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useful function that they serve? This question is asked in the context of evolutionary history; It is assumed that humans evolved not just out of Africa but also from a hunter-gather society to an agricultural one and then, more recently, to a mostly urban society. Stigmas and stigmatization are ubiquitous in human societies, globally and historically (Smith, 2007), and appear in other social species, from ants to chimpanzees (Goodall, 1986;Hughes & Cremer, 2007;Wilson, 2000). Stigmas' appearance across human cultures, through human development, and across species suggest that they are wholly, or partially, the product of natural selection and therefore useful. In the lexicon of behavioral ecologists examining behavioral evolution, the question emerges, "Is stigma adaptive?" As Neuberg, Smith, and Asher (2000) argue, stigmas follow one principle: humans generate stigmas for and stigmatize people presenting a threat to effective group functioning. One major challenge to group functioning is infectious disease (ID); many historical and modern examples highlight stigmas associated with infection. Indeed, evolutionary psychologists argue that all stigmas and stigmatization processes evolved from disease-avoidance mechanisms (Park, Faulker, & Schaller, 2003), highlighting the fundamental connection between disease and stigmas. We explain how ID stigmas may have evolved and what adaptive function they might have played in a social-living species such as early humans or our close relatives. The next section discusses how human interaction patterns have changed in modern society and the consequences for ID stigmas in the modern age. This essay focuses on relational aspects to stigmas, and not on identity or cultural perspectives; in other words, it addresses the mesolevel of stigma processes in the framework integrating normative influences on stigma (FINIS; Pescosolido, Martin, Lang, & Olafsdottir, 2008). The thesis of this brief essay is that although ID stigmas may have served functions for early humans, in modern times, stigmas are no longer adaptive for the human species, much less good. --- A Brief History of the Intelligent Ape This essay is based on the premise that humans, Homo sapiens, are the product of natural selection evolving from ape-like ancestors in the same genus (group) called Homo to be a singularly inventive species earning the name, intelligent ape (Homo sapiens) (Schwartz & Tattersall, 2010). Modern humans appeared between 250,000 and 100,000 years ago in Africa and subsequently moved out of Africa to colonize the world (Henn, Cavalli-Sforza, & Feldman, 2012). Both humans and their close relatives live in groups. (Notably, group communication theories and research [Frey, Gouran, & Poole, 1999] also highlight modern human's focus on groups. This scholarship represents a diverse array of perspectives on human behavior, such as evolutionary, culturally-determined, etc.) When animals live in groups, natural selection can act on traits for individuals and for the group (Wilson, 2000). For a solitary organism, self-defense has an evolutionary advantage, so natural selection favors adaptations that lead to improved self-defense. (Notably, for a group living species, personal survival is important; but so is the survival of other group members, including relatives (kin selection) and non-relatives (group selection). An adaptation associated with living in larger groups with non-relatives, such as flocks of starlings or shoals of fish, is linked to predator-prey dynamics: as prey live in higher densities, the probability of an individual prey getting eaten decreases (Molles, 2002). Even though each member of the flock or shoal, then, benefits from the safety in numbers rule and move together, they may only share food with and raise the offspring of relatives. What this emphasizes is that selection acts at different levels, such as the individual, family unit (kin) or group (Bourke, 2011). Importantly, as social defenses for groups evolved, group member conformity became more pronounced (Wilson, 2000). One social defense for groups is stigma. --- Evolutionary Function of Infectious Disease Stigmas A stigma may be defined as "a simplified, standardized image of the disgrace of certain people that is held in common by a community at large" (Smith, 2007, p. 464). As stated earlier, stigmas follow one principle: Humans will generate stigmas for and stigmatize people who present a threat to effective group functioning (Neuberg et al., 2000). For ID stigmas, the disgrace is being infected with a contagious disease. IDs threaten a community's ability to perform effectively by limiting infected members' ability to perform their roles within a group or by killing them. Further, IDs inherently tap into the social nature of groups, by spreading from member to member through interaction. IDs can destroy communities and societies as they diffuse through social systems. For example, measles, which emerged in humans about 7,000 years ago (Weiss & McMichael, 2004), creates severe symptoms and death; is transmitted from person to person via respiratory droplets (Atikinson, Wolfe, & Hamborsky, 2012); is credited for destroying the Aztec empire historically; and is a significant contributor to current, global, death rates (Weiss & McMichael, 2004). Species, then, who created, communicated, and enacted ID stigmas were able to protect uninfected members by identifying those infected with a contagious disease, and eliminating infected members' ability to interact with uninfected members. In species depending on each other for survival, ostracism from the community meant certain and speedy death from a combination of the infection, from lack of access to resources (e.g., food), or lack of protection from predators (Wilson, 2000). Indeed, predators adapted to social defenses by watching for deviant members failing to participate in social defense strategies, because the deviants become more vulnerable to predation (Wilson, 2000). When humans lived in small, family-based groups, intergroup interactions were less common. Groups mixed for war or trade. Group members transitioned to new kin groups on a more permanent basis for procreation, and these were typically healthy adolescents shifting groups for reproductive opportunities since kin mating is always selected against because of the harmful genetic cost imposed (Wilson, 2000). Thus, ostracized members rarely gain entry into another group. Ostracism, then, eliminated not only further spread through the community but also the disease's reservoir for future infections. Even with these functions, ID stigmas did not stem disease-diffusion perfectly for a few reasons. First, sometimes people can be infected with an ID and be infectious (i.e., able to spread it to others) before or without showing symptoms (e.g., human herpes virus, Koelle & Wald, 2003). Human stigmas rely on some sort of mark to identify stigmatized persons; for disease-related stigmas, these are typically visible symptoms (Park et al., 2003). Some IDs, then, may spread before community members recognize symptom-stigmata and enact stigmatization-based ostracism. Notably, other species, such as lobsters, use other senses that better identify infected, infectious lobsters before they become symptomatic (Behringer, Butler, & Shields, 2006). Second, IDs evolve in reaction to changes in the environment. Pathogens evolve to take advantage of species' contact patterns (Messinger & Ostling, 2009), and can even influence behavioral changes in hosts to promote the transmission (Lefevre et al., 2009). For example, rabies induces interpersonal aggressiveness and increased salivation (in animals and humans), which both increase viral transmission (Lefevre et al., 2009). --- ID Stigmas in Modern Times For most of human history we lived in small, family-based groups, but since the advent of agriculture 11-9,000 years ago, population sizes have increased as humans transitioned from roaming packs of hunters to settlements (Diamond, 1999; ). More recently (5-3,000 years ago) humans began to build and live in cities, and now, for the first time in history, more than half of humans live in urban landscapes. With cities came booming populations and many mouths to feed, which required increased agricultural productivity. Both high-density living and close encounters with the animals that humans domesticated for food has meant exposure to more infectious diseases (Diamond, 2002;Wolfe, Dunavan, & Diamond, 2007). In recent history (3000 years), the human population has grown dramatically, transportation has allowed for frequent and widespread contact between humans, and medicines have been developed for treating IDs. For this modern phase, stigmatizing people with IDs does not have the same fitness outcomes as in pre-modern times, because human patterns have changed. Infected persons are unlikely to perish before interacting with others. Even infectious diseases which have been created into biological weapons, like franscisella tularensis, take a few days before they create symptoms and kill their host (Centers for Disease Control and Prevention, 2013). People, in general, interact with multiple people a day (Salathé et al., 2010). Further, ostracism from one group may not lead to complete isolation: infected, ostracized persons' contact may shift to other infected persons and/ or new communities who are unaware of their infection (Goffman, 1963). Indeed, through increased connectivity, ostracized people can find each other, and may have quicker bonding based on shared beliefs and ostracism experiences (Herek, 2002). In modern society, ID stigmas are not an effective means to stem spread of infectious diseases. Further, ID stigmas may make things much worse. If infected persons shift their interactions to spend more time with each other, they may infect each other with different strains of a disease. Co-infections can lead to new strains that are more lethal and/ or more infectious (e.g., Balmer & Tanner, 2011). Through diagnostic procedures, people may learn about an infection and remain infectious before showing stigmatizing symptoms; in order to avoid the pain of stigmatization, infected persons may keep the infection secret (see Smith, 2011 for a review). Even if an infected person can enact enough prevention behaviors to avoid infecting others, the stress of secrecy and anticipated stigmatization creates biological stress responses (e.g., elevated cortisol, Dickerson & Zoccola, 2013), which comes at the cost of a depressed immune system (Cohen, Janicki-Deverts, & Miller, 2007). Others may avoid testing altogether, in order to avoid potential stigmatization, eliminating abilities to access medical treatments of the infection (see Smith, 2011 for a review). Further, hosts (humans) with depressed immune systems may become more infected with an ID, allowing for new strains to develop within a host that are more lethal and/or more infectious. In addition to complicating disease dynamics, stigmas are persistent: there is no consistent, solid, reliable means by which to remove a stigma (Smith, 2011), even when there is compelling evidence that a person is not (e.g., cured) or never was infected or infectious (e.g., false positive results). The mistakenly stigmatized person still lives with the stress and stigmatization, leaving those persons with the lack of resources and/or social stress that can compromise health and well-being for the rest of their lives. These effects can transfer to the secret-keepers (e.g., children keeping a family secret) as well (Goffman, 1963). Last, stigma communication is the messages spread through communities to teach members to recognize the stigmatized groups and to enact stigmatization (Smith, 2007(Smith,, 2011)). The content used to facilitate this process includes information about marks by which to identify stigmatized persons, about responsibility for their condition, and about the moral and physical peril linked to them as well as labels for the stigmatized group. Communication about stigmas, then, makes person-based attributions salient, to the likely exclusion of other explanations. Many infectious diseases are transmitted via a vector (e.g., mosquito, mouse), not from person to person directly. Stigmas around vector-based infectious diseases can generate attention to person-based explanations and person-based responses, which can hinder the recognition of a non-human mechanism. For example, when an outbreak of a lethal respiratory infection was noted in the Four Corners area of the United States in 1993, the stigma communication around the Navajo flu quickly spread, and those in the area were subject to stigmatization. The actual illness, hanta virus, was spread via mice; until the mice became the center of attention, the hanta virus continued to spread. The stigma experienced by the Navajo continued long after the outbreak ended (Harper & Meyer, 1999). --- Conclusion In the modern age, there is no fitness advantage to stigmatizing those infected with IDs. The harms of ID stigmas are significant, and they provide no benefit to public health. Indeed, stigmas may change the environment in which ID pathogens exist, allowing the pathogens to become more problematic than without stigmas in place. Whether viewed through an ethic to do no harm, to protect the public's health, or for social justice, there is no support for stigmatizing infectious diseases and every reason to actively avoid stigma promoting communication. Social-living species may be particularly apt to create and communicate ID stigmas, and enact ID-related stigmatization, due to hold-over adaptions that evolved in the pre-colonizing age. In modern times, ID stigma-related processes no longer function to protect effective group-functioning in human communities. Stigmas do not increase the ability of modern societies to survive infectious diseases, but in fact may be important drivers of problematic disease dynamics and act as catalysts for failures in protecting public health.

At multiple times in human history people have asked if there are good stigmas. Is there some useful function stigmas serve in the context of our evolutionary history; is stigma adaptive? This essay discusses stigmas as a group-selection strategy and the human context in which stigmas likely appeared. The next section explores how human patterns have changed in modern society and the consequences for infectious disease (ID) stigmas in the modern age. The concluding section suggests that while social-living species may be particularly apt to create and communicate ID stigmas and enact ID-related stigmatization, such stigma-related processes no longer function to protect human communities. Stigmas do not increase the ability of modern societies to survive infectious diseases, but in fact may be important drivers of problematic disease dynamics and act as catalysts for failures in protecting public health.

Introduction Race, ethnicity or national-origin based discrimination (hereafter referred to as "discrimination") is a type of hate speech that systemically and unfairly assigns value based on race, ethnicity, or national-origin and affects the daily realities of many communities. Researchers have used a variety of proxy measures to assess discrimination at scale, such as policies (Kawachi and Berkman 2003), or bias-motivated crimes (Sharkey 2010). However, policies usually have large spatial resolution, not all discrimination escalates to a crime, and as a measure, crimes don't describe any details regarding specific issues, antecedents or motivations of the crime that can be used to better illuminate and mitigate discrimination. This need for better understanding of discrimination is compounded, or brought to attention by recent increases in hate crimes in the United States (U.S.) (Farivar 2018). Accordingly, much recent social media research is in the exploration of types of hate speech and potential links between physical events (ElSherief et al. 2018a;2018b;Olteanu et al. 2018;Müller and Schwarz 2018b;2018a). Here, we build on this work and and study both social media hate and hate crimes based on the same biases (race, ethnicity and national-origin based discrimina-tion, which are the largest form of hate crimes in the United States (Federal Bureau of Investigation 2018)). This will enable us to understand how virtual and physical world discrimination may have similarities or differences, and as well to examine virtual world discrimination in different places (different types of features, properties of those users with discriminatory text, etc.). Some prior social media research has focused on racebased discrimination experienced, and specifically on describing the racist concepts (e.g. appearance or accent related) most experienced by people of different races (Yang and Counts 2018). For the United States specifically, research has shown that anti-Muslim hate crimes since Donald Trump's presidential campaign have been concentrated in counties with high Twitter usage (specific content was not parsed) (Müller and Schwarz 2018b). Further, some social media research has identified self-narration and targeted hate speech both as important (Yang and Counts 2018;ElSherief et al. 2018a). Self-narration is important to consider as 86% of 18-to 29-year-olds have witnessed harassing behaviors online, and 60% of those ages 30 and older, and 24% of 18-to 29-year-olds have experienced mental or emotional stress as a result of their online harassment (Duggan 2014). Simultaneously, it is estimated there are approximately 10,000 uses per day of racist and ethnic slur terms in English on Twitter (Bartlett et al. 2014). For targeted discrimination, research has examined the scope of targets (personal or towards groups) (ElSherief et al. 2018a). In sum, a gap remains to examine how online discrimination varies linguistically and comparatively, as well as online discrimination's possible association with physical events by place, especially across the United States. We address these important gaps and build upon prior social media research by examining a specific type of hate speech: race, ethnic or national-origin based discrimination, enabling us to study these alongside hate crimes (as we can filter those by this same group of biases), across 100 different cities in the United States. This examination across the entire country allows us to assess the relationship across varying levels of urbanization, across different constituent properties of cities, and as well across different levels of social media usage in different places. While understanding the relationship between the two does not necessitate a causal pathway (nor do we aim to show one), this analy-sis helps to identify the way(s) in which social media may be relevant as a source for understanding structural discrimination, and helps illuminate how discrimination on social media may vary by place, in comparison to hate crimes. Although virtual-world (social media) and physical world (hate crimes) measures considered here are based on the same biases, we highlight that the reason for studying them both here is to examine how virtual and physical world discrimination may have similarities or differences, and as well to examine virtual world discrimination in different places (different features, users, etc.). As well, our spatial analysis allows us to incorporate and assess linguistic differences associated with race-based discrimination on Twitter across cities in the United States. Specific contributions of this work are: --- Related Work Social Media and Hate Speech There is a recent and growing literature in the social media research community on characteristics of hate speech. Beyond just detecting hate speech, research has gone further, for example, in analysis of the differences between personally-targeted and broadly-targeted online hate speech, showing linguistic and substantive differences (ElSherief et al. 2018a). Also, comparative study of hate speech instigators and targeted users on Twitter found personality differences in both, different from the general Twitter population (ElSherief et al. 2018b). The above work was focused comprehensively on any hate speech, which is defined as speech that attacks a person or group on the basis of attributes such as race, religion, ethnic origin, national origin, sex, disability, sexual orientation, or gender identity (ElSherief et al. 2018a). Given that in the research here, we want to describe the association between social media discrimination and hate crimes, we specifically narrow this research to race, ethnicity and national-origin based hate speech, as hate crimes are described by different biases that motivate them, this being one of the categories (race, ethnicity and national-origin motivated hate crimes are often grouped so we could not separate these out for all of the years and cities considered, and moreover these are often grouped together in studies of the implications of discrimination (Williams, Neighbors, and Jackson 2003)). In regards to race-specific hate speech, there is research distinguishing self-narration of racial discrimination and identifying which types of support are provided and valued in subsequent replies (Yang and Counts 2018). A user-level analysis characterizing those who display hate speech on Twitter was performed by annotating users' entire profiles, showing differences in activity patterns, word usage as well as network structure (Ribeiro et al. 2018). --- Comparing Online Hate Speech to Offline Events To-date there have been a few efforts in examining hate speech in social media in relation to offline events. An analysis found that extremist violence leads to an increase online hate speech, using a counterfactual time series method to estimate the impact of the offline events on hate speech (Olteanu et al. 2018). The social media data and crimes examined in this work were based on Arabs and Muslims specifically. Research by Müller et al. showed that rightwing anti-refugee sentiment on Facebook predicts violent crimes against refugees in otherwise similar municipalities with higher social media usage. Essentially, in this work they compare how social media posts affect crimes within the same municipality compared to other locations in the same week. Though this link was found, this paper was focused in Germany, the content examined was manually collected from one Facebook group, and the social media data and crimes examined were based on anti-refugee sentiment specifically (Müller and Schwarz 2018a). In the United States, another study has shown that that the rise in anti-Muslim hate crimes since Donald Trump's presidential campaign has been concentrated in counties with high Twitter usage (specific content was not parsed) (Müller and Schwarz 2018b). In sum, related work on social media hate speech motivates that hate crimes are likely to have many fundamental drivers; social media can help illuminate some of these local differences (such as variation in xenophobic ideology or a higher salience of immigrants). To advance this work, we focus on hate crimes biased by race, ethnicity and national-origin, and appropriately parse social media to understand the same type of discrimination. This enables us to compare discrimination in social media to offline events at scale across the United States. --- Data We focus on city-level analysis here. While select individual cities in the U.S. also publish sub-city data (e.g. Zip code level), we focus on city-level data in this study to include a wider and diverse group of places. Moreover, not all cities may have a diversity of relevant features at a sub-city level. The city spatial resolution also improves statistical reliability of the census data considered in this study. --- Hate Crime Data The --- Social media data We used Twitter's Streaming Application Programming Interface (API) to procure a 1% sample of Twitter's public stream from January 1st, 2011 to December 31st, 2016. From this data set we selected Tweets made in the specified 100 cities using the "place" attribute. The place attribute contains