities when it comes to risk management? How is this connected to perceived individual and authorities' preparedness? • Do the socio-demographic variables show trends connected to e.g. age, or education? Fig. 2 Average values in terms of impact on respondent and impact on others in the country for each of the nine phenomena, by country. The above list is just an example of the number of questions this dataset has the potential to address, alone as an independent dataset or together with other pre-existing data. Indeed, this dataset could gain even deeper value if coupled with other relevant datasets that were recently published, such as the global analysis of COVID-19 risk perception by Dryhurst et al. 30, performed in Spring 2020 with smaller national samples but including more countries, or the dataset on government interventions in response to COVID-19 by Desvars-Larrive et al. 12. Such valuable information does not only have scientific relevance, but also has the potential to inform policy makers for developing and updating risk management policies, while improving risk communication campaigns. --- Illustrative exploratory analysis. To show the potential of the dataset, we present a simple exploratory analysis of the differences between the two samples. One of the interesting results that emerged from the data is that both countries show an optimistic bias in terms of the phenomenon's impact (Fig. 2a,b). The optimistic bias is the tendency for people to report that they are less likely than others to experience negative events 31. In both countries, respondents show an optimistic bias when it comes to floods (<unk> Additionally, respondents in Italy feel as prepared and as knowledgeable as the responsible authorities for all of the phenomena (as shown in Fig. 3a,c), with no statistically significant difference to be noted. On the contrary, respondents in Sweden tend to perceive their preparedness and knowledge as lower, compared to that of the responsible authorities (see Table 2, and Fig. 3b,d). These results could potentially shed light on country-level differences when it comes to trust in the authorities responsible for risk management, safety and public health. --- Code availability All code for reading, processing and graphically representing the data is freely available at https://github.com/ elenamondino/nationwide_survey. Information on the packages used are listed in the same repository. --- author contributions M.R. and G.D.B. obtained the ethical clearance to conduct the survey. All authors designed the survey. E.M., J.M. and G.D.B. set up the online survey. E.M. conducted the illustrative exploratory analysis. E.M. wrote the first draft of the paper, to which all authors contributed. All authors revised the final manuscript. --- Competing interests The authors declare no competing interests.

Knowing how people perceive multiple risks is essential to the management and promotion of public health and safety. Here we present a dataset based on a survey (N = 4,154) of public risk perception in Italy and Sweden during the COVID-19 pandemic. Both countries were heavily affected by the first wave of infections in Spring 2020, but their governmental responses were very different. As such, the dataset offers unique opportunities to investigate the role of governmental responses in shaping public risk perception. In addition to epidemics, the survey considered indirect effects of COVID-19 (domestic violence, economic crises), as well as global (climate change) and local (wildfires, floods, droughts, earthquakes, terror attacks) threats. The survey examines perceived likelihoods and impacts, individual and authorities' preparedness and knowledge, and socio-demographic indicators. Hence, the resulting dataset has the potential to enable a plethora of analyses on social, cultural and institutional factors influencing the way in which people perceive risk.

Introduction Automobiles since their invention have catered to our basic need for transport. However, driving also entails a constant need for information, communication and entertainment. Researchers have therefore been utilizing ubiquitous computing that can serve these needs anywhere we go and build smarter cars for the future. In-car infotainment systems for instance, have comfortably weaved into our automobiles to support us with a variety of functionalities. Since communication while driving is addressed by mobile phones, researchers have also designed tools to ensure less distraction for in-car mobile phone usage while driving. MirrorLink (previously Terminal Node) for instance optimizes Smartphone content for in-car usage with minimal user distraction [19]. It mirrors Smartphone applications such as calls, maps & music for easy operability with in-car controls [5]. Furthermore, advanced cameras on smartphones have been used to alert drowsy drivers [27] and predict waiting time-windows during traffic signals [16]. These innovations show that cars can be potential avenues for next generation ubiquitous computers. Hence, in this paper we have presented our qualitative study on user's needs and challenges related to driving and the means of coping with them in urban India. Through this study, we intend to put forth certain design implications for future smart-cars. --- Related Work Researchers from varied domains have explored driving habits of users in different locations across the world. These studies highlight that cars are not mere transportation means. They are extensions of our identities, preferences and personal spaces, as is evident in Bell's study [4]. Users' identity is manifested through personal belongings held in a car and personalization made to it. Heikkinen et al. in their contextual study have conducted pre and post-trip interviews corroborated by on trip observations [9]. Their study reveals the role of mobile phones while driving primarily for entertainment, driving support and even work-related tasks. Their study also explored the supportive role of co-passengers serving the needs for information and entertainment. Likewise, Haddington and Rauniomaa focus on driver's actions to attend a call inside the car [8]. A 100 car study at Virginia tech revealed that the use of mobile phones and hand held devices were distractions leading to accidents [25]. This study indicates that in-car ubiquitous technology should also account for possible distractions to the driver. Researchers also compare driving behaviors and car usage patterns across different countries. One such study by Ozkan examines driving behavior differences across Britain, Netherlands, Greece, Turkey, and Iran using Manchester Driving Behavior Questionnaire (DBQ) [20]. Even though DBQ measures behavior only in terms of driving errors and violations, it does reveal differences in driving behaviors due to environmental situations and traffic regulations. Similarly, a large-scale survey [15] assessed preferential differences among Austrian, American and South Korean car owners. It revealed varied cultural perceptions towards personal vehicles as luxuries as against necessities. Yet, as quantitative surveys, they do not reveal much about users' environment and accompanying needs. A contextual study in this space is thus required to corroborate such surveys and highlight intrinsic user needs. Through an in-depth ethnographic study, Zafirgolu et al. examined car usage in Brazil, China and Germany [28]. They reveal that infrastructural issues determine driving in Germany and that security threats were critical in Brazil. However, the need for socializing on the move was high in Brazil and China. Their study shows how socio-cultural differences determine driving behaviors. Their study also implies that a qualitative data of driving habits is required in addition to dynamic driving data in order to have more robust findings. It is suggestive from the cross-cultural studies that a dedicated field immersion for specific countries is worthwhile. Nonetheless, there is a dearth of studies to explore this space in the India. According to a global study [6], 48 % of Indian car owners want to upgrade to 'connected' vehicles, as against 27 % in USA, 22 % in UK and 20 % in Germany. Likewise, It is anticipated that the Indian auto-market will be larger than most European Markets by 2020 [11]. On the other hand, India being highest in reported road accident deaths from traffic causalities also warrants a dedicated understanding of driving behavior in this region [12]. At the same time, with nearly 74 million users on internet, India is set to become the third largest web-consuming country [13]. Thus, a study in this region is worthwhile given the challenges related to traffic, urban planning, and infrastructure [14]. In this paper, we share our qualitative study to better understand driving behavior in India and identify design opportunities to contribute to the smart car space of the morrow. --- Methodology The following research questions were considered for the field immersion: • What are users' quotidian driving practices? • What are the challenging situations faced while driving? • How do users respond to these challenges? A team of two researchers gathered data in three-phases -open discussions, situational observations and guided interviews lasting 2 h. Discussions were undertaken to understand users' vehicle in general. Subsequently, for situational immersions, researchers were with users as they drove [3]. During the journey, researchers had open-ended conversations with users, where interview questions were conversationally weaved in. The focus was on actual events that users encountered as they drove, for e.g. traffic/road/driving condition. Finally, one-on-one guided interviews were carried out with all participants, where participants clarified situational observations gathered by researchers. All interviews were undertaken in English, Hindi or Kannada, according to respondents' convenience. The extended interviews were carried out within a day of situational interviews to ensure easier recall of driving events [2]. Field study was undertaken in urban Bengaluru, which has seen burgeoning of population, poor planning and increasing traffic-related problems [21]. Users were selected according to following attributes: vehicle owned, Smartphone used; expertise in driving; marital status; and gender. Twenty participants were interviewed as part of this qualitative study. They were recruited through snowball sampling and were between 20-40 years of age. All respondents owned a smart, media device. 12 participants were male and 8 were female. Of these, 8 male participants and 4 female participants were married and had at least one child. Out of 20 users, 14 owned both hatchbacks and SUVs, while 6 owned a sedan and a hatchback. Finally, 11 participants were local to Bangalore, while the rest had moved in with driving experiences from other places of India. Data was gathered as field notes, audio and video captures. Data was analyzed through modified Grounded Theory method and affinity Analysis [7]. The latter exercise yielded 172-first level themes, which were abstracted into 66-second level and finally clustered into 5-third level themes. Findings from cluster analysis are described in subsequent sections. --- Findings and Observations --- The Car-A Personalized Shared Asset Cars were more than means of transport for users. People affirmed that the vehicle lent them personal space and the means to socialize. They further enhanced their individual space by personalizing it with accessories to meet personal needs. Yet, respondents shared the wheel with their family and car-pooled with their friends. The sociality in driving practices meant that driving decisions were not personal and often influenced by members of one's personal network. Still there was a critical need to personalize and undertake personalization to maximize social experiences. To enable personalized experiences, users fitted accessories. Some adorned their cars with religious symbols. Others fixed stereos, wide-angled mirrors and reverse sensors. Minimal personalization was for those who avoided "spoiling by overdoing." Despite the private space it afforded, a vehicle was often shared between respondents and their personal social networks. Sharing occurred most when households with one vehicle had multiple family members. An interviewee mentioned sharing in his household as follows, "My wife, brother and I share these two cars. My wife and I go out on weekends. Weekdays, my brother and I go to work in the same direction." Highlighting comfort as a factor in choosing between multiple vehicles, a user said, "Depending on who commutes longer, we decide on X over Y, because X is comfy. If Dad or I go nearby, we take Y." Urgency and easy access to vehicle determined users' choice of vehicles. Wheel sharing revealed a lack of personalization. In this regard, a respondent said, "I manually adjust seat level and incline. It's never the same from what it's left at. My wife, dad and brother adjust it for themselves." Carpooling occurred when people were routinely bound for the same destination; were keen to avoid traffic challenges; and wanted to save fuel. Respondents mentioned car-pooling with friends and colleagues as well. Routine and leisure driving decisions were influenced by children and elderly parents. The father of a 3 year-old said, "My son gets cranky on the way to school. But music soothes him. My H car has a music system, but not the V sedan. So, I prefer H." For the sake of his motion-sick toddler, a user avoided long, leisure drives. Driving ensured family time through socializing and extended conversations. To enable sociality, people undertook measures like renting vehicles and turning down media devices. To optimize on family time, people reduced speeds and adopting greater safety practices. With preferences of family members tied into their driving, it was natural for users to perceive the car as an extension of their home. It afforded space during commutes for storing children's toys, toiletries, food and pillows. Recreating a'multi-utility space' was critical in long journeys. The intimacy of enclosed spaces was negotiated constantly by users. Most significantly, they carried the comfort bubble of their home. As technology providers, we must consider personalization of settings in this shared space through ubiquitous devices. --- Activities Before Driving People undertook planned and pre-emptive activities prior to turning the engine on. These would influence their drive and journey. In turn, activities undertaken prior to driving were determined by past experiences and learning of users. Measures for safety and route planning/navigation aid were the most common pre driving activities. There were some activities undertaken as soon as users entered the car, irrespective of whether they were drivers or passengers. Wearing the safety belt and ensuring the safety of their personal belongings were some of them. Many respondents preferred comfort and ensured that the rest of the journey required least effort for certain activities, including music listening, accessing the mobile from easy-to-reach locations in the car and basic controls [air conditioner, rearview mirrors and sun visor]. Pre-driving activities were also about pre-empting critical eventualities like lack of fuel. If it were near low, users would get a fuel recharge at the earliest opportunity. Some respondents ensured safety by relocking their doors and checking their belongings before restarting their vehicle after a traffic signal. Some of the factors that influenced people's choice of vehicles before heading out were infrastructural conditions of the city and destination planned. A participant, who owned a big and small vehicle, explained that his preferences to take a big sedan or a smaller hatchback for the day were driven by availability of parking space. Most tasks were undertaken to ensure smooth driving experience and seamless connectivity. Thus, the need for a smart car experience began even before users entered their car and continued after they stepped out. --- Activities While Driving Of all activities undertaken while driving, music, navigation support and communication on mobile were predominant. Music was considered ubiquitous to driving in most conditions, including while driving alone and with others. Activities related to safety and social conversations with co-passengers were common too. In fact, multitasking occurred when a parallel activity required less effort and did not interrupt the primary, or attention demanding activity of driving. Hence, even phone calls were deferred. However, priorities and activities changed when people became passive drivers. Switching on music or connecting the mobile device frequently occurred, whilst changing music playlists was less. The latter was time-consuming when on the move and was done before a journey. Other user activities were related to safety and comfort, for e.g. being alert for traffic-related visual cues, or adjusting the air conditioner. Ensuring safe conditions in driving was critical. The dashboard was constantly monitored for 'warning' signs; i.e. fuel, odometer, oil/brake lights. Users multitasked between attending to car's functionalities and road requirements. People also undertook other activities as passive drivers or passengers, including socializing with friends/family, or playing 'antaakshari' [a musical game played between two or more people]. Some used the time to plan their work. Many undertook coordination for pre-planned journeys. A respondent, who often did long journeys with others said, "Not all are familiar with the destination. Each of us drives on our own. So, I reset our Odometer and start. We call each other, as we drive to check how many kilometres we've done and guess our distance from each other." Music listening while driving was a norm. Users felt that it provided relief from the task of handling road conditions/driving. It was also a continuous activity to accompany the primary job of driving. There were different choices to music. Few preferred radio. Others wanted their own content. Listening to the radio was a substitute for some, when the primary source of music [e.g. an iPod] was unavailable. For others, the choice was driven by easy accessibility of storage devices. Context, such as user's mood, preferences, driving challenges and need for comfort levels also determined music preferences. Explaining his preferences, a user said, "When alone I listen to English. With family it's Hindi. With mom and dad it's safe, old Hindi. When I'm sleepy, or when I drive long, I like a mix of Old Bollywood and English." It was interesting how spouses managed music preferences on shared devices. A respondent, who shared the wheel with his wife said, "Our music is dumped in one iPod. Whoever drives gets to hear their choice. It's the driver's prerogative." Another primary activity was managing communication on the move. Users restricted it to situations, where communication could not be deferred. An entrepreneur who had to be in touch with clients, said he will pull up and answer only client calls. For another respondent, calls from his wife (who recently had a baby) were urgent, since "She doesn't call when I'm driving. But when she does, I know it's important." Familiarity with each other's context prompted users to decide on answering calls/messages. Most users preferred calls, messages and checking e-mails at particular time-windows, i.e. traffic signals or when the car was stationary. People wanted to weave in communication with driving by having easy access to a mobile phone [switching on speakerphone, Bluetooth and placing it in easily reachable locations]. Thus, participants deferred and did not stop communication events. Unlike navigation support, which was seen as a break from driving, music/mobile media consumption was not. Despite the cognitive load, it allowed weave-ins during driving and media devices were hence kept accessible. Yet, safety and coordination activities when not done through mobile were seen as breaks. Our findings reaffirm opportunities for providing lightweight entertainment and information to users. --- Context Determined the Use of Driving Support Systems The use of features or facilities made available for driving was dependent on how well they fitted to people's present situation. It varied from conditions as dynamic as users' driving context, to something all-encompassing as their social roles and technology comfort. Usually, tried and tested workarounds were preferred to features bundled in vehicles, which users then considered as redundant. Preferences and expectations were greatly determined by users' social roles and technology exposure. Participants mentioned not having used certain facilities in their vehicle, since there was nothing that necessitated it. There were other functions, which were not used unless prompted by an event. For instance, wipers and hazard lights were used only in rains, while the odometer was for out-of-town jaunts. The use of functions depended on how important it was for people's daily driving. Besides, as a user pointed out, they were workarounds, which made certain features redundant. Needs and actions of users were always context driven. Present context determined the urgency of weaving communication into driving. In this regard, a respondent revealed, "It depends on which call or message is important. If my boss calls, I answer. But tomorrow I will not." Context also determined the speed at which people drove. Respondents explained that they drove fast to work, but drove slowly with family to savor the moments spent with them. Context also influenced the means adopted for navigation support. Navigation aid was minimal for straight stretches, or familiar routes, or in the presence of adequate road signage. Users mentioned not wanting GPS aid or planning for familiar destinations. However, on unfamiliar roads, people would call their social circle for navigation aid. Often they would even ask for landmark-based directions from strangers. An interviewee said, "After I drive into a town from the highway, I must know where to turn. I promptly roll down my windows to ask the auto or truck drivers, tea-stall owners and corner shop guys. They point out landmarks and I follow that." People were particular about what they considered non-negotiable. If features did not address basic concerns, such as privacy, it was less likely they would use them. Connecting to in-car gadgets was avoided, if it intruded on privacy. A respondent recounted, "Once, my boss dropped me back and his wife called. He answered via the car speaker and said he was with someone. She hung up. It was so embarrassing. Now, I will never connect my car-phone." Similarly, users expressed displeasure over a recent law to remove window tints, since it compromised their privacy and safety. One of the contexts, particularly for women, was in the social roles they played. Driving signified self-reliance for some female respondents. For others, it was a sign of sharing equal responsibilities with male family members. Yet, there were many instances where women played a passive role. One of these was for car servicing. "When the car is being serviced, I wait in the other car. I don't talk to the mechanic. My husband does," a respondent stated. There were also instances of gender interdependencies. For instance, an interviewee said, "I drove all the way to Shimoga and my husband checked for directions on his GPS to guide me." --- Learned Responses from Driving Experiences Driving was a series of learned responses in a loop. People had to constantly relearn their responses to effectively address the ever-changing road and traffic conditions in the city. Initial learning was by drawing upon learned responses and knowledge of members in one's social network and even from online, special interest groups. Over time, people drew on their own repository of experiences to respond to situations and even devise workarounds to them. Learning was a continuous activity. It ranged from responding to cues about car diagnostics and mechanism, to information about routes and navigation support. In addition, users learned driving in a smaller vehicle and shifted later to larger ones. Initially, people sought support from friends and family while parking, entering a busy road from a by-lane, highway and night driving. Support was also sought for car diagnostics, because many feared appearing ignorant. With learning though, people believed that they were better equipped. Previously perceived challenges were not daunting anymore, for e.g. operating stick shift vehicles and dashboard controls. Learning from experience also made people discern a vehicle's likely response to certain driving actions. Many respondents explained how they changed their driving style based on engine feedback. Users could also guess when there was a problem with their vehicle and would take pre-emptive steps. Experience also taught people how to respond to traffic/road challenges. For instance, a respondent stated, "If I stay long in these intersections, I can never get out. So, I wait for an auto rickshaw like this to turn and I turn with it, using it as a cover, since autos can worm their way." Navigation though was not resolved, despite driving experience. Alignment of roads in familiar cities and unfamiliar towns was a challenge. Others mentioned challenges like incorrect directions from local people, improper road signs or signs written in local scripts. It was thus found that initial learning entailed understanding the user's immediate vicinity, i.e. the automobile; its controls and response mechanism. The next level of learning was to understand larger space, i.e. roads, traffic and navigation. Learning ensured that users became less risk averse. --- Discussions and Research Implications Our study reveals that the car was perceived as an extension of the self (identity) by users, than as mere transport as discussed in [4]. The need for easy communication was also felt across all the users, as highlighted by Heikkinen et al. [9]. Some of the widely discussed emerging economy problems such as infrastructural constraints, navigation problems and safety [28], were also strongly dominant in Indian driving context. It may imply that there are common problems faced across nations, which can be addressed to achieve ideal smart-cars with culture-specific adaptations. However, there were some differences in our premise, which led us to certain findings. Zafiroglu et al. [28] and Jeon et al. [15] have discussed infrastructural problems that affect user's route planning and way-finding. However, our study revealed that route information in India was not just limited to directions but also to avoid mob-protests, potholes, road-blockages and similar other unpredictable events. Several studies including Haddington and Raoniuomaa [8] have also pointed out the role user's social circles play in driving experience especially in terms navigation, safety and communication support. However, in our study, the social roles were not confined to user's closed social members. They also extended to members outside of the vehicle and local sources of information (such as Rikshaw pullers and passersby etc.). Most importantly, findings by Haddington & Raoniuomaa [8], Heikkenen et al. [9], Jeon et al. [15] and Lee et al. [17] focus mainly on in-car interactions on the go. Whereas, our open-ended approach towards understanding user's activities associated with driving led us to infer that pre-driving decisions critically affect driving. In other words, there is a strong need in users to stay connected with their driving experience, which starts even before they enter their cars. This clearly indicates that ubiquitous systems designed to build smart-cars, should also take into account pre-driving activities users undertake for a seamless driving experience. Figure 1 illustrates how activities before driving affect user's experience while driving. Actions undertaken before and while driving support each other in a continuous loop. In fact, activities before driving enable users to devise workarounds to cope with challenges while driving. By virtue of learning from prior experience of driving, users devise better coping strategies and pre-emptive steps to deal with various challenges. Workarounds are determined by certain innate conditions, for e.g. users' social roles/identities and driving skills to name a few. The study findings have helped us realize a design space for smart-cars, which includes before and while-driving situations. In the following sections, we highlight some of these avenues for further design and research to build well-integrated smart-cars in the near future. The study findings have helped us realize an overarching research and design space for smart-cars, which includes before and while-driving situations. The research opportunities also include harnessing users' social circles to offer seamless driving experiences. In this regard, we believe there is a strong need for an intelligent ubiquitous solution to keep us connected with our cars at all times. Such solutions can leverage on the advances in smart devices technology (e.g. smartphones, wearable devices etc.) and augment the experience via in-car controls and ambient technologies. In the following sections, we highlight some of these avenues for further design and research to build well-integrated smart-cars in the near future. --- Weaving the Personal and Social Car Influences from social/personal network greatly affected users' actions in navigation, personalization, in-car activities and safety related strategies. It was perhaps a cultural manifestation of preference for interdependence, unlike the individuality of Europe and North America [24]. In fact, to cope with varied familial needs, users had a smaller hatchback and a larger sedan/SUV. This strategy ensured personal and social space in changing contexts. Several decisions before entering the car such as media preferences, wheel sharing and car-pooling heavily involved people's social circles. Thus, it is reasonable to infer that the car constantly keeps switching its role as a personal and a shared asset. Despite sociality of driving, there was the issue of personalizing features for those, who shared a vehicle. Few workarounds to the absence of personalized music device was to take turns to consume content within pre-designated time windows, or create different folders in the same device before starting the journey. In-car seating and other controls also needed adjusting. This highlights the need for an intelligent-solution that understands users personally and personalizes the vehicle based on their requirements. For instance, a shared car can have multiple profiles (akin to desktop computers with two accounts) for different users, which can be activated via smart devices. While there have been solutions designed to engage co-passengers in monotonous drives, such as [12,23], there is still an opportunity to utilize ambient technologies in Fig. 1. Smart-Car design space: activities before and while driving Exploring Smart-Car Space in Urban India cars to engage co-passengers in the driving experience. There is a similar opportunity for developing traditional games among people (e.g. antakshari), into an inter-device game, between multiple devices carried by occupants. These are certain research avenues to design solutions for people's social space in driving. --- Enhanced Navigation -Beyond Maps and Routes Route information was crucial to people before the journey. A factor that made navigating and route planning daunting was the presence of unpredictable road blocks in addition to infrastructural and traffic challenges. Solutions have already been tested to detect such challenges through Smartphone sensors [16,18]. Thus, further examining the capabilities of sensors on smartphones for driving can be worthwhile. However, researchers should also consider how social roles can impact sharing of route related/navigation information with the community. There is an opportunity to integrate such technologies with social media (given its popularity in emerging markets) [26]. However, route planning is not always done real time given the practice of using printouts of online maps, or memorizing landmarks before getting inside the vehicle. In this regard, it would be worthwhile to further explore the capability of smart-cars, to learn from user's previous driving experiences and put forth the information for offline usage in upcoming drives. Navigation has often been a challenge inside cities with dynamic road conditions, complex routes and lack of authentic information. People often seek directions to nearest landmarks from friends, passersby and online navigation tools. Leveraging this coping strategy, future smart-cars can have landmark-based incremental navigation for better visual judgments, apart from turn-by-turn contextual navigation [17]. It is also an opportunity to explore intelligent ways of integrating social, local and technological sources of navigation. --- Intelligent and Ubiquitous Car Diagnostics Checking for fuel and air before driving was essential for users to ensure smooth driving experience. Users were also concerned about any abnormal feedback from the car while driving and often depended on friends and family for support. Perhaps this can be an area for audio/voice based alerts or feedback while driving to ensure less distraction and allowing users to prepare for an action. Moreover, technologies such as 'automatic' [1] can be utilized to connect car to smart-devices for a ubiquitous car diagnostics. It is also an opportunity to investigate communication support systems during car breakdowns. A design direction can be to build intelligent systems that recommend driving optimizations, according to a vehicle's capabilities and user's skill levels. --- Design for Safety and Social Support Gender identities influenced how users coped with navigation challenges and safety, especially night-driving for female users. Our findings revealed that a close involvement by family and friends to ensure safety at such times was common. Map-based applications such as Safetipin utilize this factor [22]. Contacting close family members before the journey highlights the social roles played to ensure safety even before driving. Communication devices and sensors can be leveraged further to detect safety threats around the car and connect to appropriate authorities, as well as users' personal network during such threats. A crowd-sourcing approach can be taken here as well to enable people to broadcast route safety to others. --- Conclusions A primary implication of our study is that a smart car experience is not confined to driving alone, but begins even before a journey is undertaken. Activities before driving and the experience during a drive impact each other in continuous cycles. Besides, the presence and influence of users' social circles for informational and emotional support is critical to the driving and pre-driving experience. In all this, the car has to continually shift between personal and social spaces. Consequently, the design space for a smart-car has wide implications for pre-driving and post-driving situations. It also suggests that design avenues for next generation smart-cars should not be confined to users (drivers in this case) alone, but should also focus on members of social circles and other social information sources too. Thus, the findings and implications from this study lay the foundation for future research on smart-cars in India.

Driving is a quotidian activity that people across cultures have long engaged in. Given the pervasive need for information on the go, the smart-car era is well nigh. To develop solutions in this direction, an understanding of users' needs with respect to their cars is necessary. In this paper, we present our exploratory study of user's driving behavior in urban India. We found that the basic need for a smart-car begins even before entering a car and is not confined to driving alone. Activities before and during driving cyclically impact each other. Moreover, we found that driving is not limited to users alone, but also involves critical participation from users' social circles. From these findings, we discuss design implications that can impact pre-driving and while-driving modes and can thereby inform future research in smart-cars for urban India.