the name of the city where a Tweet was made, determined using both the point and polygon coordinates associated with a Tweet. We manually accounted for changes in the way cities are described by name over time. Using place is computationally faster for matching city names as compared to mapping coordinates to cities using a polygon mapping algorithm with each Twitter JSON object. In total this resulted in 532 million Tweets. The text, time-stamp and location of the Tweets were used in discrimination classification; user id's were used in the bot analysis. --- Census data Census data for demographic and other city-attributes which, from domain knowledge may relate to discrimination, were included to control for their effect on the relationship between the online prevalence of discrimination and the number of race, ethnicity and national-origin based hate crimes. These included: the percentage of white, black, Asian, hispanic/latino, foreign born, female and ages 18-64 in the city. As well, population density (population per square mile) and median income (dollars) were included (US Census Bureau 2018a). We used data from Census Quick Facts, as it combines statistics from the American Community Survey (ACS) with other surveys to give a broader view of a particular geography (includes population, density and income variables) (US Census Bureau 2018b). As well, Quick Facts uses ACS 5-year estimates which have increased statistical reliability compared with that of singleyear estimates, particularly for small geographic areas and small population subgroups which we do have in this study. Further, the five-year estimates capture information across a large portion of our study years (2012)(2013)(2014)(2015)(2016). --- Methods --- Social Media Classification The classification pipeline to identify discrimination Tweets, and then delineate those into self-narration of discrimination or targeted is illustrated in Figure 2. To classify Tweets we used shallow neural networks, which have shown improved performance over traditional classifiers (dos Santos and Gatti 2014; Tang et al. 2014), especially for short texts such as Twitter messages, which contain limited contextual information. The n-gram based approach and classifier parameters were the same as in previous work on discrimination classification that showed good performance (Relia et al. 2018). As well, the overall approach followed from this same previous work in order to ensure that the resulting classified Tweets indicate discrimination and not colloquial uses of keywords and phrases. For example, not all text that con-tains the "n-word" are motivated by racist attitudes (Relia et al. 2018). More details are in the following sections. --- Spatially-diverse Training Data To improve classification performance, and account for possible language/terms specific to different locations across the United States, we developed a spatially diverse training data set. To do so, we used Tweets made in the top 11 cities ranked by total hate crimes. We specifically chose these cities, as there were more Tweets (245 million) made in these cities as compared to the next 39 ranked cities combined (206 million --- Labelling Data Procedure We used the services of Figure Eight 1 (formerly known as Crowdflower) to label the training data, to capture and expand the keywords and phrases that are used in a discriminatory context. We clearly defined the criteria for labelling a Tweet (only the text of the Tweet was provided to the annotators) as indicating "discrimination" (versus "no discrimination") as a Tweet against a person, property, or society which is motivated, in whole or in part, by bias against The label result was chosen based on the response with the greatest confidence of the labels. The confidence score (between 0 and 1) is calculated based on the level of agreement between multiple contributors, weighted by the contributors' trust scores (Figure Eight Inc. 2018). A high average confidence score of 0.92 (SD: 0.19) resulted for the task, and our team manually labeled Tweets where there was a conflict of labels between the annotators. Finally, appending 14,012 Tweets not containing any discrimination keywords chosen equally from across the 11 cities and 6 years, resulted in a training data of 16,000 Tweets (1698 discrimination and 14,302 non-discrimination). This proportion is consistent with 10-13% positive labels in a training dataset of 16,000 Tweets (Le and Mikolov 2014;Dai, Olah, and Le 2015;ElSherief et al. 2018b). --- Selection of Decision Boundary and Active learning for Classification For the shallow neural net classifier, selection of the decision boundary (threshold), 0.623, was made by optimizing the balance between precision and recall (Wulczyn, Thain, and Dixon 2017). The F1 score and AUC for this decision boundary, calculated by averaging the scores from a k-fold cross validation (k=10), were 0.85 and 0.89 respectively. Further, we used active learning to improve classification at the decision boundary. The entire active learning procedure involved first randomly sampling 10,000 Tweets from the top 11 cities, ranked by hate crimes, and classifying them using the shallow neural network. We then manually labelled the 1000 Tweets (5% of Tweets on each side of the decision boundary) and appended these Tweets into the training data (active learning portion). We did this iteratively until performance of the classifier plateaued (Relia et al. 2018). Finally, out of a total 17,000 Tweets in the training data, this resulted in 1987 discrimination and 15,013 non-discrimination Tweets. The average F1 score of the classifier improved to 0.86 and average AUC improved to 0.90 after this procedure. It should be noted that we also examined classifier performance by systematically decreasing the number of nondiscrimination Tweets, to assess sensitivity to the balance, and found that F1 and AUC reported above, for the chosen balance, were the highest. --- Delineating Targeted and Self-Narration Discrimination Previous social media research has discussed both targeted (ElSherief et al. 2018a) and self-narration (Yang and Counts 2018) aspects of hate speech. Targeted discrimination is defined as someone being discriminatory as compared to self-narration of discrimination where someone is sharing their exposure to discrimination; either a direct experience or witnessing someone experience it. In line with existing work which used simple first-person pronoun filtering to identify self-narration of discrimination (racism) in Reddit posts (Yang and Counts 2018), we used a similar first-person pronoun filtering approach. To categorize Tweets as selfnarration, we selected Tweets that contain any of the firstperson pronouns: I, me, mine, my, we, us, our, ours. As simple first-person pronoun filtering resulted in a high false positive rate (e.g., "I think so-called white trash turns to white supremacy because, a., they're victimized by minority criminals, and b., they're uppity whites"), we also required an absolute majority of number of first-person pronouns over number of second and third-person pronouns in a Tweet for a Tweet to be categorized as self-narration of discrimination. This condition helped to decrease the false positive rate by 75%, measured by our team on a randomly chosen sample of 1000 Tweets. --- Hate Crimes and Social Media Relationship To examine the relationship between race, ethnicity or national-origin based hate crimes and discrimination on social media by city, we use a regression modeling approach where the number of race, ethnicity or national-origin based hate crimes in all years, for each city, is the dependent variable, while accounting for other potential covariates. We caution that the approach does not imply that the social media measures directly causes hate crimes in different cities. Assessing this relationship would be a first step towards assessing any potential causal pathway, or the possible uses of social media discrimination in complement to hate crimes, for example to study issues at higher spatialresolution than is available through hate crimes, such as at the neighborhood-level. Each model controlled for the census attributes discussed in the Census Data section. All analyses were conducted in R v3.5.2. --- Linguistic Analysis To assess affect and linguistic-related features of discrimination on social media at the city, user and Tweet level, we used EMPATH. EMPATH is a tool that can generate and validate new lexical categories on demand from a small set of seed terms and capture aspects of affective expression, linguistic style, behavior, and psychological state of individuals from content shared on social media by deep learning a neural embedding across more than 1.8 billion words. The performance of EMPATH has been found to be similar to LIWC (considered a gold standard for lexical analysis), EMPATH is freely available, and EMPATH also provides a broader set of categories to choose from compared to LIWC (Fast, Chen, and Bernstein 2016). We selected several affectrelated features based on prior work in understanding selfnarration of discrimination and discussion of racial equity (Yang and Counts 2018;De Choudhury et al. 2016): positive emotion, negative emotion, disappointment, sadness, aggression, violence. Motivated by studies regarding risk factors for racial/ethnic discrimination we also selected EM-PATH features potentially related to socio-economic status (work, money) and culture (night e.g. nightlife) (Williams, Neighbors, and Jackson 2003). --- City-level To understand the relationship between these linguistic features and hate crimes in a city, we used a regression modeling approach, where the number of race, ethnicity or national-origin based hate crimes in a city is the dependent variable, and the per-city normalized proportion of each linguistic feature are independent variables. Negative binomial regression is used to model the count data, and account for over-dispersion. We also present iterative model selection results (backwards step-wise model selection by exact Akaike information criterion) to protect against overoptimism and assess predictors that contribute a significant part of explained variance. User-level Here we examine the features used by users who discuss increased amounts of discrimination (>21 discrimination Tweets total) versus those who only had one discrimination Tweet. Those users with >21 discrimination Tweets represent those (0.01% of all users with any discrimination Tweets) with the very highest number of discrimination Tweets in our dataset (more description of this range in the Descriptive Analyses of Discrimination Results section). Tweet-level At the Tweet level, we examined the distribution of all EMPATH linguistic features in discrimination versus non-discrimination Tweets. Using normalized means of the category counts for each group, we compute the correlation across these two types of Tweets and examine the odds of EMPATH feature categories likely to appear in discrimination Tweets. --- Discrimination Content by Bots Increasingly, there has been a recognition of bot accounts on Twitter that spread malware and unsolicited content that in particular has included public health and antagonistic content and towards eroding public consensus (Broniatowski et al. 2018). Given the antagonistic nature of the content examined in this study, we also assessed and analyzed the prevalence of bots and bot-generated Tweets in our data. We used seven available lists of bot accounts (used in (Broniatowski et al. 2018)) to identify bot accounts. These lists (Lee, Eoff, and Caverlee 2011;Cresci et al. 2017;Varol et al. 2017;Frommer 2017;Cresci et al. 2015;2018;Popken 2018) which id's of 8076 bots generally overlap in time with our study period (except for (Lee, Eoff, and Caverlee 2011) in which the data was collected from December 30, 2009 to August 2, 2010, thus possibly very few users from this list would be relevant to our data). We assessed i) the total proportion of bot accounts in our data, and those responsible for discrimination content, and ii) the spatial distribution of those accounts. Regarding the possibility of other forms of untrustworthiness in the Twitter data, as this study is concerned with discriminatory text online, even if the data is generated as spam, or purposefully inflammatory, this still qualifies in terms of what is discriminatory online, thus should not be distinguished in the analysis. --- Results --- Classification Training Data Representation We found that the top 20 features that were most predictive of a Tweet being classified as containing discrimination occurred in more than 25% of the discrimination Tweets made in the top 11 overall hate crime cities. We studied the spatial and temporal distribution of these top 20 features to assess the spatial (and temporal) balance of the training data. We first assessed the temporal changes in the use of features and found there was no significant difference between the % use of any of the top features in each city between all pairs of consecutive years (two-tailed Student's t-test, p >0.05). We then compared the distribution of these top 20 features in the 11 high overall hate crime cities with the distribution in the remaining 89 cities (medium and low hate crime) and high correlation between the use of features in the two groups determined using the Spearman's rank correlation (<unk>=0.87, p <unk>0.05). We also performed the same analysis for the entire keyword list, and found no significant difference between the 2 sets of cities in any consecutive years (p >0.05) and high spatial correlation (<unk>=0.84, p <unk>0.05). Therefore, as the overall feature and keyword distributions were similar spatially and over consecutive years, we found it sufficient to use the training data generated by the top 11 hate crime cities to classify Tweets made in the additional 89 cities. --- Spatial Distribution Crime distribution Phoenix, AZ had the highest number of race, ethnicity or national-origin based hate crimes over the 6 years (566). On the other hand, Castleton, VT and Riverton, WY had zero race, ethnicity or national-origin based hate crimes. 26 cities had 9 total or less over the 6 years considered. The biggest differential in rank of race, ethnicity or national-origin based hate crimes and total discrimination Tweets were in Castleton, VT (lowest number of race, ethnicity or national-origin based hate crimes and 17th highest proportion of discrimination Tweets), and Montpelier, ID (in the 19th lowest cities based on number of race, ethnicity or national-origin based hate crimes, and 5th highest proportion of discrimination Tweets). Social Media Feature Distribution Overall we found that most of the top features identified were used consistently across cities, but notably, there were some features that were found specifically in particular cities. For studying the top discrimination feature distribution we used the top 10 features in each of the top 21 cities ranked based on race, ethnicity or national-origin based Hate crimes (the 21st was San Francisco, which added geographic diversity, also San Francisco ranked highly for hate crimes in general (13th)). Figure 3 illustrates the distribution of the top discrimination features across a) targeted and b) self-narration Tweets. In terms of top features, there were three used in all of the top 21 cities ranked by race, ethnicity or national-origin based hate crimes: f*cking n*ggers (* added to censor offensive language) which was the top feature in 10 of the top discrimination hate crime cities, most racist person which appears in all top 21 cities (and is the top 1 or 2 feature in 9 cities), white trash which is the top 1 or 2 feature in 4 cities, Indianpolis, IN, Cincinnati, OH, Las Vegas, NV and San Diego, CA. Three features were only found in single cities: f*cking wiggers (Seattle, WA), insane redskin trash (Washington, DC), n*gger is like (Seattle, WA). Consistency of some of the top features, but appearance of some features only in specific places indicate there is some geographic variation that may not have been discovered if we did not ensure the training data was well distributed spatially. The most common feature was used in targeted discrimination and 15 of the 23 top features were used in targeted discrimination Tweets and the rest in self-narration discrimination Tweets, except white trash which we found is used in both contexts (Figure 3). In 36 of the 100 cities, the proportion of discrimination that is targeted was higher than that of self-narration of discrimination experiences. The top and bottom ranked cities for targeted to self-narration discrimination ratio were: Woodbury, NJ (0.91), Greeneville, TN (0.89), Norman, OK (0.82), Missoula, MT (0.8), Neptune, NJ (0.79) and West Jordan, UT (0.02), Providence, RI (0.02), Riverton, WY (0.02), Mandan, ND (0.04), San Antonio, TX (0.05). --- Descriptive Analyses of Discrimination The overall number of users by city who discuss any discrimination on Twitter has a long tail distribution, with a mean of 731 users and standard deviation of 1448. When examining the number of users in relation to the number of discrimination Tweets, the largest number of cities have users with 2-3 discrimination Tweets (Figure 4a). Cities with a relatively higher proportion of Tweets to users (more discrimination Tweets by each user on average) are: Miami Beach, FL (8.7), Neptune Township, NJ (8.1), Taunton, MA (8.1) and Omaha, NE (8.0). In examining the proportion of discrimination Tweets that are targeted, compared to selfnarration of discrimination by city, gives a more consistent distribution (Figure 4b), with 9 cities having a ratio above 0.7. These cities are: Woodbury, NJ (0.91), Greeneville, TN (0.89), Norman, OK (0.82), Missoula, MT (0.80), Neptune Town, NJ (0.79), Devils Lake, ND (0.79), Fullerton, CA (0.78), Milwaukee, WI (0.77) and Montpelier, ID (0.73). --- Hate Crimes and Social Media Relationship Upon visual inspection, we noticed that a few cities had a very high number of hate crimes (in general, including specifically race, ethnicity or national-origin based hate crimes): Phoenix, AZ, Boston, MA, Columbus, OH, Los Angeles, CA, New York, NY, Seattle, WA and Kansas City, MO. These cities are known for various reasons to have high number of hate crimes. Phoenix has a bias crimes unit which most major cities do not have, and Phoenix police say they look to be as thorough as possible when it comes to hate the state of Massachusetts) has more agencies contributing information to the FBI than most other states (Jarmanning 2018). The higher number of reported hate crime incidences in Columbus, OH has been recognized and attributed to it's disclusion of heightened punishments for crimes such as assault or murder though, and lack of inclusion for protections for sexual orientation, gender identity, age, disability, or military status (Kocut 2018). Finally, Kansas City, MO is also known to be one of the top crime (in general) cities in the country (Alcock 2018). We thus performed the regression analysis both with and without these outlier cities. Regression results show that the proportion of discrimination Tweets that are targeted has a positive relationship (<unk> > 0) with the number of race, ethnicity or nationalorigin based hate crimes in a city, and this variable is significant when controlling for all of the demographic and other city attributes (Tables 1234). The stepwise model shows that percentage black and foreign born also contribute a significant portion of the explained variance. When outliers are removed, the main difference in model results is that the stepwise model shows the total percent of discrimination Tweets that are self-narration, percent black and population density of cities to also contribute to explained variance along with the targeted to self-narration ratio (all with positive coefficients). --- Linguistic Results City-level Results Of the EMPATH features selected based on their potential relation to our outcome, in discrimination Tweets, both positive and negative emotion were significant predictors of hate crimes. Surprisingly, positive emotion had a positive significant relationship while negative emotion a negative relationship with the number of race, ethnicity or national-origin based hate crimes. Disappointment, money, and night all had a positive, significant relationship with the number of hate crimes. Work-related features had a negative significant relationship. --- User-level Results In assessment of the linguistic characteristics of users who discuss relatively high amounts of discrimination (>21 discrimination Tweets), we found that correlation of the resulting EMPATH categories in their discrimination Tweets was very high both with the discrimination Tweets of users who made only 1 discrimination Tweet, as well as with those who made between 1 and 21 (<unk> = 0.99, --- Tweet-level Results We further examined the specific EMPATH characteristics that did not fall in line with the correlation via the normalized mean of each feature count. Table 5 shows the top 10 features with a normalized mean in discrimination tweets compared to the normalized mean for the same feature in non-discrimination Tweets. In general, negative features that do all have some intuitive relation with discrimination are most common. The average normalized mean ratio is 3.6; and so these features are at least twice or more times likely to be in discrimination versus non-discrimination text (minimum is 7.2 times in the table). --- Discrimination Content by Bots We found a minimum of zero% (18 cities) to maximum of 31.6% (Washington, D.C.) discrimination users that were classified as bots based on the lists of known bots, with a mean of 7.8% (sd: 6%) (fairly spatially consistently distributed, with only 11 cities above 15%). Some example Tweets by identified bots are "Giants playing terri-bly against a terrible franchise. Enjoy gloating skins fans, you're still white trash. #Giants #redskins" (New York, NY). "@Usernameredacted it a proven fact that #blackpeople are the most racist people out there" (San Francisco, CA). Overall there were many themes in the bot posts that were classified as indicating discrimination. We decided to keep Tweets from the bots in our analysis, as these Tweets would be visible to followers as they were posted, though we remark that these should be further investigated or noted in any further analyses of the causal reasons for or implications of discrimination in social media. --- Discussion Summary of Contributions to Social Media Research In this work, we study the characteristics of race, ethnicity and national-origin based discrimination on social media spatially, as well as hate crimes motivated by these biases across the United States. In creating the spatially diverse training data set of social media discrimination, we found that most of the features predictive of discrimination were common, but there are examples of less common features that only appear in select cities. As well, we showed that there is a larger distribution of features in discrimination Tweets that are targeted compared to those that are self-narration of discrimination in the cities with the most race, ethnicity and national-origin based hate crimes. In terms of the relationship between social media discrimination and race, ethnicity and national-origin based hate crimes, the proportion of social media discrimination that is targeted was significantly related to the number of hate crimes. When not considering specific cities with outlier numbers of crimes, the proportion of social media discrimination that is selfnarration was also significant. Linguistically, we identified features more common in discrimination Tweets versus nondiscrimination Tweets, and also showed that positive and negative emotion, as well as disappointment, money, night and work were significantly related to race, ethnicity or national-origin based hate crimes by city. The surprising significance of positive emotion may be potentially related to high-levels of emotion in general in discrimination, or positivity in response to self-narration of discrimination experiences (Tynes et al. 2012). The ubiquity of emotion in discrimination is also supported by the increased frequency of the empath feature sadness in discrimination Tweets (Table 5). Finally, we also showed that there was race-based discrimination from existing, recognized lists of Twitter bots, linked to most of the 100 cities considered, and most predominantely in Washington, D.C.. --- Implications of Analysis We stress that while our work makes no causal claims directly between discussion on social media and crimes, findings from this study are pertinent for better discrimination surveillance and mitigation efforts. In particular, as this work shows that social media may significantly explain some of the variation in hate crimes, discrimination on social media should be studied further to understand, contrast and assess the possible synergies of online and physical world discrimination. The linguistic analysis highlights the opportunities of social media to dissect and understand more about different types of discrimination in the country. These opportunities are discussed further in the Future Work section below. As there has been some concern regarding the criteria and consistency in how hate crimes are reported in different cities, social media also provides a different measure of systemic discrimination by which to augment our understanding of this phenomenon; for example discrimination on social media encompasses that which doesn't necessary elevate to the level of a crime or for which there are no laws mandating reporting in a particular region (e.g. sexual-orientation based discrimination), or location (e.g. sub-city level regions), but such day-to-day negative insults can be internalized, still impact communities and should be ascertained (Williams, Neighbors, and Jackson 2003). Future Work Beyond this spatial analysis, and given newly released statistics from the FBI that show a 17% increase in hate crimes nationwide, in 2017 (Farivar 2018), a temporal analysis of both discrimination on social media and hate crimes could be of relevance. It should be noted that changes in Twitter (or any company's) policies around hate speech should be carefully considered if attempting to unpack temporal changes or causal mechanisms. In generating the spatially balanced training data, we did find a sudden drop in the number of Tweets containing discrimination keywords across all cities in 2016 as compared to previous years. This drop was likely caused by Twitter's strategy in decreasing hate speech (e.g. using e-mail and phone verification) announced in December 2015 (Cristina 2015). This change coupled with the aggregation of hate crimes motivated by biases in different ways across the years would have to be accounted for in any temporal analysis or assessment of discrimination based on more specific biases. Though the drop based on Twitter's actions was spatially consistent across all Tweets, and therefore not a concern in the context of our spatial analysis

We study malicious online content via a specific type of hate speech: race, ethnicity and national-origin based discrimination in social media, alongside hate crimes motivated by those characteristics, in 100 cities across the United States. We develop a spatially-diverse training dataset and classification pipeline to delineate targeted and self-narration of discrimination on social media, accounting for language across geographies. Controlling for census parameters, we find that the proportion of discrimination that is targeted is associated with the number of hate crimes. Finally, we explore the linguistic features of discrimination Tweets in relation to hate crimes by city, features used by users who Tweet different amounts of discrimination, and features of discrimination compared to non-discrimination Tweets. Findings from this spatial study can inform future studies of how discrimination in physical and virtual worlds vary by place, or how physical and virtual world discrimination may synergize.

and Jackson 2003). Future Work Beyond this spatial analysis, and given newly released statistics from the FBI that show a 17% increase in hate crimes nationwide, in 2017 (Farivar 2018), a temporal analysis of both discrimination on social media and hate crimes could be of relevance. It should be noted that changes in Twitter (or any company's) policies around hate speech should be carefully considered if attempting to unpack temporal changes or causal mechanisms. In generating the spatially balanced training data, we did find a sudden drop in the number of Tweets containing discrimination keywords across all cities in 2016 as compared to previous years. This drop was likely caused by Twitter's strategy in decreasing hate speech (e.g. using e-mail and phone verification) announced in December 2015 (Cristina 2015). This change coupled with the aggregation of hate crimes motivated by biases in different ways across the years would have to be accounted for in any temporal analysis or assessment of discrimination based on more specific biases. Though the drop based on Twitter's actions was spatially consistent across all Tweets, and therefore not a concern in the context of our spatial analysis, it is the type of mitigation that this work can potentially inform (via the types of features or the need for spatially-different linguistic features and differences to be considered). Further, our finding that the proportion of race, ethnicity or national-origin discrimination online that is targeted is a significant predictor in the regression model indicates a focus on this measure. Further analyses should also consider unpacking differences in the relative prevalence of hate crimes and social media discrimination in different cities, discrimination against different groups based on the language/terms used, studying the content of discriminatory features commonly used in different places in more details, incorporation of non-english languages and communication through emojis (Barbieri et al. 2016).

We study malicious online content via a specific type of hate speech: race, ethnicity and national-origin based discrimination in social media, alongside hate crimes motivated by those characteristics, in 100 cities across the United States. We develop a spatially-diverse training dataset and classification pipeline to delineate targeted and self-narration of discrimination on social media, accounting for language across geographies. Controlling for census parameters, we find that the proportion of discrimination that is targeted is associated with the number of hate crimes. Finally, we explore the linguistic features of discrimination Tweets in relation to hate crimes by city, features used by users who Tweet different amounts of discrimination, and features of discrimination compared to non-discrimination Tweets. Findings from this spatial study can inform future studies of how discrimination in physical and virtual worlds vary by place, or how physical and virtual world discrimination may synergize.

INTRodUCTIoN Advances in information and communication technology (ICT) have diversified teacher instruction and it is claimed that "ICTs have the potential to improve the quality of education and training" (Department of Basic Education, 2004, p. 8). This is imperative for the integration of ICT in learning expressed through South Africa's White Paper 7 on e-Education (Department of Basic Education, 2004), where it is stated that "ICTs can advance higher order thinking skills such as comprehension, reasoning, problem-solving, creative thinking and enhance employability" (p. 14). Furthermore, with regards to teaching it is asserted that "e-Education will connect learners and teachers to better information, ideas and to one another via effective combinations of pedagogy and technology in support of educational reform " (p. 14). By having this resource at hand, teachers will have access to the needed information to allow them to explain content in a more comprehensible way but also demonstrate it to learners (Ramnarain & Moosa, 2017). In South Africa, ICT integration is also seen as having a transformational effect in advancing national educational goals such as equity and quality in an education system that has historically marginally Black students (Ford & Botha, 2010;Ramnarain & Modiba, 2013). Given the potential contribution of ICT to learning, there is a need to study more closely teacher competency in their instructional actions when integrating ICT into their teaching practice. --- TPACK and TPACK-P Frameworks The appropriateness of pedagogical representation selections and planned learning activity designs involving ICTs are determined by teachers' technological pedagogical content knowledge (TPACK). According to Van Driel, Verloop, and de Vos (1998), TPACK, like Pedagogical Content Knowledge (PCK) that was pioneered by Shulman (1986) is regarded as craft knowledge that teachers use when they support students in constructing understanding of an idea or domain (Hsu, Yeh, & Wu, 2015). TPACK is defined by Koehler, Mishra and Cain (2013) as "the basis of effective teaching with technology requiring an understanding of the representation of concepts using technology" (p.16). It is important for teachers to have the necessary TPACK to ensure that ICT integration in the classroom will be effective. Further to this, Jen, Yeh, Hsu, Wu, and Chen (2016) explain the TPACK of teachers will allow the teaching of topics to be more understandable to learners. Mishra and Koehler (2006) conceptualised TPACK using Shulman as a basis, where they added "technology to the two knowledge bases of pedagogy and content, to explain technology-supported teaching and learning" (p. 46). Their framework on TPACK puts more emphasis on the "connections, interactions, affordances, and constraints between and among content, pedagogy and technology" (p. 1025). These knowledge bases of teachers cannot be isolated and will always be intertwined with one another to ensure that effective teaching will take place. As seen in Figure 1, Mishra and Koehler (2006) developed a model that emphasises the "complex interplay of these three bodies of knowledge" (p. 1025). The above framework demonstrates the working of TPCK when it was originally developed. The framework for technological pedagogical content knowledge is now known as TPACK. As seen in the above framework, teachers must ensure that they have a good knowledge or understanding of how to use technology as a foundation for teaching content in the classroom, The above framework also demonstrates the vast amount of knowledge teachers must have to ensure that they will have a welldeveloped TPACK. The TPACK framework allows for the utilisation of better teaching techniques, that allows teachers to implement technology-assisted teaching effectively allowing for a deeper approach to the content. Jen, Yeh, Hsu, Wu and Chen (2016) explained that teachers in our "digital age" should ensure that they know how to use technology properly in their classrooms (p. 46). Various models of TPACK have evolved from different perspectives on the role of ICT integration (Ay, Karadag & Acat, 2015). In large part, these models address knowledge and skill dimensions independent of teaching experience. The TPACK-Practical model (TPACK-P) however, focuses on teaching experience and is a knowledge framework for science teachers that "considers the teaching process as the basis upon which application knowledge (teaching experience) and TPACK skills work together" (Ay, Karadag & Acat, 2015, p.98). Within the model of TPACK-P, there are three knowledge domains that play an important role in a teaching environment: Planning and designing, practical teaching, and assessment. The planning and designing domain refer to the techniques that teachers use to prepare the curriculum adaptively with the considerations of learners' individuality and features of the target curriculum. Yeh et al., (2015) explained that planning and designing is when "teachers prepare for upcoming teaching practices" (p. 79). When teachers are planning and preparing for their lessons, they must consider the different teaching techniques they are going to use in the lesson but also the learners' knowledge of what the topic demands. When teachers understand what learners understand, but also what they struggle with, the lesson plan can be improved using various teaching techniques, including technology. With technology as a teaching technique, misconceptions that learners might have on a concept can be included in the lesson planning and teachers can retrieve different educational videos to demonstrate the concept. The practical teaching domain involves teaching practically and employing the various techniques to ensure that ICT-integrated instruction can be carried out smoothly in various learning contexts. In science education, teachers cannot rely on theoretical knowledge alone; practical application of the theoretical knowledge plays an important part in learners' understanding. Yeh et al. (2015) explained: "Science teaching needs to guide and support students as they explore nature and make inquiries, while ICTs offer stimuli, representations and channels" (p. 80). Concepts within science need to be practically implemented in the classroom to ensure that learners grasp the content. Even though chemicals are expensive for some schools, the use of technology can improve the practical teaching of some practical concepts. Teachers do not have to rely on the use of chemicals to demonstrate the effects to learners, technology can be used to virtually demonstrate the theoretical concepts to the learners. Yeh, Lin Hsu, Wu and Hwang (2015) explain that "ICTs offer stimuli, representations, and channels to accommodate preservice science teachers with heterogeneous cognitive development in different inquiry activities" (p. 80). Lastly, the assessment domain involves assessing how learners are using multiple techniques to construct knowledge (Yeh, Hsu, Wu, Hwang, & Lin, 2015). The assessment domain also includes the techniques teachers use that inform them about their learners. In science education, learners develop misconceptions on concepts, and this can affect their overall understanding. Technology can be used to continuously assess the learners in a lesson on concepts that poses a problem. TPACK-P suggest that teachers' knowledge in ICT-infused assessment is critical, since it determines how well they assess students' learning with proper ICT tools and strategies (Falk 2012;Fan, Wang & Wang, 2012). --- ICT and Teacher Education The roll-out of the technology in our South African classrooms can have a positive impact on the education of our learners but there are also a few barriers to this technology-assisted teaching. Teachers are not all trained in the effective implementation and the use of technology in their classrooms. Jen, Yeh. Hsu, Wu and Chen (2016) explain that the "lack of necessary knowledge and confidence" contributes to the unsuccessful usage of technology (p. 45). Mumtaz (2000) stated a list of inhibitors has been found in previous studies. A few of the barriers to the limited use, is the "lack of teaching experience with ICT, lack of on-site support for teachers using technology, lack of supervision of children when using computers, lack of ICT specialist teachers to teach students computer skills, lack of computer availability, and lack of financial support." (p. 320). Mishra and Koehler (2006) further explains that "teachers will have to do more than simply learn to use currently available tools; they will also have to learn new techniques and skills, as current technologies become obsolete" (p.1023). Consequently, as technology becomes outdated every year, teachers should stay updated to ensure they will use technology effectively with different techniques. To ensure that teachers stay updated with all technological developments, "teachers need to be provided with adequate facilities and training to be able to use those facilities, in order to progress in technology-rich context" (Mumtaz, 2000, p.336). The South African White Paper on e-learning emphasizes the role of higher education institutions such as universities in ensuring the preparation of teachers to effectively integrate ICT in their teaching (Department of Education, 2004). This is revealed in the excerpt below from this document: Accredited pre-service teacher training programmes will provide students with the basic knowledge, skills and attitudes required to integrate ICTs into subjects of specialisation. This will require that each graduating teacher is able to combine knowledge of the learning process and instructional systems theory with various forms of media and learning environments, to create the most effective and efficient learning experiences. (p.27) With the use of surveys and questionnaires, researchers have tried different approaches in investigating teachers' TPACK. These surveys and questionnaires allow teachers to choose answers on these surveys and questionnaires that is more suitable to their understanding of TPACK. The resulting information has not only revealed how well teachers' knowledge and application is developed on teaching with technology, but constructive directions for future teacher education was also established. There is thus a renewed sense of urgency for teacher education institutions to adequately prepare teachers to fulfil this mandate of technology-assisted teaching. This research provides information on the competency of student teachers in science education implementing ICT use in their classrooms and identifying specific gaps in teacher TPACK such as ICT-integrated teaching strategies, ICT to assess learners and ICT and instructional management. This baseline information could be useful for higher education institutions in reviewing their teacher development programmes for student science teachers. According to Lux, Bangert and Whittier (2011), is important "for evaluating the quality of instructional technology training that occurs in teacher preparation programs (p. 419). Yeh et al., (2014) elaborated that teacher education programs should not only focus on the integration of technology but also on the experiences of teachers using technology in the classroom. The research was guided by the following question: What is the TPACK-P proficiency of preservice science teachers? --- RESEARCH dESIGN ANd METHodoLoGy This research adopted quantitative design in collecting data from a sample of 103 Life, Natural and Physical Sciences pre-service science teachers at a South African university. The students were either in their third or fourth year of a four year Bachelor of Education qualification. The decision to focus on this cohort of students was due to them been orientated towards TPACK in their methodology modules in these years of study, and having experience in the integration of ICT during their teaching practicum at schools. The data was collected by means of a questionnaire developed by Yeh et al. (2015). The questionnaire based on the TPACK-P framework comprises 17 items that describe instructional scenarios on science teachers' implementation of ICTs in their instruction. Hence, the items solicit data on teachers' TPACK-P proficiency levels. This instrument had been administered previously to preservice teachers (Jen, Yeh, Hsu, Wu, & Chen, 2016), and was deemed by researchers at three local universities to be valid in terms of constructs being addressed for the same targeted group of participants in South Africa. The items were also piloted with the same year group of South African university students pursuing a Bachelor of Education qualification at another university, and the readability of the items was confirmed. The items in the questionnaire are clustered together according to the three knowledge dimensions mentioned earlier. Questions one to six focus on the assessment dimension of the preservice science teachers. Questions seven to 13 focus on the planning and designing knowledge dimension. Lastly questions 14 to 17 focus on the enactment knowledge dimension. Table 1 shows how the 17 items of the questionnaire were clustered according to the three different knowledge domains of TPACK-P, known as planning and designing, practical teaching and assessment. Each item has four options that individually represent typical performances that teachers at levels 1 to 4 display. Level 4 (reflective application) is the highest proficiency level that science teachers could achieve, and it indicates that they are adept at using their experience based TPACK to employ ICTs in assisting their learners in learning about science. Teachers at level 3 (infusive application) use ICTs to guide students to self-explore and independently construct their science knowledge, whereas teachers at level 2 (simple adoption) use ICTs to help learners learn about science but via more teacher-centred strategies or with less well-founded rationales. Level 1 represents teachers that only have a basic understanding of technology resulting from their lack of, or limited experience, negative impressions regarding technology in the classroom, or a lack of intention to implement ICTs in their classrooms. For example, item 1 that focused on the assessment domain, was formulated as follows: How do you think your use of videos/animation in the classroom helps you to better understand your students' learning? The following options were offered to students: A. They help me learn how students feel about the use of videos /animation in instruction. B. They help me assess students' content comprehension through dynamic presentations. C. They help me elicit students' prior knowledge and/or misconceptions. D. I don't believe videos /animation are useful for assessing students' individual differences. Option C represents a performance at level 4, option B at level 3, option A at level 2 and option D at level 1. The data collected was analysed by employing Rasch analysis. The mean score and standard deviation for the frequency with which the preservice science teachers select an option corresponding to a proficiency level was calculated. Reliability (internal consistency) for the instrument was established by calculating Cronbach's alpha. Knowledge differences between the 103 preservice science teachers were explored by applying a unidimensional Partial-Credit Model (PCM) to the response data collected from the TPACK-P questionnaire. All responses on the 17 questions were scored according to the corresponding proficiency level (i.e., 1, 2, 3, 4). A blank response was scored as 0, referring to proficiency level 0 where "the respondent had no idea how to use technology in a science class" (Jen et al., 2016, p. 51). The data collected were analysed using item response theory (IRT), by employing Rasch modelling. The four options for each item were designed to represent the four proficiency levels. Proficiency level 1 was coded 1, proficiency level 2 as 2, proficiency level 3 as 3, and proficiency level 4 as 4. The Rasch analysis does not require the student to answer all the items in the questionnaire and preservice science teachers can still be compared on a "single equal-interval scale" (Boone, 2014, p. 8). For this study the single equal-interval scale that preservice science teachers were compared with, is that of their proficiency level in their knowledge of TPACK-P. In answering the questionnaire, the students were instructed to select an option that they most agreed with in relation to the instructional scenario's that were provided to them. Their responses were not regarded as right or wrong but coded by proficiency levels (Masters, 1988). Preservice science teacher's TPACK-P were estimated with weighted likelihood ability estimates. Weighted likelihood estimates (WLEs) were proposed by Warm (1989), providing "a bias correction to the maximum likelihood method by solving a weighted loglikelihood equation" (Tao, Shi & Chang, 2012, p. 298). We then used the WLEs and item thresholds to produce a WrightMap. A WrightMap was previously known as the person-item map and is