Background: Increased access to transportation and information has led to the emergence of more diverse patient choice and new forms of health care consumption, such as medical travel. In order for health care providers to effectively attract patients, more knowledge is needed on the mechanisms underlying decision-making of potential travelers from different countries. A particularly promising method of studying the travelers' motives is collecting data on social media. Objectives: The aim of this study was to test what factors influence decision-making of potential medical travelers and how these factors interact. Based on existing literature, the factors analyzed included quality, cost, and waiting time for 2 procedures varying in invasiveness across 12 different destination countries. Methods: Decision-making patterns were examined using a pilot questionnaire that generated a large amount of data from over 800 participants in 40 countries. Participants indicated their willingness to travel given different scenarios. Each scenario consisted of a combination of several factors. Additionally, participants were asked to indicate the reasons for their choice. results: Individuals display high willingness to travel for medical care when combining all participants and scenarios, travel for care was chosen 66.9% of the time. Among the factors influencing their decisions, quality of the medical procedure abroad was considered most important, and cost was least important as shown by chi-square tests and corresponding odds ratios. Log-linear analyses revealed an interaction between time waiting in the local health care system and type of procedure, whereby time pressure increased the odds of agreeing to travel for the more invasive procedure. The odds of traveling to Europe and the USA were by far the highest, although participants indicated that under certain conditions they might be willing to travel to other medical destinations, such as Asia. for medical care, it is not clear which factors have more influence and whether they interact with each other to influence decisionmaking. To address this lack of evidence (20), we investigated which factors influence individuals' decision for or against obtaining medical care abroad the most and how these factors interact with each other. The factors included the location of the destination clinic, waiting time, cost, quality, and invasiveness of the procedure. A survey, covering a large number of hypothetical medical travel decisions constructed as combinations of the factors mentioned above, was used to elucidate the structure of decision-making of potential medical travelers from various geographical regions. --- MaTerials anD MeThODs study Design A binary (Yes/No) questionnaire was developed in order to assess under which circumstances people would decide in favor or against medical travel. The design of the present questionnaire was developed similarly to the measurement used in the London Patient Choice Project (LPCP) and is explained in more detail by Garcia-Garzon and colleagues (Garcia-Garzon et al., under review). The LPCP investigated the factors influencing patients' socioeconomic choices using a combination of revealed and stated preferences (17). The present questionnaire consisted of hypothetical scenarios framed in a realistic way. The scenarios required respondents to imagine being in need of a specific medical treatment given a certain initial situation. The hypothetical scenarios were a combination of three different factors: procedure, reason for traveling, and the country of the destination clinic (Figure 1). Two specific procedures were selected from a pool commonly referred to in medical travel literature [e.g., Ref. (21)] and aimed to capture two distinct levels of invasiveness, whereby "hip replacement" is considered to be a less invasive and less life-threatening procedure than "heart valve replacement. " Invasiveness was considered important as it should influence the perceived urgency of the treatment. The more invasive procedure is assumed to be perceived as more threatening and hence more urgent. Three reasons for traveling -quality, waiting time, and cost -were included in the questionnaire based on a literature review and consultancy expertise that implicated these factors in determining patients' decisions to receive care abroad. Finally, 12 countries were selected based on their prospective attractiveness for medical travelers. For the purpose of the analyses, these countries were grouped into six regions: Northern Europe (Germany and UK), Southern Europe (Portugal and Malta), Middle East (Qatar and Dubai), Southeast Asia (Thailand and Philippines), Pacific (Singapore, New Zealand, and Australia), and the USA as its own region. Each scenario specified one out of the two procedures, inTrODUcTiOn National health care systems differ largely in terms of structure, provision of services, quality, and costs. These differences, combined with increased access to transportation across borders, and the availability of information brought on by technological advances, are leading to the emergence of patient choice, new forms of consumerism, and production of health care services (1). One dimension of this development is the selective movement of patients beyond national borders to pursue medical treatment, a phenomenon that has been labeled as "medical tourism" or "medical travel" (2). Though medical travel itself is not new, there has been a shift in travel patterns in recent years (2). Wealthy individuals traveling abroad to obtain more advanced health care and better quality treatment are no longer representative of the situation (3). Instead, a rising number of individuals from developed countries travel to developing countries for the same purposes. Many of them cannot be characterized as affluent individuals but rather as conscious consumers seeking affordable high-quality medical care (4). In this emerging context, medical travel is defined as any patient crossing national borders with the purpose of receiving treatment that has been determined as essential to maintain quality of life by a health professional but may not need to be performed urgently. Estimated numbers of patients traveling abroad for medical care vary (5), but all of them indicate an immense growth in this phenomenon (4,6). Despite the expansion of a global health care industry and considerable attention from researchers, policy makers, and the media, hard evidence-based reports on the flow of medical travelers are absent. Although initial estimates were based on a limited body of empirical evidence, they were cited so often that they became treated as absolute. However, it is now recognized that they should be interpreted with caution (6,7). Moreover, the majority of existing literature on medical travel focused on medical tourism [e.g., Ref. (8,9)], more specifically on traveling for elective procedures, such as cosmetic surgery (2), as opposed to traveling for necessary medical procedures [e.g., Ref. (10,11)]. Only a small number of studies have focused on identifying push factors that make a person elect to travel for medical care and pull factors that cause a person to select a particular type of treatment (12)(13)(14). To date, these factors include treatment accessibility in the home country and the nature of the treatment, commonly orthopedic, eye, and heart surgery (3). Based on the limited available evidence (15,16), the primary reasons for seeking medical treatment abroad include the prospect of access to higher-quality treatment, lower costs, and shorter waiting lists (7,10,(17)(18)(19). Although current literature has been helpful in identifying some key factors in decision-making process when it comes to traveling an advantage in cost, waiting time, or quality and was set in one of the 12 destination countries. The dependent variable was the participants' choice to receive care abroad for each scenario. The permuted combinations of 12 countries, two procedures and three factors resulted in a pool of 72 scenarios. Besides the demographic items, such as rating of the aspects of local health care and socioeconomic status details, each participant was presented with a random selection of six scenarios. By doing this, a lengthy questionnaire was avoided and a multiplicity of observations was made possible to be obtained. This approach was crucial for another reason: randomizing the scenarios increased the independence of observations and decreased the systematic variation in the responses that would otherwise arise from a fixed order of scenarios. sample Participants were recruited via social media advertising and completed the questionnaire in English online. Data were excluded if participants only completed a fraction of the questionnaire and did not answer the questions for all six scenarios or took too much or too little time to complete the questionnaire. Valid data were obtained from 543 participants, resulting in 3155 observations. The majority of the sample were female (67.8%), highly educated (74.5%), and European (87.7%). On average, it took participants a little more than 7 min to complete the questionnaire. Ethical approval was obtained from the Department of Engineering Ethics Committee at the University of Cambridge. --- statistical analysis Pearson's Chi-Square tests with contingency tables were used to analyze the relationship between the main predictors or demographic variables with the dependent variable (choice to travel for medical care). To extend the analyses to interaction effects of procedure, reason, and destination region on the choice to receive care abroad, multiple logistic regression was used. First, chi-square tests and linear regression were used to test for associations between demographic control variables and the frequency of agreeing to travel for care. For the purposes of categorical analyses, Likert scale ratings (1-5) and the destination regions were treated as categories (22). Second, goodness-of-fit chi-square test was used to test whether there was an overall tendency to agree to travel for medical care. Next, a chi-square test was used to test for associations between the procedure and the indicated choice to travel. The effect was quantified in terms of the ratio of the odds of traveling for heart valve and the odds of traveling for hip replacement (23,30). Similar tests were run to test for associations between reason or destination region with the stated choice to travel. Furthermore, frequencies of the reasons indicated as important for the stated decision to travel in a given hypothetical scenario were recorded for the most interesting scenarios with unusual response patterns. Specifically, since participants were not likely to choose to travel for care to Asia, it was important to analyze post-decision information for that region to clarify the motivation behind negative decisions. In order to clarify the interactions between the predictor variables, log-linear analyses were carried out. In particular, interactions between main predictors, such as procedure and reason, were included alongside with interactions between control variables, such as rating of health care aspects in one's home country, and the reason presented in the scenario. --- resUlTs --- Descriptives On average, participants rated the quality and the cost of their local health care system positive to very positive, and assigned a neutral to below neutral rating to the waiting time in their local health care system (see Table 1). A small proportion of participants (5%) had previous medical travel experience. Overall, two-thirds of the responses indicated willingness to travel for medical care, when main predictor variables were not taken into account. Most participants reported that their income was average compared to the income of a fully employed person in the same country. --- stated choice to Travel by control Variables (Demographics) Chi-square tests were conducted to test for associations between control variables and the decision to travel or not to travel for care (see Table 2). Participants who rated waiting time as more problematic in their own country were more likely to opt for medical travel. The No significant correlations were found between the odds of agreeing to medical travel and the rating of quality and between odds of traveling [F(1,3) = 3.88, r = -0.75, p > 0.05 and F(1,3) = 3.68, r = -0.74, p > 0.05, respectively]. --- stated choices to Travel for Medical care Without controlling for other factors, in most of the 3155 scenarios (66.9%) that were presented, participants agreed to travel for care, <unk> 2 (1) = 362.29, p <unk> 0.001 (Table 3). A significant association was found between the procedure and the choice to travel for medical care, <unk> 2 (1) = 12.23, p <unk> 0.001. Participants in the heart valve scenario were more likely to travel for care than participants presented with hip replacement, which represents a small effect of the medical procedure. There was a significant association between the reasons for medical travel and the decision to travel for care: <unk> 2 (2) = 180.16, p <unk> 0.001. Participants were most likely to travel for quality, followed by waiting time and cost. In addition, there is a significant association between the destination and the decision to travel for medical care: <unk> 2 (5) = 295.51, p <unk> 0.001. Germany or UK (Northern Europe) are the most likely destinations, with the odds of agreeing to travel to these countries being over three times as high as the odds of traveling to any other region (see Figure 2). Participants were less likely to travel to Thailand and Philippines (Southeast Asia, odds = 0.72), as the odds of other regions, including Southern Europe, Northern Europe, USA, and Pacific were at least two times as high as the odds of traveling to Southeast Asia (see Figure 2). The odds of traveling to the Middle East were the second lowest (odds = 1.63), being 1.75 times lower than the odds of agreeing to travel to the USA, and 5.75 times lower than the odds of UK and Germany (Figure 2). The odds of traveling for care were higher than 1 for all the regions of destination except Southeast Asia, indicating that the number of "yes" replies for those regions was higher than the number of "no" replies. For Southeast Asia, however, the odds of traveling for care were lower than 1, indicating that the likelihood of a participant not willing to travel to this region was higher than the likelihood of agreeing to travel. Since the stated preference rates for medical travel were lowest for Southeast Asia, this region provides some crucial insights into factors driving medical traveler's decisions to go abroad and deserves further analysis. A breakdown of the willingness to travel to that region by reason (Figure 3, the left y-axis) shows that the willingness to travel differs significantly across the three reasons when participants are presented with Southeast Asia as destination of medical travel, <unk> 2 (2) = 78.84, p <unk> 0.001. The decision to travel is significantly more frequent if participants are told they would receive higher quality of treatment than if they are presented with shorter waiting times or lower costs in Asia. To quantify this effect, the odds of traveling to Asia for quality (reported on the right y-axis in Figure 3) are 6.5, 95% CI (4.07, 10.25) times higher than the odds of traveling there for cost and 4.5, 95% CI (2.86, 6.98) times higher than the odds of traveling for waiting time. Those who decided against traveling for care to Asia (310 negative replies) were presented with a choice of possible reasons that they could indicate as important for their previous decision. The most commonly indicated reason was that they had little knowledge of the country (see Figure 4A). When given the option to state their own reasons in an open question, participants pointed out that they had concerns about aspects of quality of care (20 cases) in Thailand or Philippines (such as hygiene), and that they would try to avoid the challenges of traveling so far away (17 cases) with a medical condition. When asked whether they would reconsider their decision if they were given additional benefits, participants most often (in terms of most common response) indicated that they would not travel for care under any circumstances (see Figure 4B). However, in about a third of the cases, participants stated that they would travel if follow-up care in the home country was offered. In approximately 20% of the cases, participants were willing to travel if a significant other could accompany them. Several participants emphasized the importance of quality in the open questions as they agreed to travel for care if they would be provided with satisfactory assurance of high-quality treatment abroad, such as the approval by the local authorities or doctors. --- stated choice to Travel by interaction between reason and Procedure The hypothesis that there are differences between the frequencies of agreeing to travel across combinations of different factors was tested using log-linear analyses. First, the interaction between reason and procedure was analyzed. The three-way log-linear analysis produced a final model that retained all effects. The model shows that the highest-order interaction was significant [reason <unk> procedure <unk> choice to travel, <unk> 2 (1) = 16.59, p <unk> 0.001]. To break down this effect, separate chi-square tests on the procedure and choice to travel for care were performed separately for cost, quality, and waiting time (reasons). A significant association between the procedure (heart valve and hip replacement) and waiting time was found, <unk> 2 (1) = 27.79, p <unk> 0.001. The odds of deciding in favor of medical travel in a hypothetical scenario with shorter waiting time were two times higher, 95% CI (1.54, 2.56) for heart valve than for hip replacement. In brief, it was found that while there are no interactive effects between procedure and cost or procedure and quality, the decision to travel given the waiting time scenario depends on the type of procedure. Reduced waiting time had a significantly stronger influence for the more invasive procedure, since heart valve replacement (in interaction with waiting time) was associated with higher odds of traveling for care (see Figure 5). --- DiscUssiOn --- Key Findings Decision-making underlying medical travel is complex and influenced by a combination of factors. The objective of this study was to explore the contribution of certain factors that individuals consider when formulating their decision for or against traveling abroad for medical treatment. A new experimental tool was designed to test the relative influence of different destinations, procedures, reasons, and interactions of these factors on stated choices to travel for medical care. Evidence emerging from this novel approach confirmed some of the findings in the previous literature and provided new insights into decision-making of non-patients, focusing on medical travel rather than medical tourism. Key findings included that (1) individuals display high willingness to travel for medical care; (2) quality is the most important and cost is the least important stated factor; (3) waiting time and procedure have interactive effects on decisions to go abroad for care; and (4) Northern Europe is exceptionally popular, followed by the USA and Southern Europe, though potential travelers would consider going to locations that were chosen less frequently, such as Asia, if certain conditions (notably assurance of higher quality) were provided. These findings were in line with the results of the control variable analysis. Although several associations exist between control variables and the stated willingness to travel exist, they do not provide evidence strong enough to be of interest. Indeed, they are much weaker than the associations between regions of destination and choice to travel as well as reason and the choice to travel. However, greater dissatisfaction with waiting times for local health care operationalized in the corresponding lower ratings reliably predicted higher odds of choosing to travel for medical care, as revealed by the regression analyses. Similarly, dissatisfaction with the quality and cost of local health care drives participants to go abroad for medical care, as shown by moderately strong correlation between the rating of quality or rating of cost and choice to travel. Assuming that participants have the same priorities when receiving health care abroad and at home, this finding supports the result that quality and waiting time significantly influence participants' decision-making. These factors influence their decision-making directly (as shown in the analysis of the hypothetical scenarios) and indirectly, when the participants are considering their local health care. Moreover, the answers of potential medical travelers in hypothetical scenarios were found to agree with the actual choices of medical travelers (London Patient Choice Report, 3). Since stated preference paradigm reliably indicated the revealed preference patterns, the conclusion that individuals value waiting time over cost can be generalized and holds even for expected revealed preference patterns. --- individual Decisions for Medical Travel Regardless of the combination of the motivating factors, participants were more likely to agree to travel for care than to refuse to travel. This confirms the trend that we find in the development of medical travel and tourism over the last decade: more and more people go abroad for medical care. Among UK citizens specifically, the number of medical travelers in 2010 was 6 times as large as that in 2000 (5). However, inferences about the willingness to travel for care must not be too quick, since the scenarios in this study were framed to offer advantageous and simplified combinations to the participants. When actually in need of a specific treatment and considering medical travel, individuals face more diverse conditions that might decrease their willingness to go abroad for care. Decision-making under conditions of experienced time pressure tends to be guided by affective evaluation rather than by analytic cognitive processes (24), especially if the incentives for using the latter are low. When participants are presented with positive information, such as a certain type of advantage, individuals' global affective evaluation of the choices becomes more positive (25). Therefore, participants in our study might have agreed to medical travel more easily than if they would have considered both the benefits and the costs. Against this explanation of high willingness to travel speaks the fact that many participants indicated reasons for their decision (not) to travel for care. While it is conceivable that this may be a post hoc rationalization of an affective decision, it seems more plausible that the decisions were reasoned rather than affective since on average participants spent over 7 min completing the questionnaire and should not have experienced any externally imposed time pressure. The weak association between the type of procedure and the decision for or against medical travel shows that the treatment procedure is not important enough to modify the outcome variable by itself. This result may be due to the fact that our young sample (mean age = 27.6) was not sensitive to the potential complications associated with the respective procedures when considering it in combination with a variety of other factors. However, when procedure was combined with waiting time, participants realized that heart valve transplant was more urgent than hip replacement and displayed higher willingness to travel for the more invasive procedure. Different types of procedures as well as more differentiated sample age need to be considered in future study replications to gain more conclusive results. The effects of the various reasons on the decision to travel differ significantly: quality has the strongest and cost the weakest association with deciding to receive medical treatment abroad with waiting time being of intermediate importance compared to the other two factors. These associations corroborate the body of evidence that quality is a key reason for receiving medical care (10,19,26). More importantly, this study indicates that participants are more motivated to travel for care by the promise of shorter waiting times than by the promise of lower costs of the treatment. This effect pattern is invariant across all income categories, which means that cost may play an inferior role regardless of the respondent's economic background. Therefore, both those who saw themselves as falling in above and below average income categories are guided by the same considerations, assigning waiting time a more important role than financial issues. The effects of different reasons are robust across all education degrees. They may be unaffected by control variables because individuals follow the socially accepted maxim "health is more important than money" and place waiting time (which often goes along with deterioration of health) and quality of treatment above cost. To counteract some effects of social desirability, the study was conducted online and participants' personal information remained anonymous. In previous reports, it has been often claimed that considerations of costs are the driving force behind the decision-making process (7,17). However, this assumption has not been empirically supported to date (2) and might have been adopted from country-specific or economic cases, where affordability is a major concern for patients. The USA represent a typical example of a location where cost-saving opportunities would increase interest in medical travel, as the rise in the cost of local health care and economic recession lead individuals to seek treatment abroad (27). Results from our predominantly European sample show, however, that cost is less important than quality and waiting time for a treatment, likely linked to less daily concern about such costs given national health finance structures. With respect to the areas of destination, we discovered a strong association between deciding for medical travel and the destination countries. The particular interest in the UK and Germany might at first glance be a result of proximity. Given that also USA, Portugal, and Malta were associated with a high number of positive answers, our results more likely reflect a general preference of European or "Western" countries due to reputation and cultural familiarity. The popularity of Europe as a region for medical travel was also found in descriptive reports by Hanefeld and colleagues (5) who pointed out that between 2000 and 2010, 72% of all medical journeys from the UK were to Western, Eastern or Central Europe, noting an increase in patients going to Asia and India. Our sample aimed to represent all parts of Europe rather than focus on the UK and thus found that Asia is, contrary to Hanefeld's findings, a less preferred location. Our results partially contradict the conclusions of previous studies: Gallup (19) found that only 54% of European Union citizens were "open to travel to another EU country to seek medical treatment. " As our study shows, Europeans display much stronger readiness to travel within EU borders: 69.0% were willing to travel to Malta or Portugal and 90.4% agreed to travel to Germany or UK regardless of procedure and reason. Even tempered for potential effects of this being a stated preference rather than an observed behavior, this would seem to indicate much greater openness to such participation. Participants from all over the world are less willing to travel to the Middle East, Pacific countries (Australia, New Zealand, and Singapore) and Southeast Asia (Thailand and Philippines). The key reason not to travel to Asia is the perceived lack of quality of health care. While most replies indicate unwillingness to travel to Asia for lowers costs or shorter waiting time, the promise of better quality in Asia reverses the trend and results in a surprisingly high number of positive replies (67.9%, see Figure 3). Given that participants are attracted by high quality of medical care, it is reasonable to assume that they prefer Europe and the USA due to the high-quality standards and the high reputation of the clinics there (11). As previous research points out, all aspects of quality of treatment, including success rates of operations, doctors' experience, and rates of complications, are considered by actual medical travelers. When considering destinations of medical travel, such as Thailand and Philippines, travelers are first of all looking for quality. Moreover, they are concerned that the long journey and being in an alien environment could negatively influence their health. For some participants, the decision against medical travel to Asia is not final. The possibility of receiving follow-up care in their home country would change their decision in one-third of the cases. The assurance of receiving follow-up care at home may alleviate the concerns that individuals have about the risks of procedures abroad. Although travelers were skeptical about the quality of treatment, they also indicated that they had little knowledge about the country (for approximately 50% of replies) and would reconsider their decision if they had sufficient favorable evidence (in form of research, personal reports, doctoral recommendation, or information about the abroad doctors' qualifications), suggesting that the quality of treatment in Asia is adequate. In many cases (for approximately 20% of replies), the comfort of being with their family was so important to participants that they would change their mind and travel to Asia for care if they could bring a significant other with them. Potential travelers value quality and sometimes require credible assurances of Asian clinics fulfilling certain standards (Kácha et al., under review) to be motivated to travel there. Another important concern is, given the highly European sample, distance to Asian countries. Transportation is burdensome and discourages people from traveling, and also makes it more difficult for family and friends to visit the patient, resulting in pressure on convenience as the ultimate lever. Though the presence of a significant other does not influence physical health, it does have an effect on mental health and well-being of the patients (28,29) and is, thus, an important factor to consider for policymakers, should medical travel be looked at as a tool for health systems. --- interactive effects Previously, we have seen that the overall differences in willingness to travel for hip or heart valve replacement are rather small, though statistically significant (23). There is no variation in willingness to travel between procedures and cost or quality as reasons (see Figure 5). However, procedure does play a role when the participants consider waiting time as a reason to go abroad for medical care, and in that case willingness to travel for the invasive procedure (heart valve) was higher than willingness to travel for the less invasive hip replacement. When presented with a more invasive procedure, individuals feel under time pressure to receive treatment and may be driven toward receiving care abroad if foreign clinics reduce waiting time. A limitation of this conclusion may be that it is not simply the invasiveness of procedure that motivates individuals to go abroad whenever the waiting time in their home country is long, but rather the diminishing quality of life or the risks of delaying the treatment that differ across procedures. --- limitations The sample comprises 543 participants, and every participant received 6 questions, hence resulting in 3258 (3172 valid) observations. The fact that there were six binary yes/no questions per each participant created a problem for the assumption of independence that is fundamental for chi-square contingency tests and log-linear analyses. The following argument can be made in favor of independence of individual data points: even though six questions were given to the same participant, the questions consisted of a different combination of procedure, reason, and destination region. Thus, the same participant viewed a different question every time. The dimensions of the questions were separated and grouped together only at the stage of analyzing the data. More importantly, the questions were randomly assigned to the participants, resulting in random differences in responses and allowing for a more strict control of independence. This argument still leaves open the question of whether each participant's answer to, e.g., a question about quality was not influenced by their previous answer to a question involving quality. It is possible to view every set of six questions per person as a repeated measures approach, where the participant is presented with the same factor (e.g., hip replacement) over and over again. A better analytic approach must relax the assumption of independence and allow for possible interactions across individual observations. Finally, the sample was mostly European and more data from all over the world would be required to increase generalizability. The Brazil, Russia, India, and China (BRIC) states were intentionally left out and data on Russia were collected. The geographical distribution of the sample is the result of the data collection method that can be presented both as a strength and as a limitation: online social media advertising allows the researchers to reach out to a wide pool of participants from different regions that would otherwise be hard to access. However, it also limits the target group to English-speaking individuals who are active on social media and are responsive to the questionnaire adverts. The group primarily targeted in this way consists of young, student-linked people in European countries. As previously shown, our participants came from different perceived income categories, which somewhat increases the generalizability of findings. Furthermore, the sample is predominantly female. Given these limitations in the sampling method, policymakers have to be careful in utilizing such evidence as even a sophisticated, highly adapted approach to modeling raised concerns about appropriate use of the data. Highly relevant factors of minority groups and choices -that is, small but very important factors and outcomes may be missed due to large majority factors. This was particularly the case for medical choices between age groups, for individuals from regions highly affected by conflict, and also by under-represented countries in the data whose patterns may not fit those of highly represented countries, which also presented a proxy for national economic and health service standards. cOnclUsiOn Our findings provide crucial insights into the factors driving the decision-making of potential medical travelers. Since the most important factor is the quality of treatment, it is crucial that the quality standards are upheld in the destination country and credible assurances of a high-quality treatment are provided in order for individuals to consider going abroad for care. Geographical preferences found in this study largely reflect the finding that participants prioritize quality. Potential travelers' decisions are not always influenced by any one factor in isolation. Instead, they can be the result of an interaction between several factors, such as the invasiveness of the procedure and the waiting time. While waiting for a more invasive procedure does not influence the willingness to travel for care on its own, it becomes important when considering the waiting time in one's home country and abroad. Participants' decisions not to travel for care are often not final. Even if an individual does not think favorably of medical travel, they are often willing to consider trade-offs. For instance, they might change their mind about traveling to an Asian country if their concerns about follow-up care are addressed. Offering certain advantages, such as assurances of quality, the possibility of followup care at home or the presence of a loved one in the destination country may convince even those who initially were against going abroad for medical care. Though this may be seen as crucial insight from an industry perspective, it is critical that the global health policies consider this when setting minimum standards with the goal of protecting potential patients from being misled and put at risk. If treated carefully, the insights into the factors that influence patient choice obtained in this study could be valuable in tackling the challenges arising with the implementation of new policies, such as cross-border health care directive in the EU. As it is clear that medical travel is likely to expand in the near future, careful use of the insights into decision-making from our study and further work on this topic is necessary to inform relevant health policies. Understanding more about what drives these decisions is one of many important factors that must be built into such policies, as these present the opportunity to safeguard against potential risk as well as to ensure that any expanded access to care through medical travel offers genuine benefits to health and health services. --- acKnOWleDgMenTs The authors are grateful to the University of Cambridge Engineering Department for providing financial support for this study. The authors also would like to thank Madeleine Dalsklev and Laurien Nagels-Coune for their help in some of the measure development. --- Conflict of Interest Statement: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Copyright <unk> 2016 Zhukovsky, Ruggeri, Garcia-Garzon, Plakolm, Haller, Petrova, Mahalingam and Menezes. 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Our measurements yielded several reliable insights into the factors driving medical decision-making. An essential next step would be to expand these findings with a more encompassing sample and more elaborate statistical modeling.

Introduction Western societies are currently dealing with the rapid ageing of their population. This has become a central issue in policymaking as new concepts, programmes, and services to fulfil the expectations of the older population-as well as service providers and policymakers (Iecovich, 2014)-are being developed. Two concepts have been dominating both the scholarly and public debate: active ageing and ageing in place. According to the World Health Organization (WHO, 2002, p. 12), active ageing is "the process of optimizing opportunities for health, participation, and safety to improve the quality of life of people as they age." Active ageing adopts an inclusive view of late-life health, capable of capturing the full range of factors that-beyond types of care-can positively influence the life course of the older population. The goal is to prevent the deterioration of health among people in their old age through the development of policies and services that enable the individual to consciously choose an ageing path more appropriate to their needs and motivations. Older age is a transitional period when people experience changes not only in physical health, but also in social roles (e.g., retirement), and successful ageing has been empirically defined to include a low probability of disease and disease-related disability, a high level of physical and cognitive functioning, and active engagement in life (Carr et al., 2013). Alongside successful ageing and healthcare prevention, there has been a steady increase in the discussion of ageing in place in recent years. Ageing in place involves developing services and facilities that allow older people to stay in their homes or chosen environments for as long as they can as they grow older. Mainstream scientific and public discussion has underlined how most older people prefer to age in place rather than relocate to another place or residential care facility, as ageing in place allows them to maintain their independence, social engagement and networks, as well as to remain in a safe and comfortable environment (Whitney & Keith, 2006). Empirical studies have underlined how older people wish to stay in their homes as long as possible, but their demands are influenced by policies and their own individual needs (Means, 2007). Most older people are attached to their independence and prefer to live in the environment with which they are most familiar (Vermeij, 2016). Independent living also contributes to maintaining a sense of self-esteem and self-reliance (Milligan, 2009). In this framework, ageing in place means growing old in one's own home rather than in an institution (i.e., nursing home). It also means living independently in old people's homes and communities safely, autonomously, and comfortably regardless of age, income, or functional limitations (WHO, 2017). Broadly speaking, to age in place is to continue to live in the same "place" as always (Löfqvist et al., 2013). This article focuses on the project Invecchiare bene/Bien vieillir (ageing well; hereafter INCL) funded by Interreg Alcotra France-Italy and implemented in the Valleys of Monviso in Piedmont, northern Italy (Agostini et al., 2023). It is based on primary sources such as original data collection (survey, semi-structured interviews, and focus groups; see Section 2) from the monitoring and evaluation activities conducted by the Observatory on Second Welfare and develops those results within the framework of an ongoing discussion, in the literature, about active ageing and ageing in place. INCL specifically targeted older people living at home in mountainous areas, where the possibility of ageing well is at risk due to chronic diseases and social isolation. The literature recognizes a wide variety of definitions of social isolation. Biordi and Nicholson (2009, p. 97) defines social isolation as "an individual's distance, psychological or physical or both, from the desired or necessary network of relationships with other people. Thus, social isolation takes the form of a loss of positioning within a group." More specifically, two dimensions of social isolation have been identified: a subjective dimension, which is a perceived deprivation of one's social resources, such as companionship or social support (and is thus closer to the concept of loneliness); and an objective dimension, which includes a lack of contact with others due to contextual factors (e.g., reduced social network size, rare social interaction, or lack of participation in social activity). Risk factors leading to social isolation can be psychological (e.g., a depressive state), physical (e.g., chronic illness), or, indeed, social (related to inequalities, economic or cultural aspects, transportation, social activities, etc.; see Biordi & Nicholson, 2009;Nicholson, 2009). Social isolation is therefore distinguished from loneliness, which relates to a subjective and negatively experienced discrepancy between the quality and quantity of existing relationships and a person's desires or standards regarding those relationships (Machielse, 2015). One can feel lonely while not being socially isolated. Nevertheless, the two concepts are related: Loneliness can be conceived of as a risk factor for social isolation because persons who deal with prolonged feelings of loneliness often see their social network shrink (Machielse, 2006); both loneliness and social isolation affect the physical and mental health and health-related behaviours of older people (Choi et al., 2015;WHO, 2021). Both problems are amplified in mountainous areas, which are experiencing depopulation, the closure of commercial and community activities, and lack of transportation (see Section 2). Concerning the current debate on services for older people and ageing, INCL has at least two main points. The first is understanding its target (older people) and the relative specificity of its needs and services. There is a growing awareness of how the people that comprise the "older population" are profoundly diverse among themselves and how the needs of people in their old age vary as they grow older and as physical, cognitive, and mental complications occur. Indeed, not all older people are in a state of non-self-sufficiency or are passive recipients of services: Some of them actively participate in social life and can be a resource for the entire community (Longo & Maino, 2021). The life-course approach is a concept that has become widespread in rethinking the logic of intervention to support the older population. Looking at the long phase that begins with retirement (from age 65/67 onward), it is possible to identify three subgroups corresponding to the three main stages of old age: the silver age (aged 65-74), the mildly frail age (aged 75-84), and people at greater risk of non-self-sufficiency (aged 85 and older). These three profiles ideally reflect the exacerbation of needs related to increasing age. Ageing is characterized by an increase in the risk of frailty, disability, and sedentary conditions, the risk of social isolation, and depression. The likelihood that an older person may fall and injure themselves also increases. The three profiles must therefore be associated with different goals, tools, and services that better reflect the differentiation of care needs and responses (Maino & De Tommaso, 2021). The transition from active life to non-self-sufficiency goes through different stages characterized by increasing frailty, which is largely also related to the condition of social isolation and loneliness to which older people are increasingly exposed (Maino & De Tommaso, 2021). The role of local welfare thus becomes that of supporting-through caretaking-older people from one stage to the other. It is thus a matter of flanking restorative interventions (which aim to offer answers to manifest needs) not only with preventive interventions (which aim to postpone the non-self-sufficient phase as long as possible) but also with "proximity" interventions based on "light" services that go beyond prevention and look to the well-being of older people. This third type of action is in line with the most recent transformations in local welfare, which increasingly focus on the promotion of a model variously defined as proximity and community-based through generative and capacitating approaches. What these definitions have in common is the centrality of the community and the idea that territories are systems in which "first welfare" actors (public agencies) compete with "second welfare" actors (third sector, for-profit and non-profit entities, and also ordinary citizens) in the production of interventions aimed not only at responding to and preventing needs but also at promoting well-being in a broader sense (Longo & Maino, 2021;Maino, 2021). In other words, thinking about older people, it is necessary to combine care and assistance with preventive interventions and activities that can promote mobility and sociality, as well as autonomy inside and outside the home, to delay physical and cognitive decline as much as possible. Achieving this goal requires identifying the multiplicity of needs of individual older people and adopting specific and necessarily multidimensional interventions. The second point of the INCL is related to community development, an alignment whereby individuals who are part of a community are committed to working together in the process of community evolution (Walter & Hyde, 2012). The active participation of local actors-public, for-profit, and non-profit or families-is aimed at innovating local public policies via renewed forms of local community participation. The final aim is to establish "structured" pathways of community empowerment to restore bonds of trust, sharing, and assumption of a community perspective that goes beyond individual interest; to strengthen the capacity of residents, associations, and organizations (private and public) to promote positive change through the creation of social ties among people; and to leverage spontaneous mechanisms of aggregation and mutual recognition that are based on the adoption of collective behaviours inspired by mutual responsibility (Berloto, 2021;Longo & Maino, 2021). This study, therefore, investigated the impact of the INCL project on both older people ageing in place (and, indirectly, active ageing) and community development. The remainder of this article is divided into four sections. The next section outlines the research questions and methods. The third section briefly presents the background, objectives, and phases of the project. The fourth section focuses on the analysis of the direct impacts on the health and living conditions among the project's recipients and the local model innovation of care (i.e., on social workers and the local community). Conclusions are presented in the fifth section. --- Research Question and Methodology Starting with the results of the monitoring and evaluation activities, our analysis answers two research questions: How has the INCL project's model of care improved the health and living conditions of older people? How has the project fostered innovation in the local model of older people care (i.e., regarding community development)? The research was structured into two parts. The first part investigated the impact that the INCL-as a typical project in the field of ageing in place-could have in fostering the transition from active life to non-self-sufficiency while mitigating and preventing dependency, as well as the role of local welfare in supporting older adults from one phase of life to another. The first part of the research interweaves and illustrates three dimensions: (a) the project's main characteristics and goals; (b) the experiences of both individual older adults and social workers to analyse how effective the project was in relation to its intended objectives and recipients' satisfaction; and (c) the factors facilitating or hindering the project's success to determine areas where it could be improved. Data collection was conducted via the monitoring forms filled out by operators at the beginning of the project (61 forms), an online structured questionnaire that professionals filled out for each of the recipients whose projects were still active as of 7 September 2022 (52 questionnaires). Each questionnaire collected data on specific analytical dimensions (personal health and well-being, interpersonal skills and sociability, housing, daily life, relations with territorial services) and focused on four parts: achievement of the objective of the project; satisfaction among older adults with the activities; difficulties encountered by the operators; and services/activities that should be enhanced and/or included. Each questionnaire was completed by the professionals who managed the individual projects. The professionals carried out the evaluation (and related completion). This choice was intended to compensate for the difficulties that older people may have in completing the questionnaire on their own and, on the other hand, to enhance the overall view of the project's effects, which could be offered by the operators involved in the activities. Moreover, six in-depth semi-structured interviews related to relevant case studies were conducted to delve into the factors that facilitated the success of the intervention. The interviews concerned six older women and men involved in the INCL project who were signalled by the members of gruppi integrati di presa in carico (GIPIC, groups composed of different professional figures, such as social workers, nurses, health workers, and professional educators in charge of providing care to older people) for their good level of participation in the project activities and because they were able to talk about their experience clearly and comprehensively. The interviews involved members of the technical project committee, while the focus groups addressed the six GIPIC teams supporting the valleys targeted by the intervention. --- INCL: Project Description and Goals This article analyses the model of the intervention tested within the INCL project, implemented between June 2021 and September 2022 in a partnership led by the Consortium Monviso Solidale (CMS) in collaboration with the Local Health Enterprise of Cuneo (ASLCN1) and the Cuneo Social Welfare Consortium. CMS is a public body established by the will of 58 municipalities and is responsible for the associated management of social and welfare services. INCL is part of the PITER Terres Monviso Integrated Territorial Plan and is funded by the European Regional Development Fund, Interreg Alcotra Programme 2014-2020. INCL involves a territory that includes, in Italy, the mountain community Valli del Monviso (composed of Varaita, Po-Bronda, and Infernotto) together with the three mountain unions of Valle Grana, Valle Maira, and Valle Stura; in France, the project involves the local communities of the Guillestrois-Queyras, Serre-Ponçon, and Ubaye-Serre-Ponçon municipalities. This section illustrates the project's background and context (Section 3.1) as well as its dimensions, goals, and phases (Section 3.2). --- Background and Context INCL is a project that promotes ageing in place, or "the ability of older people to live in their own homes and communities safely, autonomously, and comfortably, regardless of age, income, or functional limitations" (WHO, 2017, p. 6). The project targeted older people whose possibility of ageing well was at risk due to health issues and the social isolation derived from living in mountain villages. While the processes of physical and cognitive deterioration, as well as the feeling of social exclusion, are typical of ageing, one's specific context exacerbates the living conditions of older population: Consider, for instance, scarcely populated villages far from city centres, poorly connected to them-if at all, and the resulting difficulty in accessing social, commercial, health services. The "INCL territory" shares common sociodemographic trends. In recent years, this area has suffered a slow-but progressive-demographic decline, determined by the constant depopulation of the high valleys, mainly due to the geographical marginality of the mountain territory, the lack of job opportunities, and the scarcity of services in rural areas. Further social dynamics are linked to the persistence of a digital divide between urban and rural areas, which has spread a deep disadvantage for those living in marginal areas where access to digital services remains limited. However, while the socioeconomic context seems more fragile in the higher villages, the social relationships are also stronger. Indeed, community and neighbourhood social ties are more present and effective in small towns and upper valley areas, where all community members know each other and there is a constant monitoring of the situation of the more fragile and isolated individuals. The reference persons are doctors, pharmacists, and social workers, but neighbours and relatives are also ready to report situations of criticality or distress. While active ageing activities in some territories had never been attempted, in others (Valle Varaita and Valle Grana) they were successful, especially with the involvement of volunteers. Moreover, during the Covid-19 lockdown (in 2020 and 2021) in Val Varaita, older people were taught to use new technologies to, for example, send SMS, make video calls and send emails, using both tablets and mobile phones. --- Core Goals, Dimensions, and Phases INCL had two main objectives: (a) to implement an innovative mode of taking care of older people with identified physical and cognitive frailty (and, thus, a quasi-severe clinical profile) and (b) to test, albeit on a small sample compared to the width of the recipients in the main target, an individualized plan of care, allowing the older people and the whole local community to identify social needs while co-designing possible responses. The project involved 61 beneficiaries: 36 women and 25 men, aged 60-95 years (28 of them were between 80 and 90 years old). Half of them did not have any caregivers. Most of the beneficiaries enjoyed a good level of independence in activities of daily living and instrumental activities of daily living. They had minor health problems but needed support for therapy/care management. Beneficiaries of the INCL project had no economic problems but experienced loneliness (reported in 70% of cases) and needs related to the partial and progressive loss of their autonomy. Of the beneficiaries, 21 lived in inadequate housing (e.g., with architectural barriers or no hot water) and 13 in partially adequate housing (e.g., isolated or in need of housekeeping). There are two main dimensions at the core of the project. The first involves the design of policy tools specifically calibrated to the project's priority target, notably frail older people (Maino & De Tommaso, 2021). The second requires innovation of the local model of care through the deployment of intersectoral (thus involving multiple policy sectors) and multidimensional interventions, aiming to intervene simultaneously for the different needs of older people and in the direct participation of local communities with a view towards community building (Zazzera, 2021) and proximity welfare. In fact, Maino (2021, pp. 50-51) To select the appropriate model to achieve these objectives, the implementation of the project was preceded by an accompanying activity (lasting about six months and conducted with the support of an external consultant) that led to the creation of the GIPIC in charge of providing care to older people. INCL established a GIPIC for each territorial area involved in the project-a total of six teams, three of which were active in the Cuneo area and three in the Saluzzo area. Each GIPIC met, on average, every three weeks to carry out its activities. In addition, collective meetings were held between GIPIC teams to discuss, among operators, the local best practices and specific training activities-that is, the management of health issues, the professional skills required to work in multidisciplinary teams, and the socio-relational strategies necessary to promote dialogue with older people. The second phase, carried out between September 2021 and September 2022, encompassed the project implementation-and related services-envisaged by the individual projects. The main services concerned improvement of autonomy, health monitoring, prevention of loneliness, personal and house hygiene, transport, and grocery shopping services. Aside from health and social services, the local community was directly involved in the activities. The involvement and cooperation between the local community and public services in a structured programme were one of the main innovations of the project. Community members were asked to activate a territorial network able to care for older people and prevent their social isolation with several activities (e.g., community lunches, musical evenings, out-of-town trips, art and photography workshops, home reading). From a community-building perspective, these activities often involved other older people in the area, including "more active" older people and retirees, with free time and willingness, who proposed the activities and took on the burden of organizing and leading them. These activities required strong coordination with social welfare consortiums, public administrations, and voluntary associations. The ASLCN1 also asked to participate directly in local meetings to combine aggregative activities with moments of health prevention such as the "Health Education in Pills"-a health education opportunity managed by the ASLCN1 and based on a playful mode of learning. --- Analysis of Results This section presents and analyses the results. Section 4.1 presents the data about the recipients, while Section 4.2 presents the results from the perspective of operators and service providers. --- Services: Assessing Effects on Health and Living Conditions Among Recipients This section presents data collected via the monitoring surveys filled out by operators at the beginning of the projects (61 recipients) and a structured questionnaire only addressed to recipients whose projects were still active as of 7 September 2022 (52 recipients). Although the subject of the questionnaire was the recipient, the evaluation (and related completion) was carried out by the operators. The project addressed frail older people affected by mild physical and cognitive decline (i.e., the partial loss of their independence) who were socially isolated. Most of the individual projects focused on improving autonomy (49), followed by health monitoring (39), prevention of social isolation (35), and maintenance of personal and household hygiene. Fewer projects addressed the provision of transport ( 15) and grocery shopping services (14; see Figure 1 On the one hand, the project achieved very good results overall for personal health and well-being, particularly with respect to the objective of "encouraging a proper use of therapeutic procedures" (e.g., taking medications), which was rated fairly or very effective in almost all cases where it was implemented. The sphere of interpersonal skills and sociability, on the other hand, was controversial, representing both the project's main opportunity and criticality, although the experience was evaluated positively overall. Indeed, the project was rated fairly/very effective in "promoting socialization by reducing the risk of isolation" in 64% of cases, but also not very or not at all effective in 36% of cases. For 72% of respondents it was fairly or very effective in "maintaining/improving interpersonal relationships," although for 28% it was little or not at all effective (Table 1). Activities and services that relate to personal health and well-being, such as "activities/services to monitor health status" and "help with the correct taking of medications and the correct use of medical devices," were the most appreciated by older people (Figure 2). Judgements on social activities were also rather fragmented: They were not at all or little appreciated in 48% of the cases for which the activity was carried out (with 24% not appreciating it at all) and fairly/very much appreciated in 52% (Figure 2). On the side of interpersonal skills and sociability, both goals of the activities-promoting socialization by reducing the risk of isolation and maintaining/improving interpersonal relationships-were rated as hardly effective (31% and 24%) and fairly effective (27% and 39%). These activities were highly appreciated among recipients (43%), although 48% of them declared that they were not at all or only poorly satisfied with these activities (Figure 2). Another important issue for the project, which aspired precisely to encourage older people to stay in their own homes, was housing. The goal of creating a more comfortable and safe home environment was not achieved, or was achieved poorly, in 38% of the cases, while that of promoting adequate hygiene of dwelling was not achieved in 46% (Table 1); hygiene activities/services related to the home were poorly appreciated by 48% of participants-almost half (Figure 2). This result can be explained, first, by the difficulty of being In the daily life sphere, the project was effective in facilitating the handling of paperwork/commissions/ shopping, which was rated positively in 91% of cases, and quite good in the facilitation of transport-the transportation service received a negative rating in only 22% of cases (Table 1). The shopping/meal service was also highly appreciated, receiving positive ratings in 88% of the cases for which this activity was carried out (Figure 2). Regarding the relationship with local social services, the project achieved excellent results (although the figure may be conditioned by the fact that the operators carried out the assessment). The goal of improving the trust of older people towards operators was considered to have been achieved in 96% of cases (Table 1). In this sense, a very delicate stage was the engagement of people in old age who had not connected to the services before, as revealed in the interviews. In this regard, emblematic is the case of one interviewee who recounted that she was initially wary because she thought she had been "hooked" by social services to be taken away from home. The objective of addressing older people towards the services available in the area was achieved in 91% of cases (Table 1). These activities were fairly/very much appreciated in 86% of cases (Figure 2). Obstacles reported in 26 cases (half) concerned reluctance to participate in social/collective activities or to leave home for 20 cases (Figure 3). Another factor that emerged from the interviews was older people's desire to protect their independence, a sentiment often conditioned by the presence of close relatives. Although with some difficulties, as mentioned above, social/collective activities and services were appreciated and-according to interviewees-considered beneficial, because they allowed respondents to get to know new people. Furthermore, when asked what services/activities should be improved/ strengthened, the most needed was strengthening aggregation and socialization activities, reported in 30 cases-more than half. This response was given mainly by those who are fully or fairly autonomous (about 60% for both combined), further confirming that, for socialization activities, there is a need to invest precisely in this target group, which emerged as the most critical. Reluctance of recipients to par<unk>cipate in socializa<unk>on ac<unk>vi<unk>es 50 Caregivers and volunteers' <unk>me shortage to support the old-age person adequately 25 Absence of a family or friend network to work with 25 Difficulty of coordina<unk>on among the operators involved in the project 2 Reluctance of recipients to be supported by strangers in personal and home care ac<unk>vi<unk>es 29 Reluctance of recipients to leave home 39 Finally, regarding the services that could be strengthened/included, older respondents underlined the need to invest in socialization activities (58%), transport services (44%), and improvements in the number of paid social workers (35%) and volunteers (33%). A small quota-2% of respondents-asked for assistive home automation tools (Table 2). --- Networks: Assessing the Innovation of the Local Model of Care for Older People The innovations introduced through INCL have had significant impacts on how care is provided, on the professionals' work, the management of services for older people, and the construction (or consolidation) of territorial networks. The innovative target group-which involved frail older people-was associated with integrated caretaking on three fronts: health, the social sector, and community. The project adopted a multisectoral perspective and aimed at social and health integration: The GIPIC teams brought together practitioners with social and health skills and volunteers, and the projects focused on objectives and interventions that covered both sectors. Most projects involved the integration of ASLCN1, social services, and the local community-or two of these together. While there are long-lasting structural issues at play (Longo & Maino, 2021), in Italy, as in many other countries, integrating health and social care services has become a central aim of welfare policies (Tousijn, 2012). Two important factors have acted as the main drivers of change: the growing number of people affected by multiple and chronic diseases who require more holistic care (Tousijn, 2012) and the de-institutionalization and de-hospitalization of social and health services to contain costs and keep people as much as possible in their own home and community (Burau et al., 2009). Third sector-mostly, voluntary-organizations have long offered support services to older people to fill existing gaps in public provisions. The various institutional actors involved in healthcare and social care are now being asked to cooperate, providing a proper institutional framework for more effective and efficient care. New models and structure are needed to coordinate, merge, and foster new processes that have been separate for a long time: Members of different professions are expected to integrate their work practices (Tousijn, 2012). This is the case of INCL. This local innovation allowed for a multidimensional response to both manifest and hidden old-age needs, which tended to be neglected by traditional social services. Social and healthcare integration would not have been possible without establishing GIPIC teams (see Section 3). Teamwork was a valuable experience for the operators for several reasons. First, the synergy with professionals from other areas allowed them to reflect critically on their internal capabilities, while minimizing the routinization of professionals' tasks from a learning perspective. In one interviewee's words: This model is certainly valid. It should be more and more like this, more and more networked. When I think about professional diversity, the fact that she [points to another colleague] is from a different cooperative than I am, I find it very enriching. We are often used to building comfort zones that teamwork forces us out of. You can also put yourself in the other operator's shoes because it is not necessarily the case that if you have been doing it for 30 years then you do it well or you always have to do it that way. Still, you can also learn from others. (Social worker, CMS, translated from Italian) On the one hand, the INCL process guaranteed a deeper understanding of the individual and contextual situations of people in their old age in the area, unveiling their neglected needs. On the other hand, it shared an emotional-more than professional-burden in caring for complex individual situations, improving both professional care and the lives of individual older people. The absence of volunteer workers in the GIPIC teams (because they were involved only in the implementation phase) was considered a limitation because they would have facilitated the identification of needs, given their close relationship with older people living in the area. As reported in interviews, the role of volunteers is central in defining population needs because they are actively involved on the ground 24/7. Voluntary associations have-and should continue to have, based on the prospect of social and health care integration-a key role in taking care of older care recipients. However, two shortcomings-and, therefore, areas for potential improvement-emerged. The first concerns strengthening human resources-that is, the number of operators and volunteers involved (about the latter, the need to improve their skills was also reported). The second concerns the fact that accompaniment has improved the social relations for older people, but their volunteer network has often been limited to the closest neighbourhood. Hence, there is a need to enhance community involvement to achieve proximity welfare that can widen the network of "caregivers" for mildly frail older people. In any case, the innovations generated by the mode of work in GIPIC teams have improved the quality of services offered to older people: The holistic approach to the person makes it possible to observe latent and manifest needs. In addition, intervention time was reduced, because professionals could carry out their tasks more quickly by working together in synergy: With INCL, we carry out a comprehensive assessment of the person through the team, which has different professional skills within it. This allows us to understand their needs and situation. Before INCL, we used to respond to specific requests. Now we try to understand, for example, if the older adult needs a meal, if he has a health situation that is better to keep under control, for example, because he has diabetes....So the nurse does her part, the social worker does hers...and if we see that the person has needs related to socialization, then we activate the educators and try to structure specific moments. So, the assessment and the responses are 365 degrees. (Child and families social service manager, Technical Project Committee, CSAC, translated from Italian). Finally, INCL also had an impact on territorial networks, consolidating them where they were already present or promoting their construction where they were not. This has been possible for two main reasons. The first is that, through collaboration with local public and civil society, INCL practitioners have become a point of reference for the community. According to some interviewees, INCL fostered mutual helping relationships among older people. Socialization activities made it possible to bring together people with shared needs who otherwise would have never met on their own. The second is that the project promoted the building of relationships between the mildly frail older people in charge with other older people in the area who participated in the animation activities. In any case, the development of community activities was strongly conditioned by the pre-existent development of local networks: In valleys where networks were already built, the implementation of territorial animation was easier; in valleys where they were not already in place, sometimes the territory welcomed and promoted INCL's actions, while in other cases institutions and local realities were reluctant to support the project and the GIPIC teams. Social and healthcare integration developed an extensive local network. Respondents reported that the GIPICs fostered a great stimulus to community development: If we look at the territory, the networks activated are a great asset. For example, if tomorrow there were no more GIPIC, I know that the social worker is still there, who has seen the mayor many times for this project, who knows the nurses, and so on....The volunteer who goes today to bring the groceries or who anyway sees the shutter down but knows that the older person is there and rings the doorbell...these relationships have been created over time, and when you create the relationship, automatically you create the network. (Project manager, CMS, translated from Italian) Changing local conditions have affected the likelihood of people becoming involved in community development while working to improve humanistic aspects of community life. While citizen participation is not synonymous with community development, it is a means to realize the humanistic elements of community development through compelling involvement by public and private actors to foster self-help efforts among all segments of the population (Dillman, 1983). As we delve into the conceptualizations of community inherent in the theories of community development, Phillips and Pittman (2015) point out that, within this theoretical area, communities are, first and foremost, a group of people and the ties exist between these individuals. It is territory per se-not only because of its physical texture and boundary definition but also because it hosts a series of social actors and resources, both tangible and intangible-that determines its facticity and it is the relationships between these actors and objects that constitute its identity (Goldenberg & Haines, 1992). --- Conclusion In the field of old-age policies-more specifically, ageing in place-INCL focused on promoting home care by adopting a multidimensional, and proximity approach. The project has tried to address the issue of ageing by considering it not only from the point of view of better management of needs that have already occurred but also of risk prevention through early identification and care provision for fragile individuals. The initiative has, therefore: This approach was translated into goals and consequent activities and services that focused on promoting health and independence in and out of the home, as well as creating an "older people-friendly" environment. The project efficiently facilitated physical mobility inside and outside the home; the meal supply service and help with grocery shopping were also highly appreciated. This latter is an essential achievement because proper nutrition is a prerequisite for healthy ageing (e.g., preventing diabetes, cardiovascular disease, and obesity), but inaccessible in mountain villages that, given the scarce presence of grocery stores, can be considered "food deserts" (USDA, 2009). Because the project sought to encourage older people to stay in their homes, an important aspect concerned housing quality, especially regarding hygiene and creating a safe and comfortable home environment. On this point, the project has not been very effective, which requires further attention. Even if there are "structural" reasons the project could not have changed (older people often live in obsolescent buildings with architectural barriers), other elements could be addressed, such as the difficulty-reported by some beneficiaries and operators-for older people to let "a stranger" into their house, which could be overcome by intervening in social relationships and mutual trust. Finally, the effect on the development of relations and the contrast of loneliness was controversial, representing both the project's main opportunity and area for improvement-however positive the overall assessment was. The difficulties encountered can be traced to the attitude of older people towards participating in aggregative/socializing activities, leaving their homes, and, at other times, being determined to protect their independence. Integrating the social and health dimensions improved the quality of services because it provided operators with a complete picture of older people's situation and allowed sub