used to display "very complex rating scale data and test data" (Boone, 2014, p. 112). WrightMap allows the Rasch results of the study to be shared with researchers and for those who are unfamiliar with the concept of Rasch modelling, to be able to "digest the results and make sound decisions about complex data" (Boone, 2014, p. 8). The WrightMap also allows the researcher to evaluate how the items of the questionnaire completed by the participants of the study, define traits sufficiently as well as swiftly (Boone, 2014). A WrightMap has two sides. The left side shows the distribution of the respondents weighted likelihood ability estimates from the most able at the top to the least able at the bottom. The options of the items on the right side are distributed from the most difficult (highest threshold) at the top to the least difficult at the bottom. This explains that for each proficiency level 0-4 of the preservice science teachers TPACK-P, there will be an estimated mean. --- RESULTS oF RASCH ANALySIS Using Rasch modelling, the thresholds of the 17 questions were established using the WrightMap software. Figure 2 demonstrates the proficiency levels for all 17 questions. For most of the 17 questions, items corresponding to level 3 was selected by the preservice science teachers as the best option to use in the instructional scenarios that were provided to them, while items corresponding to level 1 was chosen as the most unsuitable option to use within these instructional scenarios. Table 2 reveals the thresholds of the proficiency levels of each of the questions. Based on the 103 preservice Table 1. Item clusters under the three knowledge domains of TPACK-P --- KNOWLEDGE DOMAINS --- Planning and Designing Practical teaching Assessment --- 7. Learning about subject content using technology. --- 14. Why technology-supported instruction is considered special. --- 1. Use of video's/ animation in the classroom helps to better understand student learning. --- 8. Types of subject content suited to teaching with technologysupported instruction. --- 15. Opinion regarding synchronous and asynchronous communications. --- 2. Simulations help to identify learning difficulties. --- 9. Factors influencing teachers planning and designing of technology-supported instruction. --- 16. Handling of problems with technology-supported instruction. --- 3. Usefulness of technology integration helping preservice science teachers with different learning styles and needs. --- 10. Instructional objectives appropriate for technologysupported instruction. --- 17. Opinions about applying technology to instruction management. --- 4. Teacher understanding of technology-supported assessments. --- 11. Selecting appropriate technology tools for content presentation. --- Distinctive features of technology-supported assessments 12. Selection and use of teaching strategies to assist technologysupported instruction. --- 6 Teacher's use of technologysupported assessments to evaluate preservice science teachers in science instruction. --- 13 The effects of group collaborations coupled with technologysupported instruction. science teachers' responses, the thresholds of the 4 proficiency levels for the 17 questions on the TPACK-P questionnaire were identified. By averaging the thresholds across the items, the thresholds of proficiency levels were located for the dimension of knowledge about TPACK-P as -3.00, -1.47, -0.42, and 0.50 (logit). Logit is a metric system used within the application of the IRT. Ludlow and Haley (1995) defined logits as the "interval level units of measurement corresponding to the total scores that have undergone an exponential transformation" (p. 969). They are defined as the "natural log of odds-ratio" (Ludlow, Hayley and Gans, 1992, p. 68). --- Validity and Reliability of Assessment from Item Infit and outfit Statistics The mean-square statistics were used to evaluate the validity of our assessment. Two fit-indices were reviewed: information-weighted mean-square (infit MNSQ) and unweighted mean-square (outfit MNSQ). The two fit-indices have different foci: while outfit is more sensitive to unexpected observations by persons on items that are relatively very easy or very hard for the subjects, infit is more sensitive to unexpected patterns of observations by items roughly targeted to them (Smith, Schumacker, & Busch, 1995). According to David et al. "Whereas the infit statistics deals with overall performance of an item, the outfit statistics are used to analyse if the responses are irregular and sensitive to outliers" (p.81). These indices "represent the differences between the Rasch model's theoretical expectation of the item performance and the performance actually encountered for that item in the data matrix" (Bond & Fox, 2015, p. 57). The MNSQ-values of the items should be close to 1. Linacre (2002) explained that thresholds used for these statistics are 0.5 to 1.5, with 1 being the ideal value. For all 17 questions, the infit and outfit MNSQ were equal to 1.00, and the t-values were located in between -1.96 and 1.96. The results suggested that the equal discrimination assumption was sustained (Bond & Fox, 2015;Jen, Yeh, Hsu, Wu, & Chen, 2016). Therefore, the proposed PCM was used to interpret the participants' responses on this TPACK instrument. --- distribution of Preservice Science Teachers According to Proficiency Levels The preservice science teachers' TPACK-P was estimated by weighted likelihood estimates (WLEs). According to the means of thresholds for the proficiency levels in Table 2, WLE between -3.00 and -1.47, places them on level 1, between -1.47 and -0.42 places them on level 2, between -0.42 and 0.50 places preservice science teachers on level 3 and from 0.50 and higher places preservice science teachers on the highest proficiency level of 4. Table 3 shows the distribution of preservice science teachers on the different proficiency levels of TPACK-P. As demonstrated by Table 3, 82.52% of preservice science teachers have a proficiency level 3 for their knowledge on TPACK-P. A proficiency level of 3 demonstrates the infusive application, where the teacher makes use of ICTs to guide learners to self-explore and independently construct their science knowledge. Only 9.70% of the preservice science teachers were located at level 4 where they are adept at using their experience-based TPACK to employ ICTs in assisting their learners in learning science. Considering the great number of preservice science teachers found on level 3 proficiency of TPACK-P, the knowledge of TPACK-P by these preservice science teachers is quite high. --- dISCUSSIoN ANd CoNCLUSIoN TPACK-P is a knowledge developed by teachers over a period of time using their experiences in longterm planning and instruction using ICT to support their different teaching needs. With the roll-out of currently taking place in South Africa school classrooms, the need for teachers to effectively implement technology becomes a key imperative, and this underline the importance for in-service teachers to have high proficiency in TPACK-P. To ensure teachers are well-developed in the implementation of technology in the classroom, tertiary institutions need to ensure that their teacher education programs have a strong curriculum focus on ICT integration. As we have seen in this research study, 82.52% of preservice science teachers at a South African university demonstrated a proficiency level 3 for their knowledge on TPACK-P. While this is an encouraging result, it is a concern that 7.78% of student teachers operate at demonstrate proficiency at levels 1 and 2. These two levels either demonstrate the preservice science teachers on a simple adoption level where teachers use ICTs to help the learners learn about science via more teacher-centred strategies or with less well-founded rationales, or teachers with a basic understanding of technology resulting from their limited experience in the implementation of ICTs in the classroom. We maintain that making the transition toward higher levels of TPACK-P should be a target for future teacher education. It is also a recommendation that due to the pre-service teachers at the South African university that formed the focus of this study having very adequate proficiency in TPACK-P that some of the curriculum support materials that have been developed be made available to the provincial and national departments of education for possible use in their in-service teacher upliftment programmes that address ICT integration. A limitation of this study is a lack of triangulation in data collection with the TPACK-P questionnaire being the sole source of data. Chen and Jang (2019) reveal a similar limitation in their research on Taiwanese secondary in-service teachers' TPACK in remarking that the use of self-report measures are often susceptible to social desirability bias (Fisher, 1993). It is therefore suggests that future investigations should also include lesson observations to establish how student teachers in their practice enact the indicators of TPACK-P identified in the framework. The current study was also confined to one university, and so it is recommended that a larger-scale study be planned involving other South Africa university. In this way the status on the TPACK-P proficiency of South African preservice science teachers may be more broadly established. Further to this, research could be planned to compare the TPACK-P proficiency of pre-service and in-service teachers. A study conducted in Taiwan using the same 17-item questionnaire found that that there were no significant differences between in-service and pre-service teachers' TPACK-P (Jen, Yeh, Hsu, Wu & Chen, 2016). It would be of interest to established whether a similar results would be found for South Africa.

The purpose of this study was to investigate preservice science teachers' proficiency levels regarding their practical knowledge of technological pedagogical content knowledge (TPACK-P). A sample of 103 third-and fourth-year participants from a South African university were surveyed on their TPACK-P proficiency levels using a 17-item questionnaire developed by Yeh, Lin, Hsu, Wu, and Hwang. Rasch analysis was employed to analyse the data. The findings of the study showed that the great majority of preservice science teachers have a proficiency level of 3 for their knowledge on TPACK-P. A proficiency level of 3 demonstrates the infusive application, where the teacher makes use of ICTs to guide learners to self-explore and independently construct their science knowledge. These baseline findings could inform higher education institutions in reviewing their teacher development programmes for pre-service science teacher preparedness in harnessing the affordances of ICT in their teaching.

Introduction Virtual worlds are computer-simulated games where real-world people or players can create avatars to live, interact and communicate among themselves or with the virtual environment within a particular context or theme [1]. The last two decades has seen the rise of scientific studies of virtual worlds and their potential connection to the real-world [2][3][4][5][6]. Data extracted from virtual worlds allow researchers to test theories on human behaviour in highly controlled environments, for example, sociological behaviour [5,7], human mobility [8], international relations [9,10] and economic models [6,[11][12][13]. A major question, however, is whether the data extracted from virtual worlds are representative enough to study real-world socioeconomic phenomena and whether they capture real-world human behaviour. In a related content many other works have addressed the issue whether digital data can be exploited to assess specific socioeconomic phenomena. Examples include the use of online posts and mobile communications to infer individual economic status [14], and inferring socioeconomic status from large-scale online data sources [15]. We now provide some examples of how social and economic actions in virtual worlds can be used to study socioeconomic phenomena. World of Warcraft (WoW) provides a popular virtual (online) world in a fantasy setting where players can either fight each other or collaborate to meet the game's preset challenges. Martoncik [16] observed that WoW players were on average more social in the game than in the real-world. Through interactions in the game, players develop different feelings and generally experience less loneliness and social anxiety compared to those feelings in the real-world. The difference is more prominent for players who prefer to operate in in-game social groups. Zhang and Kaufman [17] studied the social interactions in WoW and the socio-emotional well-being of players. They found that adult players who are part of a club inside WoW can develop meaningful online relationships including friendship with other players. Destiny is also a virtual (online) world in a futuristic setting, where players can play either individually or in groups (with real-world friends or strangers) to complete a number of challenges designed by the game developers. Destiny was used by Perry et al. [18] to analyse the impact of (in-and out-game) relationships between friends and strangers in the in-game behaviour of players. Pardus is another virtual (online) game that can be accessed via an Internet browser. It represents a futuristic universe where players compete for the limited space whilst interacting in various ways (including fighting) with other players. It has been extensively used for scientific research [4,5,8,19,20]. In particular, Szell et al. [19] analysed the population of players and the different interaction channels between them and found that in-game communication, friendship, and animosity interaction networks had non-trivial structural properties. Using both the friendship and enmity networks, they found strong evidence for a generative mechanism known as social balance theory [21,22] that is also found in real-world networks [23][24][25]. The typical number of social interactions per player in Pardus [26] is similar to Dunbar's number, in the range 100-250, that is a suggested cognitive limit to the number of people with whom one can maintain stable social relationships in the real-world [27,28]. Thurner et al. in [20] studied sequences of in-game actions in Pardus and observed a higher probability of "positive" ("negative") action if the player had received a "positive" ("negative") action in the preceding time step, suggesting the existence of reciprocal in-game behaviour. EVE Online is a sandbox massive multi-player on-line game (MMOG) [29] developed by CCP games [29] where over half a million players fight, trade, collaborate, and explore a futuristic galaxy. The players' actions are recorded with a high level of precision and detail in space and time. Feng et al. [30] have studied the temporal evolution of in-game activity and population for three consecutive years. They found daily cycles and weekly periodicity in the number of social connections of players. EVE Online provides a player-driven complex economy as all items need to be produced from raw materials and traded by players with minimal intervention of the game developers. Hoefman et al. [13] have studied the price of the items in the EVE Online free market and found empirical evidence in support of the theory of hedonic pricing. Hedonic pricing theory proposes that the price of an item in a homogeneous class of goods can be expressed as a function of the prices of the different functional characteristics of that item [31]. Although EVE players have full information about functional characteristics and strong incentives for rational behaviour, they are not only willing to pay for functional characteristics but also for social characteristics of in-game items [13]. Using EVE data, Carter [32] https://www.ccpgames.com/). We have a contract with Crowd Control Productions that grants us access to the data for non-commercial scientific research. For further requests please contact KS ([email protected]). Authors may also request these data directly from Crowd Control Productions ([email protected]). The data for the real-world social and economic activities (such as the Global Terrorist Index, the Global Peace Index, the Consumer Price Index, the Real Effective Exchange Rate, the Unemployment Rate) used in the presented analysis are publicly available and references are given in the text. has conducted a study of the use of propaganda during war times as an essential factor for maintaining the morale. Belaza et al. [9,10] have developed a framework based on statistical physics and structural balance to model international relationships. The model was validated against the network of relationships between alliance groups in EVE Online and international relationships between countries during the Cold War era that have similar network structures. The authors provided evidence that a virtual world can be used as a cleaner and a more extensive laboratory than the data from the real-world for evaluating generative mechanisms for networks of relationships observed in the real-world. In this paper we study the virtual-world Eve Online [29]. We use data on daily social and economic activities of players to study whether the real-world socioeconomic environment in which players live permeates their in-game behaviour. The focus of our work is on connections between real-world and in-game socioeconomic behaviour at the country level. To this end, we time-aggregate over the data of all individual players from a particular country. We first propose a methodology to generate from a time series of selected player in-game activities, country profiles for average in-game player activity. Next we study the statistical relation between in-game and real-world behaviour using international indexes at the country level. Our research contributes to understanding to what extent virtual worlds can be seen as effective and reliable proxies that accurately reflect the country variation in real-world environments. --- Materials and methods In this section, we first introduce EVE Online game, the relevant data of players in-game activities, and the real-world socioeconomic indexes that will be used. Then, we introduce a methodology to aggregate player behaviour and trade activity at the country level. --- EVE Online EVE Online is a sandbox massive multi-player on-line game (MMOG) [29] developed by CCP games [29]. To play EVE Online, a player needs to pay a subscription fee of 15 USD or 15 EUR per month, or spend the equivalent amount by buying an item (called PLEX) inside the game. Once the item is activated and consumed, the subscription extends for another month. The mere fact that there is a subscription fee in combination with the technological requirements impacts the distribution of players over the different countries. Per capita we observe that there tends to be more players from high-income countries than from low-income countries. For countries with more than 100 accounts, the number of accounts corresponds with a fraction of the total population that varies from the subpercent level to about 8%. There is one exception to this: for Iceland, where the headquarter of CCP games is located, the number of accounts corresponds with about 30% of the total population. There are over half a million players who fight, trade, collaborate, and explore a futuristic galaxy. Players can choose to engage in different activities, ranging from mining asteroids to waging war. For example, the distribution of raw materials is pre-defined by the game developers but the extraction, processing and manufacturing of items, and transport and trading of goods are made and controlled by players. The player's experience is shaped by the activities of the other players. Altogether, this dynamics gives rise to an emergent economy with specialisation of players and intricate economic interactions. Inter-player interactions also play a role at other levels since they create complex social hierarchies used to control territories and exploit their resources. Not least, these structures and frequent inter-player interactions generate a complex world with espionage and game-wide wars as emergent social phenomena. The analysis presented in this work is based on collected EVE Online data from December 2011 to December 2016 (61 months) for the trade activity and the year 2016 for the social and economic activity. --- Measures of in-game social and economic activity We select EVE activities and extract data that are most relevant to study social behaviour, aggressiveness, and production of individual players (Table 1). To capture the in-game social behaviour of a player, we define two variables: (i) "Added As Negative" and (ii) "Added As Positive" encoding whether a particular player gets tagged as friend or enemy, respectively, during inter-player contacts. The difference between these two variables is a measure of in-game prosocial behaviour ("Reputation"). The number of times a player gets involved in virtual combats with other players, both as aggressor or defender, gives the in-game aggressiveness of a player. Aggression is thus the number of "Engaged Attack" minus "Engaged Defense". In-game aggressiveness is also captured by the number of events involving killing of a Non-Player Character (NPC), which is a ship controlled by the game ("Kill NPC"). To measure in-game production (and recycling) activities of the individual players, we use three variables: the actual production of items ("Production"), the extraction of raw materials from Asteroids ("Mining") and extraction of material from destroyed ships ("Salvaging"). --- Measures of real-world social and economic activity To measure aggressiveness in the real-world at the country level, we use the Global Terrorist Index (GTI) and the Global Peace Index (GPI) from the year 2016. The GTI [33] is proposed as a measure of the impact of terrorism in 196 different countries and comes from the Global Terrorist Database curated by the Institute for Economics & Peace. The GPI [34], published by the same institute, combines data on terrorist attacks and other indicators, including for example, criminality rates and military expenses. A low value of GPI indicates a higher level of peace. To measure real-world socio-economic characteristics of each country, we use the Consumer Price Index (CPI), the Real Effective Exchange Rate (REER), and the Unemployment Table 1. In-game activities representing the levels of social interaction, of aggressiveness, and of production activity of players. --- Variable Category Description --- Added As Negative social interaction Interacting players can mark the counter-party as friend, enemy or neutral. --- Added As Positive social interaction This mark is visible whenever players meet. --- Reputation social interaction (Added As Positive)-(Added As Negative) Engaged Attack aggressiveness Attack another player. --- Engaged Defense aggressiveness Being attacked by another player. --- Aggression aggressiveness Conflict against others: (Engaged Attack)-(Engaged Defense). Kill NPC aggressiveness Destroy ships controlled by the game, usually so-called pirates. --- Production production activity Produce an item, using other items as input. --- Mining production activity Extract materials from asteroids. --- Industrial production activity Production + Mining --- Salvaging production activity Recover materials from destroyed ships. https://doi.org/10.1371/journal.pone.0240196.t001 rate (UNEMP) from the World Bank for the year 2016 [35]. CPI is an inflation index measuring the evolution of a weighted average price level of a fixed basket of basic consumer goods and services like food, ICT, medical care and housing. REER is an exchange rate index describing the strength of the local currency with respect to the rest of the world. It is a weighted average of all exchange rates of the local country currency to the currencies of all the country's trading partners, weighted by the trade volume. UNEMP is the fraction of the working age population that is unemployed and looking for a job. --- In-game country profile We construct an activity-based in-game profile per country from the selection of eight independent key activities listed in Table 1. A country's profile is based on the time and player average profile of the players that come from that particular country. Upon determining the time series of the players' in-game profiles we face the challenge of heterogeneity in the time scales of the selected in-game activities. For example, marking someone as a friend is an instantaneous event whereas the process of mining an asteroid can take up to half a minute. Data for the individual players are aggregated on a weekly basis, creating a specific profile per week for all players and weeks in 2016. To deal with different scales and metrics, we define an adimensional "activity coefficient" that combines in-game events and is representative for the activity level of each player during a given week. The ratio of the action to the normal activity determines the adimensional coefficient. The temporal evolution of these profiles could for example be used to study in how far players adapt their in-game behaviour in response to an out-game stimulus. These studies are beyond the scope of the current work as our focus is on collective socioeconomic behaviour at the country level. For the country profile, we take the average of all the profiles of players belonging to that country and normalise by the standard score of all countries with at least 15 players in EVE online. The threshold of a minimum of 15 players is a trade-off between data cleanliness and country coverage. We wish to have as many countries as possible in our analysis. We have checked that noisy country profiles are generated when including countries with only a few players. The required minimum number of players (= 15) in each country is set to a level to keep a significant sample of countries (106 countries) for analysis. We have checked that increasing the threshold from 15 to a higher number does not markedly modify the results whilst reducing the country coverage in our analysis (See In-game player behaviour and the real-world socioeconomic environment). For the sake of clarity we provide a step wise description of the data curation process that allowed us to create country profiles from the recorded players' in-game activities during the year 2016. Step 1: For each player and week, we sum the number of times they perform each action. The variables Production, Mining and Salvaging involve the production of an item and are measured through monetary value instead of counting the number of times that the activity has been completed. The produced value is the sum over the items whereby the cost of each item is determined by that week's average market price. For example, a player mining two items with a market price of 5000 ISK and three items with a market price of 1000 ISK has a Mining value of 13000 ISK for that week. At the end of this step we possess a weekly player profile for all studied actions. Step 2: We remove the activities from "sporadic players", i.e. players that have no recorded activities for all weeks of the covered time period. Step 3: To deal with different scales and metrics, for each player-measure combination we define an adimensional "activity coefficient" for each week. To this end, for each measure and player we determine the ratio of the player's measure of that week relative to the crossplayer and cross-week average. In computing those averages all zeroes are removed. The resulting profile of each player provides for each measure information on how more or less frequent the player performs the action in comparison with the "average player". For example, if all players killing NPCs kill on average 200 times per week, and a specific player kills 500 times in a particular week, the player's activity is recorded as "Kill NPC 500/200 = 2.5" for that particular week. For each week during the period analysed we determine the profile for all individual players and measures. Step 4: To create a country profile for a particular measure, we average the weekly profile discussed in Step 3 over all its players. Step 5: The country-based measures for the in-game activities are re-scaled to zero mean and unit variance (Z-score). --- Measures of in-game trade activity The EVE market operates according to a double auction system. Players can set a sell or buy order of a specific item for a certain price. They can also see the full list of active orders and opt to fulfill them. For each country c and item i, we determine the monthly sell price P c Si, the monthly buy price P c Bi, and the monthly volume of sell and buy orders, respectively, V c Si and V c Bi. We collect the data for M = 106 countries c with more than 15 players and for 6,882 unique items i. Table 2 shows the in-game measures of trade activity for each player for a specific country. All measures include a sum over all the different items. The mean for each item i is taken over M countries, for example, for buy price hBii --- Results In this section, we first present the activity-based in-game country profiles and then perform a regression analysis of the socioeconomic behaviour of players inside the game in comparison to the their country-of-origin in the real-world. --- Variable Definition Description Buy Price X i P c Bi <unk> hP Bi i c hP Bi i c Buy price in country c relative to the average over all countries. Bid Ask X i P c Si <unk> P c Bi P c Si <unk> P c Bi Bid-ask spread in prices for country c. --- Buy Volume X i V c Bi <unk> hV Bi i c hV Bi i c Volume per transaction of buying orders in country c relative to the average across countries. --- Bid Ask Volume X i V c Si <unk> V c Bi V Si <unk> V Bi Bid-ask spread for the traded volume per transaction in country c. --- Bid Ask Transactions X i N c Si <unk> N c Bi N c Si <unk> N c Bi Bid-ask spread in the number of transactions in country c. --- P c Bi ; V c Bi ; N c Bi stand respectively for price, volume, and number of transactions of buy orders for item i in country c. --- P c Si ; V c Si ; N c Si are the equivalent for sell orders. https://doi.org/10.1371/journal.pone.0240196.t002 --- In-game country profiles and trade activity The in-game country profile is generated by combining a selected number of in-game activities capturing the social interactions, aggressiveness, and production of players. Table 3 shows the country profiles of selected countries and the cosine similarity between pairs of countries for eight in-game activities (See section Materials and methods for details). The cosine similarity is calculated using the hyper-dimensional vectors that correspond to the country profiles based on all eight in-game activities. We analysed the similarity between country profiles using the subset of countries with more than 100 players (62 countries). Fig 1 shows the cosine similarity of pairs of countries. The countries are first clustered via an iterative algorithm that at each time step aggregates the two closest clusters (See function hierarchy.linkage in the Python scipy.cluster module and [36,37] for more details of the algorithm) and then ordered in clusters with similar profiles. Fig 1 shows one cluster of countries (upper-left part of the matrix) with highly similar profiles, with Oceanic and Asian countries a bit over-represented, and another cluster of Eastern Europe countries, i.e. Ukraine, Russia, Belarus, Moldova, Bulgaria, Lithuania, among others. Furthermore, France and the United Kingdom have similar profiles, as well as Germany and Austria, suggesting that geography may be relevant. Canada and Ukraine are the countries with highest profile difference (cosine similarity is -0.98). The calculated similarities indicate the robustness of our method. Using the transaction data from December 2011 to December 2016, we create monthly (61 months) measures of in-game trade activity of individual players grouped according to country-of-origin for the 106 countries with more than 15 players (Table 2). The data is normalised using the average and the standard deviation (Z-score). We also winsorize the data by removing 1.5% of the outliers, i.e. all data points larger than 3 standard deviations. Table 4 shows the summary statistics for each trade activity. --- In-game player behaviour and the real-world socioeconomic environment In this section we study the relation between real-world aggressiveness at country-level and ingame social interactions, aggressiveness, and economic activities of players at the level of their country of origin. Previous studies have suggested that the real-world aggressiveness in a country as defined by the Global Terrorist Index (GTI) correlates with a variety of social, economic, and geographical measures, like the linguistic fractionalisation, the GDP, and the Human Development Index (HDI) [38,39]. As players perform social and economic activities in EVE Online, we hypothesise that the players' in-game activities and attitudes reflect their real-world socioeconomic environment. For both the GTI and the GPI, and for all the in-game socioeconomic activities in Table 1 (See Materials and methods), we propose the following three models: • Model I: The minimal model that correlates real-world aggressiveness with aggressive ingame behaviour. These models are GTI I and GPI I. In-game similarity between countries. Cosine similarity between in-game socioeconomic profiles of countries with more than 100 players (+ 1 indicates high similarity and -1 low similarity). The profiles are represented as hyper-dimensional vectors and are obtained with the eight independent variables in Table 1, after averaging over all players for each country (See Materials and methods). https://doi.org/10.1371/journal.pone.0240196.g001 • Model II: An extension of Model I variants that also includes pro-social in-game behaviour (i.e. Reputation). These models are GTI II and GPI II. • Model III: An extension of Model II variants that adds the measures of productive in-game behaviour (Industrial, Salvaging). These models are GTI III and GPI III. Table 5 shows the results of Ordinary Least Squares (OLS) regressions for all models. Aggression measures the likelihood that players of a given country are the aggressors in the fights they have with other players. Positive Aggression indicates that players of this country tend to be the first shooter in the game fights they get involved. Industrial is a country-level measure of Production and Mining activities. Salvaging is a country-level measure of extraction of materials from destroyed ships and is thought of as productive (recycling) behaviour in the game. For countries with more than 15 players, there is correlation between the real-world aggressiveness (GTI and GPI) and in-game player behaviour. The linear regression for the Global Terrorist Index (GTI) has a lower R 2 than for the Global Peace Index (GPI) (Table 5), that takes into account more variables than GTI. GTI only includes intentional acts of violence or threats of violence by a non-state actor (See [33]). On the other hand, GPI includes more indicators as for example the jail population per capita, the size of the armed forces per capita, the number of homicides per capita, as well as the Terrorist index (See [34] for the methodology to construct the indexes). Based on the AIC (Akaike information criterion), none of the models can be discarded. For all tested models, the coefficient of the in-game aggressiveness against non-player characters (Kill NPC) is positive, though only significantly in models GTI III and GPI III. In-game aggressiveness against NPCs is thus related to higher real-world aggressiveness. The opposite is also true for aggressiveness against fellow players, i.e. Aggression is negatively correlated with both the GTI and the GPI indexes in all our models. These results suggest that in-game aggressive behaviour against other players is not a good measure of real-world aggressiveness in the country of origin of these players. Although players from unsafer countries display on average more in-game aggressiveness against non-player characters, they also show on average less in-game aggressiveness towards other players than players from safer countries. One interpretation is that in-game fighting with actual players is in fact a social activity, while systematically killing of non-players characters reflects real world aggressiveness. Another interpretation is that ingame aggressiveness against other players may act as a safety valve for inherent aggression, making the real world a safer place. We turn back to this interpretation in the discussion. Pro-social behaviour is given by the Reputation that is measured as Added As Positive minus Added As Negative. Positive country's Reputation indicates that other players mark players from this country more often as friends than enemies. Pro-social behaviour is positively correlated with the GPI, implying that players from more aggressive and less peaceful countries tend to have more friends than enemies in the virtual world, suggesting again that the virtual world may to some extent act as a safety valve: if you life in a country where making real friends is hard, you can still make then on line. We have performed robustness checks of the above results. First, we have divided our data into two groups containing respectively 80% and 20% of the data. The linear regression model estimated with the 80% group shows results qualitatively similar to those of the 20%-group. The results from the full data set and the 80%-group are also consistent. In addition, we have tested the imposed minimum number of players per country required for inclusion in the sample (as discussed above we set the threshold at 15 players per country). Imposing a stricter minimum of 25 players per country (and thus adding less countries in the sample) produces results completely in line with those of Table 5 with comparable values for R 2. On the other hand, relaxing the inclusion constraint to a minimum of 10 players (consequently adding countries with very few players to the sample) introduces very noisy observations in the sample and produces results that are more difficult to interpret. For example, comparing the results for the threshold value of 10 to those for a threshold value of 15, the value of R 2 for the GPI III model is reduced by about a factor of two and also the observed signal for Reputation weakens substantially. --- In-game trading activity and real-world economic outcomes In this section we study the relation between real-world economic outcomes at the country level and measures of in-game trade activity (market behaviour) at the level of the country of origin of the player. Since a player can pay the subscription either with real-world money or buy in-game items from other players, those earning enough in-game currency can pay the full subscription without spending any real-world money. Through the subscription cost in the local real-world currency, price variations and unemployed risk in the real-world can all be transmitted to the in-game financial behaviour. We hypothesise that unemployment risk will encourage players to be more cautious in their in-game transactions, as the opportunity cost of real-world money has increased whereas the cost of spending in-game time has decreased. We also hypothesise that exchange rates affect the ratio between the value of in-game currency and real-world currency. Players may react to a real-world depreciation by being more eager to pay for their subscription with money earned in the game, for example by trading more actively or by demanding higher prices for selling in-game goods. Our third hypothesis is based on the fact that inflation creates a connection between real-world money and real-world goods. Therefore, players who experience inflation in the real-world may be inclined to mimic this behaviour in the virtual world by increasing in-game prices (both buy and sell prices). We propose a single regression model for each variable CPI, REER, and UNEMP, taking into account all the in-game trade activities in Table 2 (See Materials and methods). Table 6 shows that all three regression analysis have low explanatory power (low R 2 ). Players from countries with higher consumer prices inflation in real-world items (CPI) tend to buy more than sell in-game (higher Bid Ask Volume). This result suggests that real-world inflation experiences in the country-of-origin are transmitted into in-game inflation expectations. The real effective exchange rate is negatively correlated with the in-game Buy Price and Buy Volume, but positively correlated with the bid-ask spread (Bid Ask). That means if a country's real currency depreciates, in-game money becomes relatively more expensive for the players of this country, urging them to buy smaller quantities at lower prices and to trade more efficiently. Finally, the level of unemployment is strongly related to most of the studied in-game trading behaviours. Players from countries with higher levels of unemployment not only buy less (Buy Volume), at cheaper prices (Buy Price) and more efficiently (Bid Ask), but also have more sell transactions relatively to buy transactions (Bid Ask). These findings suggest that players of countries with high unemployment attach a relatively higher opportunity cost to real-world money than to real-world time, increasing their willingness to work in the game to earn ingame money necessary to pay for their subscription, since real-world money is limited or nonexistent. To check the robustness of our results, here we also randomly divided our data in two sets with 80% and 20% of the original data. The estimations using the 80% sample yields results consistent with those given by the full sample. Estimates using the remaining 20% of the data are also inline to the full data. The root-mean-square error (RMSE) of the estimations on the two samples differ less than 10%. --- Discussion EVE Online is a paid multi-player online game where over half a million players fight, trade, collaborate, and explore a futuristic galaxy. It is not only a social but also a economic game where one of the main activities is trade. In this paper, we propose a series of socioeconomic hypotheses and test them using EVE Online data to find whether in-game player behaviour is connected to real-world human behaviour and to the socioeconomic context in which players live. We first propose a methodology to combine data from multiple players and to create a representative country profile containing the average player behaviour. This is a fundamental step because individual player data are noisy and difficult to link to individual real-world behaviour in this context. The country-level analysis also helps to understand particular socioeconomic aspects of societies. Our analysis indicates a negative relation between in-game aggressiveness against other players and real-world aggressiveness in the players country of residence, as measured by the Global Peace Index and Global Terrorism Index. This result suggests that players experiencing violence in daily life have a tendency to be less aggressive to fellow players in comparison to players who are less exposed to violence and its consequences to society. This unexpected result is in line with the findings of the study of [40] where it was observed that in the USA violent crime was more likely to show decreases instead of increases in response to the release of violent video games. One possible explanation for this reduction in violence put forward in [40] is that playing violent video games works as a safety valve for inherent aggression and thus leads to a catharsis. In other words, when people play violent video games, they are able to release their aggression in the virtual world instead of in the real world. We further find that players from less peaceful countries tend to make and maintain more friends than enemies in the game relatively to those living in less violent countries. This result indicates that trust and confidence in the virtual world may act as a substitute for positive real-world social experiences. We have observed however a positive relation between in-game aggressiveness against non-player characters and real-world aggressiveness. In this case, players from more violent countries tend to act more violently against non-human characters than those living in peaceful countries. The analysis of trading patterns indicate a significant, though relatively small, correlation between in-game trading and real-world variables reflecting the macroeconomic context where players live. We find that higher unemployment rates and weaker currencies in the country of residence are associated to more efficient and money-conscious in-game trading behaviour and market dynamics. Not least, the less attractive economic environment of certain countries encourages players from these countries to earn more in-game money. This can be partially explained by the fact that players can use in-game money to pay for their continuous membership on EVE Online. In this paper, we have found evidence of correlations between social and economic indicators in the real world and the players behaviour in EVE Online, a game simulating a fantasy galaxy with real-world inspired trading and social dynamics. While correlations do not necessarily imply causality, it is intuitive to expect in our study that due to the relative dimensions (i.e. population sizes of both worlds), the country-of-origin of players affect their in-game behaviour and not vice-versa, as in online vs. offline feedback dynamics in specific contexts [41]. Our statistical models could be further improved to better explain the variation of the real-world socioeconomic indicators, their temporal evolution, and the mechanisms driving the influence and inter-relations between players in-game. The study of the temporal evolution of some quantities and reactions to real-world events could be done for countries with a large amount of players. Future research directions also include similar analysis at the individual player level using online questionnaires. Overall, our study provides evidence on the in-game impact of the real-world socioeconomic environment and socio-cultural norms in which players are immersed and experience daily-life. These results also support previous research encouraging the use of virtual worlds as realistic in-silico environments to perform controlled experiments and test relevant social and economic theories. --- All relevant data for the country profiles are within the paper and its Supporting Information files. The data sets for the in-game activities of the players of EVE online belong to Crowd Control Productions (URL: --- Supporting information

Games involving virtual worlds are popular in several segments of the population and societies. The online environment facilitates that players from different countries interact in a common virtual world. Virtual worlds involving social and economic interactions are particularly useful to test social and economic theories. Using data from EVE Online, a massive online multi-player game simulating a fantasy galaxy, we analyse the relation between the real-world context in which players live and their in-game behaviour at the country level. We find that in-game aggressiveness to non-player characters is positively related to real-world levels of aggressiveness as measured by the Global Peace Index and the Global Terrorist Index at the country level. The opposite is true for in-game aggressiveness towards other players, which seems to work as a safety valve for real-world player aggressiveness. The ability to make in-game friends is also positively related to real-world levels of aggressiveness in much the same way. In-game trading behaviour is dependent on the macro-economic environment where players live. The unemployment rate and exchange rate make players trade more efficiently and cautiously in-game. Overall, we find evidence that the real-world environment affects in-game behaviour, suggesting that virtual worlds can be used to experiment and test social and economic theories, and to infer real-world behaviour at the country level.