The increase in ageing societies is posing new and urgent societal and political challenges to meeting people's medical, personal, and social needs in old age. Ageing should not be considered a uniform phase of life and at least three phases should be distinguished: (a) silver age, (b) the mildly frail age, and (c) those at risk of dependency. Policy tools and logics should prevent and support specific needs in a life-course approach and the preventive approach is seen as among the most useful interventions, with a baseline objective to promote ageing in place, minimize the institutionalization of care, and prevent psychophysical deterioration by supporting older people and their families through tailor-made approaches and policies. Our study focuses on the project Invecchiare bene/Bien vieillir (ageing well) funded by Interreg Alcotra France-Italy and implemented in the Valleys of Monviso in northern Italy. The project targets older people living at home in mountainous areas, where healthy ageing is difficult due to chronic diseases and social isolation. This article presents an analysis of preventive-based interventions and services that promote innovative ageing policies and investigates the involvement of the local community and how it can lead to the deployment of new preventive measures. The research covers the direct impact on the health and living conditions of the recipients (older people) and innovation by the local care model (among social workers and the local community). Qualitative (documentary analysis, semi-structured interviews, and focus groups) as well as quantitative (questionnaire and secondary data analysis) methods were used.

of grocery stores, can be considered "food deserts" (USDA, 2009). Because the project sought to encourage older people to stay in their homes, an important aspect concerned housing quality, especially regarding hygiene and creating a safe and comfortable home environment. On this point, the project has not been very effective, which requires further attention. Even if there are "structural" reasons the project could not have changed (older people often live in obsolescent buildings with architectural barriers), other elements could be addressed, such as the difficulty-reported by some beneficiaries and operators-for older people to let "a stranger" into their house, which could be overcome by intervening in social relationships and mutual trust. Finally, the effect on the development of relations and the contrast of loneliness was controversial, representing both the project's main opportunity and area for improvement-however positive the overall assessment was. The difficulties encountered can be traced to the attitude of older people towards participating in aggregative/socializing activities, leaving their homes, and, at other times, being determined to protect their independence. Integrating the social and health dimensions improved the quality of services because it provided operators with a complete picture of older people's situation and allowed submerged needs to be brought to light, enabling a holistic approach to the older person's well-being. Working in teams was a valuable experience for professionals: The confrontation and fostering of a holistic approach allowed them to learn and improve their work. A second aspect of interest is the aggregative activities and related community involvement. Thanks to the provision of these activities, the project fully promoted the shift from traditional "on-demand" welfare to proactive welfare (Longo & Maino, 2021). The first describes the user's (i.e., the recipient) and individual demands for welfare services. Recipients manifest their needs by applying for welfare services. The second one refers to a proactive, own-initiative welfare services approach in which social services analyse, know, and identify (new) social targets and implement social services to tackle their needs. This is a multidimensional analysis of needs that involves proactive scouting, user orientation, and user accompaniment. This transition had already begun in the territory. For this reason, the responses were differentiated in all of the valleys that took part in the experiment. In some valleys, a developed network facilitated the implementation of INCL, while in others, a local network still needs to be created, although the local community got involved anyway. In others, however, there was a certain reluctance among the institutions and local actors or of the older people. Beyond the peculiarities of each context, the project has generated essential legacies because of the results achieved and because it shows how individual local projects can represent real laboratories for social innovation. The need for a "sense of community" was recognized as the need to create networks and social relationships among people within a community context, not necessarily in the sense of community as a group of persons living in an area, thus generating "communities of purpose" (Mannarini, 2004). Proximity-and community-based approaches-align with these purposes to reduce the distance between citizens and (public and private) services. --- Conflict of Interests The authors declare no conflict of interests. World Health Organization. (2017). Global strategy and action plan on ageing and health. World Health Organization. (2021). Social isolation and loneliness among older people: Advocacy brief. Zazzera, A. (2021). Definizione e finalità del community building. In F. Longo & S. Barsanti (Eds.), Community building: logiche e strumenti di management (pp. 27-44). Egea. Celestina Valeria De Tommaso is a second-year PhD student in political studies at the University of Milan (Italy). Her research interests include long-term care policies and elderly healthcare programs at national level, from a comparative perspective. She is also interested in multidimensional poverty reduction and related welfare state policies. Among --- About the Authors --- Chiara

The increase in ageing societies is posing new and urgent societal and political challenges to meeting people's medical, personal, and social needs in old age. Ageing should not be considered a uniform phase of life and at least three phases should be distinguished: (a) silver age, (b) the mildly frail age, and (c) those at risk of dependency. Policy tools and logics should prevent and support specific needs in a life-course approach and the preventive approach is seen as among the most useful interventions, with a baseline objective to promote ageing in place, minimize the institutionalization of care, and prevent psychophysical deterioration by supporting older people and their families through tailor-made approaches and policies. Our study focuses on the project Invecchiare bene/Bien vieillir (ageing well) funded by Interreg Alcotra France-Italy and implemented in the Valleys of Monviso in northern Italy. The project targets older people living at home in mountainous areas, where healthy ageing is difficult due to chronic diseases and social isolation. This article presents an analysis of preventive-based interventions and services that promote innovative ageing policies and investigates the involvement of the local community and how it can lead to the deployment of new preventive measures. The research covers the direct impact on the health and living conditions of the recipients (older people) and innovation by the local care model (among social workers and the local community). Qualitative (documentary analysis, semi-structured interviews, and focus groups) as well as quantitative (questionnaire and secondary data analysis) methods were used.

Introduction Many stud ies have documented agerelated declines in impor tant com po nents of cog ni tion, such as processing speed, work ing mem ory, longterm mem ory (Zeisel et al. 2020), and par tic u larly epi sodic mem ory (Salthouse 2013). However, such declines vary greatly across indi vid u als and pop u la tion sub groups. Innate and genetic dif fer ences, as well as vary ing life expe ri ences (e.g., edu ca tion, occu pa tion, par tic i pa tion in cog ni tively stim u lat ing activ i ties), con trib ute to dif fer ences in latelife cog ni tion. Identifying the fac tors that sup port opti mal latelife cog ni tion is crit i cally impor tant, given that cog ni tive health is highly related to qual ity of life, dis abil ity, pro duc tiv ity, and healthrelated expen di tures (Albert et al. 2002;Tabert et al. 2002). Moreover, the suc cess of many pol i cies designed to alle vi ate the costs of pop u la tion aging (e.g., rais ing retire ment ages, extending the period of inde pen dent liv ing) depends on the pop u la tion's abil ity to main tain high cog ni tive func tion ing through out adult hood and into old age (Prince et al. 2015;Skirbekk et al. 2013). Recently, a num ber of stud ies have suggested that fam ily size is another fac tor related to latelife cog ni tion (e.g., Read andGrundy 2017 andSaenz et al. 2021). Some of them try to iso late the causal rela tion ship between the num ber of chil dren and late life cog ni tion by sta tis ti cally con trol ling for socio eco nomic, health, and other char ac ter is tics in stan dard regres sion mod els. For instance, Read and Grundy (2017) com pared indi vid u als aged 50 or older with no chil dren/one child, two chil dren, or three or more chil dren. They found that hav ing two chil dren as opposed to fewer or more chil dren was asso ci ated with bet ter cog ni tive func tion ing across a range of mea sures. However, the asso ci a tions between hav ing three or more chil dren and latelife cog ni tion gen er ally weak ened or disappeared once they sta tis ti cally con trolled for indi vid u als' socio eco nomic and health char ac ter is tics. Their results sug gest that much of the appar ent rela tion ship between hav ing more than two chil dren and latelife cog ni tion is due to con found ers or selec tion effects. From a meth od o log i cal stand point, sta tis ti cally con trol ling for poten tial con found ers in a tra di tional regres sion model might make the poten tial causal effect of fer til ity on latelife cog ni tion some what more plau si ble. However, sta tis ti cally con trol ling for all poten tial confounding fac tors is often unfea si ble, par tic u larly because many data sets lack infor ma tion about even the most rel e vant con found ers (e.g., paren tal pref er ences, innate cog ni tion) or may mea sure such con found ers inad e quately. It is there fore dif fi cult to dis en tan gle selec tion effects (i.e., the extent to which peo ple with higher fer til ity have char ac ter is tics that pre dis pose them to bet ter or worse latelife cog ni tion) from causal effects (i.e., the extent to which higher fer til ity causes var i a tions in latelife cog ni tion) (Aaronson et al. 2014;Lovenheim and Mumford 2012;McCrary and Royer 2011;Monstad et al. 2008). The instru men tal var i able (IV) approach offers a more strin gent way of estab lishing cau sal ity. It entails using a source of var i a tion in the explan a tory var i able of inter est (in this case, the num ber of chil dren) that is related to the out come var i able of inter est (here, latelife cog ni tion) only through its effect on the explan a tory var i able. This method relies on a num ber of assump tions about the source of var i a tions, which we dis cuss later in the sec tion devoted to the empir i cal strat egy. In the cur rent study, we use an IV approach and data from the Survey of Health, Ageing and Retirement in Europe (SHARE) to exam ine the extent to which hav ing three or more chil dren ver sus two chil dren caus ally affects latelife cog ni tion. SHARE sur veys rep re sen ta tive sam ples of the older pop u la tions in 20 Euro pean countries and Israel, collecting exten sive infor ma tion on par tic i pants' chil dren and obtaining objec tive cog ni tive test scores (BörschSupan et al. 2008). We exploit the sex com po si tion of par tic i pants' first two chil dren (same or mixed sex) as a source of exog e nous var i a tion in the prob a bil ity of hav ing three or more chil dren. We can thereby esti mate the effect of sex com po si tion on latelife cog ni tion by using the twostage leastsquares (2SLS) esti ma tor and com pare the results of the IV and tra di tional empir i cal approaches (e.g., the ordi nary leastsquares [OLS] esti ma tor). To our knowl edge, this is the first study to use an IV approach to study the causal effect of high fer til ity on latelife cog ni tion. Further, we explore whether the effect of hav ing three or more ver sus two chil dren varies across four Euro pean regions and exam ine the extent to which hav ing three or more ver sus two chil dren is related to latelife finan cial (net worth and house hold income) and social resources (the fre quency of con tact with chil dren). Does Childbearing Affect Cognitive Health in Later Life? Our study also con trib utes more gen er ally to the lit er a ture on the effects of chil dren on oldage health. A large body of the lit er a ture inves ti gated the asso ci a tion between chil dren and laterlife health, but only a few stud ies addressed the issue of endogeneity regard ing fer til ity choice. To our knowl edge, only one study ana lyzed the effect of fer til ity on health out comes in old age. Kruk and Reinhold (2014) used the first three waves of SHARE to inves ti gate the effect of fam ily size on depres sion in old age using an IV strat egy based on mul ti ple births and sex com po si tion of the first two chil dren. They found no effect of addi tional chil dren on men's men tal health but found that a third child can be det ri men tal to women's men tal health. More pre cisely, the effect was sig nifi cant when they used the mul ti ple births as an instru ment for hav ing more chil dren con di tional on hav ing at least two chil dren but was not sig nifi cant when they used the sex com po si tion of the first two chil dren as an instru ment. CáceresDelpiano and Simonsen (2012) used U.S. data to inves ti gate the effect of fer til ity on moth ers' over all wellbeing, includ ing health out comes, with mul ti ple births as a source of exog e nous var i a tion. They found that this unex pected increase in fer til ity increased the risk of obe sity and high blood pres sure among women aged 20-45. --- Fertility and Cognitive Functioning in Later Life Fertility may affect latelife cog ni tion via sev eral path ways. First, hav ing an addi tional child often incurs con sid er able finan cial costs, such as the costs of extra food, clothes, lei sure activ i ties, transportation, school ing, and a car with more space or a larger house (Bradbury 2008(Bradbury, 2014;;Dey and Wasoff 2010). Moreover, hav ing an addi tional child reduces fam ily income and increases the like li hood of fall ing below the pov erty line (CáceresDelpiano and Simonsen 2012). Having an addi tional child can there fore decrease the stan dard of liv ing for all fam ily mem bers and may cause finan cial worries and uncertainties, which could con trib ute to cog ni tive dete ri o ra tion (Mani et al. 2013). Second, hav ing an addi tional child is caus ally related to women's lower labor mar ket par tic i pa tion, fewer hours worked, and lower earn ings (Aaronson et al. 2021;Rosenzweig and Wolpin 1980;Vere 2011). The neg a tive effect is most evi dent when chil dren are young, although it grad u ally vanishes or even becomes pos i tive as chil dren grow older (Cools et al. 2017). In turn, labor force par tic i pa tion (com pared with retire ment) pos i tively affects cog ni tive func tion ing among men and women ( Bonsang et al. 2012;Grotz et al. 2015;Rohwedder and Willis 2010). Third, chil dren can rep re sent an impor tant social resource, par tic u larly in later life. Having chil dren decreases the risk of social iso la tion among older indi vid u als (Vlachantoni et al. 2015), which is a key risk fac tor for cog ni tive impair ment and demen tia (Ihle et al. 2018). Having more chil dren could raise the level of social inter ac tion and sup port, which can be pro tec tive against cog ni tive decline at older ages (Ertel et al. 2008;Zunzunegui et al. 2003). Finally, hav ing chil dren can be stress ful. Parents with more chil dren can expe ri ence more stress, have less time to invest in cog ni tively stim u lat ing lei sure activ i ties, and have less time to relax. Too much stress can also affect health risk behav iors and adversely affect adult cog ni tive devel op ment (Aggarwal et al. 2014;Prenderville et al. 2015). Moreover, hav ing chil dren often implies sleep dep ri va tion for the par ents (CostaFont and Flèche 2020;Richter et al. 2019), poten tially lead ing to neg a tive longterm effects on cog ni tive func tion ing (Richter et al. 2019;Virta et al. 2013). In sum, higher fer til ity likely has both pos i tive and neg a tive effects on latelife cog ni tion via its effects on finan cial and social resources, stress, and labor mar ket expe ri ences. It is dif fi cult to pre dict which of these mech a nisms might pre dom i nate or how these mech a nisms may inter act with one another. We also expect that the effect of hav ing more chil dren dif fers across countries char ac ter ized by vary ing insti tu tional and cul tural back grounds. --- Empirical Strategy --- Estimation Method The aim of the empir i cal anal y sis is to mea sure the effect of hav ing more than two chil dren (C ict ) on the cog ni tive func tion ing of the par ent i liv ing in coun try c at time t (Y ict ). The equa tion to be esti mated is the fol low ing: Y ict = <unk> 0 + <unk> 1 C ict + X ′ ict <unk> <unk> 2 + <unk> ct + <unk> ict,(1) where X ′ ict is a vec tor of con trol var i ables that are likely to be related to cog ni tive func tion ing; <unk> 0, <unk> 1, and <unk> <unk> 2 are param e ters to be esti mated; <unk> ct are coun try-wave spe cific fixed effects; and <unk> ict is the error term. Under the assump tion that the error term is uncor re lated with C ict and X ′ ict, the param e ter of inter est (<unk> 1 ) can be esti mated by OLS. This assump tion is unlikely to hold in the pres ent con text. The deci sion to have more chil dren is clearly non ran dom and depends on sev eral unob served char ac ter is tics that are likely to be cor re lated with cog ni tive func tion ing in later life (e.g., child hood health, finan cial resources, labor mar ket oppor tu ni ties, innate cog ni tive and non cog ni tive skills). To iden tify the causal effect of hav ing more than two chil dren on the par ents' cog ni tive func tion ing, we use an IV approach. Equation (1) is there fore esti mated by 2SLS. The firststage equa tion is defined as fol lows: C ict = <unk> 0 + <unk> 1 Z ict + X ′ ict <unk> <unk> 2 + <unk> ct + <unk> ict, (2 ) where Z ict is the instru men tal var i able defined as a dummy var i able that is equal to 1 if the first two chil dren have the same sex and 0 if they do not. We esti mate each of the two equa tions for the full sam ple and sep a rately for women and men. Given that our aim is to iden tify causal effects, we report unweighted esti ma tes (see Solon et al. 2015). Because we have more than one obser va tion for many indi vid u als in the sam ple, we report clus terrobust stan dard errors at the indi vid ual level. --- Identification Strategy Assumptions Given that we can not dis card the hypoth e sis of treat ment effect het ero ge ne ity (i.e., the effect of hav ing more than two chil dren on cog ni tion might dif fer across indi vid u als), the 2SLS esti ma tor allows us to iden tify a local aver age treat ment effect (LATE), Does Childbearing Affect Cognitive Health in Later Life? which is defined as the aver age treat ment effect of the com pli ers-that is, the sub pop u la tion that reacts to the instru ment as intended. In such a set ting, the instru ment must meet four cri te ria (Imbens and Angrist 1994). First, the instru ment must be related to the prob a bil ity of hav ing more than two chil dren (the rel e vance assump tion). Second, it should be as good as ran domly assigned; that is, it should be inde pen dent of the poten tial out comes and poten tial treat ment assign ments (the inde pen dence assump tion). Third, although the instru ment may have no effect on the prob a bil ity of hav ing more than two chil dren for some indi vid u als, all those who are affected should be affected the same way (the mono to nic ity assump tion). Finally, the instru ment should affect cog ni tive func tion ing only through its impact on the prob a bil ity of hav ing more than two chil dren (the exclu sion restric tion assump tion). In line with pre vi ous stud ies (e.g., Cools and Hart 2017;Kruk and Reinhold 2014), we argue that the sex com po si tion of the first two chil dren can be used as an instru ment to esti mate the causal effect of hav ing more than two chil dren (instead of two). The sex com po si tion of the first two chil dren meets the rel e vance assump tion: par ents gen er ally pre fer to have at least one son and one daugh ter as opposed to two chil dren of the same sex (see, e.g., BenPorath and Welch 1976), and par ents who have either two daugh ters or two sons are more likely to have a third child than par ents who have one son and one daugh ter (e.g., Angrist and Evans 1998). The instru ment also meets the inde pen dence assump tion: the sex com po si tion of the first two chil dren is plau si bly ran domly assigned, and there is no rea son to believe that the sex com po si tion of the first two chil dren would be related to any other char ac ter is tics related to latelife cog ni tion (e.g., innate abil ity, pref er ences). For the sex com po si tion of the first two chil dren to meet the mono to nic ity assump tion, there should not be any one who would pre fer to have more chil dren after hav ing one son and one daugh ter but not after hav ing two chil dren of the same sex. Although we can not rule out this pos si bil ity, de Chaisemartin (2017) showed that vio la tions of the mono to nic ity assump tion do not affect the results under either of two con di tions: (1) the LATEs of com pli ers (peo ple who react to the instru ment as expected) and defi ers (peo ple who react the oppo site way) do not dif fer too much; or (2) a sub group of com pli ers accounts for the same per cent age of the pop u la tion as the per cent age of defi ers and has the same LATE, in which case the 2SLS esti ma tor still allows iden ti fi ca tion of a LATE. Finally, to meet the exclu sion restric tion assump tion, the sex com po si tion of the first two chil dren should affect latelife cog ni tion only via its impact on fer til ity. As Angrist and Evans (1998) discussed, one poten tial threat to the exclu sion restric tion assump tion is that it is more likely to have two chil dren of the same sex when the first child is a boy, given the slightly higher like li hood of hav ing a boy than a girl ( Markle 1974). Children's sex, in turn, is related to their health out comes (MacLean et al. 2013), par ents' labor mar ket out comes (Lundberg and Rose 2002), and par ents' prob a bil ity of divorce (Dahl and Moretti 2008). The sex com po si tion of the first two chil dren may there fore poten tially affect latelife cog ni tion through chan nels other than its impact on fer til ity. However, the poten tial cor re la tion between the sex com po si tion of the first two chil dren and chil dren's sex can be eas ily addressed by using dummy var i ables to sta tis ti cally con trol for the sex of the first and sec ondborn chil dren. As an addi tional check, we use two alter nate instru ments: a dummy var i able equal to 1 when the first two chil dren are girls and another dummy var i able equal to 1 when the first two chil dren are boys. As Angrist and Evans (1998) explained, this alter na tive iden ti fi ca tion strat egy allows us to per form an over iden ti fi ca tion test to check whether the chil dren's sex might bias the results. The moti va tion for using this test is that the bias due to an effect of child sex on cog ni tive func tion ing should be dif fer ent according to the instru ment used (i.e., two sons vs. two daugh ters). The null hypoth e sis of the over iden ti fi ca tion test is that the two sons and the two daugh ters instru ments pro duce the same esti ma tes when we use them sep a rately. For this test, we use the Hansen J sta tis tic, which is assumed to be dis trib uted as a chisquare with 1 degree of free dom under the null hypoth e sis. The lit er a ture refers to two other poten tial threats to the exclu sion restric tion assump tion. First, hav ing samesex chil dren might affect childrearing costs because, for exam ple, par ents may pre fer that daugh ters and sons have sep a rate bed rooms. Rosenzweig and Wolpin (2000) found that hav ing mixedsex chil dren was asso ci ated with higher childrearing costs in rural India, but Bütikofer (2011) found no mean ing ful dif fer ences in richer countries, such as the United Kingdom, Switzerland, Mexico, Bulgaria, and Albania. The sex com po si tion of the first two chil dren is there fore unlikely to mean ing fully affect childrearing costs in Europe, the focus of the cur rent study. Second, because par ents tend to pre fer hav ing at least one daugh ter and one son (which ensures the rel e vance of the instru ment), the sex com po si tion of the first two chil dren may affect the wellbeing of par ents who had two chil dren of the same sex but did not have more chil dren. In turn, lower wellbeing (e.g., depres sive symp toms) may affect latelife cog ni tion. Previous research, how ever, found no evi dence that the sex com po si tion of the first two chil dren is related to latelife depres sion (Kruk and Reinhold 2014), and depres sive symp toms do not always appear to be a risk fac tor for cog ni tive decline (Brailean et al. 2017). In sum, the sex com po si tion of the first two chil dren is a rea son able instru ment for establishing the causal effect of hav ing three or more chil dren ver sus two chil dren on latelife cog ni tion. As in any IV strat egy with het ero ge neous treat ment effects, our esti ma tion method cap tures effects on indi vid u als affected by the instru ment (Angrist et al. 1996), which has some impli ca tions for the exter nal validity of our esti ma tes. In our case, our method identifies the causal effect of a planned change in fer til ity for par ents who have pref er ences for mixedsex off spring. Moreover, using the sex com po si tion of the first two chil dren as an instru ment means that the ana ly ses can not deter mine the causal effect of hav ing more chil dren at lower par i ties (e.g., hav ing one vs. no chil dren, hav ing a sec ond child) on latelife cog ni tion. Nevertheless, ana lyz ing the effect of hav ing three or more ver sus two chil dren is highly rel e vant in the Euro pean con text, given that much of the change in Euro pean fer til ity over the past decades has been due to a decrease in the pro por tion of peo ple hav ing three or more chil dren. Fertility ide als and inten tions in Europe have been declin ing, and more adults view two rather than three chil dren as ideal (Sobotka and Beaujouan 2014). --- Regional Heterogeneity Analysis and Mechanisms To exam ine poten tial het ero ge ne ity of the effect of fer til ity on cog ni tive func tion ing across the four Euro pean regions, we repeat the 2SLS regres sion ana ly ses sep a rately Does Childbearing Affect Cognitive Health in Later Life? for each region. Because of sam ple size restric tions, we do not con duct sep a rate esti ma tions for men and women. We also explore the poten tial role of finan cial and social resources as mech a nisms linking higher fer til ity to latelife cog ni tion. We con duct 2SLS ana ly ses with high net worth, pov erty, and fre quency of con tact with chil dren as the out come var i ables for the full sam ple and sep a rately for each Euro pean region. Again, because of sam ple size restric tions, we do not con duct sep a rate esti ma tions for men and women in the regional ana ly ses. --- Additional Robustness Checks To test the robust ness of our results, we check whether our main results change when we use data on only those indi vid u als interviewed for either the first or last time; use the imme di ate recall, delayed recall, flu ency, and the serial sev ens test1 (that was avail able only from Wave 4 onward) as sep a rate out come var i ables; use sam ple weights; and allow the effect of hav ing three or more chil dren to dif fer between men and women (i.e., a male <unk> three or more chil dren inter ac tion) in the regional ana ly ses. --- Data --- Analytic Sample The anal y sis is based on pooled data from SHARE Waves 1, 2, 4, 5, and 6. We exclude data from (1) Wave 3 because it was a ret ro spec tive sur vey with no rel e vant data; (2) Israel because our focus is on Europe; and (3) Ireland because of its small sam ple size. Participants are from 19 Euro pean countries: Austria, Belgium, Croatia, Czech Republic, Denmark, Estonia, France, Germany, Greece, Hungary, Italy, Luxembourg, the Netherlands, Poland, Portugal, Slovenia, Spain, Sweden, and Switzerland. Data were col lected using a com puterassisted per sonal interviewing pro gram, supplemented by a selfcom ple tion paperandpen cil ques tion naire. For more details, see BörschSupan et al. (2008). The ana lytic sam ple includes all par tic i pants aged 65 or older (N = 127,036) who had only bio log i cal chil dren (N = 100,073) and at least two chil dren (N = 79,483). We exclude indi vid u als whose age at the first child's birth was below the 0.5 per cen tile of the gen derspe cific dis tri bu tion and indi vid u als whose age at the sec ond child's birth was above the 99.5 per cen tile of the gen derspe cific dis tri bu tion (leav ing N = 77,178). We exclude 478 par tic i pants who had miss ing val ues for one or more of the explan a tory var i ables and 3,347 par tic i pants who had miss ing data on at least one cog ni tive mea sure. Thus, the final sam ple com prises 73,353 par tic i pants. The level of miss ing data on the pre dic tor var i ables is low, but miss ing val ues on the cog ni tive data are more sub stan tial. Furthermore, miss ing cog ni tive scores are largely due to the use of proxy inter views, whereby an infor mant com pletes the ques tion naire when ever the intended respon dent is too phys i cally or men tally impaired to com plete the inter view her or him self. The sys tem atic exclu sion of peo ple with lower phys i cal and men tal capac ity may there fore bias our results. To

The online ver sion of this arti cle (https: / /doi .org /10 .1215 /00703370 -9930490) con tains sup ple men tary mate rial.