Background The prevalence of obesity and associated diseases such as diabetes and hypertension is very high and increasing in the Pacific [1][2][3]. Tonga is among the top five countries worldwide in terms of obesity, [4] with 84% of Tongan males and 93% of females classified as overweight or obese [5]. During the last 30 years, Tonga has experienced an epidemiological transition characterized by extended life expectancy coupled with increasing burden of chronic, non-communicable diseases and decreasing burden of communicable diseases [6]. The disease pattern is changing as a result of marked changes in diet, reduced physical activity and other obesogenic behaviours and environmental factors. The current health care budget is already compromised with over 60% being used for the management of non-communicable diseases. Sound evidence-based strategies are crucial in order to counteract the rising levels of obesity. There is a high rate of tracking of obesity from adolescence to adulthood [7,8] and comprehensive, multi-faceted communitybased programs that start with a focus on young populations [9] are an important part of population obesity prevention. The Obesity Prevention in Communities (OPIC) project, conducted in Tonga (and Australia, New Zealand and Fiji) between 2004 and 2008, used a multilevel capacity-building approach to promote healthy lifestyles amongst adolescents [9]. The comprehensive community-based intervention program in Tonga, known locally as the Ma'alahi Youth Project (MYP), aimed to address unhealthy eating patterns and low levels of physical activity, the two major modifiable risk factors for obesity. The primary goal was to empower youth and their families to live and value healthy lifestyles. A 10-point action plan was developed and used as a road map to guide programme development and activities. The action plan consisted of three standard objectives on capacity building, social marketing and evaluation; four nutrition (promote healthy breakfast, school lunches, fruit and vegetables and water consumption); two physical activity objectives (increase organized sports and informal physical activities), and one about championing key people as role models [10]. The plan provided a framework for effective and enhanced engagement between communities, schools, and government and non-government organisations. Process evaluation is essential to the assessment of a project's implementation, and assumes greater importance in the case of large, complex community-based intervention projects which deliver multiple, non-standardised interventions tailored to specific communities [11][12][13]. This paper describes the process evaluation of MYP in its mission to combat adolescent obesity. It describes the conduct of the MYP program and evaluates it in terms of the achievement of its strategic objectives, its strengths and weaknesses, and a set of best practice principles for community-based obesity prevention. --- Methods --- Staffing and Governance Ethics approval was obtained from the Ministry of Health and Deakin University prior to project commencement. MYP was approved by the Tongan Minister of Health and endorsed by Cabinet in 2005. The project was conducted by the Fiji School of Medicine in collaboration with the Tongan Ministry of Health. It was funded by the Wellcome Trust (United Kingdom) and supported by Deakin University (Australia) and University of Auckland in terms of training, expertise and evaluation. The local project team comprised nine staff: a co-investigator, a project coordinator, three research assistants (who were responsible for the conduct of multiple communitybased intervention activities), an administrative assistant, a social marketing officer and two temporary research assistants (who assisted with data collection and intervention-related activities). In addition, two managerial positions were shared by OPIC Fiji and Tonga: a study manager who provided project management in both countries, and a data manager. The Tonga Non Communicable Diseases committee advised MYP, and a management committee (comprising 12 representatives from the Ministries of Health, Education and Agriculture, schools, and non-government organisations) provided strategic direction and monitored progress. --- Participants MYP targeted secondary school students aged 11-19 years and their families. Three intervention districts (Kolonga, Houma, and Nukunuku) on the main island of Tongatapu were selected for the intervention, comprising a total population of 2868 adolescents (according to the 1996 Census). The intervention districts comprised 22 villages and seven intervention schools (two government [public] and five church schools). Of these seven schools, three were located within and four outside the intervention districts. Those located outside were chosen because of their high enrolment of students from the intervention districts. The selection criteria for the intervention sites are further described in more detail elsewhere [9]. The comparison group consisted of six schools on the island of Vava'u, a more northerly island within the Tonga group. --- Design, development and implementation of the interventions The project intervention and evaluation was based on a number of frameworks. A two day Analysis Grid for Elements Linked to Obesity (ANGELO) workshop [14] was conducted in February 2005 with 14 students from the intervention schools, 19 adults including representatives of the Ministry of Health, church ministers, parents, and town officers, plus 24 adolescents including youth leaders and Tonga National Youth Congress representatives. A draft 10-point Action Plan was formulated [10,15] and later modified and further developed to guide intervention activities in schools, churches and the community. A series of data collections (a baseline survey around dietary intake and physical activity behaviour, school food audit questionnaire, community readiness assessment, sociocultural questionnaire and interviews) were conducted to inform intervention development [16]. Students were measured at baseline and follow-up in year three, with the key project outcomes being anthropometry (body mass index z-score), body fatness measured by bioelectrical impedance) and quality of life [measured by the Assessment of Quality of Life [AQoL-6D] and the Paediatric Quality of Life Inventory [PedsQL]. A research assistant was assigned to each intervention district to manage the development and implementation of the intervention program in villages, schools and churches over the period from 2006 to 2008. In each district, a committee was established to assist and support the implementation of the intervention program. In every village, a contact person was either selected by the coordinator or nominated by the community intervention committee. Schools also nominated focal points. One school appointed student ambassadors from senior forms (years six and seven, youth aged 16-18 years) to be role models for the MYP objectives. --- Process evaluation Throughout the project, intervention-related activities were recorded by MYP staff, using a data collection proforma which included the process (i.e. how the activity was conducted), dose (i.e. scale/duration of the activity), frequency (i.e. how often the activity/event was conducted), reach (i.e. how many/type of people involved) and associated resource use (i.e. for the subsequent economic evaluation). Data were supplemented by information drawn from the MYP implementation reports, staff diaries and weekly plans, minutes of meetings, correspondence and communication with those involved in the intervention delivery on each of the strategic objectives. All intervention data were recorded on an Excel database. Given the capacity-building focus of the MYP program, the New South Wales Framework for capacity building [17] was adopted, and its domains (partnerships, leadership, resource allocation, workforce development and organisational development) were used to structure the evaluation of this aspect of the program (Table 1). The program was also assessed (in the Discussion) against a set of Best Practice Principles developed by the Collaboration of Community-based Obesity Prevention Sites (CO-OPS) as a result of a review of the international literature and extensive community consultations [18]. --- Results --- Evaluation by Strategic Objective In this section, the process evaluation results set out in Tables 1,2, 3 and 4 are discussed under each strategic objective or group of objectives -Capacity Building, Social Marketing, Nutrition (objectives around the promotion of healthy breakfasts, school lunches, fruit and vegetables and water consumption) and Physical Activity (increased organized sports and informal physical activities). --- Capacity Building The Capacity Building objective aimed "to build the capacity of and to empower youth, their families and communities to reduce obesity through the promotion of healthy eating and physical activity among adolescents". Initiatives undertaken under this objective are documented in Table 1, and are discussed below under the domains of the New South Wales Capacity Building Framework [17]. (a) Resources Given limited core funding for intervention implementation, supplementary funding was sought from external donors. Despite their inexperience in preparing funding proposals, MYP staff were successful in attracting additional resources from a range of both local and regional donors to facilitate intervention activities. For example, the successful vegetable gardening project was made possible by funding obtained from the Food and Agricultural Organization of the United Nations, Secretariat for Pacific Communities and AusAID. (b) Leadership Equipping project staff, students and community leaders with leadership skills was a key factor in delivering effective interventions [19]. The consultation conducted during the project with community groups and non-government organisations revealed that lack of motivation, limited leadership skills, poor governance structures, and inadequate knowledge minimized the prospect of both the community's acknowledgement and ownership of various health related issues and of intervention sustainability. As a result, training (using a range of validated training tools such as the Pacific Star Lifeskills Training manual [UNICEF] and the Youth Leadership Training Manual [Secretariat of the Pacific Community]) was conducted in four villages to empower and strengthen the leadership skills of both individual and groups around championing healthy lifestyle strategies. Despite planning at the community level and training around healthy eating and physical activity, obesity did not rate highly on the agenda of communities. Villagers did not consider it a priority or a concern relative to more pressing issues of unemployment, poor public roads, and inadequate street lighting or water supply. There were many concrete examples of students being empowered, as illustrated by their active participation in workshops, and their subsequent demonstration of newly acquired skills in initiating and conducting activities, preparing funding applications, and approaching stakeholders (Table 1). In one school, a school ambassador program used students as role models and motivators for change to promote better health in the school, the home and communities. Choosing students in their final year of school capitalised on their seniority but reduced the continuity of the program from one year to the next. The ambassador program was modelled on that of another OPIC site (Australia) and was, in hindsight, probably a less relevant strategy for Tonga because of the limited ability of Tongan adolescents to influence home and school environments. The other schools chose not to pursue an ambassador program but to focus on physical activity programs such as aerobics, sports competition. In a hierarchical society such as Tonga, the targeting the teachers as role models could be more successful than using students. Tonga needed to create its own strategies to fit its own peculiar situation, culture and available resources rather than adopting strategies which were effective in very different jurisdictions. including increases in the availability and consumption of vegetables, employment and household income. The vegetable growing project has clear governance structures in place, is registered as a co-operative organization, and has nurtured an online chat room where the wider community can share the experience of developing sustainable vegetable gardens. Given the low starting base in Tonga in terms of research and health promotion experience, the provision of opportunities for staff capacity-building was a key component. Table 1 illustrates that every opportunity was taken, within the constraints of available budget, for team staff to attend training workshops and to attend and present at forums both locally and internationally. Substantial training was also provided by OPIC staff from Australia and New Zealand primarily around topics related to the evaluation component of the projects (e.g. conduct of interviews, anthropometric measures, qualitative and quantitative analysis); evaluation is not the focus of this paper and these activities are not detailed in Table 1. (d) Partnerships Mobilizing resources and building alliances with community groups, businesses, non-government organisations, the Ministries of Agriculture, Health and Education and the mass media were instrumental to the successful implementation of the project and numerous requests for implementation of MYP activities in non-intervention communities plus invitations to participate in meetings and workshops regarding decision-making around obesity prevention (these are too numerous to detail in Table 1). For example, MYP was a key player in the drafting of the Planning Framework for the newly established Tonga Health Promotion Foundation. MYP developed particularly strong, positive and ongoing relationships with the Health Promotion Unit (within The Ministry of Health) and the Ministry of Agriculture through the Development of Sustainable Agriculture in the Pacific program, which was a key contributing factor to the success of the vegetable gardening project. However, while all groups and organizations approached by MYP were supportive, sometimes the contact was minimal, short-lived and not sustained. --- Social Marketing The aim of MYP's social marketing component was "To develop a culturally sensitive, long-term national social marketing campaign to raise professional, family, and public awareness of the obesity epidemic and its effects on health and quality of life". As shown in Table 2, the social marketing relied heavily on printed materials, television advertisements and radio sessions. Television and radio advertising is very cheap in Tonga, which explains the extensive use of these transmission modes to convey key messages to the target group, and to achieve wide community exposure. Another unique opportunity was to involve students as actors in the television advertisements. Talk-back radio programs attracted considerable feedback, plus a significant adult audience which was important given their role in determining the food consumed at home. Follow-up questionnaires responses suggested that the use of talk-back radio was effective. Project branding included the development of a simple, positive project slogan "Kai Lelei mo Longomo'ui (Eat well and be active), It's so Easy!" that reflected both the nutrition and physical activity objectives of MYP. The slogan was applied to the logo, which was used on various materials (e.g. stickers, banners and television advertisements). The use of the popular rock song "It's so Easy" sung by Linda Ronstadt, gave the slogan momentum which was quickly picked up by the target audience. There was minimal focus on the print media except for a few newspaper columns and media releases around MYP activities printed in a national newspaper (which has an estimated readership of one third of Tonga's population or about 34,000 persons). Most materials were developed in-house and focused mainly on the nutrition objectives with little on physical activity. The social marketing campaign was intended to move beyond awareness-raising to achieving behavioural change. However, it is difficult to change behaviour in a short time and in Tonga this was compounded by the fact that obesity is not considered a priority issue or a health problem. Despite this, there was some evidence of success in changing behaviours. For example, the consumption of (bottled) water significantly increased at church functions at the expense of sweetened drinks. A survey conducted at one church's annual conference over consecutive years showed that the proportion of persons drinking water during the conference rose from 75% to 85%; this was attributed to MYP mounting a water campaign during that event which included television advertisements (that used church leaders and students as key players), talk-back radio programs, a banner displayed during church conferences and water promotion displays in shops located in the intervention sites. --- Nutrition The nutrition objectives focused on the promotion of a healthy breakfast (objective 4), healthy school lunches (objective 5), vegetable and fruit consumption (objective 6), and water versus sweetened drinks (objective 9). While most intervention activity was focussed on vegetable gardening given strong partnerships with other agencies and specific funding by various donors (Table 3), all four nutrition objectives were addressed by the social marketing campaign (Table 2). The nutrition objectives are discussed under headings which correspond to Table 3. (a) Policy The nutrition component of the project primarily focused on grass-roots activities, with little done in the way of developing nutrition policy. The team lacked the skills and experience to drive policy change using top-down approaches but later realised that effective obesity prevention strategies needed to be embedded in well-established policy. School food policy designed by the Ministry of Health and modified by the Non-Communicable Diseases Nutrition Sub-committee was introduced into three intervention schools where the canteen manager was supportive. These policies needed further refinement at the school level as most healthy food is expensive and not affordable by students. Also, a dedicated person was required within a school to drive policy implementation. (b) Activities Activities refer to one-off initiatives or events while programs relate to ongoing initiatives. Amongst the activities initiated, fruit tree planting demonstrations were held in 16 of the 22 villages in the intervention districts, while, given funding constraints, healthy breakfast demonstrations (based on local, affordable, traditional food) were limited to one village which specifically requested such. Activities around food at school were limited to the establishment of a new canteen in one school and the conduct of a canteen operators' workshop for the seven intervention schools. The latter did not result in a change in the healthiness of the food sold, thereby illustrating the importance of a topdown approach, the development of partnerships with schools, and the need for a designated person within the school to steer change. With respect to the objective of promoting water rather than sugar sweetened drinks, most of the activities took place in association with the physical activity and social marketing programs. Considerable effort was invested in the promotion of water, during the one week Free Wesleyan Church of Tonga annual conference. The church leaders were encouraged to act as role models by providing only water for drinking during all conference meals. This was endorsed by the First Secretary of the Church and letters were distributed to all community church leaders to inform them of this decision. People's attitudes to this initiative were positive and promising. The church maintained the water only policy at their next annual conference and several other churches and villages followed with similar policies. The significance of this achievement cannot be downplayed in a culture where food is a status symbol. It is a sign of wealth and caring and a source of pride for Tongans to provide their guest with copious quantities of food and drink which is often very high in sugar and saturated fats. The success of the church program reflects the importance of a top-down approach in churches as well as in schools. (c) Programs The growing of vegetables was a key plank of the nutrition objectives. The main strategies were to make vegetables available for a community's own consumption and to simultaneously improve eating habits. The gardens were located in close proximity to the villages to facilitate resident access. Despite a lack of previous agriculture experience, participants were enthusiastic and committed. All group members were involved right from the outset in planning through to implementation and distribution of produce, and participated in various training opportunities offered by different organizations in relation to vegetable gardening (Table 1). Technical support for the program was provided through involvement of agricultural and marketing personnel from the Ministry of Agriculture, and both local and international donor support was secured. All participants were required to sign a Memorandum of Understanding around the program objectives and expectations around promoting health. In addition to the development of 20 new family gardens within the intervention communities, there has been a multiplier effect beyond the intervention site with the establishment of new gardens. Interested groups from schools, churches, villages and youth groups have now formed committees (including representative of the Ministries of Health and Agriculture) to ensure the ongoing conduct of the program. (d) Infrastructure and equipment As part of the vegetable gardening activities, two green houses were erected, and drip irrigation was installed in 13 vegetable gardens. --- Physical Activity Physical activity objectives in the action plan were to increase participation in informal physical activities (objective 7) and organised sports (objective 8). Activities organised under this programme ranged from aerobics, walks for health, volleyball, tennis, cleaning up of communities, soccer, hip hop, cultural dancing, krump, action song, fun runs and sports competitions. The amount of activity generated under the category of physical activity was considerable (Table 4). However, while these programs were enjoyed very much by the community, they were not sustainable hence their impact was short-lived. The intervention team was unable to keep up with the heavy demand for physical activity programs, and the lack of funding did not allow proper training of instructors from villages and schools. An aerobics instructors' training course was conducted, but failed to produce ongoing instructors given the lack of continuing support available to them. In hindsight, more forward planning around the sustainability of physical activity activities and the choice of activities would have aided integration of the programs into existing structures. The physical activities program was conducted primarily at the village level and attracted the whole of the community; while this was beneficial in itself, the impact on the adolescent target group was likely to be diluted. Physical activity programs directed towards the secondary schools instead of communities may have been more sustainable. --- Discussion The MYP project implemented a large number of activities and initiatives over the three year period. In this section, the program is discussed using the best practice principles developed for community-based obesity prevention initiatives [18]. --- (a) Community engagement Before any community-based intervention is implemented, a planned approach to community engagement is important [19]. It requires genuine community participation from the beginning: identification and acceptance of the problem, agreement that it needs to be addressed, an understanding of the target group's situation, and the engagement of influential people in the community as well as parents, youth, community groups, churches etc. Whole-of-community (churches, schools, parents, leaders, adolescents) engagement and collaborative partnerships were critical to the implementation of the MYP project. In the early stages, the coordinators visited their designated intervention site multiple times to familiarize themselves with the community setting. Meetings were organised with key people such as village leaders and the community health officer, whose support was vital if the community was to be engaged. In hindsight, more time was needed for this phase of community engagement so that the interventions better matched communities. Monetary incentives are commonly used by projects to elicit community engagement in Tonga; many externally run projects pay people to participate in surveys and programs. Payment for involvement was often raised but MYP staff endeavoured to convince adults that the project priority was their children's health and they would benefit from this program. The policy of no monetary payments did make the team's task of engendering community support and commitment more challenging. The level of community engagement secured varied throughout the intervention sites. In some villages, the complexity of communal living made it difficult for the project to introduce strategies, while other villages welcomed any initiatives offered. A commonly heard phrase in discussion with the communities when trying to win them over to lead a healthier lifestyle was "eating is mine to decide upon, diseases is for the doctors to take care of". This reflective of community attitudes towards obesity; the fact that it was not considered a problem made the project team's task more difficult. --- (b) Program design and planning Program design and planning was under pressure because of delays in hiring MYP staff and pressure to match the schedule of the other three OPIC sites. The development phase of the social marketing campaign provides an example where pressure to proceed with interventions meant that the baseline survey results were not available in time to inform the strategy. As a result, MYP sometimes introduced initiatives that matched available staff resources and expertise, rather than building on community needs or preferences. Some implemented programs would have benefited from more planning to ensure delivery suited specific community situations, the adolescent target group, village's socio-economic status, geographical location and cultural values. For instance, early initiatives to promote active transport to school were unrealistic as most students in the target group travelled long distances by bus to school in Nuku'alofa. Likewise, while the preparation of local foods for breakfast was encouraged, this was impractical as most students left home early to catch the one and only bus service to school. On the other hand, the vegetable farming project was highly relevant in the Tongan context given that farming is part of the everyday life of most Tongans. --- (c) Implementation and sustainability Intervention activities were implemented at various levels, with multiple audiences and in multiple locations; the limited resources (staff and funds) coupled with the differing levels of community engagement inevitably meant that the intervention dose was not necessarily equal across all 22 villages and seven schools. Also when MYP project activities were initiated in the intervention districts, government agencies sometimes withdrew any current activities around healthy eating and physical activity and redirected their attention to non-intervention sites. Although the target group of the MYP project was secondary school students, most activities were conducted at the village community level with all age groups. However, program impacts beyond adolescents were not captured and the intervention dose to adolescents was diluted by such whole-of-community programs. Overall, the intervention dose was probably inadequate as health promotion programs typically take a long time to mature and for the benefits to be realised. The 2.5 years of MYP meant that the intervention was still maturing when the project funding ceased. For example, the social marketing officer who offered the capacity to galvanise social mobilization was recruited late in the project; and the implementation of the interventions was severely interrupted both by a long period of mourning following the death of the Tongan king and a period of civil unrest. Tonga is a church-oriented society with a high proportion of the population regularly participating in church activities. In retrospect, faith-based organisations could have been more involved in delivering MYP messages and capacity building activities. --- (d) Governance and accountability The successful conduct of a large, multi-faceted community-based intervention project such as MYP is reliant, in part, on having a project coordinator who is confident, committed, motivated, has a strong ability to network, and has the leadership skills to manage a multi-disciplinary team and to coordinate multi-sectoral action with other stakeholders, multiple communities and settings. Governance needs leadership, alliances, and staff expertise. All were a challenge because of Tonga's low professional capacity and its inexperience in health promotion and research. A strong alliance with professionals from other sectors such as education, agriculture, labour and commerce and non-government organizations is also required. Staff recruitment around specific areas of the project (eg. nutrition, physical activity) together with supporting roles from others may have been a more effective model than research assistants being assigned to geographical areas and being expected to embrace all facets of the project. The process evaluation reported in this paper is necessarily different from that of other projects reported in the literature [11][12][13]. The latter process evaluation papers generate relate to the delivery of a standardised intervention. However, in the case of MYP, intervention activities were much less structured, and were organic and evolving. Activities varied between schools and villages depending on their own specific needs and interests; as a result, the range of different activities undertaken was large. Our process evaluation was, as a consequence, limited to dose, frequency and reach, and did not cover other issues such as fidelity and quality used in other process evaluations. The key lessons learnt from the process evaluation of MYP are as follows: • Intervention activities should suit the local cultural context and be tailored to community needs. • Top-down policy approaches are crucial in all settings. • Adequate time needs to be allocated for planning and community engagement prior to embarking on intervention activities. • Social marketing is fundamental to project success but is potentially time-consuming and expensive. • Successful community-based projects are dependent on sustained alliances with a wide range of players. --- Conclusions The adolescent obesity interventions implemented as part of the MYP program comprised a wide range of activities conducted in multiple settings, touched a broad spectrum of the population (wider than the target group), but the dose and frequency of activities were generally insufficient and not sustained. While the project resulted in increased community awareness of healthy behaviours, it confirmed that Tonga is still in its infancy in terms of conducting public health research and lacks research infrastructure and capacity. Despite its limitations, the MYP project was an extremely beneficial and relevant study for Tonga given its high level of obesity and non-communicable diseases. It should be considered as a base on which to further build and strengthen future public health research in Tonga, particularly around obesity prevention. Since this is the first large, multi-faceted community-based project of its kind in Tonga, it is important to take learning from both of its achievements and failures. Effective programs require good leadership, comprehensive planning, widespread community engagement, multiple approaches, multiple partnerships, extensive capacity building, adequate intervention dose and most importantly, community-based initiatives designed, implemented and monitored in a culturally context perspective. --- Author details 1 School of Public Health, Fiji School of Medicine, Fiji. 2 Deakin Health Economics, Deakin University, Australia. 3 WHO Collaborating Centre for Obesity Prevention, Deakin University, Australia. Authors' contributions KFF was involved with data collection, implementation of project activities, analysis and interpretation of results, and drafting of the first manuscript. MLM contributed to the design and evaluation of the program and its activities and was closely involved in drafting the manuscript and critically reviewing it in terms of intellectual content. HMM reviewed the manuscript for errors and important intellectual content. SP conducted the social marketing component of MYP and contributed to this section of the paper. JTS was involved with the design and development of MYP and editing of the manuscript. BAS participated in the designing of the study and critical review of the manuscript.

Background: The rising burden of obesity in Tonga is alarming. The promotion of healthy behaviours and environments requires immediate urgent action and a multi-sectoral approach. A three-year community based study titled the Ma'alahi Youth Project (MYP) conducted in Tonga from 2005-2008 aimed to increase the capacity of the whole community (schools, churches, parents and adolescents) to promote healthy eating and regular physical activity and to reduce the prevalence of overweight and obesity amongst youth and their families. This paper reflects on the process evaluation for MYP, against a set of Best Practice Principles for community-based obesity prevention. Methods: MYP was managed by the Fiji School of Medicine. A team of five staff in Tonga were committed to planning, implementation and evaluation of a strategic plan, the key planks of which were developed during a two day community workshop. Intervention activities were delivered in villages, churches and schools, on the main island of Tongatapu. Process evaluation data covering the resource utilisation associated with all intervention activities were collected, and analysed by dose, frequency and reach for specific strategies. The action plan included three standard objectives around capacity building, social marketing and evaluation; four nutrition; two physical activity objectives; and one around championing key people as role models. Results: While the interventions included a wide mix of activities straddling across all of these objectives and in both school and village settings, there was a major focus on the social marketing and physical activity objectives. The intervention reach, frequency and dose varied widely across all activities, and showed no consistent patterns. Conclusions: The adolescent obesity interventions implemented as part of the MYP program comprised a wide range of activities conducted in multiple settings, touched a broad spectrum of the population (wider than the target group), but the dose and frequency of activities were generally insufficient and not sustained. Also the project confirmed that, while the MYP resulted in increased community awareness of healthy behaviours, Tonga is still in its infancy in terms of conducting public health research and lacks research infrastructure and capacity.