val ues for one or more of the explan a tory var i ables and 3,347 par tic i pants who had miss ing data on at least one cog ni tive mea sure. Thus, the final sam ple com prises 73,353 par tic i pants. The level of miss ing data on the pre dic tor var i ables is low, but miss ing val ues on the cog ni tive data are more sub stan tial. Furthermore, miss ing cog ni tive scores are largely due to the use of proxy inter views, whereby an infor mant com pletes the ques tion naire when ever the intended respon dent is too phys i cally or men tally impaired to com plete the inter view her or him self. The sys tem atic exclu sion of peo ple with lower phys i cal and men tal capac ity may there fore bias our results. To assess the poten tial for bias due to miss ing cog ni tive data, we com pare the char ac ter is tics of peo ple with miss ing cog ni tive test scores and peo ple with out miss ing data. Table A1 in the online appen dix and the accom pa ny ing dis cus sion pres ent descrip tive sta tis tics for peo ple with and with out cog ni tive data and explain why miss ing cog ni tive data could bias the OLS esti ma tes but not the IV esti ma tes. Because we pool data from mul ti ple waves, some par tic i pants are observed more than once. We there fore also check whether the num ber of waves a per son par tic i pated in is asso ci ated with the sex com po si tion of the first two chil dren. --- The Measures of Cognitive Functioning SHARE includes five mea sures of cog ni tion: (1) imme di ate and delayed word recall, which mea sure epi sodic mem ory (i.e., mem ory of per sonal expe ri ences); (2) ver bal flu ency to mea sure exec u tive func tion ing, which reg u lates one's thoughts and directs behav ior toward attaining a par tic u lar goal (see, e.g., Shao et al. 2014); (3) numer acy; (4) ori en ta tion in time; and (5) the serial sev ens test. The numer acy and ori en ta tion intime tests were admin is tered only for indi vid u als who were interviewed for the first time, and the serial sev ens test was assessed only in Wave 4. We thus focus on the imme di ate recall, delayed recall, and ver bal flu ency mea sures. Episodic mem ory and exec u tive func tion ing are widely rec og nized to be sen si tive to cog ni tive aging (Souchay et al. 2000). In the imme di ate and delayed recall tasks, the inter viewer recites 10 words. Par ticipants are then asked to recite as many words as they can remem ber imme di ately (imme di ate recall) and once again after com plet ing the ver bal flu ency and numer acy tasks (delayed recall). For the flu ency task, respon dents are asked to name as many ani mals as pos si ble in one min ute. We use prin ci pal com po nents anal y sis to com bine the scores from the three tasks into a gen eral index of latelife cog ni tion, defined as the first prin ci pal com po nent. Before anal y sis, we nor mal ize scores so that the mean is 0 and the stan dard devi a tion is 1. --- The Number of Children and the Instruments Information on par tic i pants' chil dren is based on par tic i pants' first inter view. We cal cu late the num ber of chil dren. We use chil dren's birth years to iden tify the two oldest chil dren. 2 The sex com po si tion of the first two chil dren is our main instru ment. We cre ate a first two chil dren: same sex dummy var i able (1 = first two chil dren are of the same sex, and 0 = first two chil dren are of dif fer ent sexes). We cre ate four addi tional dummy Does Childbearing Affect Cognitive Health in Later Life? var i ables to use as sta tis ti cal con trols and to test over iden ti fi ca tion (as described ear lier): (1) first two chil dren: two sons; (2) first two chil dren: two daugh ters; (3) first born daugh ter; and (4) sec ond-born daugh ter (all coded as 1 = yes, and 0 = no). --- Sociodemographic Control Variables Our model includes sev eral con trol var i ables. Although the inclu sion of con trol var i ables should not affect the con sis tency of the 2SLS esti ma tes (because none of the var i ables are asso ci ated with our instru ment, as we will show later), it can help to improve the esti ma tes' pre ci sion. We con trol for a cubic func tion of par tic i pants' age to account for cog ni tive aging; we con trol for age at sec ond birth because it was (pos i tively) asso ci ated with latelife cog ni tion in a pre vi ous study (Read and Grundy 2017). Age is mea sured in months (e.g., for an indi vid ual aged 70 years and two months, age = 70.1666). We also con trol for whether the respon dent was born abroad (1 = yes, and 0 = no) and for par tic i pant sex (1 = male, and 0 = female). We con trol for edu ca tion according to the ISCED1997 clas si fi ca tion (pri mary edu ca tion or less, sec ond ary edu ca tion, ter tiary edu ca tion, or miss ing). Individuals with miss ing edu ca tional data account for 0.7% of the sam ple. To con trol for coun try-wave fixed effects, we cre ate one dummy var i able for each coun try-wave. --- Financial and Social Resources As described ear lier, higher fer til ity is likely to affect latelife cog ni tion via sev eral mech a nisms. Of the pre sumed mech a nisms, SHARE data include reli able indi ca tors for only finan cial and social resources. Detailed infor ma tion about respon dents' work his to ries is avail able in SHARELIFE, a ret ro spec tive sur vey included in Waves 3 and 7. However, the ques tion naire was admin is tered to a much smaller and more selec tive sub sam ple of par tic i pants (as noted in foot note 2). We used the fre quency of con tact with chil dren per month as an indi ca tor of par tic i pants' social resources. This mea sure is based on a ques tion asked for each child of the respon dent: "During the past twelve months, how often did you (or your hus band/wife/part ner) have con tact with child name, either per sonal, by phone or mail?" For each of the six response options, we impute the num ber of con tacts per year: daily = 365; sev eral times per week = 156; about once per week = 52; about every two weeks = 26; about once per month = 12; less than once per month = 6; and never = 0. We then sum the total num ber of con tacts with each child and divide it by 12 to obtain the aver age num ber of con tacts with all chil dren per month over the last 12 months. We use house hold net worth and income as indi ca tors of par tic i pants' finan cial resources. Household net worth cor re sponds to the sum of the house hold net finan cial assets (gross finan cial assets minus finan cial lia bil i ties) and house hold real assets. Household income is mea sured as the yearly total net house hold income. Household income pri mar ily reflects the amount of pen sion income. We use equiv a lent house hold income by divid ing house hold income by the square root of house hold size. All amounts are mea sured in euros and are adjusted for pur chas ing power par ity and denominated in prices obtained in Germany in 2005. Household income and net worth were imputed for a sig nifi cant pro por tion of respon dents, which may decrease the accu racy of the results and bias the esti ma tes toward 0 because the impu ta tion pro ce dure did not take the sex com po si tion of the chil dren into account (Bollinger and Hirsch 2006;Hirsch and Schumacher 2004). To min i mize bias due to impu ta tion and to decrease the influ ence of out li ers, we use the house hold income and net worth data to define two dichot o mous var i ables. First, we define a dichot o mous pov erty var i able, with 1 equal to equiv a lent house hold income below 60% of the coun trywavespe cific median and 0 equal to equiv a lent house hold income at or above the 60% of the coun try-wavespe cific median (a com monly used defi ni tion of pov erty; see, e.g., Filandri and Struffolino 2019). Second, we define a dichot o mous high net worth var i able, with 1 representing net worth higher than the coun try-wavespe cific median and 0 representing net worth below the coun try-wavespe cific median. --- Results --- Descriptive Statistics Table 1 pres ents the descrip tive sta tis tics for the full ana lytic sam ple and sep a rately by the sex com po si tion of par tic i pants' first two chil dren. As expected, peo ple whose first two chil dren are of the same sex have more chil dren than peo ple whose first two chil dren are of mixed sex (2.80 vs. 2.68 chil dren, respec tively); they are also more likely to have three or more chil dren rel a tive to their peers whose first two chil dren are of mixed sex (48% vs. 41%, respec tively). People whose first two chil dren are of the same sex also have worse latelife cog ni tion (com bined index), imme di ate recall, and flu ency; there are no sig nifi cant dif fer ences with respect to delayed recall. Fur ther, we find no other sta tis ti cally sig nifi cant dif fer ences between the two groups of par ents. The descrip tive evi dence sug gests that the sex com po si tion of the first two chil dren is rel e vant and ran domly assigned and that hav ing three or more ver sus two chil dren is related to worse latelife cog ni tion. --- First-Stage Results Table 2 pres ents the firststage OLS esti ma tes of the effect of first hav ing two chil dren of the same sex on hav ing three or more chil dren (vs. hav ing two chil dren). The results are presented for the full sam ple and for men and women sep a rately. Consis tent with pre vi ous stud ies (Angrist and Evans 1998;Kruk and Reinhold 2014), the results con firm that par ents whose first two chil dren are of the same sex are seven per cent age points more likely to have three or more chil dren than other par ents. The effect is very sim i lar for men and women. The find ings do not dif fer by whether the first or sec ond child is a girl ver sus a boy or by whether the par ent first has two sons ver sus two daugh ters. It is worth not ing that the effect of first hav ing two daugh ters on hav ing three or more ver sus two chil dren is slightly larger than the effect of first hav ing two sons, suggesting a slight pref er ence for sons. However, the dif fer ence is not sta tis ti cally sig nifi cant. --- Results From the 2SLS Estimators Table 3 pres ents the results of the OLS and 2SLS esti ma tes of the effect of hav ing three or more ver sus two chil dren on latelife cog ni tion, as well as the results of the endog eneity and over iden ti fi ca tion tests. The first two col umns of Table 3 pres ent the OLS esti ma tes with out and with the inclu sion of the sociodemographic con trol var i ables, respec tively. The OLS esti ma tes indi cate that par ents who have three or more chil dren have worse latelife cog ni tion than par ents with just two chil dren. 3 Controlling for par tic i pants' sociodemographic char ac ter is tics weak ens the asso ci a tion, but the effect of hav ing three or more ver sus two chil dren remains sig nifi cantly dif fer ent from 0 at the 0.1% level. Neither the sex of the first born child nor that of the sec ondborn child is related to latelife cog ni tion. The neg a tive asso ci a tion between hav ing three or more ver sus two chil dren and latelife cog ni tion is sim i lar for men and women. The last two col umns of Table 3 pres ent the 2SLS esti ma tes, with first hav ing two chil dren of the same sex as one instru ment and first hav ing two sons or two daugh ters as sep a rate instru ments. In all cases, the F tests of the excluded instru ment(s) con firm the results from Table 2: hav ing two chil dren of the same sex, hav ing two sons, and hav ing two daugh ters each strongly pre dicts the prob a bil ity of hav ing three or more chil dren. The F tests sug gest that the 2SLS esti ma tes are unlikely to suf fer from bias owing to weak instru ments. Table 3 also shows that the endogeneity tests4 reject the null hypoth e sis that the num ber of chil dren is exog e nous, jus ti fy ing the use of the 2SLS to esti mate the causal effect of hav ing three or more ver sus two chil dren on latelife cog ni tion. Furthermore, we con duct an over iden ti fi ca tion test (see Angrist and Evans 1998) for which the null hypoth e sis is that the effect of hav ing more than two chil dren on cog ni tive func tion ing does not dif fer by whether the two sons instru ment ver sus the two daugh ters instru ment is used. The moti va tion for this test is that the bias due to an effect of child sex on cog ni tive func tion ing should dif fer according to the instru ment used. To test the null hypoth e sis, we use the Hansen J sta tis tic, which is assumed to have a chisquare dis tri bu tion with 1 degree of free dom. The over iden ti fi ca tion matest does not reject the null hypoth e sis and sug gests that the esti mated effects are not sen si tive to whether the two first chil dren of the same sex are girls ver sus boys. The results presented in the last two col umns of Table 3 clearly indi cate that hav ing three or more ver sus two chil dren is det ri men tal for latelife cog ni tion, and the neg a tive cog ni tive effect is large in mag ni tude. Based on the esti mated impact of the con trol var i ables, the neg a tive effect is sim i lar to being 6.2 years older (for an indi vid ual aged 74.3, the aver age age in our sam ple), or about 90% of the advan tage in Does Childbearing Affect Cognitive Health in Later Life? latelife cognition asso ci ated with hav ing com pleted sec ond ary ver sus pri mary edu ca tion. 5 The impact is sim i lar for men and women. The 2SLS esti ma tes of the effect of hav ing three or more chil dren are larger than the OLS esti ma tes, indi cat ing pos i tive selec tion of those hav ing more than two chil dren. In other words, indi vid u als who have three or more ver sus two chil dren appear to have unob served char ac ter is tics that par tially pro tect them from the neg a tive impact 5 These com par i sons are cal cu lated using the esti mated coef fi cients for age and level of edu ca tion. of hav ing more chil dren on latelife cog ni tion. Nevertheless, the OLS esti ma tes are neg a tive, indi cat ing that the neg a tive causal effect still out weighs the selec tion effect. The dif fer ence between the OLS and 2SLS esti ma tes of hav ing three or more ver sus two chil dren may also be partly due to the sam ple selec tion bias of the OLS esti ma tor, as discussed in sec tion 1 of the online appen dix. The main results are highly sim i lar when we use each cog ni tive test score as a sep a rate depen dent var i able, weighted esti ma tes, or data from those indi vid u als interviewed for either the first or last time (see sec tions 2-4 of the online appen dix). In fol lowup ana ly ses, we found some evi dence of pos i tive selec tion: indi vid u als who were in a house hold with 100+ books at age 10 were more likely to have three or more chil dren (p <unk>.01; see sec tion 5 of the online appen dix). This result sug gests that indi vid u als who have more than two chil dren share other unob serv able char ac ter is tics that are pos i tively cor re lated with cog ni tive func tion ing in later life. --- Regional Heterogeneity We now inves ti gate whether the effect of hav ing more than two chil dren on cog ni tive func tion ing in later life dif fers across Euro pean regions: Northern Europe (Denmark and Sweden), Western Europe (Austria, Belgium, France, Germany, Luxembourg, the Netherlands, and Switzerland), Eastern Europe (Czech Republic, Poland, Hungary, Slovenia, Estonia, and Croatia), and Southern Europe (Italy, Spain, Portugal, and Greece). This aggre ga tion was used in ear lier stud ies (FernándezCarro and Vlachantoni 2019;JerezRoig et al. 2018;Nielsen et al. 2017). Table 4 pres ents the results from the 2SLS ana ly ses of the effect of hav ing three or more ver sus two chil dren on latelife cog ni tion for each of the four Euro pean regions. The firststage esti ma tes indi cate a pref er ence for mixedsex off spring in all regions. Given the smaller sam ple sizes, the esti mated effects of the 2SLS regional ana ly ses are less pre cise than the ana ly ses based on the full sam ple. The esti mated effect of hav ing three or more ver sus two chil dren is neg a tive across each of the four regions, but the effect is larger and is sig nifi cantly dif fer ent from zero only in Northern Europe. The results there fore sug gest that hav ing three or more ver sus two chil dren is par tic u larly det ri men tal for latelife cog ni tion in Northern Europe com pared with the other Euro pean regions. We find no evi dence that the effect of hav ing three or more ver sus two chil dren dif fers for men rel a tive to women (see sec tion 6 of the online appen dix). In a fol lowup anal y sis based on data from only Western, Eastern, and Southern Europe, we found the neg a tive effect of three or more ver sus two chil dren on late life cog ni tion to be sig nifi cant at the 10% level (p =.079). Thus, although the effect appears to be more salient in Northern Europe, the esti mated over all cog ni tive effect of hav ing three or more ver sus two chil dren is not solely driven by the rela tion ship observed in this region. --- Exploring the Potential Mechanisms Table 5 pres ents the results of the 2SLS ana ly ses of the effect of hav ing three or more ver sus two chil dren on high net worth, pov erty, and fre quency of con tact with chil dren. Overall, hav ing three or more ver sus two chil dren decreases the prob a bil ity of hav ing high net worth, although the effect is sig nifi cant at the 10% level, but does not sig nifi cantly affect the prob a bil ity of pov erty. Having three or more ver sus two chil dren also increases the fre quency of con tact with chil drenan effect that is sig nifi cant at the 0.1% level. However, the results also indi cate that hav ing three or more ver sus two chil dren has dif fer ent con se quences for finan cial and social resources across the four Euro pean regions. Namely, hav ing three or more ver sus two chil dren decreases the prob a bil ity of hav ing high net worth in Northern Europe (p <unk>.10), whereas no effect is evi dent in the other Euro pean regions. Similarly, we find some sug ges tion that hav ing three or more ver sus two chil dren increases the like li hood of latelife pov erty in Northern Europe (a non sig nifi cant find ing; p =.112) but decreases the like li hood of latelife pov erty else where. Because our mea sure of pov erty pri mar ily reflects the amount of pen sion income received, the trend may reflect that hav ing three or more ver sus two chil dren has a more neg a tive impact on life time earn ings in Northern Europe. Having three or more ver sus two chil dren is asso ci ated with more con tact with chil dren in Eastern, Western, and espe cially Southern Europe, but not in Northern Europe. Together, the results of the effect of hav ing three or more ver sus two chil dren on latelife finan cial and social resources sug gest that the effect of hav ing more than two chil dren is par tic u larly det ri men tal for latelife cog ni tion for par ents in Northern Europe because higher fer til ity more neg a tively affects their finan cial resources but does not improve their social resources. However, in the absence of medi a tion ana ly ses, this con clu sion remains highly ten ta tive. --- Discussion and Conclusion Understanding the fac tors that con trib ute to opti mal latelife cog ni tion is essen tial for ensur ing suc cess ful aging at the indi vid ual and soci e tal lev els-par tic u larly in Europe, where family sizes have shrunk and pop u la tions are aging rap idly. For indi vid u als, late life cog ni tive health is essen tial for maintaining inde pen dence and being socially active and pro duc tive in late life; stud ies have linked cog ni tive health with qual ity of life, dis abil ity, and healthrelated expen di tures and care needs (Albert et al. 2002;Tabert et al. 2002). For soci e ties, ensur ing the cog ni tive health of the older pop u la tion is essen tial for extending work lives and reduc ing health care costs and care needs. Compared with other fac tors, such as edu ca tion or occu pa tion, fer til ity has not received much atten tion as a poten tial pre dic tor of latelife cog ni tion. Fertility may affect latelife cog ni tion via sev eral mech a nisms, includ ing finan cial and social resources, labor mar ket expe ri ences, and stress. Previous stud ies have suggested that higher fer til ity is related to worse latelife cog ni tion (e.g., Read and Grundy 2017). However, evi dence of a causal effect has been lacking. To the best of our knowl edge, our study is the first to dem on strate a causal effect of higher fer til ity on latelife cog ni tion. Using an IV approach, we found that hav ing three or more ver sus two chil dren causes worse latelife cog ni tion in Europe for both men and women. The neg a tive effect of hav ing three or more ver sus two chil dren is large in mag ni tude, equiv a lent in our sam ple to being 6.2 years older and nearly the same as the cog ni tive advan tage asso ci ated with hav ing com pleted sec ond ary ver sus pri mary edu ca tion. Our results sug gest that the decrease in the pro por tion of Euro pe ans hav ing three or more chil dren may have pos i tive impli ca tions for the cog ni tive health of the older pop u la tion. Given the mag ni tude of the effect, future stud ies on latelife cog ni tion should also exam ine fer til ity as a pre dic tor along side Does Childbearing Affect Cognitive Health in Later Life? more com monly researched pre dic tors, such as edu ca tion, occu pa tional expe ri ences, phys i cal exer cise, and men tal and phys i cal health. We also need more infor ma tion on the types of inter ac tions, sup ports, and con flicts that occur between par ents and chil dren, which may influ ence cog ni tive out comes. We found evi dence that the neg a tive cog ni tive effect of hav ing three or more ver sus two chil dren was larg est in Northern Europe rel a tive to the other Euro pean regions. Although stan dards of liv ing in the Nor dic countries are very high, so are costs. Estimates based on pur chas ing power par i ties sug gest that the prices of goods and ser vices are up to three times higher in the Nor dic than in other Euro pean coun tries (Eurostat 2020). Housing costs in the Nor dic countries are also among the high est in the world (Bengtsson et al. 2017). Having a third child in Northern Europe may there fore incur more finan cial costs (and poten tially higher finan cial stress) than in many other regions. Moreover, the expec ta tion that chil dren should care for their aging par ents may be lower in Northern Europe, where insti tu tions are expected to pro vide sup port (Marckmann 2017). Future research should address what the cur rent study has not been able to ana lyze. First, we exam ined the aver age effect of hav ing three or more ver sus two chil dren on latelife cog ni tion for indi vid u als affected by the instru ment (i.e., the sex of the first two chil dren). It is plau si ble, how ever, that some par ents or sub pop u la tions will not have a pref er ence for mixedsex off spring, which has impli ca tions for the exter nal validity of our results. Our research focuses only on the tran si tion from two to three or more chil dren. Future stud ies should inves ti gate the effects of hav ing an addi tional child at lower par i ties (the tran si tion to first and sec ond births), which may dif fer from the effect of hav ing three or more ver sus two chil dren. Read and Grundy (2017) esti mated the asso ci a tion between the num ber of chil dren and cog ni tive func tion ing in later life and found that being child less (com pared to hav ing two chil dren) is related to worse latelife cog ni tion for women. They argue that hav ing chil dren pro vi des a source of inter ac tions and pro motes social activ i ties that are asso ci ated with bet ter cog ni tive func

The online ver sion of this arti cle (https: / /doi .org /10 .1215 /00703370 -9930490) con tains sup ple men tary mate rial.

results. Our research focuses only on the tran si tion from two to three or more chil dren. Future stud ies should inves ti gate the effects of hav ing an addi tional child at lower par i ties (the tran si tion to first and sec ond births), which may dif fer from the effect of hav ing three or more ver sus two chil dren. Read and Grundy (2017) esti mated the asso ci a tion between the num ber of chil dren and cog ni tive func tion ing in later life and found that being child less (com pared to hav ing two chil dren) is related to worse latelife cog ni tion for women. They argue that hav ing chil dren pro vi des a source of inter ac tions and pro motes social activ i ties that are asso ci ated with bet ter cog ni tive func tion ing. However, other aspects of child less ness could have pos i tive con se quences for latelife cog ni tive func tion ing by pos ing fewer finan cial and time con straints dur ing adult hood rel a tive to hav ing chil dren. Following delayed and post poned fer til ity, more Euro pe ans are remaining child less (par tic u larly in Central, Northern, and Western Europe) or hav ing only one child (par tic u larly in Eastern Europe). Understanding the effects of transitioning to par ent hood or to a sec ond child is there fore of increas ing impor tance in the Euro pean con text (Kreyenfeld and Konietzka 2017; Zeman et al. 2018). Our results also pro vide the first evi dence that hav ing three or more ver sus two chil dren may affect latelife cog ni tion by affect ing par ents' latelife finan cial and social resources. However, the evi dence is only sug ges tive; meth od o log i cal prob lems and data lim i ta tions made it impos si ble to con duct a for mal medi a tion anal y sis. Future stud ies should exam ine other poten tial medi a tors (e.g., stress, emo tional sup port) and test medi a tion more strin gently. Future research should also exam ine the effect of higher fer til ity on cog ni tive change as opposed to latelife cog ni tion at a sin gle point in time, given that pre dic tors of decline may dif fer from pre dic tors of change. <unk> --- E. Bonsang and V. Skirbekk This article uses data from SHARE Waves 1, 2, 4, 5, and 6. The SHARE data collection has been funded by the European Commission, DG RTD through FP5 (QLK6- CT-2001-00360)

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Introduction As life expectancy increases, most women spend more than a third of their lives in menopause [1]. By 2025, there will be 1.1 billion postmenopausal women worldwide [2]. In Korea, the number of postmenopausal women is expected to increase to 6 in 10 by 2060 [3]. Although menopause is a developmental transition, postmenopausal women experience physical, psychological, and social changes due to estrogen and androgen reduction or imbalance related to the loss of ovarian follicular activity, with both short-and long-term consequences [1,4]. Specifically, they may experience (a) hot flashes, night sweats, mood changes, genitourinary syndrome (e.g., urinary incontinence, vaginal dryness, and dyspareunia), and sleep disorders in the short term, and (b) low quality of life or chronic diseases such as diabetes, cardiovascular disease, and osteoporosis in the long term [5][6][7][8]. Women's health during this period determines successful and healthy aging [9]. Current literature indicates that healthy lifestyle behaviors in postmenopausal women are a critical window for preventing chronic diseases, enhancing their quality of life, and improving their health and function in later life [6,10,11]. Previous reviews have found that healthy eating habits improve cardiovascular and metabolic health and reduce the incidence of breast cancer [12,13]. In addition, low physical activity, smoking, and obesity have been shown to increase the overall cardiovascular disease incidence and all-cause mortality [14]. Therefore, a sufficient understanding of lifestyle behaviors among postmenopausal women is necessary [6]. According to the health lifestyle theory [15], health lifestyle refers to collective patterns of health behaviors that people have adopted based on their life opportunities or circumstances. Although individuals choose their lifestyles, the individual choices are determined by the norms, values, and social environments shared by a particular group or social class [15][16][17]. This theory presents class circumstances (i.e., socioeconomic status [SES]) as the most important structural factor influencing lifestyle formation [15,16]. Empirical studies have consistently indicated a significant relationship between lifestyle and SES in postmenopausal women. For example, a study conducted in the U.S. [18] found that higher household income was associated with higher physical activity. Additionally, a nationally representative study in Korea found that lower household income was associated with high-risk alcohol consumption [19]. Given that heterogeneous lifestyle patterns exist and SES is an important determinant of these patterns [15,20], it is critical to identify lifestyle patterns according to SES among postmenopausal women. To identify lifestyle patterns, recent researchers have used latent class analysis (LCA) across different age groups. For example, two systematic reviews identified the predominant patterns of obesity-related risky lifestyles in children and adolescents [21] and substance use behaviors in young adults [22], respectively. In addition, Zhang [23] identified health lifestyle patterns among Chinese older adults [23]. LCA, a person-centered approach, is useful for classifying individuals who share unobserved latent characteristics [24]. Latent class models (LCMs) assume a mutually exclusive underlying set of subgroups (i.e., latent classes) based on individual response patterns to their categorized behavioral characteristics [24]. LCMs enable an increase in the effectiveness of interventions by offering tailored intervention programs based on multidimensional individual characteristics [25]. However, previous studies on postmenopausal women's lifestyles have primarily focused on (a) one particular lifestyle and (b) its' linear relationships with risk factors based on variable-centered approaches [18,19,[26][27][28]. Moreover, a thorough understanding of the influence of SES on postmenopausal women's lifestyles is essential for understanding the disparities in their lifestyles and subsequent health outcomes [29]. Therefore, in addition to identifying LCMs of lifestyle in postmenopausal women, it is important to identify SES-specific LCMs. However, LCA studies of postmenopausal women's lifestyles have assumed the same LCMs across SES levels [10,[30][31][32]. Although the previous LCA studies of postmenopausal women identified two to five homogenous latent classes (e.g., healthier, poor diet, low physical activity, substance use, and risky-lifestyle classes) [10,[30][31][32], there are few studies that examine whether the LCMs among low-and high-SES groups are comparable. This makes it difficult to provide detailed information on latent class differences between low-and high-SES groups [24]. This study aimed to investigate lifestyle patterns using LCA and the predictors of lifestyle patterns among low-and high-SES postmenopausal women. Given that household income affects lifestyle, health outcomes, and quality of life of postmenopausal women [18,19,[33][34][35], we used household income as an indicator of SES [15]. Therefore, based on the health lifestyle theory and the aforementioned studies indicating the close relationship between income and lifestyles [15,[17][18][19], we hypothesized that (i) distinctive lifestyle patterns would be identified between the low-and high-income postmenopausal women and (ii) the predictors of lifestyle patterns would be different across the two groups. --- Methods --- Data and participants We used secondary data from the Eighth Korea National Health and Nutrition Examination Survey (KNHANES VII) collected in 2019-2020. The KNHANES is a nationally representative and cross-sectional data collected by the Korea Disease Control and Prevention Agency (KDCA) since 1998. The purpose of the KNHANES is to identify the population-based health status, health behaviors, and nutritional intake [36]. To recruit a nationally representative sample, the KDCA selected participants using stratified multistage cluster sampling. Specifically, KNHANES VII (a) divided 192 primary sampling units (PSUs) per year based on administrative district, residential place (i.e., rural or urban), and housing type, and (b) selected 25 households from each PSU. The data from the KNHANES conducted included 15,469 participants. Of the 3582 women aged 50-79 years, 2581 who reported natural menopause were selected. Premenopausal and artificially menopausal women were excluded. Our data were limited to postmenopausal women who reported their household income. The health lifestyle theory states that upper and upper-middle class lifestyles are generally healthier [15]. Therefore, we used the household income variable which was monthly household income standardized according to the number of family members (i.e., monthly household income divided by the square root of the number of household members) and classified into quintiles, from the lowest (Q1) to the highest (Q5) based on the raw data. We dichotomized the variable into low-income (i.e., Q1 and Q2) and high-income (i.e., Q3, Q4, and Q5). Finally, we included 2570 postmenopausal women, including 1186 low-income and 1384 high-income women (Fig. 1). --- Measures --- Indicators of lifestyle behaviors We selected nine lifestyle factors associated with healthrelated quality of life and chronic diseases in postmenopausal women: current smoking, current and high-risk drinking, insufficient walking and muscle-strengthening exercises, insufficient sleep duration, nondaily vegetable and fruit intakes, and lack of weight control efforts [13,[37][38][39][40]. Considering that identification problems may exist with more parameters to be estimated in LCA [24], we dichotomized all indicators. Substance use included tobacco product and alcohol use. Current smoking status was measured using six questions about the participants' lifetime and current tobacco product use (i.e., combustible cigarette [CC], electronic cigarette [EC], and heated tobacco product [HTP] use). Current CC use was defined as having smoked 100 or more CCs in their lifetime and currently smoking CCs [41], current EC use was defined as having used ECs in their lifetime and in the past 30 days, and current HTP use was defined as having used HTPs in their lifetime and currently using HTPs. Based on the information on current smoking status, the current use of at least one tobacco product among CC, EC, and HTP was defined as current smoking. Current drinking was assessed by asking the participants if they had consumed alcohol at least once a month in the past year. High-risk drinking was defined as the consumption of five or more alcoholic drinks on the same occasion at least once a month [42]. For physical activity, two dichotomous items were included: walking and muscle-strengthening exercises. We defined insufficient walking as not walking for more than 30 min at least five days per week, and insufficient muscle-strengthening exercise as not performing musclestrengthening exercises (e.g., lifting weights, sit-ups, and push-ups) two or more days per week [43]. In addition, two continuous variables were used for sleep duration: the average self-reported hours of sleep on weekdays and weekends. We estimated average sleep duration using the following formula: 5/7 <unk> average weekday sleep duration + 2/7 <unk> average weekend sleep duration. Insufficient sleep duration was defined as less than seven hours of sleep per day on average [44]. For dietary behavior, we included vegetable and fruit consumption. Consumption of vegetables, including kimchi (i.e., a traditional Korean fermented vegetable food), and fruits less than once a day in the past year were classified as nondaily vegetable and fruit intakes, respectively. Finally, weight control efforts were assessed using the following question: "Have you tried to control your weight intentionally in the past year?" A lack of weight control effort was defined as no intentional effort to control weight in the past year. --- Predictors of latent class membership Based on the literature on postmenopausal women's lifestyle [10,18,[30][31][32], we used four demographic variables and two chronic diseases as predictors. First, demographics included age (<unk> 65 and <unk> 65 years), education (high school graduation or lower and two-year college or higher), living with a spouse (yes and no), and employment status (unemployed and employed), which were measured using single items. Second, hypertension and diabetes were included as representative chronic diseases in postmenopausal women. Hypertension was defined as (a) a systolic blood pressure level of 140 mmHg or higher, (b) a diastolic blood pressure level of 90 mmHg or higher, or (c) self-reported use of antihypertensive medication [45]. Diabetes was defined as (a) a fasting glucose level of 126 mg/dL or greater, or (b) self-reported use of diabetes medication [46]. --- Data analysis We analyzed secondary data using SAS Version 9.4. First, to identify the sample characteristics by household income, we used descriptive statistics incorporating a complex sampling design (i.e., strata, weight, and primary sampling units) and domain analysis [47]. Second, to estimate the latent lifestyle classes among low-and high-income groups, we used PROC LCA Version 1.3.2 [48]. We tested the LCMs with one to five latent classes for the entire sample. To select the best-fitting model, we compared the likelihood-ratio statistics (G 2 ), Akaike information criterion (AIC), Bayesian information criterion (BIC), adjusted BIC, entropy, and log-likelihood values. Entropy is defined as the degrees of uncertainty, and higher values indicate better latent class separation [24]. Higher values of entropy and lower values of G 2, AIC, BIC, adjusted BIC, and log-likelihood indicate a better model fit [24]. Additionally, we considered the percentage of seeds associated with the best-fitting model, interpretability, and parsimony of each model. The higher percentage of seeds associated with the best-fitting model presents the better identified model [24]. Once the bestfitting model was determined for the entire sample, we evaluated the measurement invariance across low-and high-income groups. We estimated (a) a model with free estimation of item response probability parameters and (b) a model with constrained same item response probability parameters across groups. We then conducted a G 2 difference test and determined measurement invariance to be established when the results did not show a significant difference [48]. A significant difference implied that the measurement invariance was violated, requiring separate estimation of the LCMs across groups [49]. Third, we identified associations between predictors and latent class membership using a multivariate analysis. We conducted a multinomial logistic regression analysis to investigate the relationships between the predictors and class membership among low-and high-income groups [49]. Four demographics and the health status of participants (i.e., with or without hypertension and/or diabetes) were included as predictors. --- Results --- Sample characteristics For the low-income group, 59.6% were aged 65 years or older, and 6.9% had a two-year college or higher education. Approximately 61% resided with their spouse and 39.9% were employed. The prevalence of hypertension and diabetes among low-income participants were 54.2 and 21.3%, respectively. In the high-income group, 23.0% were aged 65 years or older, and 23.8% had a two-year college or higher education. Approximately 82% resided with their spouse, and 50.3% were employed. The prevalence of hypertension and diabetes among high-income participants were 38.3 and 14.4%, respectively. Detailed information on the sample characteristics is provided in Table 1. --- Patterns of lifestyle behaviors among lowand high-income groups Before estimating the LCMs across household incomespecific groups, we estimated the LCMs of lifestyle behaviors using the entire sample. As the number of latent classes increased, the values of G 2 and AIC decreased. However, the adjusted BIC was the lowest in the three-class model and the level of model identification was poor (i.e., low percentages of models were associated with the best-fit model) in the four-and five-class models. Considering the parsimony and easy interpretability of the models, we selected the three-class model. To test measurement invariance across low-and highincome groups, the model with measurement invariance imposed (G 2 = 430.88, df = 992) was compared to the model without measurement invariance imposed (G 2 = 375.97, df = 965). The results showed that measurement invariance across household income was violated (<unk>G 2 = 54.91, df = 27, p =.001). Thus, we estimated the LCMs separately for each income group [49]. We compared the fit statistics of one-to five-class models among low-and high-income groups. In both groups, the values of G 2 and AIC decreased as the number of latent classes increased. However, the adjusted BIC indicated that the three-class model fit better than the four-and five-class model, and the differences in G 2 and AIC among three-, four-, and five-class models were not substantial. Furthermore, considering the poor level a Unweighted frequency and weighted percentage b Percentages may not total 100.0 due to rounding of model identification, interpretability, and parsimony in the four-and five-class models, we selected the threeclass models for both groups (Table 2). For the low-income group, we labeled the classes as "relatively healthy (RH; 45.8%), " "lowest physical activity, insufficient fruit intake, and no intention to control weight (LP-IFW; 45.5%), " and "high-risk drinking and insufficient fruit intake (HD-IF; 8.8%). " Those in the RH class had lower probabilities for most indicators than those in the other classes. Participants in this class had the lowest probabilities of insufficient walking (50.1%) and muscle-strengthening exercises (83.2%). The LP-IFW class was characterized by the highest probabilities of insufficient walking (76.5%) and muscle-strengthening exercises (96.6%), and those in the LP-IFW class had the highest probabilities of nondaily fruit intake (70.7%) and weight control efforts (55.3%). The HD-IF class comprised participants with higher probabilities of current (97.6%) and high-risk drinking (87.2%) than the other classes. Three classes for the high-income group were labeled as "RH (46.0%), " "lowest physical activity (LP; 40.7%), " "high-risk drinking and insufficient fruit intake and sleep (HD-IFS; 13.3%). " In the RH class, participants had less than 50% probabilities for all indicators except insufficient muscle-strengthening exercises (73.6%). Those in the LP class had the highest probability of insufficient walking (76.3%) and muscle-strengthening exercises (96.9%). The HD-IFS class was characterized by the highest probabilities of current drinking (98.4%) and high-risk drinking (73.3%); those in this class had higher probabilities of insufficient sleep (59.5%) and fruit intake (65.6%) than the other classes (Table 3). --- Predictors associated with class membership Table 4 presents the associations between predictors and latent class memberships using the RH class as a reference class. In the low-income group, participants aged 65 years or older had a higher risk of belonging to the LP-IFW class (odds ratio [OR] = 5.93) and a lower risk of belonging to the HD-IF class (OR = 0.38). Those with a two-year college education or higher were less likely to belong to the LP-IFW class (OR = 0.08). Living with a spouse and being unemployed decreased the likelihood of belonging to the LP-IFW and HD-IF classes. Diabetes was associated with an increased likelihood of belonging to the LP-IFW class (OR = 2.09). In the high-income group, those aged 65 years or older had a lower risk of belonging to the HD-IFS class (OR = 0.26). A two-year college or higher education, living with a spouse, and unemployment decreased the likelihoods of belonging to the LP and HD-IFS classes. Hypertension was associated with an increased likelihoods of belonging to the LP (OR = 1.74) and HD-IFS classes (OR = 1.79). --- Discussion This study offers new insights into the lifestyle behavioral patterns of postmenopausal women according to income level as an indicator of SES. The use of LCA provides a better understanding of the role of income in lifestyle patterns than variable-centered approaches. As hypothesized, the classification of the three subgroups differed by income: (a) RH, LP-IFW, and HD-IF classes for low-income group and (b) RH, LP, and HD-IFS classes for their high-income counterparts. Previous LCA studies of postmenopausal women investigating patterns of lifestyle behaviors did not consider differences in patterns by SES [10,[30][31][32], making it difficult to directly compare the results of previous studies with ours. However, the characteristics of the LCMs in our study were consistent with those reported in previous studies. For example, the proportion of the RH class was the largest in both groups in our study, which was consistent with previous studies on postmenopausal women in the U.S. and Australia [10,30]. In addition, latent classes in both groups were less likely to engage in sufficient physical activity, especially muscle-strengthening exercises. Similarly, a previous study examining race-specific lifestyle patterns in postmenopausal women found that participants in an Asian group were physically inactive across all classes [10]. Consistent with the health lifestyle theory [15][16][17], we found differential patterns between low-and highincome groups, and the low-income latent classes showed multiple unhealthy characteristics. When comparing RH and LP-IFW in the low-income group and RH and LP in the high group, to which about 90% of the participants belong in each group, latent classes in the low-income group had higher risks for various unhealthy lifestyles. For example, the RH class in low-income group showed high probabilities of insufficient musclestrengthening exercises, walking practice, and sleep duration. Unlike the LP class in the high-income group, the LP-IFW class in the low-income group was more likely to have insufficient sleep duration, nondaily fruit intake, and lack of weight control efforts as well as insufficient physical activity. These findings are supported by previous studies indicating that low-income adults are more likely to engage in a greater number of risky lifestyle behaviors than their high-income counterparts [50,51]. The consistency of our findings with the theoretical and empirical evidence highlights the need to understand lifestyle patterns among postmenopausal women according to their income level. In terms of predictors, higher education served as a protective factor that reduced the likelihood of unhealthy lifestyle patterns in both groups. These findings are consistent with those of previous LCA studies in postmenopausal and middle-aged women [10,30,52]. According to the health lifestyle theory [15][16][17], these associations between SES and unhealthy lifestyle behaviors may be because those with low income and education levels do not have enough structural context for healthy lifestyle choices or changes. Specifically, those with low SES may (a) lack the ability to access and understand information about healthy lifestyles [20,53] and (b) have insufficient resources for healthy lifestyles [16,20,53]. Moreover, Pampel et al. [20] assert that those with low SES are less motivated to engage in healthy behaviors and may engage in unhealthy lifestyle behaviors to cope with higher stress levels. Latent class memberships in both groups differed by age. Similar to previous studies [54,55], participants aged 65 years or older had an increased likelihood of belonging to the low-income LP-IFW class but not to the high-income LP class. These findings suggest that the negative impact of age on lifestyle behaviors may be greater in postmenopausal women with low-income. Consistent with the health lifestyle theory [15,17], the high probability of an unhealthy lifestyle among lowincome elderly women may be attributed to the fact that poverty can constrain their healthy lifestyle choices and chances. However, we found that participants aged 65 years or older were less likely to belong to high-risk drinking classes in both groups. These results are consistent with those of previous studies [19,56,57]. The two potential reasons for these negative associations between age and high-risk drinking classes across both groups are (a) reduced alcohol consumption due to poor physical health [58] and (b) reduced opportunities for social participation in which alcohol is provided in older age [57]. Living with their spouses was associated with a lower risk of being in the unhealthy classes than the RH class among both groups, which is consistent with previous LCA studies of postmenopausal and midlife women [30,52]. These results provide evidence that the spouse's role is important for postmenopausal women to maintain a healthy lifestyle. Given that spousal support is an important health issue for postmenopausal women, previous studies have argued that including a spouse is a critical strategy for maintaining a healthy lifestyle [59,60]. Regarding the association between LCMs and employment status, employed individuals were less likely to belong to the RH class in both groups. Similarly, a previous LCA study of middle-aged U.S. women found that the proportion of employed women was significantly higher in the drinking class than in the healthy class [52]. The association between employment and unhealthy lifestyle patterns may be partially because employed women have less time to practice a healthy lifestyle [61] and are more exposed to drinking opportunities than their unemployed counterparts [62]. In our study, we found that those with hypertension were more likely to belong to the LP and HD-IFS classes in highincome group, and those with diabetes were more likely to belong to the LP-IFW class in low-income group. These findings may be due to the multiple unhealthy lifestyles in the classes. For example, the LP-IFW class in low-income group had multiple risk factors for diabetes, such as lower physical activity levels, nondaily fruit consumption, and lack of weight control efforts. These associations of lifestyle patterns with hypertension and diabetes are supported by two previous LCA studies of postmenopausal U.S. women: multiple lifestyle and psychosocial risk patterns (a) had the highest proportion of hypertensive patients who had ever been diagnosed with hypertension [10], and (b) had the highest risk of diabetes after approximately 15 years [32]. These results suggest that multiple-risk lifestyle patterns have a synergistic relationship with cardiovascular diseases, such as hypertension and diabetes, compared to low-risk lifestyle patterns [63,64]. Despite the poorer lifestyle characteristics, the association between hypertension and LCM of low-income group was not significant. Our findings may be partially attributable to the difference in the age distributions of the study participants: a much higher proportion of participants aged 65 years or older in the low-income group than those in the high-income group. Previous studies have indicated that the association between multiple unhealthy lifestyle behaviors and the risk of hypertension is attenuated in older women [65]. Cohen et al. [65] stated that the weakened relationship between lifestyle and hypertension with aging can be explained, in part, by physiological differences (e.g., increased arterial stiffness and blunted autonomic nervous system responses to stimuli) among older women. However, considering that mechanisms underlying the differences in susceptibility to hypertension according to income level are complex and unclear [66], further research is needed to fully understand the relationship between hypertension and lifestyle patterns according to income level. --- Practical implications Although SES plays a significant role in disparities in health and health behaviors from a public health perspective [20], most lifestyle interventions for postmenopausal women do not consider participants' individual lifestyle patterns and differential pattern characteristics according to income or other SES factors [12,67]. Lifestyle interventions tailored to the characteristics of the different patterns among low-and high-income postmenopausal women are required. Since the influence of unmeasured confounding factors has not been determined in this study, practical implications should be discussed cautiously. However, our study highlights the need for a person-centered approach to fully understand the risk of varying patterns of unhealthy lifestyles according to income. Despite the fact that the LP-IFW class does not use substances, health professionals should not consider those in the LP-IFW class in low-income group to be less risky than those in the HD-IF class. The LP-IFW class has multiple risky lifestyle behaviors and is strongly associated with ages 65 years or older and diabetes. These findings suggest that paying more attention to this class is an appropriate strategy to enhance healthy lifestyles. It is important to intensively monitor the lifestyles of elderly and diabetic patients. For both income groups, being employed was significantly related to unhealthy lifestyle patterns but tended to have a greater impact on the patterns in high-income group than in low-income group. Considering these points, health professionals should provide resources or develop interventions to enable postmenopausal working women to engage in healthy lifestyles [61]. In addition, women aged under 65 years in both groups were likely to experience HD-IFS classes; therefore, interventions to address alcohol-related concerns may need to be considered for younger women. --- Strengths and limitations Our study had several strengths. First, it confirmed the income level-specific lifestyle behavior patterns of postmenopausal women. Second, we performed a secondary analysis of nationally representative data to facilitate generalization to postmenopausal Korean women. Third, we used biometric data for hypertension and diabetes to increase the accuracy of the relationship between the latent class memberships and chronic diseases. Molenaar et al. [68] suggested using a self-reported questionnaire with biometric data, because self-reported hypertension and diabetes may underestimate the prevalence. However, our findings should be interpreted with the following limitations. First, owing to the cross-sectional nature of the data, causal inferences between lifestyle patterns and predictors were not established. Second, it was not possible to use validated lifestyle measures and adjust for potential unmeasured confounding factors because we conducted a secondary data analysis. Third, all lifestyle behaviors were self-reported. Self-reports of substance use may be underreported and those of exercise may be overreported due to social desirability [69]. --- Conclusions This study identified the differential patterns of lifestyle behaviors among low-and high-income postmenopausal women using a person-centered approach. Compared to high-income group, the unhealthy lifestyle patterns of the low-income group appeared to be relatively more complex. Considering the importance of lifestyle behaviors for health and quality of life later in life, it is necessary to provide tailored lifestyle interventions based on the income levels of postmenopausal women. Further research on lifestyle patterns according to SES in postmenopausal women is required. First, although income was used as a proxy variable for SES, future studies using various SES proxy variables are needed to enhance the comprehensive understanding of SES and lifestyle patterns. Second, experimental studies should be conducted to verify the effects of tailored lifestyle interventions that consider the characteristics of lifestyle patterns according to SES in postmenopausal women. Third, the effects of SES-specific lifestyle patterns on diverse health outcomes in postmenopausal women should be confirmed using longitudinal data. --- Availability of data and materials Data from the KNHANES are publicly available, therefore, any researcher can be obtained after request from the website https:// knhan es. kdca. go. kr/ knhan es/ eng/ index. do. --- Abbreviations --- SES --- Declarations Ethics approval and consent to participate Before conducting this study, we obtained approval from the Institutional Review Board (Approval Number: CUIRB-2023-E004). All methods were carried out in accordance with relevant guidelines and regulations. Any identifying data was not included in the manuscript. --- Consent for publication Not applicable. --- Competing interests The authors declare no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background Healthy lifestyle behaviors among postmenopausal women are important to prevent chronic diseases and improve health later in life. Heterogeneous lifestyle patterns may exist among postmenopausal women, and socioeconomic status (SES) is a critical determinant of lifestyle behaviors. However, little is known about distinct SES-specific patterns of lifestyle behaviors among postmenopausal women. Thus, this study used latent class analysis to identify subgroups of postmenopausal women with different health behaviors according to income and to examine the predictors of income-specific subgroups.We analyzed nationally representative data from the Eighth Korea National Health and Nutrition Examination Survey, collected in 2019 and 2020. We used nine lifestyles (i.e., current smoking and drinking, high-risk drinking, walking, muscle-strengthening exercise, sleep, vegetable and fruit intakes, and weight control efforts). We conducted a multiple-group latent class analysis using monthly household income as a proxy for SES. The monthly household income variable was calculated by standardizing monthly household income by the number of family members and then divided into quintiles. We classified the participants into low-(i.e., Q1 and Q2) and high-income (i.e., Q3, Q4, and Q5) groups.Although the three-class models best fit the data of low-and high-income groups, we found differential patterns by income: (a) for low-income group, "relatively healthy (RH), " "lowest physical activity, insufficient fruit intake, and no intention to control weight, " and "high-risk drinking and insufficient fruit intake" classes and (b) for highincome group, "RH, " "lowest physical activity, " "high-risk drinking and insufficient fruit intake and sleep" classes. The proportion of the RH class was largest in both groups. However, lifestyle patterns in low-income group showed multiple and unhealthy characteristics than those in high-income group.This study suggests that different underlying lifestyle patterns exist in postmenopausal women with low-and high-income. To promote healthy behaviors among postmenopausal women, health professionals should develop and apply lifestyle interventions tailored to lifestyle pattern characteristics according to income.

INTRODUCTION In organizations, gender-based dominant and minority groups are formed due to the development of gender roles and occupational stereotypes that are based on the social status of the male and female genders. These factors also have an impact on the organizational structure that is a component of the social system. For instance, the idea of "tokenism" is reflected in the organization's numerical minority of women. Kanter (1977Kanter (, 2003)), who advocates the view that individuals who are numerically a minority in the organization have a disadvantaged position, states that this situation has consequences such as the visibility of their actions within the organization, polarization, and assimilation for the individuals in the minority position. The visibility of their actions means that individuals are expected to work in roles deemed appropriate for them within the organization, and as a result, they experience high levels of stress. Polarization is the formal and informal exclusion of individuals from a group and their isolation. Assimilation, on the other hand, means that people in different professions are expected to behave according to professional stereotypes. Ongoing studies on the subject brought up the question of whether being a minority in the organization has the same results for men, as well as the experience of men who prefer to work in professions called "women's professions", bringing a strong criticism to the theory of "tokenism." It has led to the emergence of the concept of the glass escalator, meaning the status of being a token turns into an advantage for men. The idea that being a minority (tokenism) has different effects for men and women (Stroshine and Brandl, 2011;Williams, 1992;Yoder and Sinnett, 1985) was first used by Christine Williams (1992). Since it is called a glass escalator in his work titled "The Glass Escalator: Hidden Advantages for Men in the "Female" Profession" it is often attributed to Williams (1992) in the literature. To illustrate how gender as a status characteristic interacts with the consequences of tokenism in two occupations, sociologists Floge and Merrill (1986) first employed the idea in relation to the token status of male nurses in the workplace. The results of a study done with 44 hospital employees-including male nurses and female doctors in two distinct hospitals-show that men gain substantially from this circumstance. Also, the results of the studies conducted with men working in occupations defined as female occupations to understand the outcomes of being a minority for men show that men and women working in non-traditional occupations do not experience the consequences of being a minority in the same way (Sargent, 2000;Shen-Miller, Olson, and Boling, 2011;Williams, 1992). While being a minority creates a negative situation within the organization for women, it creates a positive situation for men (Gustafson, 2008;Williams, 1992). In addition, the visibility of female minorities prevents them from working efficiently, while the visibility of male minorities gives them the chance to choose leadership and duties (Floge and Merrill, 1986;Williams, 1995a). Acker (1990) states that studies in this field are important in that they emphasize sexist institutions and professions that produce different experiences for men and women. The results of the study conducted by Wingfield (2009) show that the roles, skills, and abilities of men provide them with privileges and facilitate their progress. Williams (1995b) explains this situation by stating that masculinity is commonly associated with competence and mastery, and this perception persists even men work in a traditionally female occupation. For this reason, part of the perception that men do not belong to these jobs is always the idea that men are more talented and successful than women and that they should belong to jobs that reflect this. As Williams (1995b) states, the main idea is that men are suitable for more masculine professions, meaning that men are more talented and have more leadership characteristics than their female colleagues. This is the result of power relations between men and women, largely due to the patriarchal social structure. The power and status brought by the patriarchal social structure provide men with situational dominance, and men effectively utilize their traditional advantages even in professions called women's professions (Cross and Bagilhole, 2002;Cognard-Black, 2004;Floge and Merril, 1986), and they have the chance to succeed thanks to their favored minority status (Evans, 1997;Hultin, 2003). This situation causes men to think that they are more advantageous in terms of wages if they work in women's jobs (Hultin, 2003;Karlsen, 2012;Price-Glynn and Rakocski, 2012). In addition, the fact that women continue their careers at lower ranks or take a break due to family responsibilities divided according to gender roles also supports the concept of glass escalators in favor of men (Evers and Severdiy, 2014). That men are supported by their female supervisors and colleagues is another issue that supports the formation of the glass escalator concept in the career development process (Budig, 2002;Evans, 1997;Fairhust and Snavely, 1983;Hultin, 2003;Maume, 1999;Morris, 2010;Simpson, 2004;Williams, 1992;Wingfield, 2009;Zimmer, 1998). This situation arises from the belief that men will be more talented and better leaders (Crocker and McGraw, 1984;Floge and Merrill, 1986). Ritter and Yoder (2004) reveal in their study that even when women are more numerous in the group, the leadership task is given to men in large proportions. In many organizations, the fact that management levels are dominated by men (Budig, 2002) seems to be acceptable as an indicator of this. The glass escalator can't only be explained by the majority status of men in managerial positions. Because this situation is a result and reflection of social culture, it is possible that the causes and consequences of the glass escalator may differ between countries. It is possible to say that this situation arises from the social and cultural structure, which also affects the organizational culture significantly. The cultural characteristics of a society determine the institutional and administrative processes and practices in those societies as well as providing clues about the cultural characteristics of the institutions (E<unk>inli & <unk>ak<unk>r, 2011). This situation also manifests itself in educational organizations that reflect the social structure. It is important to work in pre-school institutions, which is a profession attributed to women within the framework of professional stereotypes of management (Adler, 1999) and also one of the professions to which power is attributed. So this study aims to investigate the experiences of male pre-school administrators in Turkey regarding the concept of the glass escalator and the possible effects of cultural values on the causes and consequences of the concept of glass escalators. --- METHOD A qualitative research design was used in this study, which deals with the experiences of male pre-school administrators in Kocaeli, Turkey, regarding the concept of the glass escalator and the possible effects on cultural values as a result of the concept of the glass escalator. Since the subject of the research consists of the experiences of male pre-school administrators regarding the management process and their views on the impact of cultural values on their management experience, a qualitative research method is used in the research to define the common meaning of the lived experiences of a few people about a phenomenon or concept (Creswell, 2013). The study group of the research consists of male school principals working in pre-school education institutions. Although the small number of male pre-school administrators constitutes a limitation for the study, the fact that the interviewed administrators know each other provided an advantage in informing the study group and conducting in-depth interviews in accordance with the nature of phenomenology. In the formation of the study group, the criterion sampling method and the snowball sampling method, which are purposeful sampling methods, were used together. In determining the criteria, it was determined that the school administrators should be experienced and oriented to the school's culture. So, the criteria used in the formation of the study group are that school administrators have at least two years of management experience, have worked in the institution where they are currently working for at least one year, and are willing to participate in the research. Within the scope of research ethics, participants included in the study group were called by phone and informed about the researcher and the research topic to be discussed. The information about the institutions and persons mentioned during the interviews is kept confidential by the researcher, and the participants are coded as "P1, P2,..." The semi-structured interview technique, which is the main data collection technique in phenomenology research, is used to collect the data of the research. In the process of preparing the interview form, first of all, a question pool was created based on the literature. Afterward, the form was finalized by referring to the expert opinion and named as "Experiences of Male Pre-School Administrators and the Culture-Related Factors Affecting Their Experiences Interview Form." A voice recorder was used during the interviews if the participant gave permission. If the participant did not give permission, notes were taken, and what was said was recorded. To ensure the external validity of the research, the findings were defined with direct quotations, and the raw data and analysis were matched to ensure internal validity. To ensure external reliability in the research, the judgments and comments obtained were audited by an expert. Content analysis, a research method used to identify patterns in recorded communication, was used in the analysis of the data. In this context, the interviews were transcribed, and themes were created by examining the transcripted interviews. Themes are combined into two dimensions. --- RESULTS The findings related to the concept of glass escalator in pre-school education institutions are discussed in two dimensions: (1) individual factors and (2) culture-related factors. The preference of male teachers in preschool education institutions to be principals is discussed under the dimension of individual factors. The stereotype that management is a male job, cultural structure, gender perception and the "queen bee syndrome" are discussed under the dimension of culture-related factors. --- Individual Factors The results of the research reveal that pre-school institutions with female-dominated working environments are preferred by male administrator candidates for promotion. Another remarkable point that emerged as a result of the research is that school counselors who want to be administrators also prefer pre-school institutions. Some of the participants' views on this situation are as follows: There is no need to give any other reason. I wanted to be a manager, and because of my low point, there is no alternative for me. There isn't any competition in pre-school institutions. Only school counselors and pre-school teachers can prefer pre-schools in management. I prefer it, so I came. (P 1) I think being a principal as a school counselor is an advantage, because we received an interdisciplinary education at the school. Education is more important for me than teaching, and preschools are places where the development of positive behaviors in children is at the forefront. That is why I prefer pre-school institutions as a principal. (P 2) I have studied at a high school for a long time. In this time, I realized that school principals aren't sufficient in many practices, so I decided to become a school principal. I saw this energy, desire, and power in myself because, as school counselors, we have to do some of the management work, whether voluntarily or not. The reason I chose pre-school was that I wanted to be a principal, and there was a need for school principals in pre-school institutions. There is a saying that "Nature does not accept a vacuum." In kindergartens, there were always school principals who acted as proxies, as pre-school teachers generally didn't prefer management. When we were given the right to be managers as school counselors, we preferred it. (P 3) In 2004, after working at this center for 8 years, I wanted to choose different institutions. Actually, I applied for the position of school counselor. We also had the opportunity to become managers. Kindergartens were also among our choices, and then I became the principal of this kindergarten. (P 4) As may be seen from the participant's opinions, men who work as administrators in pre-school facilities have the potential to be "visible" despite being a minority. This situation shows that being in the minority position of visibility creates negative situations for female principals (Crocker and McGraw, 1984;Kanter, 1977Kanter,,1993;;Sperandio, 2010), while it creates positive situations for male principals, such as the chance of choosing a principalship in pre-school institutions. This finding is also compatible with the studies on the subject in the literature (Evans, 1997;Hultin, 2003;Williams, 1993;Wingfield, 2009). The results obtained from the participant opinions show that male teachers' desires for promotion play an active role in their preference for principalship in pre-school institutions. Moreover, research shows that men prefer to be managers in institutions that are defined as suitable for women (Karlsen, 2012;Montecinos & Nielsen, 2004;Simpson, 2004;Taylor, 2010). It is possible to say that defining managerial roles together with men plays an important role in the formation of this situation (Abreu-Hornboster, 2012;<unk>nand<unk>, <unk>zkan, Peker and Atik, 2009). --- Culture-Related Factors Another point that the participants emphasized in the interview process is that women do not prefer to be principals in pre-school institutions, and they support men to be principals in these institutions. The participants state that they think that the acceptance of the management area by society as a work area suitable for men is effective in creating this situation. The participant opinions on the subject are as follows: Women do not prefer to be principals. They started very enthusiastically, but then they quit. We work from 8 a.m. to 6 p.m. Teachers work from morning to noon. They work hard during that time, but it is only 5 hours, and they have free time for the rest of the day. That's why they don't prefer being principals. (P 1) Before we started to work, teachers definitely had prejudice. Working with male principals for years has been unusual for pre-school teachers, but we have never had a problem. Considering the concept of the manager, we did not have any problems being accepted, since it is a male role in the eyes of teachers, even if they work in pre-school. It was a new process for parents as well as teachers or other groups, but we had no problems with parents either. Even after we started as a manager, we observed that there were fewer complaints when a male manager became a manager. (P 2) We were very well received because there was an administrative problem that had accumulated over the years. As you know, female teachers did not want to be principals. Many of them have done this work by proxy. But when we became the principal, they saw an authority, and it was nice to accept it. They saw that we were getting things done. They even said that these things could be done like this; it was easy, and then they started to aspire to this field. (P 3) I think that being a male administrator in pre-school has managerial contributions. I say this based on my previous experience. Both teachers and staff approach me more positively. I think female school principals have become more oppressive. (P 4) The findings obtained are in line with the research results available in the literature. It is possible to interpret this situation as the view that the administration is male-dominated not only because of the patriarchal social structure of Turkish society, but also because it has a more global structure. The results of this dimension support the formation of the concept of glass escalator, with research results stating that men are supported by their female supervisors and colleagues in the career development process (Budig, 2002;Evans, 1997;Fairhust & Snavely, 1983;Hultin, 2003;Maume, 1999;Morris, 2010;Simpson, 2004;Williams, 1992Williams,, 1995;;Wingfield, 2009;Zimmer, 1998). It is possible to interpret the harmony between the findings and the research results as the view that management is a man's job not only because of the patriarchal social structure of Turkish society but also because it has a more global structure. Within this dimension, it is possible to claim that time restrictions and, hence, family resbonsibilities, particularly in the light of first participant's opinion, play a significant influence in career development of women. This viewpoint is supported by various research findings in the literature (Elliot & Smith, 2004;Erkol, 2015;Güldal, 2006;Kirchmeyer, 2002;Mathe, 1989;Mayatürk, 2006;Neale and <unk>zkanl<unk>, 2010;Negiz and Yemen, 2011;Sa<unk>lam & Bostanc<unk>, 2012, Weber, 1998). These factors, which are effective in the career development of women, are the result of cultural structure. It is possible to say that cultural structure is effective in educational institutions, which are a part of the social system. Masculine cultures such as Turkish society give importance to features such as independence, competition, power, and self-confidence (being assertive) (Hofstede, Hofstede, & Minkov, 1991). Hofstede, Hofstede and Minkov (1991) state that education and professional life are powerful sources of cultural learning and that more formal communication takes place in organizations with a high power distance (Hofstede, 1984). The participant view that high power distance is effective on organizational communication is as follows: As an administrator, I always try to keep my relationships with teachers at a certain level. Although I do not set very hard boundaries, I have a relationship that continues within reasonable limits. For example, I never address my teachers or employees by their first names, and I call them Mrs. (P 4) Another remarkable point that emerged as a result of the research findings is the positive opinion of male school principals working in pre-school regarding the "Queen Bee Syndrome" (<unk>rücü, K<unk>l<unk>ç & K<unk>l<unk>ç, 2007), which is considered an important organizational obstacle for women to rise to senior managerial positions. The opinions of the participants on the subject are as follows: I prefer open and transparent communication. Of course, there are still differences between the manwoman agreement and the woman-woman agreement. We see this in schools. Female teachers get along better with male principals. (P 2) It is more difficult for female teachers to work with female administrators. They conflict with each other. We don't have such a problem with male principals. (P 3) Finally, the findings of the study show that gender stereotypes, which are a part of the cultural structure, can sometimes lead to the development of negative perceptions among parents about the male principals working in pre-school institutions. The participant opinions on the subject are as follows: I believe that a female school principal should be appointed here. In pre-school education, mothers are mostly concerned with the school process of the child. Male parents are rarely concerned with school unless it is absolutely necessary. The ladies seek out the assistant principal because they need someone with whom they can better express themselves. They are averse to approaching male principals. They express themselves more easily to me because of my field, but they prefer female assistant managers. In Turkey, only 5% of pre-school principals are male. Even if the parent intends to file a complaint, the assistant principal is the first person he contacts. I believe that female parents communicate more easily with female assistant principals. When children graduate from here and enter primary school, there is no such thing. I don't know whether they want to see us as mothers or what kind of perception there is that they don't prefer us. (P 1) Some of the parents' concerns and apprehensions cause issues. We hired a gardener at the start of the year, and he was the only male employee aside from myself. Later, our male teacher came. "Sir, how many male staff members are there in this school?" a parent inquired at a parent-teacher conference. Now it's difficult for me to send my child to school. My anxiety level rose. "What if it's harassment?" you might wonder. I assured the parents that everything was done following the rules, that there would be no harassment, and that the children would never be alone. I attempted to console him. I told him he shouldn't be concerned in that way. (P 3). Considering the above-mentioned findings, it is possible to say that women employees are preferred by parents in pre-school education institutions as a result of the stereotypes shaped by the social structure, which is a summary of the information we have about certain groups (Ka<unk>tç<unk>baş<unk>, 2010). --- DISCUSSION & CONCLUSION Research findings reveal that the concept of tokenism, which was put forward by Kanter (1977Kanter (, 1993)), and which reveals a disadvantageous situation for female managers, turns into an advantageous situation when considered in terms of male principals. This situation, named "Glass Ceiling Syndrome" by Williams (1992), can be seen in pre-school educational institutions. One of the reasons why managers prefer to work in these institutions is the possibility of promotion. As a result, visibility, which is defined as a negative feature for female managers, gives male principals a chance to lead as leaders. It is possible to say that culture plays an important role in defining male principals as leaders. The paternalist leadership tendency, which emphasizes the concept of family and has significant differences in tendency between genders, is known to increase in societies with high power distance and collectivist values, such as Turkish culture (Cesur, Erkilet & Taylan, 2019;<unk>al<unk>şkan & <unk>zkoç, 2016). This situation makes it easier for men who are more suitable for the father role to prefer management with a leadership position and to be supported. The fact that male administrators are more likely to be viewed as leaders and that the management positions are consequently seen as more suitable for men is a result of the patriarchal structure of society. Patriarchy, which is defined as the domination or use of power by men over other people (Hearn, 1992), plays an important role in determining the nature of gender ideology in different contexts (Kandiyoti, 1988). However, the fact that the patriarchal structure's ability to maintain its existence so effectively in all areas of life means that this structure is internalized by women can't be denied (Köstek, 2007). It is also a result of culture-related factors that male school principals have a positive perception of the Queen Bee Syndrome (Zel, 2002), which is defined as the use of women against women by adopting male attitudes and trying to eliminate the competition of other women. As a result of these culture-related factors, it can be said that men consider themselves suitable for the managerial role, and they find female managers less successful in this regard. The managers participating in the research state that male managers are more successful than female managers in terms of establishing authority, solving problems, and communicating with female employees. According to Kanter (1993), this situation is caused by gender stereotypes accepted by both men and women in society, as well as the roles attributed to women and the masculine organizational structure formed. Stereotypes are beliefs about the characteristics shared by people in a particular group or social category (Taylor, Peplau, and Sears, 2008) or the behaviours that society expects from women and men concerning their gender (<unk>elik, 2008). In many countries in the world, management is defined by men and is defined by practices consisting of male lives and values. The fact that the masculine structure that dominates the business world forces women to practice these stereotypes also causes women to adopt stereotypes about themselves and to believe that they cannot carry out their managerial duties (Limbach, 1994;Groot, 2010), so it can be thought that male managers are preferred. Another important reason why women do not prefer to take place on management positions is the time pressure created by their social roles. Negiz and Yemen (2011) found that the responsibilities of "family, children, and the role of women as "wives" have a decisive role in the career development of women managers and that the reflections of traditional social understanding in family and business life sometimes affect women's career goals in their decisions. It has a compelling and sometimes internalizing effect; women have to make time and career plans while determining their priorities in working life, and therefore they lag behind men in the promotion to the top. Adler (1999) emphasizes that the roles defined for the individual must be compatible with the division of labor, which is an absolute condition for the preservation and continuation of human society. In this context, it can be said that the expectations regarding women's work and family roles (Weber, 1998) play an active role in women's not choosing the managerial position due to their social roles. Indeed, Mathe (1989) states that women prefer professions with more flexible working hours to be able to fulfill their motherhood and housewife duties, which are the roles that social life imposes on them, without interruption. Furthermore, it can be asserted that the fact that teaching is defined by society as a profession requiring love for students and that this definition is also effective in women's choice of teaching as a profession, The metaphors developed by the students about the teacher often have characteristics that are devoted to mothers, such as "informative, nurturing, loving, protecting, pure, sensitive, valuable, and guiding" (Tulunay-Ateş, 2016). It can be said that the fact that women constitute the dominant group in pre-school education institutions plays a part in shaping the perception of teachers in pre-school educational institutions. This situation also shows itself in the metaphors developed for pre-school teachers. The results of the metaphor research conducted for preschoolers and their teachers indicate that the metaphors of "house, tree, flower, sapling, the beginning of life, the first step, the first step of the ladder, water, and seed" (Ertürk-Kara, 2014) are frequently used for pre-school education; it also shows that the metaphors of "information source, shaper, character developer, guide" (Soydemir, 2011) are frequently used for pre-school teachers. When the metaphors produced regarding the perceptions of teachers in pre-school education institutions are examined, it is understood that pre-school institutions are seen as the beginning of educational life, and preschool teachers are seen as individuals who are protective and shape students with love and compassion. Based on this situation, it is possible to say that pre-school teaching characteristics are closely related to stereotypes attributed to women, and this situation causes a slow change in the number of male pre-school teachers. The fact that women prefer pre-school teaching field also supports this perception. It is seen that 94.3% of the teachers in pre-school education institutions are women and 5.6% are men (MEB, 2019). The definition of pre-school teaching as a female profession not only causes a slow change in the number of male pre-school teachers, but also causes male pre-school teachers who choose this field to have problems in the learning process and working life. The results of the research conducted by Haskan-Avc<unk>, Karababa & Zencir (2019) revealed that male pre-school teacher candidates have problems in personal relationships and communication, such as the reactions of the society and faculty members towards their gender, mostly due to the male minority, and the stereotypes of parents towards male pre-school teachers. Another study conducted by Ya<unk>basan and Aksoy (2016) shows that the main reason why male teachers aren't preferred in pre-school education institutions is that men are not trusted to show as much compassion and attention as women. Because of this streotype, male students studying in the preschool teaching department have a more negative perspective towards the teaching profession than female students studying in the same department. (K<unk>z<unk>ltaş, Halmatov and Sar<unk>çam, 2012;Manalova-Yalç<unk>n and <unk>zgen, 2017). Also, parents' point of view is that women will be more successful because they have a sense of motherhood, are more tolerant and patient, can communicate better with children and are more interested in them, are more careful, and can better understand children's education (Koçak and Kaygusuz, 2019). This perspective can be said to be effective in the formation of this situation. --- SUGGESTIONS Professional stereotypes and situations that develop due to these stereotypes (such as "glass ceiling syndrome") are frequently mentioned in the literature. However, there are not enough studies in the literature on men working in fields such as pre-school teaching and nursing, which are widely accepted as women's professions. Although the majority of teachers working in pre-school education institutions are women, the number of male pre-school teachers is increasing from year to year. In this context, issues such as the individual characteristics of male pre-school teacher candidates who prefer to study in this field and the reasons for choosing the field are also open to research. The problems that male pre-school teacher candidates experience during their university education are another issue that needs to be investigated. The impact of social stereotypes on these students and the perspectives of field teachers, classmates, and others on male pre-school teacher candidates are among the issues that need to be addressed. The opinions of male pre-school teacher candidates about professional self-perception and the factors affecting professional self-perception, field adequacy, and the factors that cause these opinions are also among the issues that need to be addressed. In this study, the experiences of male pre-school principals with the concept of the glass escalator are discussed. It is important to study the concept of glass escalators in different professions in terms of their contribution to the literature. In addition, in this study, the concept of the glass escalator is included only through the experiences of male pre-school administrators. It is also important to investigate the culture-related factors that caused the formation of the glass escalator concept and even to conduct comparative research on this subject, including in different countries. Finally, the concept of the glass escalator has a structural and social impact on individuals who experience it. Individual results are also among the issues that need to be investigated. Educational levels are parts of a whole that complement each other. In pre-school education institutions, beside the psychomotor, physical, social, emotional, mental, and linguistic development of children, their socialization and preparation for the formal education process are also in question. As seen in the results of the study, parents prefer female pre-school teachers for different reasons. However, some of the parents who prefer female pre-school teachers prefer male primary school teachers, especially for boys in the primary education period. It is possible to interpret this situation as parents and even society accepting pre-school education institutions as a different field from formal education. In this context, it is important to investigate the gender preferences of the parents of male students in the pre-school and primary education periods and the reasons for these preferences. Finally, pre-school education is critical for developing a child's self-concept and sexual identity, as well as an independent personality within the framework of cultural socialization norms. From this perspective, it is possible to conclude that male pre-school teachers will have a positive impact on the development of boys' personalities. In this context, it is thought that long-term qualitative studies and experimental studies, in which the effects of male pre-school teachers on the development of boys, can be observed, will contribute to the literature. And lastly, this study is limited to male school administrators working in pre-school education institutions in Kocaeli. Considering the perception that the cultural structure creates on male preschool teachers and principals, it is useful to consider the subject in a more comprehensive way with different aspects.

The glass escalator is a metaphor used to describe how men in feminized workplaces move up career ladders, and this study aims to determine the experiences of male pre-school principals and the possible effects of cultural values on the results of the glass escalator through the ranks because of gender norms and job expectations. In this context, meetings are held with four school principals, working in Kocaeli and in pre-school education institutions. As an interpretive approach, phenomenology is used in the study. The criterion sampling method and the snowball sampling method, which are among the purposeful sampling methods, are used together in forming the working group. Research findings are discussed in terms of individual and cultural factors. The former is mainly related to the preferences of male principals, who tend to see working in pre-school institutions as an opportunity for promotion. This perspective is discussed from the standpoint of 'visibility', which emerges as an advantageous feature for men but not for women. Cultural factors, on the other hand, are related to culturally-influenced beliefs regarding male and female roles. Because management is seen as a male occupation, female teachers also prefer and support male principals.

Introduction In 2009, the voluntary medical male circumcision (VMMC) for HIV prevention programme began in South Africa, a country with high Human Immunodeficiency Virus (HIV) prevalence and low VMMC coverage [1,2]. VMMC reduces the risk of HIV infection in heterosexual men [3][4][5][6]. The 2012 South African Human Science Research Council survey showed that across all nine provinces, uptake of circumcision in men aged 25-49 years was low (49.8%) when compared to those aged between 15-24 years (80.2%) [7]. The prevalence of HIV in South Africa is high among men aged 25-49 years (25.7%) [7] and women aged 20-34 years old (31.6%) [7]. Although VMMC could offer long-term indirect protection for women [8], VMMC uptake among mature adult men in sub-Saharan Africa remains low. Some challenges were reduced acceptability of the procedure, poor communication regarding the benefits of VMMC and concerns about circumcising at a mature age [7][8][9][10][11]. Data on the total distribution of number of circumcisions conducted between 2011 and 2016 from a routine VMMC service delivery programme in South Africa showed lower number of circumcisions among men aged 25 years: 32.9% (13,154/40,038) compared to those 24 years 67.1% (26,884/40,038) (internal program data from the Aurum Institute). Since the uptake of VMMC is low among men 25 years, exploring female attitudes toward circumcision of their male partners could contribute to improving current HIV prevention packages [12][13][14]. Qualitative and quantitative studies have described women as being supportive of their partners' decision to circumcise [13,[15][16][17][18][19]. One study in Kenya and another in Tanzania showed that women who were in stable relationships were able to discuss and influence their partner's decision to circumcise [18,19]. While most studies explored the perceptions that women had regarding the relationship between HIV risk and VMMC and how this could influence sexual decision making, there are few that assessed how women could start a conversation on circumcision with their sexual partners [13][14][15]17,[20][21][22]. There is a need to explore how women could introduce VMMC to their partners [16,23,24]. Communication about VMMC between couples encourages mutual decision making on VMMC [14,[17][18][19]25]. However, in certain cultures that practice traditional circumcision, like in South Africa, women or uncircumcised men are not allowed to discuss the rituals of male circumcision [26]. Women may in general have limited knowledge of circumcision which possibly prevents them from speaking to their male partners about this issue [13,25]. Some challenges that women experienced in past studies included poor communication with their partners about VMMC and limited access to information on VMMC, especially in communities where VMMC is not part of the culture [13,16,19,25]. One Kenyan study that explored the role of women in VMMC reported that the majority of women discussed the positive and negative aspects of VMMC with their partners before they were circumcised [19]. Yet, the type of approach that these women used to start a conversation on VMMC with their partners were not described. This sub-study took place as part of a larger implementation science research study (Imbizo study) that aimed to increase the proportion of men aged 25-49 years who accessed VMMC services [27]. Here, we explore the attitude and willingness of women to start a conversation on medical male circumcision with their sexual partners. --- Methods This sub-study took place from April to October 2014 at a peri-urban site, Ekurhuleni North, Gauteng province in South Africa. We used three approaches to recruit women purposively into the study in order to ensure diverse participation. First, contact information and permission to invite female partners for an interview were obtained from circumcised men enrolled in the Imbizo main study. Second, a list of non-governmental organizations that focused on women within the community was obtained and appointments arranged with those who agreed to be interviewed. Finally, female patients from antenatal clinics and those from the surrounding community were individually invited to participate. Contact information, including names and phone numbers, were recorded for all interested participants and used to set up appointments. Appointments were scheduled with women who were interested in the study and who agreed to participate in the interview at a time that was convenient for them. Participants were eligible if they were aged 18 years, agreed to be interviewed with digital recording of the session, and able to communicate in one of the study languages. All participants provided written informed consent prior to enrolment. Illiterate participants provided a thumbprint to acknowledge understanding in the presence of a witness. Participants were only interviewed once. Participants consented to their direct quotations being published. A total of 30 women were enrolled, with a median age of 30 years (interquartile range 26-33 years). Since the 30 interviews started to reveal similar information, this was an indication of saturation being reached. The interviews lasted approximately two hours each. Most women preferred the interviews to be conducted in the local language of Sepedi (46.7%) or isi-Zulu (36.7%), with a minority choosing English (16.7%) which were the most common languages in the study area. Fifteen (50%) out of the 30 women voluntarily disclosed their birthplace during their interview-the majority (66.7%) were from the peri-urban area where the study was conducted while five (33.3%) were from rural settings of other provinces but currently lived in the peri-urban area. A total of 20 (66.7%) women disclosed that their partners were circumcised while only 3 (10%) indicated that their partners were not circumcised. Seven women (23.3%) did not disclose the circumcision status of their partner. --- Ethical considerations Approval was obtained from the University of the Witwatersrand Human Research Ethics Committee (M130711) and the Centers for Disease Control and Prevention Institutional Review Board (6546). --- Data collection All participants who signed the informed consent form, also agreed verbally for the session to be digitally recorded. An interview guide was used to explore the role of women in introducing VMMC (S1 Table.) that included questions on: the types of approach to use when introducing the topic of VMMC; gender roles; benefits and barriers when speaking about VMMC; understanding of and perception of VMMC. The trained interviewers were employed by the Aurum Institute. Interviewers were trained on qualitative data collection by an experienced co-investigator. Male and female interviewers had professional relationships with participants and their interaction ended after data collection was completed. Interviewers maintained an objective attitude during data collection and this was monitored during debrief sessions. Only the interviewer and the participant were present during the session. Interviewers completed process notes after each interview that detailed the progression of the session and the demeanour of the participant during the interview. All participants who completed the interview were reimbursed $10.64 (R100.00) to compensate them for their time and travel. --- Data analysis In-depth interviews were transcribed verbatim, and translated into English where applicable. Most of the interviews that were conducted in a local language were outsourced to a registered, accredited translation company. The translation company that is based in South Africa transcribed the digital recordings to the local language and then translated these into English. The quality team at the Aurum Institute checked the transcriptions. All transcripts were available in English before the coding and analysis took place. Digital recordings and process notes were reviewed during the analysis. QSR NVIVO 10 was used for the analysis of in-depth interviews [28]. A grounded theory approach was used as the theoretical framework [29,30]. Thematic analysis was used to highlight the emerging inductive themes. An iterative approach was used to develop the codebook and index the transcripts from which categories, themes and patterns emerged from the data [29]. A co-investigator with a doctorate level qualification developed the coding scheme using the English transcripts. For reliability, the original transcript and codes were sent to two independent reviewers. The independent reviewers were part of the investigator team with medical, masters and doctorate level qualifications. The reviewers categorised the original transcript according to the codebook and suggested new codes as needed [31]. Codes where both reviewers agreed to a particular code were retained while those that lacked intercoder reliability were dropped from the analysis [30]. The codebook was revised and the themes finalised which are displayed as direct quotes [32]. Participants did not provide feedback on the findings. --- Results --- Main theme: Willingness of women to start a conversation on VMMC Most women were willing to start a conversation on VMMC with their sexual partners. Substantial sub-themes that emerged were the approach that women should use and challenges to starting a conversation on VMMC. Sub-theme: Approach that women should use when starting a conversation on VMMC. Most women felt that they should encourage their partners, show more interest in circumcision, be patient, speak in a caring and respectful tone, choose a correct time when their partner was relaxed and talk in a private space about VMMC. This seemed to be a salient theme across all categories of women, but women from the community antenatal clinics emphasised the importance of using an acceptable approach when raising the topic of circumcision with partners. One participant described how timing and the approach to discussing VMMC with her partner was crucial: "...They [Women] need to know the good approach... woman need to be patient with their partners, and avoid harassing him and give him time and chance and keep on emphasizing that it's for his health... Don't talk about it being angry, don't talk about it when he is not happy, don't just say you were with your friends and your friend told you... You must target the days he is so happy. Talk about it when you are relaxed [and] happy, talk about it after food maybe when you are in the bedroom. Say it nicely".-Aged 42 years, recruited from the community antenatal clinic. Although women were willing to raise the topic of VMMC with their partners, they still felt that circumcision remained ultimately the decision of the man. --- "...because I use[d] to tell him now and again, maybe it took him [partner] a year to decide to do it, and I was telling him that you need to do this.... I was telling him [partner] about things like that and he was also doing his research as well. And he ended up deciding to do it."-Aged 35 years, recruited from community organisation Providing detailed information on the benefits of VMMC to their partners by using magazine/newspaper articles, pamphlets or advertisements were further identified as tools that women could use to aid their discussion with their partners. In general, women did not provide specific detail of what should be included in the material, instead they felt that their partners should be exposed to circumcision material. Most women emphasised the importance of using multiple opportunities to direct their partner's attention to available VMMC information. One participant described in detail the type of materials that could be used when introducing VMMC with her partner: "Since there's a lot out there about circumcision, it's even advertised in the roads, so you can start in that way... women have to show more interest in these things about circumcision. She can use photos if she chooses... These pictures can be hung on the walls in the house, and saved on her phone... She could have CDs or something that she can play or watch in his presence. She could also surf the internet on the topic... This will attract her partner's attention." Aged 24 years, recruited from the community antenatal clinic. A soft theme that emerged was knowledge that women had on the benefits of the VMMC procedure. Almost all women felt that VMMC was a safe procedure, promoted good hygiene and reduced sexually transmitted infections or HIV. In addition, more than half of the women felt that the services provided at the clinic were free, safe and better when compared to traditional circumcision. Only five women were also aware of the benefits of VMMC to their personal health such as prevention of cervical cancer. One participant described her knowledge regarding the health benefits of the VMMC procedure: "...The way I understand, circumcision reduces many diseases. And in women, we are often told that it reduces cervical cancer... Men may be infected by the gonorrhoea AIDS, and the STDs. Any disease that a man may be infected with easily......"-Aged 32 years, recruited as partner of a circumcised man Another participant described how she felt that the counselling, health screening and follow-up visits during the VMMC procedure was beneficial: --- "..., it's [circumcision] much better than at the mountains [traditional circumcision] because you get counselling before and you also tested for diseases that you might have, like high blood and HIV and they also they you CD4 count to see whether it's fine for you to be circumcised or not. After circumcision you go for check-up to see how you are recovering, whether you recovering nicely or if there are infections."-Aged 31 years, recruited from community organisation. Although most women were willing to speak to their partners about VMMC, there were also dominant challenges to talking about circumcision that emerged as a concern. Sub-theme: Barriers to women starting a conversation on VMMC with their partners. Substantial barriers to initiating conversations on VMMC included accusations by partner on infidelity, fear of gender-based violence, cultural restrictions and hesitation to speak to a mature partner about circumcision. One participant described her fear as follows: "To me it [circumcision] sounded good because it's what I wanted him to do, but was scared to tell him"-Aged 27 years, recruited as partner of a circumcised man Some women, especially those who were partners of a circumcised man felt that if they introduced circumcision to their partner, he may have suspected infidelity. Two participants described the fear of being suspected of infidelity as follows: "If you ask him about circumcision, he will ask you which circumcised man have you engaged in sexual intercourse with. Where did you see him?"-Aged 32 years, recruited as partner of a circumcised man: "...some man will say: so you slept with a man who is circumcised, because you are saying there is difference between a man who is circumcised and a man who is not circumcised... And what is your experience or did you sleep with someone who got circumcised..."-Aged 42 years, recruited from the community antenatal clinic: Other participants were concerned about gender based violence if they started a conversation on circumcision with their partners. One participant described her fear as follows: ".. ---.Another one [partner] will just beat you up the moment you start talking about it [circumcision]..."-Aged 31 years, recruited from community organisation Women also seemed afraid to talk to their partners about circumcision due to cultural restrictions. Some cultures do not believe in circumcision while others that practice traditional circumcision consider it to be a secretive process that is applicable to men only. Concerns of breaking traditional expectations were predominantly expressed by women from antennal clinics and those from community organisations. One participant described how cultural restrictions could prevent females from speaking to their partners about VMMC: "... Some Zulu men tell us that we don't do that [circumcision]. And then we went to others: That [circumcision] is none of your business, you shouldn't be telling me about circumcision. You are not a man you know nothing about circumcision! So there's nothing I will say to you!'-Aged 31 years old, recruited from community organisation Another theme that emerged was hesitation to speak to male partners who were of a mature age. This sub-theme was salient among women who were recruited from the community antenatal clinics. Some women felt that men of a mature age would be embarrassed to access circumcision services, which is described as follows: "... when you go when you are old, it was an embarrassment... yes it was an embarrassment that you [are] circumcising with kids..."-Aged 29 years, recruited from the community antenatal clinic --- Discussion In South Africa, women need to ensure that before talking to their male partner's about circumcision, the environment and approach that they use are conducive. Although the male partner makes the ultimate decision, some viable options that women could use when talking to their partners about circumcision could include a gentle, respectful approach and general media circumcision resources. Women may have the ability to influence their partners to circumcise depending on the type of approach that they use. Other studies from Africa confirmed that women were likely to influence the uptake of VMMC among mature men [16,17,19,20]. Focus group discussions that were conducted in Tanzania, described women as being a source of information to their partners, and they also felt that the approach to be used needs to be indirect and careful using "soft" language [22]. Although previous studies reported that women supported their partner's decision to circumcise which influenced decision-making around VMMC, few described in detail the approach and behaviour that women could use when introducing the topic of VMMC [13,[15][16][17][18]33]. Women felt that they could influence men to circumcise by using multiple resources and opportunities to create awareness on circumcision in a respectful manner instead of being forceful. Women from our study felt that if men were respected and did not feel demoralised, they would be more willing to listen to options around VMMC. However, contrary to other studies in Tanzania and Kenya, women in our study did not report direct insistence on partners being circumcised as the approach to follow [14,20]. A novel finding from our study was the importance of identifying the right location and ideal opportunity to speak to men about circumcision. When a suitable place and time is identified, media resources could be used to aid the discussion on circumcision. This platform of providing detailed information on VMMC could allow male partner's the time and space needed to reach an independent decision on circumcision. Other studies confirmed the advantage of using media advertising and a pleasant approach when talking about circumcision [18,22]; while our study showed that creating the right environment is also important when talking about this sensitive issue. Communication on circumcision needs to include issues that are important to men and women. A study conducted in Zambia that evaluated attitudes, knowledge and preferences about VMMC among men and their partners highlighted that joint discussions between the couple had a positive impact on men's reported readiness to be circumcised [17]. The gender role power dynamics could influence how women talk to men about circumcision. Depending on the type of relationship a woman shares with her partner, using the appropriate approach, choosing the right environment and time could be vital when talking about circumcision. Our study showed that women felt at risk of being accused of infidelity and subject to physical abuse if they raised or introduced the topic of circumcision with their male partners. This finding was different to past research which showed that accusation of infidelity primarily took place during VMMC's post-operative period which led to gender based violence [8,33]. In certain socio-cultural contexts, women are excluded from discussions around VMMC [13], therefore male partners could feel that traditional expectations are challenged if informed by a female about circumcision. Hesitation to speak to mature partners about circumcision was another challenge, as circumcision is generally associated with younger boys. Our findings were confirmed by a qualitative study that was conducted in Tanzania with 142 participants where it was reported that adult men were ashamed of accessing clinic services with younger boys as they were married and had children of their own [34]. Based on our findings we piloted an exclusive adult clinic to provide an environment where mature men could feel comfortable to access VMMC services. Results of this intervention are reported in full elsewhere [27]. Women could encounter communication challenges and resistance when speaking to mature men about circumcision, thus learning constructive skills could assist them in creating awareness on VMMC. Limitations of the study were that women could have provided responses that were socially desirable and acceptable even if it was contradictory to their true beliefs, as some were referred to the study by their male partners. Another limitation is that most women who were interviewed in the study had partners who were circumcised which could limit generalizability of the results. However, in order to obtain comprehensive information and to explore this topic limiting biases, we recruited three categories of women (i) partners of men who were circumcised (ii) women accessing antenatal services in the community (iii) women involved in community organisations. These women had varied backgrounds and different experiences with understanding circumcision practices, which helped us gain a detailed perspective on their attitudes toward circumcision. By reassuring the participants of confidentiality, building trust and probing using different techniques, we attempted to mitigate some of the limitations. Some of the study strengths included how creating the right environment and using appropriate communication techniques could assist women to promote VMMC awareness with their partners. --- Conclusion Women were willing to speak to their partners about VMMC and felt that the manner in which they spoke and interacted with their sexual partners could encourage them to consider circumcision. Educating women on conversation techniques, types of approach and behaviour could assist them when communicating with their partner on VMMC. In addition, creating opportunities for discussion within female social network forums, highlighting to women on how to identify and use multiple opportunities of directing their partner's attention to circumcision could promote VMMC awareness. Media resources could be tailored to provide women with skills on how to approach and behave when raising the topic of circumcision with their partners. These platforms could also assist women when communication challenges around circumcision emerge. Assessing acceptance of VMMC among adult men when VMMC is introduced to them by their female partners needs to be further assessed. Women in the study reported that gender based violence could be a risk when talking about circumcision, therefore interventions to improve respect and promote gender equality are important. Creating an environment conducive to discussing issues on VMMC with women, enhancing communication and behavioural skills of when raising the topic of VMMC with their partners could be beneficial to the VMMC programme. --- All relevant data are within the manuscript and its Supporting Information files. All personal identifiers of the participants have been removed from the English transcripts and labelled with participant identification numbers. --- Supporting information S1 --- Author Contributions Conceptualization: Candice M. Chetty-Makkan, Salome Charalambous.

Voluntary medical male circumcision (VMMC) reduces the risk of HIV infection in heterosexual men and has long-term indirect protection for women, yet VMMC uptake in South Africa remains low (49.8%) in men (25-49 years). We explored the attitude and willingness of women to start conversations on VMMC with their sexual partners in a South African periurban setting to increase VMMC uptake.Thirty women with median age of 30 years (inter-quartile range 26-33 years) were interviewed in a language of their choice. Key questions included: types of approach to use, gender roles, benefits and barriers to introducing the topic of VMMC, and perceptions of VMMC. Interviews were digitally-recorded, transcribed, and translated. Through a standard iterative process, a codebook was developed (QSR NVIVO 10 software) and inductive thematic analysis applied.Most women were willing talk to their sexual partners about circumcision, but indicated that the decision to circumcise remained that of their sexual partner. Women felt that they should encourage their partners, show more interest in circumcision, be patient, speak in a caring and respectful tone, choose a correct time when their partner was relaxed and talk in a private space about VMMC. Using magazine/newspaper articles, pamphlets or advertisements were identified as tools that could aid their discussion. Substantial barriers to

Introduction Arguably, there is a dearth of scholarship on the sociocultural dimensions of Nigeria's solid waste management (SWM) strategies. Whereas, to reduce waste, interventions that draw on the social sciences are needed, particularly science of behavior change [1], which may be realized, for example, by community sustainability pledges and training, civic orientation, children literature, green movements, and programs in schools, as in many developed countries. Citizens' awareness of their roles and responsibilities in Nigeria's SWM system is necessary for positive outcomes. However, their roles and responsibilities seem not often the inclusive focus of scholarly work, resulting in persistent waste disposal challenges. In other words, (solid) waste management, in particular, generally attracts multiple disciplines because it is a major area of public policy and a subject of a burgeoning area of multidisciplinary academic research [2]. The social sciences, particularly civic education or citizens' orientation and behavioral tendency toward recycling, reusing, upcycling, and reducing household or municipal and industrial solid wastes play major roles, but they are seemingly not inclusively prominent in scholarly approaches to SWM in many (developing) countries, including Nigeria. Therefore, there is a need for a rapid evidence review (RER) of likely interdisciplinarity and/or transdisciplinary and multidisciplinary approaches in the literature on Nigeria's SWM system to ascertain the level of involvement of multiple disciplines, particularly the social sciences in Nigeria's SWM approaches. The RER should include a search for the magnitude of the evidence, or the frequency effect size (FES) [3], and the impact of each study, or the intensity effect size (IES) [4], of possible sociocultural factors in the literature on Nigeria's SWM practices. Evidence of focus on advocacy, individual and/or group inclination and participation, and their community values, beliefs, orientation, knowledge, points of view, and related modalities and conditionalities, etc., that is, the inclusion of social sciences/social work perspectives in Nigeria's SWM approaches, should be included in the search. Thus, the type and scope of data needed and the research funder's time constraints warranted the study's rapid review method [5,6] and qualitative meta-summary (see [7,8]). The two techniques synthesized the best available descriptive evidence in electronically indexed literature produced via collaborations, particularly highlighting the scholarship impact of likely sociocultural factors in Nigeria's SWM practices. --- Background The economic and political foundations of societies have, over time, distorted nature. Even modern societies often intentionally and accidentally violate urban and suburban architecture and/or planning and designs that are put in place to mitigate human distortion of nature. Thus, we have huge behavioral (and subsequently, some cultural) problems that are inimical to the sustainability of contemporary societies. In particular, waste disposal (either indiscriminate or accidental) across the world-including Nigeria's solid waste (among other pertinent variables, such as loss of biodiversity, natural resource depletion, air pollution, population growth and movement, urbanization, and poverty)-is a categorical part of the global environmental sustainability challenge. (See page 13 of the Scientific Committee on Problems of the Environment (SCOPE) in the United Nations Environment Programme [9] for a full list of 21st-century emerging issues as survey variables.) Akan et al. [10] posited that only between 9% and 12% of the total generated waste in Nigeria is recycled or incinerated, which is inadequate. Moreover, in a recent study, existing SWM practices in Global South cities resulted in land degradation, air, and water pollution, climate change, methane emissions, and hazardous leachate [11]. Thus, solid waste management should focus not only on environmental protection but also on the sustainability of contemporary social and economic environments and general well-being. The environmental problem of municipal solid waste in Nigeria, consisting of paper, metal, glass, textile, plastic, ash dust, organic content, and other micro-elements [12], is estimated at 0.65-0.95 kg/capita/day [13] or 66,828 tons/day for a total urban population of 106 million [14]. This is a substantive challenge threatening the sustainability or Sustainable Development (SD) of Nigeria-Africa's most populous nation, which is responsible for more than half of the 62 million tons/year of waste generated in sub-Saharan Africa. Interestingly, contemporary deliberations on SWM have been replaced with discussions on circular economy (CE) principles-best epitomized in the idea that nature does not waste anything and everything circulates [15]-and which are supported by the global adoption of the concept of SD [16]. Coincidentally, one of the advocated strategies for SD is interdisciplinary research [17]. In particular, a multiple disciplinary approach to research seems to have created the basis for a systems-thinking perspective in SWM practices generally and for knowledge and innovation in SD locally. Both seem applicable to waste management challenges in Nigeria. Although the concept of sustainability has been postulated to have multiple meanings and to be in danger of overuse [18] (see also [19]), it is seemingly untrue if the relationship among the main concepts of SD is examined. Since 1987, when SD was emphasized in the Brundtland Report as the enhancement of economic growth and a possible solution to the negative effects of industrialization and population growth (see the Report of the World Commission on Environment and Development [20]), concepts related to SD have been developed. Currently, three main related concepts-environmental sustainability, economic sustainability, and social sustainability-coexist, as illustrated in Figure 1. Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 3 of 17 emphasized in the Brundtland Report as the enhancement of economic growth and a possible solution to the negative effects of industrialization and population growth (see the Report of the World Commission on Environment and Development [20]), concepts related to SD have been developed. Currently, three main related concepts-environmental sustainability, economic sustainability, and social sustainability-coexist, as illustrated in Figure 1. The interdisciplinarity and hierarchy of relationships among the SD concepts, shown in Figure 1, may have engineered the evolution of the Sustainable Development Goals (SDGs) of the United Nations' 2030 Agenda. Recently, the hierarchy in relationships prompted [21] (p. 3) to postulate that "SD itself is the principle for a aining sustainability." In other words, SD postulated in the Brundtland Report as the enhancement of economic growth and mitigation of the negative effects of industrialization and population growth (which in modern dispensations are sustainable economy, quality of life, conserving the environment/landscape, air, seascape (i.e., seas and oceans), etc.) has become the foundational idea or a rule that controls the a ainment of sustainability. Figure 1 also shows that two academic departments could be essential for SD-the environmental sciences and the social sciences (the social and economic/CE as an example of the multidisciplinary approach in an SD intervention)-and omit its real infrastructural and technological aspects. However, the scope is beyond the two departments, thus the need for a multiple disciplinary or systems-thinking approach to SD, and by extension to Nigeria's SWM services, and to elsewhere globally. Subsequently, of concern in this research is the possibility for developing countries, particularly Nigeria's SWM system, to leverage the idea (pertinent to the CE) that nature does not waste anything and more of the relevant socioeconomic transitions obvious in many developed and industrial economies. Some interventions in industrial economies from linear to circular are to reduce waste or dwindling economic and ecological resources and to control the negative effects of increasing global warming and environmental stressful situations, pollution resulting from mining accidents, and poor WM practices. Such a transition embraces industry, innovation, and infrastructure (SDG9) in line with [22] SDG Target 9.A and possibly Responsible Consumption and Production (SDG12). In this regard, sustainability transition models (see [23] for an example) with implications for SWM systems have been developed. In particular, there is the multi-level perspective (MLP) sociotechnical system, which "involves interactions between three groups: niche innovations, sociotechnical regime, and sociotechnical landscape" [24] (p. 3). Generally, the sociotechnical transition has been defined as a set of fundamental change processes that have technological, cultural, consumer practices, markets, supply chains, regulations, and infrastructures, among others, which is a clear example of interdisciplinarity or transdisciplinary and multidisciplinary approaches to SD vis-à-vis global ecological challenges. In summary, the increasing global trend of providing multidisciplinary solutions (see [25]) to global warming and dwindling ecological resources is a reality. However, the environmental sciences still seem to dominate SD issues. The interdisciplinarity and hierarchy of relationships among the SD concepts, shown in Figure 1, may have engineered the evolution of the Sustainable Development Goals (SDGs) of the United Nations' 2030 Agenda. Recently, the hierarchy in relationships prompted [21] (p. 3) to postulate that "SD itself is the principle for attaining sustainability". In other words, SD postulated in the Brundtland Report as the enhancement of economic growth and mitigation of the negative effects of industrialization and population growth (which in modern dispensations are sustainable economy, quality of life, conserving the environment/landscape, air, seascape (i.e., seas and oceans), etc.) has become the foundational idea or a rule that controls the attainment of sustainability. Figure 1 also shows that two academic departments could be essential for SD-the environmental sciences and the social sciences (the social and economic/CE as an example of the multidisciplinary approach in an SD intervention)-and omit its real infrastructural and technological aspects. However, the scope is beyond the two departments, thus the need for a multiple disciplinary or systems-thinking approach to SD, and by extension to Nigeria's SWM services, and to elsewhere globally. Subsequently, of concern in this research is the possibility for developing countries, particularly Nigeria's SWM system, to leverage the idea (pertinent to the CE) that nature does not waste anything and more of the relevant socioeconomic transitions obvious in many developed and industrial economies. Some interventions in industrial economies from linear to circular are to reduce waste or dwindling economic and ecological resources and to control the negative effects of increasing global warming and environmental stressful situations, pollution resulting from mining accidents, and poor WM practices. Such a transition embraces industry, innovation, and infrastructure (SDG9) in line with [22] SDG Target 9.A and possibly Responsible Consumption and Production (SDG12). In this regard, sustainability transition models (see [23] for an example) with implications for SWM systems have been developed. In particular, there is the multi-level perspective (MLP) sociotechnical system, which "involves interactions between three groups: niche innovations, sociotechnical regime, and sociotechnical landscape" [24] (p. 3). Generally, the sociotechnical transition has been defined as a set of fundamental change processes that have technological, cultural, consumer practices, markets, supply chains, regulations, and infrastructures, among others, which is a clear example of interdisciplinarity or transdisciplinary and multidisciplinary approaches to SD vis-à-vis global ecological challenges. In summary, the increasing global trend of providing multidisciplinary solutions (see [25]) to global warming and dwindling ecological resources is a reality. However, the environmental sciences still seem to dominate SD issues. In contrast, recently some scholars of social work-which is a social scientific discipline in continental Europe-have over time established a conceptual relationship between eco-social sustainability and social work, as well as the role the profession is playing in promoting the issue of sustainability. However, there is no evidence that such an approach has been leveraged in Nigeria's SWM approaches. For example, Rambaree et al. [26] ex-plored how social work can change from an anthropocentric paradigm to an eco-social work paradigm to promote social change in community practice. Ramsay and Boddy [27] identified and explained the key attributes of environmental social work to emphasize that the adaptation of social work methods to promote social change can help create and sustain a biodiverse planetary ecosystem. Thus, social work's analysis and intervention in the interface between the human and physical environments have been conceptualized via different terminologies such as "Green Social Work" in [28][29][30], among others, and "Environmental Social Work", as in [27,31,32], to mention a few. Other conceptual terminologies include "Sustainable Social Work," as in [33][34][35], and "Ecological Social Work" in [36][37][38]. All the terminologies are basically concerned with the impact of human activity on its physical environment, one of the pillars of SD. In addition, SD is also essentially an ethical and legal issue, not only in terms of political and professional expertise, and possibly in agreement with [39] (p. 8) that "environmental justice as a social work issue"-the deprivation of people of their environmental rights-is an example of the expanded reach of social policy. In other words, environmental issues are inclusively an issue of citizens' participation and patriotism, visionary leadership, and honesty, which are of concern to professional social work. It leverages the social science perspectives or focuses on attitudes, beliefs, cultural values, knowledge, and many more to foster social development and/or the wellbeing of individuals, groups, and communities that may be experiencing sustainability or environmental challenges, which is contrary to the view of [18] (p. 20), who posited an ironic question: "What has sustainability got to do with social work?" Of course, their own answers to the question were used to elaborate on the indispensability of social work practice to leverage social sustainability as a means for long-term global security. Therefore, environmental science perspectives alone can no longer be dominant in the promotion of the global sustainability agenda or SDGs. Furthermore, the social work profession's concern with SD is just one of how the issues of SD pose new challenges and tasks for traditional professions. A similar conceptualization or multidisciplinary approach and the development of a new professional paradigm based on the philosophy of SD seem widespread in other fields as well. However, the social work profession in Nigeria (and in many developing countries) has been struggling to exist legally (see [21]), and it was not until the last quarter of 2022 that the profession was backed by Acts of Parliament. Thus, considering the profession's potentials for promoting social change to sustain the biodiverse planetary ecosystem, not much is known of the profession's role and the level of involvement of other social sciences perspectives in SWM practices in Nigeria, particularly their interventional modalities and conditionalities. Therefore, there is a need for a rapid review. --- The RER Conceptual Framework and Definition of Sociocultural Dimensions The issues of SD, or especially SWM services, appear at the intersection of architectural design and planning of the environment, policies, and laws, economics, technology, and transitions or innovation as well as the interactions of stakeholders. In particular, because Nigeria's SWM practices ought to be all-inclusive issues of many disciplines, the popular multi-level perspective on sociotechnical systems (e.g., see [23,24]) developed based on historical research and used as a strategic guide in systemic change process and positioning of relevant research services serves as this RER's theoretical illustration of Nigeria's solid waste practice landscape. The complex journey of waste-such as bio-waste, textiles, paper, plastic, glass, metals, carton, electronic, and mixed wastes, among others-which consumers may have to recycle (and possibly to grow the economy) and save natural resources can be quite complex. Thus, it has been argued that sociotechnical systems in waste management systems include not only technological dimensions but also farreaching dimensions, such as cultural dimensions, consumer practices, markets, supply chains, regulations, and infrastructural dimensions, among others (see [23,40,41]). See the illustration in Figure 2. natural resources can be quite complex. Thus, it has been argued that sociotechnical systems in waste management systems include not only technological dimensions but also far-reaching dimensions, such as cultural dimensions, consumer practices, markets, supply chains, regulations, and infrastructural dimensions, among others (see [23,40,41]). See the illustration in Figure 2. In Figure 2, sociocultural factors are dominant across the three levels, which [42] characterized as follows: landscape (worldviews, paradigms, culture, and politics), regime (interacting institutional processes), and niche (domain of novelties). Therefore, the sociocultural dimension in this RER is defined as the influence of cultural and demographic characteristics, which include education, knowledge, religion, beliefs, laws, advocacy, governments, demographics, social classes, gender, lifestyles, behavior, and a itudes as well as individual, group, and community values and the indigenous approach to SWM practices in Nigeria. Consequently, the study includes a search for evidence of interdisciplinarity, transdisciplinary, and multidisciplinary approaches and sociocultural dimensions in Nigeria's SWM system. Therefore, this study implemented an RER of qualitative and quantitative academic literature published between 1986 and 2022 generated from Scopus, Business Source Elite (EBSCO), EBSCOhost Academic Search Premier, and SocINDEX databases via UEF Primo (a search engine for printed and electronic materials at the University of Eastern Finland Library) for evidence of multiple disciplines and sociocultural focus on Nigeria's SWM practices. The following research questions guided the RER: --- <unk> Q1: What evidence of interdisciplinarity and/or transdisciplinary and multidisciplinary approaches can be found in the literature on Nigeria's SWM system? <unk> Q2: What inclusive evidence of sociocultural dimensions or social work/social science perspectives can be found in the literature on Nigeria's SWM practices? <unk> Q3: What inclusive interventional modalities and conditionalities of sociocultural dimensions or social science perspectives can be found in the literature on Nigeria's SWM strategies? In other words, quantitative and qualitative peer-reviewed studies focusing on Nigeria's SWM system could provide evidence of interdisciplinarity, or transdisciplinary and In Figure 2, sociocultural factors are dominant across the three levels, which [42] characterized as follows: landscape (worldviews, paradigms, culture, and politics), regime (interacting institutional processes), and niche (domain of novelties). Therefore, the sociocultural dimension in this RER is defined as the influence of cultural and demographic characteristics, which include education, knowledge, religion, beliefs, laws, advocacy, governments, demographics, social classes, gender, lifestyles, behavior, and attitudes as well as individual, group, and community values and the indigenous approach to SWM practices in Nigeria. Consequently, the study includes a search for evidence of interdisciplinarity, transdisciplinary, and multidisciplinary approaches and sociocultural dimensions in Nigeria's SWM system. Therefore, this study implemented an RER of qualitative and quantitative academic literature published between 1986 and 2022 generated from Scopus, Business Source Elite (EBSCO), EBSCOhost Academic Search Premier, and SocINDEX databases via UEF Primo (a search engine for printed and electronic materials at the University of Eastern Finland Library) for evidence of multiple disciplines and sociocultural focus on Nigeria's SWM practices. The following research questions guided the RER: --- • Q1: What evidence of interdisciplinarity and/or transdisciplinary and multidisciplinary approaches can be found in the literature on Nigeria's SWM system? • Q2: What inclusive evidence of sociocultural dimensions or social work/social science perspectives can be found in the literature on Nigeria's SWM practices? • Q3: What inclusive interventional modalities and conditionalities of sociocultural dimensions or social science perspectives can be found in the literature on Nigeria's SWM strategies? In other words, quantitative and qualitative peer-reviewed studies focusing on Nigeria's SWM system could provide evidence of interdisciplinarity, or transdisciplinary and multidisciplinary approaches, and sociocultural factors or social science perspectives and their possible interventional modalities and conditionalities for this RER. --- Significance of This Study One contribution of this RER is the provision of a basis for seemingly needed evidencebased recommendations for sociocultural dimensions and sociotechnical transformation of Nigeria's SWM strategies amid recurrent challenges of solid management in the country. Such a transformation could be replicable in other countries that need to strengthen their SWM systems, particularly developing countries. In addition, the potential outcomes of this study may strengthen the existing bases for the implementation of SDG9 (Industry, Innovation, and Infrastructure) and SDG12 (Responsible Consumption and Production) in Nigeria and elsewhere. Another significance of this RER is the focus on an advanced search for the literature on interdisciplinarity and/or transdisciplinary and multidisciplinary approaches to SWM vis-à-vis sociotechnical theory as a result of the need to systematically identify and highlight the main gaps and recurrent challenges in Nigeria's SWM approaches amid the global trend for collaborating on issues concerning SD. Moreover, a simple search of indexed databases revealed a seeming dearth of standard literature reviews focused on multiple disciplines and sociocultural approaches to Nigeria's SWM practices, either as systematic literature reviews (SLRs), quick scoping reviews (QSRs), evidence reviews (ERs), rapid qualitative reviews (RQRs), or rapid evidence assessments (REAs), which are possible options (see [3]). Finally, this study is a steppingstone for other new (social scientific) studies that require a broad focus on sociotechnical design for SWM in the framework of Finland-Lagos Recycling Culture Research & Development Project's (F-LRCRDP) research series. --- Methods An overview of the major techniques implemented in this RER is as follows. First, the research questions were subjected to rapid review criteria. Second, an information specialist at the University of Eastern Finland's (UEF) library was engaged, and search strategies were developed. Third, the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 flow diagram often used in SLRs was deployed to identify and screen the literature generated from the indexed databases search. Thereafter, for generic and comparative typification, extraction, and analysis of evidence relevant to this RER, the desired characteristics in the literature reviewed were coded A, AB, AC, or ABC and ABCD (or in small letters abcd to indicate their possible variants) and vice versa in the manner of Boolean algorithms. See [43,44] for a full illustration and detailed logic, respectively, of the Boolean algorithms. Fourth, limited descriptive texts and statistics compatible with the qualitative meta-summary procedure were used in the reporting of the RER results. --- Refining the Research Questions To ensure that the research questions were well-defined and developed for focus and feasibility, they were subjected to the Feasibility, Impactful, Novel, Ethical, and Relevant (FINER) criteria developed by [45] as a necessary parameter in a rapid review or RER (see also [46]). The research questions fit the criteria and comprise six subcategories-collaboration vis-à-vis interdisciplinarity, transdisciplinary and multidisciplinary approaches, sociocultural dimension or social science perspectives, and their interventional modalities and conditionalities. --- Search Strategy, Data Sources, Search Results, and Selection Criteria An information specialist at the UEF's library conducted a search in electronic databases for indexed relevant journal publications. From 21 February 2022 to 29 September 2022, two search strategies were implemented. The first search implemented via UEF Primo was ("waste manag*" OR "municipal waste*") AND TITLE (nigeria*). The search was limited to peer-reviewed literature, and 149 publications published between 1986 and 2022 were identified in the Scopus database. The second search was conducted on 29 September 2022 in the same search engine and included (circular econom* OR circular ecosystem* OR recycling) AND nigeria*. However, this search was limited by date (2010-2022) and academic journals, and it identified 76 publications in three databases: the Academic Search Premier, Business Source Elite, and SocINDEX. In other words, four electronic databases were searched via UEF Primo. Subsequently, the characteristics of all identified publications-title, abstract, date, and authors' information-were generated from quantitative and qualitative peer-reviewed literature (and some gray literature). The information was compiled in a Microsoft Word file and hard copies made for selection and screening. The following were the eligibility criteria for screening literature for the RER: peer-reviewed literature on Nigeria's SWM system, practices, and approaches; peer-reviewed literature on the circular economy; and peer-reviewed literature published between 1 March 1986 and 29 September 2022. In other words, any publication that did not exhibit the eligibility criteria above, such as gray literature, conference proceedings, or book chapters, was excluded. The PRISMA 2020 flow diagram, which is recommended for SLR processes and steps [47], was adapted to report the identification and screening of the publications retrieved for the RER, as illustrated in Figure 3. was limited to peer-reviewed literature, and 149 publications published between 1986 and 2022 were identified in the Scopus database. The second search was conducted on 29 Sep tember 2022 in the same search engine and included (circular econom* OR circular eco system* OR recycling) AND nigeria*. However, this search was limited by date (2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019)(2020)(2021)(2022) and academic journals, and it identified 76 publications in three databases: the Aca demic Search Premier, Business Source Elite, and SocINDEX. In other words, four elec tronic databases were searched via UEF Primo. Subsequently, the characteristics of all identified publications-title, abstract, date and authors' information-were generated from quantitative and qualitative peer-re viewed literature (and some gray literature). The information was compiled in a Microsof Word file and hard copies made for selection and screening. The following were the eligi bility criteria for screening literature for the RER: peer-reviewed literature on Nigeria's SWM system, practices, and approaches; peer-reviewed literature on the circular econ omy; and peer-reviewed literature published between 1 March 1986 and 29 September 2022. In other words, any publication that did not exhibit the eligibility criteria above, such as gray literature, conference proceedings, or book chapters, was excluded. The PRISMA 2020 flow diagram, which is recommended for SLR processes and steps [47], was adapted to report the identification and screening of the publications retrieved for the RER, as illustrated in Figure 3. --- Procedure for Analysis and Qualitative Meta-Summary of the Descriptive Evidence Each work included in the rapid review (n = 70) was defined and was keyworded as follows: one, collaborative studies (two authors minimum) and coded A; two, trans-, inter-, or multidisciplinary approaches (two different disciplines or departments or faculties as --- Procedure for Analysis and Qualitative Meta-Summary of the Descriptive Evidence Each work included in the rapid review (n = 70) was defined and was keyworded as follows: one, collaborative studies (two authors minimum) and coded A; two, trans-, inter-, or multidisciplinary approaches (two different disciplines or departments or faculties as minimum) and coded B; three, with evidence of sociocultural dimensions or social science perspectives and coded C, and four, with (their) interventional modalities and conditionalities and coded D. The defining and coding of the characteristics made it easy to further group the literature to properly represent appropriate data. Thus, a four-item template comprising the title, author information, abstract, date, and primary paper was created to extract the data. For the extraction, typification, and evidence synthesis, a qualitative meta-summary procedure as suggested by [6] seemed appropriate to identify, extract, and synthesize a mixture of qualitative and/or quantitative empirical evidence and by extension the literature on multiple disciplinary and sociocultural dimensions in Nigeria's SWM practices. In particular, the qualitative meta-summary created an opportunity for extraction and grouping of evidence and, possibly, the quantitative computation of the FES and the IES that mostly contributed to this review. In summary, the outcomes of the steps are shown in figures and tables, as presented in Section 3. --- Results The results for the grouping and abstracting of data are reported in this section, and a complete list of the literature included in the RER (n = 70) is in the Appendix A section (Table A1). In addition, while abstracting and grouping of evidence are displayed in Table 1, the FESs and IESs are displayed in Table 2. Detailed explanations of Tables 1 and2 vis-à-vis Figures 4 and5 are included in the following subsections. --- Group (G) Abstracting the Evidence (AE) References G2: Single Authors 5. "A major limitation to the integration of informal waste collectors and scavengers is the social acceptance of their activity as a viable source of income, and of themselves as environmental agents in the sustainability of virgin resources." SP27. --- " The study recommends inter alia that practitioners should be cognizant of the use of waste management plans (WMPs) to minimize all categories of waste, especially materials, on their projects." SP34. 7. "Findings show that the Policy Implementors preferred the use of personal contact as the channel for disseminating environmental information, whereas the Policy Formulators relied on the use of posters, radio/TV talks, and professional meetings. Some barriers to disseminating information to the public included: lack of access to information sources, lack of standards for acquisition of information, and lack of funds to publish information materials." SP36. --- " A public enlightenment campaign is recommended for proper education of the public on modern ways of garbage disposal." SP41. 9. "Successful solid waste management in Nigeria will require a holistic program that will integrate all the technical, economic, social, cultural, and psychological factors that are often ignored in solid waste programs." SP42. 10. "It highlights the roles of individuals, households, changing lifestyles and diet, business cycles, residential segregation, and state and non-state actors and institutions in waste management in Lagos." SP45. NB: The bolded (words, phrases, and texts) are aspects of the social science/social work approach to SWM. [Babayemi et al., 2017] SP50 [Ogbonna and Mikailu, 2019] SP52 [Mbah and Nzeadibe, 2017] Frequency 020 flow diagram of the study selection process [47]. Records removed before screening based on duplication, and title, abstract, and date against eligibility criteria: (n=149). A1 1 1 4 1 1 2 1 2 3 3 1 3 1 13/25 A2 2 1 1 2 1 5/25 A3 1 1 1 1 4/25 A4 1 1 1 1 4/25 A5 1 1/25 A6 1 1/25 A7 1 1/25 A82 --- screened (n=76). Records excluded: Grey Literature. Conference Proceedings, and Book Chapters (n=6). sought for retrieval (n=70). Reports not retrieved (n=0). assessed for eligibility (n=70). Reports excluded: (n=0). ncluded in the RER (n=70). Identification of studies via databases and registers --- Grouping and Abstracting the Evidence First, the defining and coding of the included literature (n = 70) created two groups of relevant literature: Group 1, with ABCD characteristics (n = 52), and Group 2,with b (n = 12) indicating single authors from different disciplines but no interdisciplinarity, and those with BCD characteristics (n = 6) that provided relevant evidence, as indicated in Figures 4 and5, respectively. In other words, the abstracting of evidence, referencing, and taking note of their frequencies focused on the relatively small number of studies, ABCD (n = 6) and ABC (n = 13), that are evidence of sociocultural dimension or social science perspectives, as well as the single-author papers (n = 6) of the BCD category. These patterns are more obvious in the illustration of the abstracting of evidence in Table 1 and in the illustration of the FESs and IESs in Table 2. Furthermore, the evidence (or AE) in Table 1 is subjected to FES and IES computation to ascertain the relative magnitude of the abstracted evidence and the impact of each study in the reviewed literature. Thus, the outcomes of both steps are explained and illustrated in the following section. --- Frequency and Intensity of the Effect Sizes The results for the computation of how often particular evidence appeared in the reviewed literature or the relative magnitude of an AE, which is equivalent to the FES, are illustrated in Table 1. Similarly, the results for the computation for ascertaining the impact of each study-the IES of each study-in the reviewed literature is also illustrated in Table 2. The outcomes of the methods implemented to ascertain and synthesize the best available descriptive evidence on probable sociocultural factors in the country's SWM practices are further interpreted in Section 4. --- Discussion --- Meaning of the Findings The results' interpretations have different facets. First, the purpose of the rapid review was to analyze and synthesize the best available descriptive evidence from the literature, particularly of probable sociocultural factors, among others, in Nigeria's SWM strategies. Almost all of the seventy works included (spanning about three decades) acknowledged the increasing SWM challenges in Nigeria, thus the need for a holistic strategy that combines the expertise of different disciplines, professions, government, and non-government intervention at different levels to devise an innovative solution that is line with current trends and the goals of SDGs of the United Nations' 2030 Agenda. Second, although there is substantive evidence of sociocultural dimensions in Nigeria's SWM practices in the literature, the number of studies from 1986 to 2022 is too small. However, those few studies agree (1) that social science approaches are needed to effectively tackle the challenges of managing refuse. Those small number of studies also agree (2) that refuse management is a burgeoning area of interdisciplinarity and/or transdisciplinary and multidisciplinary academic research. The Scopus, Academic Search Premier, Business Source Elite, and SocINDEX databases together generated only six studies (excluding the BCDs) of the ABCD category, which is the best available evidence of probable sociocultural dimensions in Nigeria's SWM approaches. In other words, the data presented in Section 3 indicate that there are a few studies with the ideal category of social-cultural dimensions in Nigeria's SWM strategies. Specifically, the constant factors in the findings and/or recommendations of the very few studies are the inadequate and weak multidisciplinary or non-holistic approaches to driving innovation and effective social impact in Nigeria's WM practices. Third, challenges implementing research findings exist in Nigeria because SP9 (2020), SP16 (2018), SP40 (2002), SP46 (2019, SP47 (2018), and SP48 (2012)-all six in the ABCD category that represent the finest level of evidence for this review-were published over two decades (2002 to 2020). In addition, this connotation suggests that there is a huge gap between research and evidence-based policy practice in Nigeria. In contrast, in agreement with [26,27], the scale or range and scope of social work practice have many configurations and possibilities [43], which may be one great or main means, among others, for addressing the problems regarding SWM and individuals, groups, communities, businesses, and other social institutions that generate waste are concerned. Therefore, as a matter of urgency, this paper recommends a strong multidisciplinary research and practice approach with strong cultural or social scientific input to lead the social impact team. In this case, the inherent expanded mandate of the social work profession for intervention in the physical environment agrees with the increasing multidisciplinary solution [25] to global warming and dwindling ecological resources worldwide. For the social work profession to fulfill its individual, environmental, and social change mandate [48], it draws theories from human

Against the background of an arguable dearth of scholarship on the sociocultural dimensions of Nigeria's solid waste management strategies and practices, this rapid review searched for evidence in the literature. A rapid evidence review and qualitative meta-summary procedure were implemented to utilize the rigor of systematic literature review that met the timelines and limited funding available for this study. It is more appropriate to identify, extract, and synthesize a mixture of qualitative and/or quantitative empirical evidence in the literature. This rapid review found little substantive evidence of scholarly sociocultural approaches in Nigeria's solid waste management. It also discovered constant factors of inadequate and weak multidisciplinary or non-holistic approaches to driving innovation and effective social impact in Nigeria's solid waste management practices. The results were interpreted vis-à-vis the need to leverage the social sciences, particularly the range and scope of social work practice configurations and possibilities, to scientifically advance and substantially accelerate the implementation of evidence-based policy and practice in Nigeria's solid waste management system. This rapid review concluded that the negative results are due to the insufficient conceptual and theoretical bases for Nigeria's solid waste management strategies and/or practices.

Nigeria because SP9 (2020), SP16 (2018), SP40 (2002), SP46 (2019, SP47 (2018), and SP48 (2012)-all six in the ABCD category that represent the finest level of evidence for this review-were published over two decades (2002 to 2020). In addition, this connotation suggests that there is a huge gap between research and evidence-based policy practice in Nigeria. In contrast, in agreement with [26,27], the scale or range and scope of social work practice have many configurations and possibilities [43], which may be one great or main means, among others, for addressing the problems regarding SWM and individuals, groups, communities, businesses, and other social institutions that generate waste are concerned. Therefore, as a matter of urgency, this paper recommends a strong multidisciplinary research and practice approach with strong cultural or social scientific input to lead the social impact team. In this case, the inherent expanded mandate of the social work profession for intervention in the physical environment agrees with the increasing multidisciplinary solution [25] to global warming and dwindling ecological resources worldwide. For the social work profession to fulfill its individual, environmental, and social change mandate [48], it draws theories from human development and behavior and social systems [49]. In other words, the generalist (or generic) foundation of social work practice has been inclusively built on system theory and the ecological system (ecosystem) perspective (see [50]), which, according to [26], are applicable at the micro-, mezzo-, and macro-practice levels for social change and to sustain society. --- Policy Recommendations The best practices of the performance economy (model)-services or commodities through rents or lease-and/or CE models (or a mixture of linear, performance, and CE) [51] is a good alternative to the popular traditional linear economy, which makes, uses, and disposes of waste materials as far as how solid wastes are generated and accumulated. Thus, any of these approaches could be anchored by social work in the best interest of business organizations, governmental levels, and every population group in Nigeria if the profession is given adequate support and cooperation with the relevant resources and necessary legislative framework. The multicultural situation in Nigeria calls for a broader and culturally sensitive research evaluation and implementation in relation to SWM strategies, which can also create opportunities for simultaneous evaluation vis-à-vis good governance and the effects of policies and legislation on citizens. Social inclusion, citizen engagement, and knowledge creation are currently three of the eight guiding objectives of [52] SWM projects. Generally, current waste management practices in Nigeria must be understandable from the legal and policy instruments that are put in place and which call for constant evaluative research. --- Limitations Notwithstanding the recommendations, it seems appropriate to acknowledge the limitations of this RER. The number of databases that were searched did not seem to have freely available and valuable literature with relevant evidence of concern. For example, the literature such as [53] that implemented meta-analysis and meta-synthesis to examine theoretical key cultural factors and social practices influencing solid waste governance and management (SWG&M) in Nigeria was not available in those four databases via UEF Primo. In addition, [54] presented a systematic review of the literature on Nigeria's WM in regard to waste characterization, waste management practices, ecological impacts, public-private partnership, ethical issues, and legal frameworks and [55] conducted a comprehensive review of the literature and critically evaluated the worsening conditions in municipal SWM in developing nations with a focus on Nigeria. Because the scholarly studies were not generated from this study's searched databases, we may conclude that other studies with relevant evidence likely exist somewhere else. Nevertheless, the number of studies with relevant evidence of focus still seems very small, pro rata. The freely available scholarly studies beyond the reach of this RER support the fact that there is a huge gap between research and evidence-based policy implementation and practice in Nigeria. --- Conclusions This rapid review searched, examined, highlighted, and summarized or evaluated the best available or existing evidence for scholarship impact on sociocultural factors in Nigeria's SWM strategies. Generally, the constant factors in the very few studies that revealed substantive evidence of sociocultural dimensions in Nigeria's SWM practices in the literature seem to expose the inadequate and weak multidisciplinary or non-holistic approach to driving innovation and effective social impact in Nigeria's WM practices. In other words, for more effective and efficient refuse management practices in Nigeria, there is an urgent need to examine the positions of social science interventions in existing SWM policies, laws, and practices. There is also a need to reconcile SWM policy documents and relevant evidence-based vis-à-vis holistic approach research because the emerging gaps are clearly due to an insufficient conceptual and theoretical basis for circular economy and waste management, on the basis of which it would be possible to build comprehensive legislation, professional expertise, policy strategies, and, ultimately, the necessary national and local waste management infrastructure, not forgetting the key role of citizens as grassroots waste managers. --- Data Availability Statement: Data will be made freely available upon request. --- Author Contributions: Conceptualization: T.A., J.H. and P.P.; methodology: T.A.; analysis: T.A.; data presentation T.A. and I.J.; writing-original draft T.A.; writing-review and editing: T.A. All authors have read and agreed to the published version of the manuscript. --- Conflicts of Interest: The authors declare no conflict of interest. --- Appendix A

Against the background of an arguable dearth of scholarship on the sociocultural dimensions of Nigeria's solid waste management strategies and practices, this rapid review searched for evidence in the literature. A rapid evidence review and qualitative meta-summary procedure were implemented to utilize the rigor of systematic literature review that met the timelines and limited funding available for this study. It is more appropriate to identify, extract, and synthesize a mixture of qualitative and/or quantitative empirical evidence in the literature. This rapid review found little substantive evidence of scholarly sociocultural approaches in Nigeria's solid waste management. It also discovered constant factors of inadequate and weak multidisciplinary or non-holistic approaches to driving innovation and effective social impact in Nigeria's solid waste management practices. The results were interpreted vis-à-vis the need to leverage the social sciences, particularly the range and scope of social work practice configurations and possibilities, to scientifically advance and substantially accelerate the implementation of evidence-based policy and practice in Nigeria's solid waste management system. This rapid review concluded that the negative results are due to the insufficient conceptual and theoretical bases for Nigeria's solid waste management strategies and/or practices.

Background Approximately 1.2 million (5%) Australians are currently living with type 2 diabetes (T2D), increasing from 840,000 people (3.8%) in 2011-2012 [1,2]. Strategies aimed at optimising blood glucose levels are a fundamental premise for the prevention and progression of complication in people with T2D. Current Australian guidelines set targets for glycated haemoglobin (HbA1c), an index of average blood glucose level over three months to assess glycaemia and as a measure of risk for the development of diabetes-related vascular and neurological complications [3]. Self-management (adherence to medications, managing diet and exercise) is an important way for people with T2D to achieve and maintain glycaemic targets. Significant inequities exist with prevalence, mortality and hospitalisations all twice as common in people with T2D from low socioeconomic backgrounds compared to people from high socioeconomic backgrounds [1,4]. Increasing levels of socioeconomic disadvantage are also associated with higher likelihood of out of target (high) HbA1c [5]. Research has shown that patients with diabetes have suboptimal levels of recall and understanding of HbA1c (only around 25% report a good understanding), which in turn impacts significantly on patients' diabetes self-care behaviours [6][7][8]. This is particularly important in the setting of socioeconomic disadvantage which is associated with low levels of health literacy and education [9][10][11]. Continuous glucose monitoring (CGM) technology provides a level of detail when assessing glucose control not provided by HbA1c measurements. CGM measures interstitial glucose levels nearly continuously allowing insights into short and medium-term fluctuations in glucose levels. Several parameters can be derived from CGM data including a measurement of percentage of time in glucose target range (TIR), a measure of the amount of time an individual spends within a specified glucose target range. Previous studies have identified a correlation between TIR and HbA1c. Having 50% of self-monitored glucose levels within 3.9-10 mmol/l (70.2-180 mg/dL) is correlated with an HbA1c of around 7% [12][13][14][15]. TIR, dependent on fluctuations in diet and physical activity, medication and adherence, is known to be an independent predictor of diabetes complications and mortality [13,16]. Understanding the association between TIR and socioeconomic status (SES) may provide important insights in addition to those of HbA1c when evaluating the socioeconomic disparity seen in T2D prevalence and the development of complications. Importantly, TIR may also be a measurement that is easier for people with T2D to interpret and comprehend, empowering them to optimise their self-care behaviours. This is because TIR directly relates to measurements that are being made (i.e. blood glucose levels and a range), whereas HbA1c is one remove from that as it indirectly references blood glucose levels, therefore possibly making this harder conceptually for people to understand. The General Practice Optimising Structured MOnitoring To Improve Clinical outcome (GP-OSMOTIC) randomised controlled trial is a study on the impact of a retrospective CGM device (Abbott FreeStyle Libre Pro® Flash Glucose Monitoring System) used in the clinical care of people with T2D in General Practice in Australia [17]. We report here on the relationship found between SES and TIR based on analysis of baseline data from the GP-OSMOTIC randomised controlled trial. --- Methods --- Design and study participants This is an analysis of baseline data obtained from the GP-OSMOTIC trial (ACTRN12616001372471) that recruited a total of 300 patients from 25 General Practices in Victoria, Australia, between October 2016 and November 2017. GP-OSMOTIC trial inclusion criteria are ages 18-80 years old, patients diagnosed with T2D, patients with the most recent (in the previous 3 months) HbA1c level 0.5% above their individualised target, patients prescribed at least 2 non-insulin anti-hyperglycaemic agents and/or insulin, and patients who have had stable anti-hyperglycaemic therapy for the last four months. Individualised target refers to an HbA1c target based on the participant's clinical characteristics and risk profile. GP-OSMOTIC trial exclusion criteria are patients with debilitating medical conditions (e.g. unstable CVD, severe mental illness, end-stage cancer), eGFR <unk> 30 ml/ min/1.73m 2, proliferative retinopathy, patients who are pregnant/lactating/planning pregnancy, patients unable to speak English/give consent, patients unwilling to use CGM device or follow the GP-OSMOTIC study protocol, a history of allergy to plaster/tape and any condition that makes monitoring diabetes using the HbA1c unreliable (e.g. haemoglobinopathies). --- Baseline data Baseline survey, anthropometric measures and pathology collection were undertaken by clinically-trained research assistants at each participant's general practice. The survey included questions on educational attainment, employment and occupation, ethnicity and smoking status. Participant's medications, co-morbidities and diabetesrelated complications were retrieved from clinical medical electronic health records. Chronic kidney disease was present if participants had evidence of microalbuminuria/ macroalbuminuria and/or eGFR of <unk> 60 mL/min/1.73 m 2 from urine and blood samples performed up to 30 days prior to baseline. eGFR was calculated by pathology labs using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula as per the Australasian Creatinine Consensus Working Group's position statements [18]. Similarly, HbA1c measures performed up to 30 days prior to the baseline visit were accepted, otherwise research assistants performed blood collection during the baseline visit. All HbA1c measurements were reported in both International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) units (mmol/mol) and National Glycohaemoglobin Standardisation Programme (NGSP) units (%). These pathology measurements were undertaken at different laboratories based on General Practice clinic preferences. Masked CGM data was collected at baseline, prior to any therapeutic intervention, using a FreeStyle Libre Pro® sensor patch. This was applied by study staff to the underside of the participant's upper arm to measure individual glucose levels in 15-min intervals for 2-weeks. After 2-weeks, the sensor was removed, and data were uploaded to a secure computer onto Microsoft Office Excel 2007 (Microsoft Corp., Seattle, WA, USA). Survey and clinical data were entered into REDCap<unk> (REsearch Data CAPture software), a secure, web-based application designed to support research data capture [19]. --- Measures TIR, defined in this study as 3.9-10 mmol/l (70.2 -180 mg/dL), is calculated using the CGM data. TIR was calculated using Microsoft Office Excel 2007 (Microsoft Corp., Seattle, WA, USA). The range of CGM data for inclusion in this study was 5 to 14 days, consistent with manufacturer's recommendations [20]. We used the Socio-Economic Indexes For Areas (SEIFA) Index of Relative Socioeconomic Disadvantage (IRSD) as one measure of SES in our analysis. The SEIFA IRSD scores for each postcode are calculated by summarising attributes of the population collected through Australia's national household census, such as income, educational attainment, employment and occupation. These scores are grouped into deciles where decile 1 represents the most disadvantaged and decile 10 represents the least disadvantaged [21]. The second measure of SES we used was the level of educational attainment. Educational levels were categorised into never attended, primary level, secondary level, Trade/Vocational training course (TAFE) and University diploma/degree. Information on diet and exercise were obtained through a baseline questionnaire. Participants were asked to write down the number of days in the last week in which carbohydrates were evenly spaced, and the numbers of days in the last week in which <unk>30 min of physical activity was undertaken. --- Data analysis Normally distributed continuous variables are expressed as mean <unk> standard deviation, non-normally distributed continuous variables as median (IQ range) and categorical variables as frequency (percentage). Mixed-effects linear regression analysis was used to examine the four associations: TIR and IRSD, HbA1c and IRSD, TIR and educational attainment, and HbA1c and educational attainment. Never attended, primary education and secondary education were grouped into one category and used as a baseline to compare with other categories of education in our analysis. Univariable and multivariable analyses controlling for age, BMI, diet, exercise and study arm were performed to examine each association. Adjustment for study arm was performed as randomisation occurred after the CGM sensor was attached and before it was removed. Robust standard errors were specified to allow for clustering at the clinic level. As baseline HbA1c and IRSD deciles were non-normally distributed, log and square transformations of these variables were considered. Residual graphs were plotted for both transformed and untransformed data. Following review of the residual graphs, data transformation was not applied in our data analysis for all models of analyses. This is because the transformation did not significantly improve the random spread of the residuals, which results in limited benefit of the added complexity transformation would add to the interpretation. All statistical analyses were performed using STATA version 13.0 software (StataCorp, College Station, TX, USA). --- Ethics The GP-OSMOTIC trial, incorporating this study, was approved by The University of Melbourne Human Research Ethics Committee (ID 1647151.3). --- Results --- Patient characteristics Data from 278 of the 300 participants in the GP-OSMOTIC trial were included in this study. Ten participants were excluded from data analysis as their CGM data duration were <unk> 5 days, thus limiting the accuracy of glucose profile output obtained from insufficient number of data points [20]. Three participants were excluded from this study's analysis due to absent Socio-Economic Indexes for Areas (SEIFA) data based on the provided postcodes, and a further nine participants were excluded due to missing CGM data. There was no difference in essential characteristics between included and excluded participants. Of the 22 participants excluded from this study, 10 (45.5%) were males, mean (SD) age was 57.4 (11.2) years, mean (SD) duration of T2D was 14.9 (4.6) years and mean (SD) BMI was 33.0 (4.6) kg/m 2. Information obtained on diet and exercise were also similar with a median (IQR) of 4 (1,5) days and 5 (2, 6.75) days respectively. The baseline characteristics of participants are summarised in Table 1. --- Association between TIR and IRSD Table 2 shows the association between TIR and IRSD using unadjusted and adjusted models. There is evidence of a positive correlation between TIR and IRSD following adjustment for confounding variables. As the mean difference in TIR between one decile change of IRSD is 1.5% (95% CI 0.5, 2.5), thus on average, TIR was 15% higher for those least disadvantaged (IRSD = 10th decile) compared to those most disadvantaged (IRSD = 1st decile) (95% CI 5,25). --- Association between baseline HbA1c and IRSD Multivariable mixed effects linear regression identified an inverse correlation between HbA1c and IRSD. As the mean difference in HbA1c between one decile change of IRSD is 0.06% (95% CI 0.01, 0.1), thus on average, HbA1c was 0.6% lower for those least disadvantaged (IRSD = 10th decile) compared to those most disadvantaged (IRSD = 1st decile) (95% CI 0.1, 1). --- Association between TIR/HbA1c and education Table 2 shows results of the association between TIR and educational attainment, as well as HbA1c and educational attainment following univariable and multivariable mixed effects linear regression. Educational attainment was not shown to be associated with either TIR or baseline HbA1c. --- Discussion Our analysis of CGM data obtained over a 2-week period from participants with T2D and sub-optimal HbA1c in primary care as part of the GP-OSMOTIC trial provides novel insight into glycaemia in this population. Least disadvantaged IRSD deciles, a composite area level measure of socioeconomic disadvantage, were correlated with better glycaemic control (both TIR and HbA1c). Our results support that an increase of 5 deciles in IRSD was associated with bringing the mean TIR in this population to almost 50%. As having 50% of self-monitored glucose levels within 3.9-10 mmol/l(70.2 -180 mg/dL) is correlated with an HbA1c of around 7% [12], this would be associated with significantly improved health outcomes and reduced risk of diabetes-related complications. However, we found no association between educational attainment, a single, individual level measure of SES, and glycaemic control (either TIR or HbA1c). Our finding that educational attainment was not shown to be associated with achieving glycaemic targets despite the strong association seen for IRSD highlights the complexity of studying the concept of SES and its relationship with chronic disease parameters. Our finding is in contrast to international studies suggesting that socioeconomic advantage measured at the individual level such as higher educational attainment [22][23][24][25], higher income [26,27] and higher residential stability [28], were associated with a greater likelihood of achieving HbA1c targets. However, there are many different measures and ways of defining SES, a concept that is made up of individual characteristics (e.g. educational attainment, income level, occupation), as well as contextual levels where the individual is situated within a physical and social location with characteristics relating to the built environment, social networks and social and supportive relationships. There is no single best indicator of SES suitable for all study aims and applicable at all stages in life. Rather there are many different possible measures, each with its own implications as well as strengths and limitations [29,30]. It is thus important for policy, practice and research to be aware of this complexity, to use relevant SES measures and concepts that are suitable for their objectives and to interpret findings in relation to SES appropriately. Individual and environmental factors likely interact with each other to affect glycaemia. People from more advantaged socio-economic backgrounds may have higher health literacy, with improved capacity to obtain, process, understand and act upon health information to support self-management of their condition [24]. However, our findings suggest that area level disadvantage is associated with glycaemia. Environmental and neighbourhood characteristics that we know are associated with more socio-economically advantaged areas such as greater accessibility to greenspace to engage in physical activities, a lower density of unhealthy food options such as fast food outlets, community norms and emphasis on healthy living and more opportunities to access health care services may all contribute to the social gradient in TIR and HbA1c that we identified [31]. It is important to acknowledge study limitations. The SEIFA IRSD represents an average of all people living in an area and does not represent individual situations. This is especially so in larger areas where there is more likely to be greater diversity [21]. The association between SES as measured by the IRSD and TIR is thus a generalised way of studying the link between neighbourhood level disadvantage with achievement of glycaemic targets. Other limitations of our study also include reliance on participants' recall for certain information, such as duration of diabetes and the likelihood that T2D may have existed for months or even years before formal diagnosis. Information regarding participant medications, medical history and diabetes-related Represents number of days in the last week in which carbohydrates were evenly spaced f Represents numbers of days in the last week in which <unk>30 min of physical activity was undertaken IRSD Index of Relative Socioeconomic Disadvantage, BMI Body Mass Index, CGM Continuous Glucose Monitor, TIR Percentage Time in Range, HbA1c Glycated Haemoglobin complications were retrieved from clinic medical electronic health records that may not be up to date. Our data were also sourced from only Victorian general practices and cannot be generalised to the whole Australian population. Lastly, heterogeneity in laboratory measurements (e.g. creatinine, albumin:creatinine ratio, HbA1c) which were performed in a variety of pathology laboratories may have weakened the correlation, though all laboratories would have been accredited and participate in a national quality control programme. No studies have used TIR to look at the association with SES. As TIR may be a measure of glycaemic control that is easier for patients to understand, utilising TIR in clinical care particularly for patients from lower socioeconomic backgrounds may aid in increasing patient engagement, which in turn could assist in optimising self-care behaviours, improving health outcomes, and could contribute to reducing health inequities seen in T2D. Our findings, in conjunction with previous international [22][23][24][25][26][27][28] and Australian [5] studies, also have significant implications for resource allocation of community-based health services to reduce the health inequity gap in patients with T2D. It also aids in highlighting the importance for GPs to consider and understand patient context when engaging and supporting patients with their diabetes self-management. Further studies involving larger patient sample sizes over a longer period throughout Australia to investigate this association are warranted, as well as further studies investigating patient and practitioner perceptions of TIR as a measure of glycaemic control. Further studies of the relative effectiveness and cost of CGMs in this population would also be useful and will be conducted as part of the GP-OSMOTIC trial at a later stage. --- Conclusion Our study showed a clinically and statistically significant association between an area-based measure of SES and glycaemic targets with more socio-economically disadvantaged people less likely to achieve glycaemic targets. Lower socioeconomic groups and areas may require prioritisation in resource allocation of primary health care services as well as policies aimed at ensuring equitable access to healthy environments to reduce health inequity. Our study highlights the importance of considering patient context during GP consultations and introduces a novel measure of glycaemia that may help with patient engagement to improve diabetes outcomes. --- Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. --- Abbreviations CGM: Continuous glucose monitor; GP-OSMOTIC: General Practice Optimising Structured MOnitoring To Improve Clinical outcomes (GP-OSMOTIC); HbA1c: Glycated Haemoglobin; IRSD: Index of Relative Socioeconomic Disadvantage; SEIFA: Socio-Economic Indexes For Areas; SES: Socioeconomic Status; T2D: Type 2 Diabetes; TIR: Percentage Time in Range Authors' contributions MLT collected data, performed data analysis, data interpretation and drafting of the manuscript. JAMN performed data analysis and interpretation, and was a major contributor in writing the manuscript. ST performed data analysis and interpretation. AJ and DO designed this study and interpreted study results. JF interpreted study results and was a major contributor in writing the manuscript. All authors read and approved the final manuscript. --- Ethics approval and consent to participate The GP-OSMOTIC trial, incorporating this study, was approved by The University of Melbourne Human Research Ethics Committee (ID 1647151.3). Written informed consent to participate was obtained from all participants. Our ethics committee approved our method of consent. --- Consent for publication Not applicable. Competing interests JF has received unrestricted educational grants for research support from Roche, Sanofi and Medtronic. DO is on the advisory boards to Abbott Diabetes Care, and Novo-Nordisk. DO and JAMN have had various financial relationships with pharmaceutical industries outside the submitted work including consultancies, grants, lectures, educational activities and travel. AJ is on an advisory board to Abbott Diabetes care and has had research grants and educational activities supported by various pharmaceutical industries outside the submitted work. The authors declare that they have no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Optimal glycaemia, reflected by glycated haemoglobin (HbA1c) levels, is key in reducing type 2 diabetes (T2D) complications. However, most people with T2D have suboptimal recall and understanding of HbA1c. Continuous glucose monitoring (CGM) measures glucose levels every 5 to 15-min over days and may be more readily understood. Given that T2D is more common in lower socioeconomic settings, we aim to study relationships between socioeconomic status (SES) and percentage time in glucose target range (TIR) which is a key metric calculated from CGM. Methods: Analysis of baseline data from the General Practice Optimising Structured MOnitoring To Improve Clinical outcomes (GP-OSMOTIC) randomised controlled trial (October 2016 -November 2017) of 300 people with T2D from 25 Victorian General Practices. FreeStyle Libre Pro® sensor patch was used for this study. SES was defined by the Index of Relative Socio-economic Disadvantage (IRSD) and educational attainment. Univariable and multivariable mixed-effects linear regression analyses controlling for age, BMI, diet, exercise and study arm were performed. Results: One hundred and sixty-seven (60.1%) participants were male, the mean (SD) participant age was 61.0 (9.7) years, and the mean (SD) duration of CGM use was 12.3 (2.5) days. The 10th IRSD decile (least disadvantaged) was associated with a 15% higher TIR vs. the 1st decile (most disadvantaged) (95% CI 5, 25; p = 0.003) and a 0.6% lower HbA1c (95% CI 0.1, 1; p = 0.03). There was no evidence of an association between educational attainment and TIR/HbA1c.Higher SES measured at an area level is associated with better achievement of glycaemic target using complementary measures of HbA1c and TIR in the GP-OSMOTIC cohort. Given that TIR may be more easily used in patient education and self-management support compared to HbA1c values, the social gradient identified in TIR provides an opportunity for clinicians and policy makers to address health inequities in T2D. Trial registration: Australian and New Zealand Clinical Trials Registry Trial ACTRN12616001372471, prospective, Date registered 4/10/2016.

Introduction During the COVID-19 pandemic, the interest in and need for telecare solutions has increased due to physical distancing. Robotic solutions used in home care for older people range from stationary medicine-dispensing robots to robotized locomotion aids [1,57,58,65]. However, it is far from straightforward to robotize any practices in humancentered services. Care work includes fundamental values, tacit knowledge, and interaction between the care worker and the care recipient that are difficult to incorporate in robots. While introducing robots to the care sector, it should be acknowledged that the skills that develop through professional and human(s) care practices ensure that care values are met [67]. Indeed, robots are better suited for assistive or instrumental tasks as opposed to more autonomous or social roles in care practices [47,52,61]. Either connected to care work values or independent of them, elder-care workers have questioned the appropriateness of robot use in their work [8,59,62]. This has also been the premise in van Wynsberghe's theory of valuesensitive care robot design, which states that robots should be designed to support and promote the fundamental values of care, for example, patient safety, dignity, and well-being [67]. While there are a considerable number of qualitative studies discussing the theory of value-sensitive care robot design [11,31,53], quantitative empirical research on care workers' value-based views of care robots is very limited. Prior attempts to find value-based explanations for relatively poor robot acceptance among nurses have implied that personal values play a part in care robots' perceived usefulness [63]. In their cross-sectional study design, Turja et al. [63] showed that compatibility between care robot use and personal values correlates positively with the perceived usefulness of care robots and social norms assigned to them. However, research has left open questions related to causality and the substance of personal values. It is unclear whether changes in value-based views would explain changes in robot acceptance. Moreover, it remains to be studied if social norms or occupational standards underlie the perceived compatibility between robot use and personal values. The aim of this article was twofold. In the first phase, we utilized longitudinal survey data to see how Finnish eldercare workers' views toward care robots have changed in the past years as care robots have been gradually introduced to welfare services. We also analyzed what explains the changes in the perceived usefulness of robots in telecare: RQ1 Do elder-care workers express temporal change in the perceived usefulness of telecare robots or perceived personal value-robot use compatibility? We hypothesized that a positive change in perceived usefulness of telecare robots would be explained by increased experiences with care robots, changed views of value compatibility, and stress caused by COVID- 19. In a second phase focusing on the follow-up data only, we used a cross-sectional study design to look into factors that would explain variations in the value-based assessment of robot use: RQ2 Which factors underlie the perception of personal value-robot use compatibility? We hypothesized that personal value-robot use compatibility would be associated with social norms toward care robots, work's meaningfulness, fear of technological unemployment, and COVID-19 stress. The rest of the article is organized as follows. First, we will introduce the background and the context of this research, including the perceived usefulness of robots, personal values in robot acceptance, and the current use of robots in elder care in Finland. The testing of the hypotheses from the first and the second phases of analysis is reported in Results section and discussed in the final sections of the article. --- Background Technology acceptance models (TAMs) initially developed by Fred Davis [12], are widely used in research to understand mechanisms behind individuals' use of and intention to use new technology. Drawing upon the theory of reasoned action [2], TAMs explain technology acceptance by social and functional beliefs, such as perceived usefulness, concerning a certain technology [28]. However, other theoretical traditions have also explained the willingness to adopt new technologies. Venkatesh et al. [66] combined the theory of reasoned action and versions of TAM to several other research models, such as the innovation diffusion theory [51], to create a unified theory of the acceptance and use of technology (UTAUT). As opposed to the TAMs and their focus on the acceptance of particular types of technology, UTAUT models user intentions, performance expectancies, effort expectancies, social influence, and facilitating conditions of technology use in general [20]. In TAMs, the perceived usefulness of technology refers to how using a particular technological solution is seen to enhance an individual's job performance [12]. In this study, perceived usefulness refers to the instrumental task value [29] of a care robot-the possibilities of robot technology to enhance care workers' job performance. The perceived usefulness of telecare robots is understood as an evaluation of the possible futures and the robot's role in it. --- Contextual factors predicting robot acceptance To date, temporal changes in technology acceptance have been mainly associated with the extent of cumulative usage of technology. Consonant with the theory of reasoned action [2], experience and training affect the perceived usefulness of technology positively. Through increased awareness and technology skills, prior experiences also affect one's views about the future potential of technology [29]. This is of particular importance because the perceived usefulness of an emerging technology, such as service robots, also relies on users' counterfactual imagination [55]. In other words, without an extensive user experience, people build their expectations toward robots on the little experience they have. Considering these perspectives, there is convincing evidence that habituation and firsthand experiences with technology increase the acceptance of new technology [26,32]. Hence, it is plausible that the more familiar elder-care workers are with certain types of care robots, the more positive views they have toward robot use in telecare. H1 More extensive experiences with care robots explain the positive turn in the perceived usefulness of robots in telecare. The extent of prior care robot use can be regarded as a contextual factor. That is, robot usage does not only depend on individual motivation for use, but rather on the availability of robots in the workplace. Another factor we have similarly located between the contextual and the individual is stress. In this study, we focus on the additional strain caused by COVID-19, which could impact the perceived usefulness of robots in telecare. While the pandemic has influenced the functionality of the whole care sector on a structural level, it has caused stress among care workers on the individual level. The challenge of maintaining good quality and a sufficient amount of care amidst physical distancing, quarantine, isolation orders, and scarce care work resources could be addressed with new remote technologies and robots. In fact, some earlier studies hinted that new technologies may improve well-being and security at work in uncertain and stressful times [22]. COVID-19 has already turned out to be a significant driver of, for example, telecare development [18]. Compared to mere software systems such as video calls on a computer, embodied telecare robots would enable a more pleasant and even committed interaction [35]. Regarding this knowledge, we hypothesize that care workers view the situation with the COVID-19 as emphasizing the need for new telecare technology. H2 COVID-19 stress is associated with more positive perceptions of the usefulness of robots in telecare. --- Compatibility between personal values and using robots at work Besides COVID-19, economic constraints and various changes in work have increased care workers' stress [64]. Ethical strain is a form of occupational stress that originates from a conflict between what is thought to be right and what is actually carried out at work [10]. It stems from a situation in which expected or realized actions are incompatible with personal values. Ethical strain can be caused by an organizational culture that is perceived as (at least partially) unethical or by task-related demands that contradict personal values [9,36]. As a psychological construct of one's worldview and thoughts on what is right or wrong, personal values play a significant role in human decision-making and attitudes [23]. Hence, compatible values are understood as important motivators for forming opinions and accepting changes. An employee forming an attitude or making a decision on a workrelated change evaluates how that change is compatible with or contradictory to their values [27]. For example, some individuals may find that care robotization shows great promise to improve the quality of care in a value-compatible way while others may be prone to view robots as ultimately diminishing human interaction, causing a role conflict between nurses' values and what is expected of them in a suddenly technologized work environment [4,13,56]. The ethical climate in a work environment represents the shared perceptions of practices related to ethical norms and decision-making [64]. The ideal is for the ethical climate to support individual workers' personal values, because people need to feel and express themselves as competent and moral actors in all their life domains [36]. If people are forced to do work they perceive as unethical, there is a risk of not only ethical stress but also negative emotions, such as self-blame [36]. In rejecting the idea of using robots in care if perceived as contradicting one's own values, people try to actively prevent role conflict that would result in using working methods that are perceived as personally inappropriate [4]. In a recent study based on a cross-sectional design, Turja et al. [63] suggested that perceived usefulness mediates the relationship between compatibility with personal values and the intention to use a care robot. The compatibility between personal values and technology use originates from the work of Elena Karahanna, who developed the TAM in a more complex and value-based direction. Karahanna et al. [28] broadened the concept of compatible technology to cover four dimensions: compatibility with preferred work style, work practices, prior experiences, and values. Adapting the value-based robot acceptance theory to care robots, there is reason to believe, that robots that are consistent with one's personal values are likely to be perceived as fostering such values and thereby also supporting the instrumental task value associated with the robotic technology. The assumption, hence, is that perceived personal value-robot use compatibility positively influences beliefs about the usefulness of robotic technology. With reference to Karahanna et al. [28], we hypothesize the following: H3 Increased personal value-robot use compatibility explains the positive turn in the perceived usefulness of robots in telecare. Social norms provide a theoretical window to further explain value-based compatibility in care robot use. Social norms can contradict robot usage, especially in a humancentered line of work. Although previous studies have acknowledged the dynamic association between personal values and social norms [51], social norms are typically addressed in a one-dimensional way. Following the tradition of TAMs, social norms are usually operationalized as the subjective norm, as in perceived views of "the important others," for example, coworkers [63]. The social norm toward robots in the workplace manifests itself as either more positive or negative discussions about new technology and robotization among colleagues. However, in the context of care work, it is essential to take into account another dimension of social norms: the ethical standards of nursing work. The occupational ethical standards of nursing include respectfulness, compassion, partnership, trustworthiness, competence, and safety [45], consistently emphasizing the relationship between the cared for and the carer. From the perspective of care ethics, empathetic and sympathetic interaction is essential to good care [25]. Care work is relational in the sense that the particularities of each cared-for individual are taken into account in a caring relationship. Care is mainly provided in dyadic relationships that manifest in embodied gestures addressing vulnerability. Moreover, care involves ethical devotion-unselfish attentiveness to another's vulnerability. Related to devotion, care work has been historically associated with an idea of intrinsic calling, yet contemporary research highlights care work as a vocational occupation [15,49]. From these ethical perspectives, care work is often considered as meaningful work and the thought of using robots may decrease the feeling of meaningfulness when using new technology in patient-nurse interaction appears to be outside the core of the humancentered work [30]. H4 A more positive social norm toward robots in the workplace is associated with higher individual personal value-robot use compatibility. H5 The higher compatibility between occupational ethics and robot use, the higher the personal value-robot use compatibility. H6 Elder-care workers who perceive their work as more meaningful report lower personal value-robot use compatibility. Besides the perceived meaningfulness of work, merely sustaining a job or career can underlie the perceived (lower) personal value-robot use compatibility. The fear of technological unemployment refers to the threat of losing a job, working hours, or income due to technical progress through which machines replace human labor. Care workers are no exception when it comes to being aware of public discussions about robots taking jobs from people and viewing that as a threat in their own field of work [43]. Hence, we hypothesize that the perception of technological unemployment caused by robots is related to value compatibility of care robot use. H7 Fear of technological unemployment is associated with lower personal value-robot use compatibility. Furthermore, COVID-19 has emphasized the need to arrange more extensive telecare practices [6]. This acknowledged need may be reflected in more positive views toward robot use among care workers. The pandemic has challenged care work in many ways, the lack of resources being one important aspect of the new situation. In social work, lack of resources is a major factor in ethical strain [40]. However, even if telecare has raised ethical concerns among nurses before [14], we assume that, if anything, the pandemic has reduced these concerns. COVID-19 forces care workers to prioritize safety before physical closeness. We hypothesize that elder-care workers who have felt considerably more strain in their work because of the pandemic stand out with respect to the higher value compatibility of care robot use. H8 COVID-19 stress is associated with higher personal value-robot use compatibility. --- Robots in Elder Care in Finland Applying robots in welfare services in Finland has been on the governmental agenda since 2016. A particular boosting and networking program, "HyteAiro," was launched in 2018 to advance the development and use of robots and artificial intelligence in the well-being and health sector [17]. Robots have been mentioned in major strategies to develop care services for older people [38,39]. Research organizations have produced a roadmap and policy recommendations to develop the Finnish ecosystem and use of care robots in a responsible way [42]. In practice, it seems that other technologies and digital services are being adopted more quickly and widely in care work than robots. For instance, remote home care visits using specific secure video-communication services as well as automated medicine-dispensing services have become more common, particularly during the COVID-19 pandemic [42]. These are paving the way for more developed technology and robotic applications: for instance, medicine-dispensing services can have a robotic physical platform to assist the user in taking medicine independently at home [1]. The maturity of technology limits the implementations of robots in care work. With regard to mobile robots, there have been more single or limited implementations, pilots, or experiments, which often take place in institutional settings. Logistic robot systems have been used in hospitals [34], and small social robots have been adopted for therapy, exercise, and entertainment (e.g., [37,43]). In rehabilitation institutions, there are both fixed and wearable robots in physiotherapeutic use. Telepresence robots in particular have been experimented with in care facilities and home settings for resident-family communication [44]. Overall, the introduction of robots in care work has been relatively slow, and the carerobot innovation and business ecosystems are still both in their initial steps in Finland [33,48]. As a future outlook, teleoperation or remote control of robots would solve some of the current maturity problems with more autonomous robots. Teleoperated robots are controlled and monitored by human operators, which makes use safer and the development simpler and more cost-efficient compared to robots that would be autonomous and intelligent enough to make independent observations and decisions. Telepresence robots are the most feasible applications of teleoperated robots used as telecare robots [57]. Telepresence robots typically provide two-way communication between two persons [44]. The robot provides the remote connection with a video-mediated medium, and the remote user can control the movement and functions of the robot in the local space. In addition to mere telecommunication, telecare robots have been developed to provide telerehabilitation [58], daily assistance with tasks such as picking up objects [64], and human-robot interaction [46]. However, new technology must be accepted by users to be adopted into everyday care. Because teleoperated robots would be first and foremost considered tools for care workers, this study investigates how nurses and other professionals view deploying robots in telecare. --- Methods This longitudinal panel study of care workers' views toward care robots is based on online survey data from November-December of 2016 (T1) and 2020 (T2). In T1, participants were randomly sampled from the member registers of The Finnish Union of Practical Nurses and The Union of Health and Social Care Professionals in Finland [63]. The respondents were nurses and physiotherapists who worked in elder care services (N 3800). Of all respondents, 71% reported that their work involved working with patients with dementia. In T2, the survey was repeated with the same 426 participants from T1 who had expressed their willingness to take part in a follow-up study and were reached via email. The response rate in T2 was 56% (238 respondents). According to the dropout analysis, there were no significant differences in distributions of age, gender, and managerial status between the survey waves. In bivariate mean comparison analysis, there was no indication of selection bias, where more positive views of telecare robots in T1 would have resulted in higher participation in T2. The majority of the respondents (N 238) were female (94%) and aged from 24 to 67 at the time of T2 (M 50.50, SD 11.30). In terms of occupations, the most common groups were practical nurses (54%) and registered nurses (27%), followed by head nurses (3%) and physiotherapists (2%). The rest (14%) were, e.g., counselors and administrative workers. Almost one-fourth of the respondents had managerial experience (24%). Nearly all (90%) of the practical nurses had a college degree. All registered nurses and physiotherapists had an education from a university of applied sciences. In the residual category of occupations, 43% had a university degree, 53% a college degree, and 4% had lower levels of education. In the data from 2020, most of the respondents did not have any experience with care robots (57%), while almost a third (30%) reported having experience with one type of care robot (8% having experience with two robot types and 5% with three or more). From the robot types listed, 24% of the respondents were familiar with a medicine-dispensing robot typically used in home care and 14% with a robotic pet, such as Paro. Less familiar robot types were physiotherapy robots (familiar to 7%), patient-lifting robots (familiar to 6%), and telepresence, logistic, and social robots (e.g., Nao), which were all familiar to 5% of the respondents. Robot experience was tested as an independent variable in Phase 1 and as a control variable in Phase 2. When answering the questionnaire, respondents were guided by robot definitions in writing and pictures. The definition of a robot was borrowed from a Eurobarometer questionnaire: "A robot is defined as a machine which can assist humans in everyday tasks without constant guidance or instruction, e.g., as a kind of coworker helping on the factory floor or as a robot cleaner, or in activities which may be dangerous for humans, like search and rescue in disasters. Robots can come in many shapes or sizes and some may be of human appearance" [16]. Before the questions about telecare robots, it was additionally explained how robots can be either human-operated or more autonomous. The study complies with the regulations of the Finnish Advisory Board of Research Integrity and more broadly with the Declaration of Helsinki. All of the participants were informed about the aims of the study and they had the right to decline participation. Consent was requested at the beginning of the survey and the data handling was designed to ensure the participants' anonymity. --- Variables The descriptive information for the variables used in the analysis is drawn from the longitudinal data used (N 238). Perceived usefulness of telecare robots was measured by twelve items presenting robotic assistance in different scenarios: "How would you consider telecare robots' usefulness in different tasks? In your answers, orient to the elder care services you are currently working in." This part of the questionnaire was identical between T1 and T2. The respondents evaluated the usefulness of robotic assistance in each scenario on a scale from 1 to 10. As illustrated in Fig. 1, there was a systematic change from lower to higher perceived usefulness in each scenario. There were also changes in the internal order of what was considered least and most useful, on average. For example, the idea to use robots in medication assistance climbed in rank from 8 to 6. For the multivariate analysis, an aggregate mean-of-means variable summing up the twelve items was constructed for both T1 (M 5.31, SD 2.27, <unk> 0.95) and T2 (M 6.84, SD 1.97, <unk> 0.91). As a novel research topic, perceived usefulness of telecare robots measure was self-developed in 2016. The items of perceived usefulness, along with the rest of the questionnaire, were developed and piloted together with care professionals: first in a focus group discussion of five persons, and later with other 13 care professionals who filled out an online version of The perceived personal value-robot use compatibility was measured by three items, identical between T1 and T2. The statements were modified from the information system acceptance questionnaire validated by Karahanna et al. [28]: 1) "Using care robots runs counter to my own values"; 2) "Using care robots does not fit the way I view the world"; and 3) "Using care robots is not appropriate for a person with my values when thinking about the role of robots." The statements were translated into Finnish by professionals. The response scales ranged from totally agree to totally disagree, where higher values indicated incompatibility. An aggregate variable was formed for T1 (M 3.40, SD 1.15, <unk> 0.93) and for T2 (M 2.33, SD 1.08; <unk> 0.88). For the final analysis, the scale was reversed for a more intuitive interpretation of value-compatibility. When used as a dependent variable in the second phase of analysis, the nonnormally distributed personal value-robot use compatibility of T2 was dichotomized (Md 2) into indication for value incompatibility (0) versus value compatibility (1). Social norms toward care robots were operationalized as a dual explanatory factor in T2. Using a response scale from totally agree to totally disagree, the first statement was about the subjective norm in the workplace: "My colleagues have mainly a welcoming attitude toward care robots" (M 2.97, SD 0.87), while the second one measured occupational ethics-robot use compatibility: "The norms and standards in my work would be a challenge in ethical use of care robots" (M 2.71, SD 1.16). These two items were treated as separate factors, with, after standardizing the scales, higher values indicating more accepting norms concerning robots. Fear of technological unemployment was measured in T2 by a single item because a planned double-item construct turned out to be internally inconsistent. The statement "I fear that robots will replace or reduce my work" had a response scale from 1 to 4 (M 3.45, SD 0.69) and ended up in the analysis as a significant explanatory factor. The statement about delegating tasks to a robot in terms of threatening one's livelihood did not prove to be a significant factor in the analysis and was thus excluded from final analyses. COVID-19 stress was measured in T2 by a single item. The statement "COVID-19 has increased work stress beyond my resources" had a response scale from 1 to 4 in which higher values indicated a higher level of perceived stress (M 2.06, SD 0.89). --- Perceived meaningfulness of work --- Statistical Analysis In the first phase of this study, the objective was to investigate the change in views toward care robots and the effects of that change. We conducted ANOVA for repeated measures and fixed effects (FE) within-regression analysis with a posthoc FE model. We employed the FE approach, which models changes within individuals over time and controls all timeconstant individual characteristics for its strength compared to, for example, a random effects (RE) approach. FE controls the effects of any observed or unobserved time-invariant personal characteristics of respondents [3]. By employing within-individual variation in estimation, the FE approach makes any causal claims more warranted compared to crosssectional correlations [68]. In terms of causal modelling, in FE estimation individuals serve as their own controls-that is, we are comparing how change in independent variables is related to change in dependent variables. In the second phase, we used binary logistic regression analysis in the cross-sectional study design of T2. --- Results To learn about the potential relationships among the attitudes toward telecare robots and the compatibility between personal values and robot-use in two measuring points, pairwise correlations were computed (Table 1). While scores within T1 and T2 were strongly correlated, the scores between measuring points were not. This was the first indication of a significant temporal change among individuals and their views on care robots. Pearson correlation analysis also showed that if colleagues perceived the use of care robots as acceptable (subjective norm) and meeting the ethical standards of care work (compatibility with occupational ethics), the respondents were more prone to have higher expectations toward the usefulness of telecare robots as well as higher perception of compatibility between personal values and robot use. Fear of technological unemployment caused by robots had a negative correlation with COVID-19 stress, indicating that respondents who reported COVID-related stress were on the average less concerned about losing work to robots. In repeated measures using ANOVA, we found that expectations regarding the usefulness of telecare robots had increased considerably in time, comparing the average scores of T1 (M 5.31, SD 2.27) and T2 (M 6.84, SD 1.97; (F(1) 40.33, p <unk> 0.001, <unk>p 2 0.21). The differences approximately followed normal distribution. Concerns regarding the compatibility between the use of care robots and personal values had also decreased from T1 (M 3.40, SD 1.15) to T2 (M 2.33, SD 1.08; (T 2590, p <unk> 0.001, d 0.68). This difference was notable considering that the mode in the perceived compatibility between personal values and robot use changed from "somewhat incompatible" (T1) to "totally compatible" (T2). These results were consistent and independent of the respondents' occupation and education level or how much firsthand experience they had with care robots. This was despite the fact that the respondents' familiarity with care robots had doubled over two years (T1: 21% vs. T2: 43%). Testing the Phase 1 hypotheses (H1-H3), the results showed how the temporal change in views about telecare robots had a significant interaction with personal value-robot use compatibility (F[1] 10.21, p <unk> 0.005, <unk>p 2 0.06), but not with increased experience with care robots or the stress caused by COVID-19. --- Within-Estimations of Robot Usefulness in Telecare In order to analyze the effect of value-based assessment on the perceived usefulness of robots in telecare, we used fixed effect analysis. Results show how a change in the compatibility between personal values and robot use has caused a change in the perceived usefulness of telecare robots (Table 2). Fixed effects analysis was rationalized for its ability to reduce the impact of confounding by time-invariant and unmeasured individual-level factors [21]. Although a majority of the respondents had developed more positive views (difference ranging from 0 to 4) of care robots in time, one fifth of the respondents showed an opposite, negative trend (difference ranging from -3 to 0) in compatibility between personal values and robot use. Because of the asymmetric effects, we conducted post-hoc tests separately for positive and negative temporal effects. As a result, the change in the perceived usefulness of telecare robots was predicted more by the effect where respondents had an increased, rather than decreased, perception of the compatibility between personal values and robot use. However, the different-direction effects in this compatibility did not prove to differ significantly from each other (F[1] 1.39, p 0.24). --- Cross-Sectional Analysis of Value-Based Attitudes To examine the nature of personal values more closely, we conducted a cross-sectional analysis. The Phase 2 hypotheses (H4-H8) regarding the compatibility between personal values and robot use were tested in a binary logistic regression model with explanatory factors available in a T2 data set. The results are presented in Table 3. The model showed an excellent goodness of fit (<unk> 2 (8) 3.59, p 0.89) with an indicative predictive power of 30-40% of the variation in perceived compatibility between personal values and robot use. Personal value-robot use compatibility was associated with managerial status, compatibility between occupational ethics and robot use, less fear of technological unemployment and higher COVID-19 stress. These results were consistent over the respondents' age, gender or firsthand experience with care robots. The perceived social norm assigned to care robots in the workplace did not prove to be a significant factor in compatibility between personal values and robot use. The results imply that social norms behind robot acceptance originated from more universal, ethical standards of care work rather than shared attitudes in the respondent's workplace. The odds of care workers recognizing the use of care robots as value-compatible were two times higher when they perceived robot use as compatible with occupational ethics. The fear of technological unemployment was another highly significant factor when it came to the threshold of accepting robot use as value-compatible. The respondents who expected robots to replace care work were prone to perceive robot use as incompatible in care work, and vice versa, those with less fear about robots causing their unemployment had more positive views on average. Furthermore, the eldercare workers who found that COVID-19 has been a major stressor had a higher probability of perceiving care robots as value-compatible rather than incompatible. The workrelated demands heightened by the pandemic were perceived as major stressors among the majority of the respondents (69%). Post-hoc analysis focused on interactions among explanatory factors, and only significant interaction was found between the meaningfulness of work and COVID-19 stress. Although the meaningfulness of work alone did not emerge as a significant factor in personal value-robot use compatibility, the feelings of doing meaningful work combined with higher COVID-19 stress resulted together in a higher probability of personal value-robot use compatibility. As for the background variables, the respondents with managerial experience, such as head nurses, stood out with the most positive views of personal value-robot use compatibility. The fact that managerial experience almost triples the odds of having no conflict between care robot use and Fear of technological unemployment caused by robots was a separate, significant explanatory factor of personal value-robot use compatibility, but the interaction between managerial status and the fear of technological unemployment did not reach statistical significance in this data. --- Discussion In this study, we investigated and found a positive turn in robot acceptance among elder-care workers. The Finnish care workers' views toward robot assistance in telecare had changed in the positive direction between 2016 and 2020. The temporal change was explained by more preferable views of personal value-robot use compatibility. Hence, personal values predicted the task value of robots. Table 4 summarizes the hypotheses and the outcomes of hypothesis testing. In the first phase of the analysis, we focused on temporal changes in care workers' views toward care robots. In the second phase, we focused on the research question regarding the factors underlying personal value-robot use compatibility. --- The Positive Change in Views Toward Telecare Robots (Phase 1) Neither of the partly contextual factors-the increased experience with robots or the strains associated with the worldwide pandemic-affected the perceived task value of telecare robots, and hence, H1 and H2 were rejected. Regarding H1, the lack of support for the relationship between prior experience and more positive views of usefulness could result from the fact that prior experiences were estimated by quantitative means only. The quality of the prior experiences were beyond the reach of this study and we cannot tell if experiences of positive nature, for instance, would have associated with higher perceptions of telecare robot usefulness. The findings support H3 by implying that value-based evaluation has a notable role in the acceptance of care robots. The belief that the use of care robots is compatible with personal values was the only construct to explain the temporally changed views about telecare robots. Care workers have the ability to observe and predict moral dilemmas when it comes to organizational and technological changes. Care robots or telecare robots can only be viewed as useful forms of care work if and when the robots are considered appropriate and value-compatible at a principle level. When robots are introduced to care, workers make value-based evaluations on robots' prerequisites for being useful or for causing ethical stress and role conflicts [4,36]. Our findings are in line with studies where the intended usage of robots is decreased when robots are viewed as a threat to human jobs and safety, as well as human identity and uniqueness [24]. Although still about one third of the respondents perceived robots as non-compatible with care work on a principle level, more often than before, the use of care robots was viewed as value-compatible. This positive turn also reflected the more positive views on the usefulness of robots in telecare. As care robots become more familiar, the reality of what robots can and cannot do becomes more evident to potential users. The expectations and fears put into perspective may explain how care robots are seen in a more positive light. There is prior evidence of robotic assistants being viewed more positively if they are considered to be tools and equipment [47,52,61]. Hence, a gradual revelation that this is exactly what the robots are capable of in their current stage of development 123 Care robots becoming more familiar without necessarily any increased firsthand user experience, includes also a dimension of a societal-political discourse. Frennert and Baudin [19] studied the perspectives of municipal elder-care actors in Sweden on welfare technology (including robots). They identified a number of reasons why welfare technology is adopted in care at such a slow pace, but they also found that both potential users and decision-makers had positive views about the technology. Two mechanisms were provided to explain this discrepancy, and both may apply to the situation in Finland. First, Frennert and Baudin [19] suggest that the political discourse surrounding welfare technology influences attitudes. The Swedish government has launched a strategy called "eHealth 2025" that sets a vision and goals for using technology to improve health and welfare services, and the pro-technology arguments may have been learned also among eldercare actors. In Finland, similar agendas and arguments promoting the use of robots are written in the programs and strategies of the government (e.g., [17]). With regard to timing, the positive turn in the Finnish data fits well into the timeline in which the programs and strategies have been published. The second explanation of Frennert and Baudin [19] is that the successful technology experiences in one place makes attitudes more positive elsewhere. The Swedish government has funded a selected group of municipalities to conduct experiments in integrating welfare technologies into care. These experiments have been reported widely throughout the nation. The experiences and changed practices in the experimenting municipalities may

Robots have been slowly but steadily introduced to welfare sectors. Our previous observations based on a large-scale survey study on Finnish elder-care workers in 2016 showed that while robots were perceived to be useful in certain telecare tasks, using robots may also prove to be incompatible with the care workers' personal values. The current study presents the second wave of the survey data from 2020, with the same respondents (N 190), and shows how these views have changed for the positive, including higher expectations of telecare robotization and decreased concerns over care robots' compatibility with personal values. In a longitudinal analysis (Phase 1), the positive change in views toward telecare robots was found to be influenced by the care robots' higher value compatibility. In an additional cross-sectional analysis (Phase 2), focusing on the factors underlying personal values, care robots' value compatibility was associated with social norms toward care robots, the threat of technological unemployment, and COVID-19 stress. The significance of social norms in robot acceptance came down to more universal ethical standards of care work rather than shared norms in the workplace. COVID-19 stress did not explain the temporal changes in views about robot use in care but had a role in assessments of the compatibility between personal values and care robot use. In conclusion, for care workers to see potential in care robots, the new technology must support ethical standards of care work, such as respectfulness, compassion, and trustworthiness of the nurse-patient interaction. In robotizing care work, personal values are significant predictors of the task values.

adopted in care at such a slow pace, but they also found that both potential users and decision-makers had positive views about the technology. Two mechanisms were provided to explain this discrepancy, and both may apply to the situation in Finland. First, Frennert and Baudin [19] suggest that the political discourse surrounding welfare technology influences attitudes. The Swedish government has launched a strategy called "eHealth 2025" that sets a vision and goals for using technology to improve health and welfare services, and the pro-technology arguments may have been learned also among eldercare actors. In Finland, similar agendas and arguments promoting the use of robots are written in the programs and strategies of the government (e.g., [17]). With regard to timing, the positive turn in the Finnish data fits well into the timeline in which the programs and strategies have been published. The second explanation of Frennert and Baudin [19] is that the successful technology experiences in one place makes attitudes more positive elsewhere. The Swedish government has funded a selected group of municipalities to conduct experiments in integrating welfare technologies into care. These experiments have been reported widely throughout the nation. The experiences and changed practices in the experimenting municipalities may have influenced how the technologies are being perceived in other municipalities. In Finland, the KATI program1 is a similarly coordinated activity and initiative for municipal experimentation and dissemination of best practices in the use of technology. Timewise the KATI program will be implemented in 2021, but the initiatives made already in 2020 can play a part in how the views toward telecare robots have changed in a more positive direction. One example of telecare robots that have become more common in Finnish home care are the medication dispensing robots. In our data, elder-care workers perceived medication dispensing robots as highly useful, much more so than in 2016. --- The Factors Underlying Personal Values (Phase 2) For the distinct nature of care work as a context to be robotized, we further investigated the substance of valuecompatibility in the second phase of this study. The threshold of personal value-robot use compatibility was examined by explanatory factors of social norms, the meaningfulness of work, the perceived threat of technological unemployment and COVID-19 stress. As a result, personal value-robot use compatibility was more likely among elder-care workers who felt that care-robot use is aligned with the ethical standards of care work (H5), who had less fear of technological unemployment (H7), and who reported higher COVID-19 stress (H8). The importance of occupational ethics-robot use compatibility emphasizes how the development and deployment of robots in care should aim at designing and investing in technology that supports the core values of care work. This finding is in line with prior studies of care workers' value-driven attitudes toward robot use [8,59]. Value-based assessment of robot acceptance seems to refer mostly to occupational ethics and the fear of technological unemployment, both of which are associated with care work as a humancentered work where dyadic interaction between people-the carer and the cared-is prioritized [25]. The results also bring evidence for how viewing the possibilities to use robots in care work, the universal ethical standards of care work stand out. The use of care robots is accepted as a value-compatible change if it is in line with ethical standards of care work, more so than the social norms in a workplace with a however closer social environment. As the perceived social norms of the workplace did not even reach a significant association with personal value-robot use compatibility, H4 had to be rejected. Workplace norms seem to have little leverage when it comes to competing with occupational ethical standards of care work, which are considered as something nurses are committed to as individuals and as a community [5]. This commitment beyond any organizational limits is bound to regulate all decision-making in nursing work, whether it is assessing operations, actions, or emerging changes in the occupation [50]. Similar to how the ethical climate is found to mediate the relationship between ethical stress and job satisfaction [64], ethical climate has potential to affect the perceived personal value-robot use compatibility. Ethical strain at work is considered to be negative, excessive stress, and should be prevented to maintain workers' motivation, job satisfaction, and commitment [7,64]. Ethical strain also relates to organizational changes. Sometimes the compatibility between work and personal values is evaluated already when choosing a career. If one chooses a certain field of study or a career based on their expectations for the high ethical standards and social responsibility associated with the line of work [40,68], it makes organizational changes more complicated. Meaningful, motivating and satisfactory work is something to pursue also during and after technological changes. In this study, personal value-robot use compatibility was viewed as acceptable among the elder-care workers who reported higher COVID-19 stress, and this association was boosted by feelings of the work's meaningfulness. Not only was the hypothesis (H6) of the negative association between work's meaningfulness and personal value-robot use compatibility rejected, but also the results of the interaction implied an opposite effect than what was expected. Those who perceived work as meaningful and at the same burdened by the current pandemic, reported higher personal value-robot use compatibility. This is interpreted as the COVID-19 situation highlighting the demands of elder-care and how a resolution is anticipated through the use of new technology. Contrary to what was expected, to find care work as meaningful is actually to value robot assistance as one way to relieve stress on the job. The most significant underlying values in personal value-robot use compatibility included both social values in terms of occupational ethics and individual values in terms of fear of unemployment. Whereas occupational ethics are centered on patient wellbeing and hence refer to moral, universal, and benevolent values, care workers' fear of unemployment refers to instrumental and more self-centered values [54,60]. Actually, several findings in this study-beyond the direct question about the fear of technological unemployment-supported the important role that trust in maintaining work, even in robotization, has on value-based robot acceptance. Elder-care workers with managerial experience had a high probability of perceived personal value-robot use compatibility which may be partly explained by a more secure job and career. Moreover, those who found care work particularly meaningful in a stressful COVID-19 situation found robot use to be value-compatible, which does not imply any specific fear of technological unemployment. --- Limitations Although they provide new information about the change in robot acceptance, our results do not indicate whether the change is enduring instead of a periodic change between the two years when the data were collected. In future studies, the longitudinal effect in the perceived usefulness of care robots will be improved through the use of more than two measuring points. Another limitation is that we were not able to test all the hypotheses in one model of multiple regressions because the sample size in T2 limited the range of analysis. The small sample size of T2 was due to a data collection strategy where only volunteers were invited to participate in the follow-up survey. Finally, as an obvious limitation, the findings are generalizable to Finnish care workers only. For this reason, cross-cultural studies are highly recommended. --- Conclusion Robotizing elder-care has raised many ethical and practical concerns in discussions about the nature of human-centered and sensitive service work. In prior theoretical studies it has been assumed that healthcare professionals see a moral dilemma in robotizing care, which can result in rejection of all robot use. This research has brought unique empirical evidence to the matter and has proven the significance that value-based evaluation has in the acceptance of care robots. The temporal change in views toward the usefulness of telecare robots was affected not simply by an increase in experiences with robots, but by higher personal value-robot use compatibility. Care workers felt on average-and more often than before-that the use of care robots is compatible with their personal values. --- Availability of data and materials Data can be shared only after the project, in 2022. Code availability Not applicable. --- Declarations --- Conflict of interests None. Informed consent The study complies with the regulations of the Finnish Advisory Board of Research Integrity and more broadly with the Declaration of Helsinki. All of the participants were informed about the aims of the study and they had the right to decline participation. Consent was requested at the beginning of the survey and the data handling was designed to ensure the participants' anonymity. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecomm ons.org/licenses/by/4.0/. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Tuuli Turja (PhD) is a researcher of social and motivation psychology in technological changes. Working at the Faculty of Social Sciences, Tampere University, her profile includes combining statistical methods to humanistic research questions. Special research interests lie in affective and effective robots in healthcare. Sakari Taipale (PhD) works as an Associate Professor at the Department of Social Sciences and Philosophy, University of Jyvaskyla (JYU), Finland, and as a part-time Senior Research Fellow at the Faculty of Social Sciences, University of Ljubljana, Slovenia. He leads a research group on digitalization and ageing at the JYU. Marketta Niemelä (PhD) is a principal scientist at VTT Technical Research Centre of Finland Ltd. Her research focuses on acceptability and adoption of emerging technologies such as robots in services and care for older adults. Tomi Oinas (PhD) works as an adjunct professor at the University of Jyväskylä. He has participated in several research projects focusing on working time, time use and job quality and has particular experience in advanced statistical methods.

Robots have been slowly but steadily introduced to welfare sectors. Our previous observations based on a large-scale survey study on Finnish elder-care workers in 2016 showed that while robots were perceived to be useful in certain telecare tasks, using robots may also prove to be incompatible with the care workers' personal values. The current study presents the second wave of the survey data from 2020, with the same respondents (N 190), and shows how these views have changed for the positive, including higher expectations of telecare robotization and decreased concerns over care robots' compatibility with personal values. In a longitudinal analysis (Phase 1), the positive change in views toward telecare robots was found to be influenced by the care robots' higher value compatibility. In an additional cross-sectional analysis (Phase 2), focusing on the factors underlying personal values, care robots' value compatibility was associated with social norms toward care robots, the threat of technological unemployment, and COVID-19 stress. The significance of social norms in robot acceptance came down to more universal ethical standards of care work rather than shared norms in the workplace. COVID-19 stress did not explain the temporal changes in views about robot use in care but had a role in assessments of the compatibility between personal values and care robot use. In conclusion, for care workers to see potential in care robots, the new technology must support ethical standards of care work, such as respectfulness, compassion, and trustworthiness of the nurse-patient interaction. In robotizing care work, personal values are significant predictors of the task values.

Introduction and Related Work The motivation to present oneself in an inviting way is rooted in the human need to belong (Goffman 1959). Social media profiles matter because they represent attempts to portray oneself in a way that facilitates relationship cultivation with desired audiences (Schwämmlein and Wodzicki 2012). People define who they are on social media in salient ways through the information they include in their profiles. Consider Figure 1: the Display Name and Screen Name (handle) identify the user, the Profile Summary communicates key elements of identity, and the friends and follower counts indicate social capital and connectivity. In this work, we characterize Twitter profiles as online bumper stickers-concise statements about identity that can describe who people are, what they like, and what they value. Profile changes could signal a significant identity choice at the micro-level (Schwämmlein and Wodzicki 2012) and the rise of a social movement at the macro-level (Raynauld, Richez, and Boudreau Morris 2018). For example, some viewers co-opted the term deplorable while others appropriated the term nasty woman during the 2016 U.S. presidential debates. There is thus significant potential of observing cultural shifts through the lens of profile changes. Although tweets have been extensively studied in the context of identity and social movements (Ray-Copyright c 2018, Association for the Advancement of Artificial Intelligence (www.aaai.org). All rights reserved. nauld, Richez, and Boudreau Morris 2018), the characteristics of profile changes are less well understood. Past computational methods investigating social media profile dynamics have focused on attributes such as screen name or follower changes (Jain and Kumaraguru 2016;Mariconti et al. 2017). Previous work has also focused on using Twitter profiles to build predictive models and understand demographics, including psycho-demographic traits, personality, age, and gender (Rao et al. 2010;Burger et al. 2011;Schwartz et al. 2013), using features such as social network, profile images and linguistic content (Liu et al. 2016;Volkova, Bachrach, and Van Durme 2016). However, research is needed to address the implications behind profile changes in the emergence and maintenance of social movements. Crucially, how frequently do changes occur and what might it mean when people change their profile information? To the best of our knowledge, our research is the first to situate the characteristics of profile change in the context of seminal work grounded in communication and psychology (Donath 2007;Goffman 1959). Our research contributes theoretical advances through a novel understanding of micro-and macro-level cultural phenomena, including cultural shifts and social movements, by analyzing content changes in users' online identities. --- Data Collection and Method To address the problem of representativeness and sample selection bias (Tufekci 2014), we designed a longitudinal study of Twitter profile snapshots. First, using Twitter's Figure 1: Sample Twitter profile and relevant fields. Streaming API, we captured 3,423,287 tweets on September 28, 2017 (approximately 1% of that day's tweets). Next, we parsed the tweets to identify 2,290,674 unique profile IDs. Third, we used Twitter's REST API (Barberá 2016) to systematically ping each profile nine times over a two-week period (October 1 to 14, 2017). 1 Each snapshot took around 36 hours to successfully ping 2.29MM profiles, totaling nine snapshots over a two-week period (called Snapshot 0 to 8). In each snapshot, we retrieved the profile ID, Screen Name (handle), Display Name, Profile Summary, Location, follower count, friend count, statuses count, and creation date. We next describe our research questions and hypothesis. RQ1: For randomly selected, active Twitter accounts, how often do users change their profile information and to what extent? We calculated the cumulative changes relative to the first observation (Snapshot 0) to identify changes across time horizons and the likelihood of a profile change up to two weeks in the future. RQ2: How does the rate of Twitter profile updates vary for users with different thematic groups? We ran correlated topic modeling (Blei and Lafferty 2007) on words used in over 654K non-empty English (detected using Ooms and Sites 2017) Profile Summary fields at Snapshot 0 using stm R package (Roberts, Stewart, and Tingley 2017). We selected the number of topics (k=49) using the anchor-based approach (Lee and Mimno 2014). We labeled the topics using quantitative measures like semantic coherence (Mimno et al. 2011) and FREX (Bischof and Airoldi 2012) and qualitative analysis. Users are partitioned into mutually exclusive groups based on their largest topic proportion. RQ3: What are the most prevalent types of content changes to Twitter profile summaries? We examined the substance of the profile changes, including the most frequently added, removed, and overall changed words across snapshots. Raw term frequencies might not necessarily indicate the most important terms; thus, we used TF-IDF measure to identify significant terms that were changed across the 49 groups identified in RQ2. Hypothesis 1: Highly influential users (i.e., via followers) are more likely to update their Twitter profile than less influential users. To test this hypothesis (from Donath 2007), we calculated influence as the number of followers that a user has at Snapshot 0 (Bakshy et al. 2011). To test our hypothesis that there is positive relationship between number of followers (influence) and the likelihood of changing one's profile, we used logistic regression on the number of followers (log transformed) on a user's likelihood to change profile fields. We also consider the user's number of posts and number of friends as additional independent variables. --- Results We describe our results below; we present the implications with respect to two formative theories from communication and psychology in the Discussion section. RQ1: For randomly selected, active Twitter accounts, how often do users change their profile information and 1 Code provided on GitHub: https://github.com/wesslen/twitterbumper-sticker-icwsm2018. to what extent? We examined the number of profiles that made any changes (relative to Snapshot 0) to one of four fields: Profile Summary, Display Name, Screen Name, and Location. Figure 2 provides the cumulative change rates for each field relative to Snapshot 0. We observe that users tend to change their Profile Summaries and Display Names the most (16.06% and 13.67% of users), while Location and Screen Names are changed less frequently. RQ2: How does the rate of Twitter profile updates vary for users with different thematic groups? Figure 3 provides the topic proportions from topic modeling with the top five terms for each topic in descending order by FREX probability. Some topics focus on personal labels (father, husband, activist in Topic 32) whereas others highlight hobbies (video gamer in Topic 22). Figure 4 provides box-plots of the likelihood to change the four profile fields over two weeks. First, organizations and professionals (e.g., Topics 21 and 39) are least likely to change their profiles, perhaps because they want to maintain a consistent brand. Second, users that were categorized into topics relating to teenagers, pop music, and gender identity (Topics 1, 35, and 16) have a higher likelihood of changing their profiles. RQ3: What are the most prevalent types of content changes to Twitter profile summaries? We examined the most prominent changed words in the users' profiles for each group using TF-IDF. We find that these words align with the labels assigned in RQ2. For example in Figure 5, the words trump, president, and MAGA were more frequently removed than added for Trump supporters. By observing differences in the frequency with which words are added and removed within a time span, we can identify social shifts. H1: Highly influential users are more likely to update their Twitter profile than less influential users. Influential users tended to change their profile more frequently than less influential users, supporting Donath's (2007) hypothesis. Assuming users' follower count as a measure of influence (Bakshy et al. 2011), we observe that users with more followers are more likely to change three of four profile metrics with 99% significance. Figure 6 provides four regression results, one for each profile metric as the dependent variable. Statuses and friend count have a statistically significant relationship with profile changes. Also, Screen Name and Location models had higher Log Likelihood values, indicating a better model fit. --- Discussion We describe our theoretical foundations and then discuss the implications of our findings in relation to these theories. Self-construal theory postulates that individuals define themselves in relation to others along three dimensions: 1) independent (e.g. #Gamer), 2) interdependent (e.g. Republican), and 3) relational (e.g. mother) (Cross, Hardin, and Gercek-Swing 2011). Signaling theory explains how identity can be consumed and reproduced on social media (Donath 2007). The content of one's profile sends a signal about one's identity-the independent, interdependent, and relational self-construals that a person chooses for selfrepresentation. Social and cultural psychologists view these as three dimensions of the self that virtually all people construct to some degree, but until recently, they have examined self-construal within ethnically or nationally defined cultures (Cross, Hardin, and Gercek-Swing 2011). In the powerful online social media culture that has the potential to catalyze social and political movements (Tufekci 2014), we use self-construal theory to gain insight into how individuals define and monitor themselves within this culture. These theories offer insight into the findings described below. Finding 1: We see in Figure 2 that users are nearly nine times more likely to change their Display Name than their Screen Name at Snapshot 8. This suggests that Display Names are a prominent field where individuals display high levels of engagement on Twitter to send signals of their collective power. Finding 2: From Figure 3, the heterogeneity of topics suggests that people are signaling key elements of identity in their Profile Summaries. Users disclose independent (e.g. artist), interdependent (e.g. conservative), and relational (e.g. father or daughter) aspects of self. Users' signaling of personal, dyadic, and group identities represents not only dimensions of identity but also value systems. Using the self-construal categories, we can infer when a user might be more self-minded or more group-minded, which has implications for estimating the potential of a user to be influenced by types of social media content. Finding 3: The range in change rates in Figure 4 suggests that certain groups (e.g. consumers of pop music and video games) engage in higher self-monitoring. This suggests that groups can be identified as a function of their need to signal social leadership (trend-setting) in certain domains. Conversely, it is advantageous for other groups (e.g. professions) to maintain a more fixed identify by not updating their display names in this way. Finding 4: The removal of keywords from a user's profile may signal shifting user preferences. Researchers can therefore look for the removal of keywords from profiles as evidence of a cultural shift. We highlight these word frequency changes as reflecting a potential social trend revealed through a simple, yet intuitive measure as TF-IDF. Limitations and Future Work: The limitations of our study point to directions for future work. (1) We could use a longer observation window to identify long-term trends than the two-week period in our current study. (2) Additional profile attributes (profile or background images, followers, tweets before or during observation window and in multiple languages) could be examined to incorporate other ways in which users express themselves (3) Advanced statistical methods such as survival analysis could be used to

We describe a novel longitudinal study of the frequency and significance of social media users' profile changes. Drawing upon two formative theories from communication and psychology: self-construal and signaling theory, we examine the likelihood that users will change their profiles and what constitutes a significant profile change. Our findings indicate that users are more likely to change their Profile Summaries and Display Names than their Locations and Screen Names (i.e. handles). Further, we used topic modeling to partition users based on their profiles to identify themes and explored how profile changes differ among these thematic groups (e.g., Trump supporters). Last, we identified the most significant word changes by users in their profiles. Our findings provide valuable baseline data for further study of Twitter profiles, including the spread of social contagion through these profiles.