Introduction Following the Supreme Court of the United States' decision to overturn Roe v. Wade and federal protection of abortion rights (1), each U.S. state now has the authority to regulate and even outlaw abortion. In turn, restrictive and harmful abortion bans were rapidly implemented across Midwestern and Southern states including Georgia, where House Bill 481 (HB 481) has now outlawed abortion after embryonic cardiac activity (estimated at 6-weeks since last menstrual period) (1)(2)(3). Given this increasingly restrictive abortion environment, the role of full spectrum doulas offering abortion support is paramount but poorly understood. A full spectrum doula, as defined by the Birthing Advocacy Doula Training (BADT) organization, is "a non-medically trained community care worker who offers support to people during the full spectrum of pregnancy-from preconception, to birth, to abortion, to miscarriage, to adoption, to postpartum" (4). The scope of full spectrum doula care can include supporting clients through in-home visits, hospital or clinic accompaniment, emotional support, pain management, education, and advocacy (4,5). Birth doula certification is typically a lengthy and expensive process that involves didactic courses as well as practical experience attending births (6). Notably, abortion and full spectrum doula training is largely decentralized but is provided by doula training agencies like BADT, Dopo, and the Doula Project in New York City (4,7,8). Payment for doula services also varies from doula to doula (with individual doulas creating their pricing for each of their services as they see fit), patient to patient, and state to state. In some cases, doulas are funded by insurance (but never for abortion), paid out-of-pocket by their client, or offered for free (pro bono) or through volunteer organizations (4,9). The limited existing literature on clinic-based abortion doula care shows there are numerous benefits including improved mental and physical health, respect for reproductive autonomy, and reduced demand on clinicians (11)(12)(13)(14)(15)(16). Doulas use similar non-medical services for their abortion clients as they would with other prenatal, birthing or postpartum clients such as "hand-holding, massage, reassurance, providing guidance with breathing, educating about the nature of the procedure or engaging in conversation" [ (12), p. 124]. These techniques lead to benefits for clients as well as for physicians and staff providing abortion care. Clients' psychosocial needs are met with abortion doula care and they are "affirmed as moral decision-makers" [ (10), p. 111, (11, 13)]. Additionally, in studies looking at doula support during first-trimester surgical abortion, clients reported feeling their educational needs were met, and they expressed gratitude for their doula educating them on abortion and post-abortion care (14,16). For physicians and staff providing abortion care, the presence of an abortion doula in the clinic allows them to focus on technical aspects of the abortion procedure, while knowing that their patient's emotional needs are being met by their doula (15). Providers at high-volume abortion clinics may see many patients throughout the day, but abortion doulas can focus on their single client's physical, emotional, and educational needs, offering continuous support and guidance. Less is known about community-based abortion doulas outside of clinical settings, particularly in restrictive abortion contexts, including their scope of work, the benefits of that work, and any facilitators or barriers for providing care. Community-based doulas are those that are not affiliated with a hospital or clinic, but rather focus directly on community members, often their own racial/ ethnic group or in a particular geographic area (17). In global settings where abortion has been historically restricted including Argentina and Northern Ireland, community-based abortion doulas have served pivotal roles in accompanying people when seeking and accessing care (18,19). Further research is needed to understand how community-based doulas can further integrate full spectrum care (including abortion support) in restrictive abortion settings-especially for socially marginalized community members. The Georgia Doula Study (20,21) is a community-engaged participatory action research project (22) based at the Center for Reproductive Health Research in the Southeast in Emory University's Rollins School of Public Health. Co-led by a doula-researcher and a non-profit community-based maternal and child health organization, the study team conducted in-depth interviews and surveys with doulas in metro-Atlanta, Georgia to understand: (1) How does the doula community in metro-Atlanta view doula-supported abortion services and abortion generally?; (2) How do abortion doulas describe their services?; and (3) What are the facilitators and barriers to accessing abortion doula support in metro-Atlanta?. --- Materials and methods This mixed methods, community-engaged study is overseen by a statewide doula stakeholder steering committee with representation from community-based doulas, hospital administrators, clinicians, insurance payers, and policymakers. The doula stakeholder steering committee first identified the need for a Georgia Doula Study that interviews and surveys doulas across the state to support policy advocacy for doula access, integration of doula care into hospital systems, and increased community awareness of doula care. The steering committee provided guidance on study design, assisted with recruitment, helped to interpret results, and aided dissemination to community, clinical, hospital, and policy stakeholders. --- Study design and recruitment This project uses a cross-sectional, observational design and concurrent mixed methods (qualitative and quantitative). Participant recruitment and data collection for the larger study occurred from October 2020 to November 2021. For this sub study, participant recruitment occurred specifically during August to November 2021. Participants were purposively sampled and recruited through emails to the doula stakeholder steering committee, abortion clinics, and local reproductive health and justice organizations in metro-Atlanta. The research team originally surveyed and interviewed seventeen doulas between October 2020 and February 2021. In the fall of 2021, additional measures on family planning and abortion were added to the interview guides, and previous participants were recontacted. Fourteen previous participants were re-interviewed; and three additional participants were interviewed and surveyed for a total of twenty doulas. Notably, some doulas could not be re-contacted for interview, and two discontinued participation in the study due to the nature of questions regarding family planning and racial discrimination. One participant explained they did not see abortion as within the scope of doula care and were made uncomfortable by the survey questions about abortion, while the second participant (white) was uncomfortable with the questions about racism and doula care. All participants were given an additional $20 for completing the additional survey and interview. If a participant completed the survey, but was not available for an in-depth interview, they were still compensated for their time with a $20 gift card. Thematic saturation was reached after 20 participants, when the academic-community study team collectively agreed that no new data were being collected after multiple iterative cycles of collection and analysis. --- Procedures Potential participants were first screened for eligibility, which included practicing as a doula in Georgia for at least six months and being over the age of 18. While not an original criterion of the study, all participants were community-based doulas. Eligible participants were then consented for participation, given a survey link, and scheduled for an in-depth interview lasting on-average 60 min. If participants did not respond after two follow-up outreach emails from a member of the study team, they were deemed unreachable. Survey data was collected using Qualtrics and no identifying information was collected: all names were replaced with anonymous participant ID numbers. Interviews were connected on Zoom, audio recorded, transcribed verbatim, and deidentified. All study participants interacted with one of two graduate research assistants (AL and AS), who were responsible for participant recruitment, screening, and interviewing. --- Instruments --- Survey measures The survey (see Supplementary Appendix A) measured demographic information including gender, race/ethnicity, age, economic status, highest level of education, current employment, sexual orientation, and immigration status. Gender was measured as (check all that apply) female/woman, male/man, transgender, genderqueer, nonbinary, or self-identify. Race/ethnicity was measured as (check all that apply) Black/African American, Hispanic/Latinx, Asian/Pacific Islander, American Indian/Alaskan Native/Native Hawaiian, Biracial/multiracial, White, Other (specify), or prefer not to answer. Age was measured as under 25, 25-25, 36-45, 46-55, Over 55. Economic status was measured as "difficulty affording necessities such as education costs, food, clothing, transportation, housing, and medical care" with response categories: yes, currently; yes, in the recent past (within 3 years); yes, in the past for a limited period of time; yes, historically throughout my life; no; or prefer not to answer. Highest level of education was measured as high school or less, some college, graduated college, graduate degree, clinical professional degree, non-clinical professional degree, or other. Current employment was measured as full-time, part-time, not employed, and not looking, and not employed and looking. Sexual orientation was measured as (check all that apply) lesbian, gay, bisexual, queer, straight/ heterosexual, don't know/questioning, self-describe, or prefer not to answer. Immigration status was measured as (check all that apply) my parents and grandparents were born in the U.S.; one or more of my grandparents were born in the U.S.; one or more of my parents was born in the U.S.; I was born in the U.S.; or prefer not to answer. This was further categorized into not an immigrant (self, parents, and grandparents born in the U.S.), first-generation immigrant (born in U.S. but not parents or grandparents), or second-generation immigrant (self and one/more parents born in the U.S. but not grandparents). Participants were also asked how long they had been a doula (years and months), what trainings and/or certifications they have completed, and what kind of doula services they provide. Doula services provided (check all that apply) were preconception/fertility, prenatal, birth, postpartum, abortion, full spectrum, radical/justice, death/grief/loss/ bereavement, prison, or other (specify). Preconception/fertility services include supporting clients, who are trying to become pregnant. Prenatal services include supporting clients through their pregnancy before childbirth. Birth doula services can include the prenatal period but focus on emotionally and physically supporting a client through their childbirth. Postpartum services can be wideranging and include emotional support, cooking, and cleaning for a client or offering newborn care during the months following a birth. Abortion doulas support clients through pregnancy termination experiences (12). Full spectrum doulas typically offer more comprehensive services, often including prenatal, birth, postpartum, abortion, and miscarriage support (21,23). Radical/justice doulas can provide a variety of doula services, but with a specific lens of client empowerment, advocacy, and Reproductive Justice (21,24). Death/grief/loss/bereavement doulas offer emotional services to clients who are either personally dying or are close to a person who was dying or deceased (25). In some cases, this includes clients who had a miscarriage, stillbirth, or infant loss. Participants were also asked what percentage of their client base received which doula services. All doulas were asked questions that assessed their abortion stigma (See Supplementary Appendix A for survey items). Abortion stigma was measured using a revised version of the Stigmatizing Attitudes, Beliefs, and Actions Scale (SABAS) with 37 items (26). The survey also measured abortion provider stigma (27,28) through a revised Abortion Provider Stigma Scale (APSS) with 13 items where abortion doulas were asked to "indicate how often you have felt or experienced the following" and given various prompts (Supplementary Appendix A) (27). Additionally, our revised APSS measured 3 subscales: "disclosure management" (6 items), "discrimination" (2 items) and "resistance and resilience" (5 items). "Disclosure management" refers to the process of deciding whether to share or hide one's identity as an abortion worker, which can lead to silencing and isolation; "discrimination" refers to judgement, poor treatment, and social exclusion because of one's work in abortion care; and "resistance and resilience" refers to positive aspects of abortion work including commitment to a mission to serve those in need (27,28). Higher scores on the overall APSS and the "disclosure management" and "discrimination" subscales indicated higher levels of stigma while a high "resistance and resilience" subscale score indicated higher resilience (27). --- In-depth interview domains In-depth interviews covering the topics of abortion and contraception were conducted with 20 participants. The domains included abortion doula training, clientele and payment, abortion and contraceptive counseling services, abortion and contraceptive stigma, and experiences of racism or other discrimination (see Supplementary Appendix B). Doulas that reported offering abortion services were asked to go into detail on their abortion and contraception services, while other doulas were asked to describe their thoughts on abortion doula care, abortion, and contraception broadly. --- Data analysis Data analyses on the 20 interviews and survey covering abortion and family planning were conducted from November 2021 to February 2022. Descriptive and bivariate analyses of quantitative data employed Stata v.14 (29). Frequencies and proportions were calculated for categorical variables (ex: type of care provided), while means with standard deviations were calculated for continuous measures (ex: abortion provider stigma). Independent t-tests were conducted to analyze group differences (e.g., abortion attitudes by type of doula). In-depth interview transcripts were cleaned of errors and deidentified before coding was conducted via online, qualitative software Dedoose v.7.0.23 (30). Team members used memo-ing techniques to summarize the main content of each interview and identify the top ten emerging topics of interest from all interviews. The comprehensive list of emerging topics augmented an existing codebook from the previous round of data collection. The team used a semi-deductive coding structure that resulted in both deductive and inductive codes about abortion, contraception, training, doula scope of work, building doula businesses, underserved populations, payment, challenges, client stories, benefits of doula care, medical outcomes, ways to improve doula care, COVID-19, and discrimination. Two members of the study team coded 1/3 of the qualitative transcripts together, met to reach consensus and clarify the codebook and its application, then individually coded the remaining transcripts separately. The coding group then developed analytic memos for each code in order to develop themes within and across codes. This process was supported by additional analyses within Dedoose including code co-occurrence and matrices. --- Ethical considerations The study protocol and materials were reviewed by the Emory Institutional Review Board (IRB) for human subjects' ethical clearance, and the study was deemed exempt because the human subjects' identities are not easily identified, and any disclosures would not place the subjects at risk of damages [see rule 45 CFR 46.104(d)(2i((2ii)]. --- Results Five key themes were identified: doulas of all kinds center reproductive autonomy, abortion doulas play important roles in reproductive autonomy, doulas have mixed feelings about contraceptive counseling services, abortion doulas provide diverse services and carry numerous benefits, and abortion doula experience challenges including stigma but offer solutions. --- Demographic information The doulas sampled for this research project were diverse in terms of race/ethnicity, gender identity, age, and other key demographic information. As shown on Table 1, about half of the doulas were Black/African American (9, 45%) and white (8, 40%) with some doulas reporting their race as Hispanic/Latinx (1, 5%) or Other (1, 10%). While nearly all doulas reported their gender identity as cisgender female, two doulas reported identifying as nonbinary or genderqueer. Additionally, around half of these sampled doulas reported being between 25 and 35 years of age (8, 40%), never experienced economic difficulty (10, 50%), and had attained a college degree (9, 45%). Nearly all doulas reported being employed full-time (12, 60%), being straight/heterosexual (16, 80%), spoke English as their primary language (18, 90%), and did not identify as an immigrant (17, 85%). The participants of this study varied in their doula service characteristics from their time to serving as a doula, the type of services they offer, and whether they were certified (Table 2). About half of the participants (9, 45%) had been serving as a doula for 1-3 years and a quarter (5, 25%) for more than 3 and up to 9 years. A third of the doulas reported offering services for less than 1 year (2, 10%) or more than 9 years (4, 20%). A majority (14, 70%) of doulas reported being certified. When asked about their available doula services, participants ranged widely in the types of services they offered. In fact, doulas often reported that their scope of work included more than one type of care. These services included preconception/fertility (7, 35%), prenatal (9, 45%), birth (17, 85%), postpartum (12, 60%), abortion (7, 35%), full spectrum (8, 40%), radical/justice (4, 20%), and death/grief/ loss/bereavement (4, 20%). --- Doulas of all kinds center reproductive autonomy All participating doulas were asked questions about abortion and contraceptive counseling services in the communities that they served, which revealed a theme that the doula community supports reproductive autonomy for their clients including (largely) abortion. While most participants were outwardly supportive of the role of abortion doulas, this support did not always translate to an interest in incorporating abortion or contraceptive counseling as part of their regular doula offerings. --- The role of an abortion doula in reproductive autonomy As demonstrated in Table 2, participants varied widely in the characteristics of their doula services, with only 7 self-identifying as abortion doulas and 8 as full spectrum. None of the abortion doulas were based in clinics, but rather worked as private, community-based doulas that found their clients through social media, word-of-mouth, or knowing them personally. Regardless of their scope of work, all participants were asked to describe the role of an abortion doula, including how the larger doula community perceived those who provided abortion services. Most surprising was the overall support of abortion services from non-abortion doulas. One such doula who offered exclusively birth and postpartum services, Brenda, stated "I think there should be a doula for everything... I just feel like [for] everything, especially important things around family, doulas are amazing. I'm in awe of abortion doulas. I'm happy to hear that there is such a thing." Despite Brenda's role as primarily a birth/postpartum doula, she voiced support for doulas that provided abortion services. Other nonabortion doulas also seemed supportive of abortion doula care and the potential benefits for clients. One such non-abortion doula, Taylor, commented on the opportunity abortion doulas had to provide all-options counseling to clients for them to make an empowered decision, --- Variable Frequency Percent --- Time as Doula Less than 1 year 2 10% 1-3 years 9 45% More than 3 and up to 9 years 5 25% More than 9 years 4 20% "I think that mothers need to be given all of their options before they make a decision to have an abortion. So, I feel like doulas do need to be there to support if they choose to have an abortion, but on the other hand... let's find resources of people who can support you if you're low income. Let's find an adoption agency if you want to go that route. I don't think that abortion is the only answer or the only option for a lot of people." --- Type of Doula This call for all-options counseling continued with nonabortion doulas describing what they thought abortion services looked like and how they personally viewed abortion doulas. Annie, a doula serving primarily birth and postpartum clients, expressed her thoughts on the abortion process and the role of the abortion doula, "I think it's a difficult decision to make [having an abortion], and that they [abortion clients] need support in a lot of ways during that process... holding their hand while they're making that decision, helping them get the resources and then also being there for them during and then those weeks to months afterwards." --- Mixed feelings on contraceptive services While a majority of participants asserted that a doula's role is to support reproductive autonomy, some did not see the doula scope of work as including contraceptive counseling. About half (9, 45%) of the participants reported offering family planning counseling, a third (6, 30%) were trained in contraceptive counseling and some (2, 10%) were not currently offering contraceptive counseling services but were interested in the future (Table 3). Doulas were mixed on when to begin providing family planning services with just under half (8, 40%) simply stating that anytime was the right time to provide family planning support. Brenda explained why she doesn't offer contraceptive counseling and hasn't pursued training in contraceptive counseling, "It doesn't feel like it falls under the umbrella of the scope of a doula. Unless it happens to come up, you know, and then, of course, talking to supporting families than that would apply but I'm not sure that specifically contraception feels like it would be under the doula umbrella." Some doulas discussed personal experiences of Black and Brown clients being targeted for family planning and referenced the historical mistrust of the medical system in general due to the history of reproductive coercion for Black/brown communities. As a result, many doulas of color were hesitant to bring these topics up with their clients or receive further training on contraceptive counseling. At the same time, Bailey (a Black full spectrum doula) explained that she provides contraceptive counseling precisely because of the contraceptive coercion Black clients face, "Research shows that Black birthing folks are asked about longacting reversible contraceptives earlier and more often than white folks. So, I make sure to bring it up with my clients as far as the postpartum piece of their birth preferences like, 'Okay... these are some things for you to think about postpartum and after you have the baby. One of these is birth control, if they haven't already asked you, they will. And you need to be aware that they will ask about it and you need to start thinking about what you want.'" Overall, participants agreed that the role of a doula is primarily to support clients in making informed, empowered decisions through major life changes including births, the postpartum period, or abortions. While this theme of support for reproductive autonomy was evident, contraceptive counseling continued to be a point of disagreement among participating doulas, with some who were interested in offering or were already offering this support and others who had no interest in providing that support in the future. Doulas that provided abortion or contraceptive counseling services were asked to describe their interactions with clients. Most of these doulas also provided abortion services. Mira described her thoughts on how these services intersect, "It's not an easy decision to have an abortion by any means and most people are not just casually throwing that out there like, 'Oh it's going to be my form of birth control'. That's not a thing... It is important to talk about sexual health after those things [abortions]. If you've had a miscarriage or a loss, what was that journey of getting pregnant? Was that a conscious decision? Was it an accident? How do we prevent future accidents if that's not what you're looking for?" Other abortion doulas reported not offering contraceptive counseling services but were interested in beginning that conversation with their clients. Alex, a postpartum, birth, and abortion doula, talked about opportunities to engage postpartum clients in family planning counseling, "I know that that's something postpartum folks have a hard time figuring out, how to prevent pregnancies after just having a pregnancy... some people believe, 'If I breastfeed, I won't get pregnant'. And it's like, well, you might!" All abortion doula participants were asked to describe their services and experiences with clients. While none of these doulas reported supporting client in an abortion clinic, they described a range of services they provide as well as how their services benefited clients overall. --- The scope of abortion doula services Abortion doulas described their services as mainly walking clients through the process of abortion by providing physical comfort, emotional support, educational resources, and "holding space" for clients to process their abortion experience-that is, an emotional presence that communicates a felt message of trust, empowerment, witnessing, and understanding (16). Nicole described her usual abortion services as first working with the client "... to formulate a plan. So that way they experience a reflecti[on] of whatever they want. Like I said, everybody's abortion is not the same... some of them are at home. Some of them are at the hospital, it just really depends on how it's done and what they need. What level of comfort they need. Sometimes they need the physical comfort and support of being there." Several abortion doula participants affirmed the need for clients to be given space and resources to make the decision that is best for them. Bailey stated, "... in a person's life being pregnant or choosing to have an abortion or even going through the fertility process, that's just one small part of their life. They have 20,000 other things going on and the doula is the person that's like, 'Hey, I have this twohour block set for us to only focus on your pregnancy'... I think that's a big piece, holding space to acknowledge the thing that's happening, whatever the thing is." Abortion doula participants recognized that the goals of their services were similar to the goals of birth, postpartum, or death doulas. These goals were described as "holding space," providing support, and encouraging education. Nicole, an abortion doula, described this as, "... the same thing as a birth doula... they [the client] already have whatever process they're going to have lined up, whether it be a D&C [Dilation and Curettage], whether it be taking the pills... they already have it lined up. I just help them formulate a plan. So that way their experience is honored in the way they see fit... my goal is to provide them with an emotional and physical presence and then just being there, allowing them to process their feelings and making sure they have other resources." Abortion doulas also described varying their services based on the specific needs of the client and the context of the abortion experience. While these services varied widely, Bailey, an abortion doula, talked about the experience of a doula-supported abortion being necessary because "... for a lot of people abortion can be really isolating... they're the only one whose body is going through the experience of pregnancy and so, even if there is a partner or a friend or a community member who can hold their hand or be there with them, I think it can still feel really isolating. And I think the average person doesn't always know how to hold space for that or how to say the right thing... I think the holding space can be important." The idea of "holding space" for clients continued in other abortion doula's descriptions of their services. Doulas who reported offering both birth and abortion services noted how the range of emotions experienced by clients was not always so cut and dry. This made it even more important to hold space for clients to fully process their emotions, physical pain, and/or other reactions to their major reproductive experience. Alex described this as, "Yes, it's about holding space for what folks are experiencing physically because it hurts... but also the range of emotion that can exist. And that's not just sadness. Folks assume typically that when folks come home with a baby, they're either through the sky, elated and happy and then if someone just comes home from having a miscarriage or an abortion that they are distraught... there are these assumptions around what emotions look like and that's not it. So, I really try to make sense of what the emotional status of my client is and help them cultivate a care plan." Abortion doulas all described their services as tailored to the client's abortion experience and personal needs which could include emotional, physical, or educational support. "Holding space" was an important aspect of their offered services, allowing for clients to process their abortion experience without judgement or stigma. --- Abortion doula benefits and client stories While abortion doulas described their care as being personalized to their client's needs, several key benefits emerged throughout the discussion of their work. Reagan, an abortion and full-spectrum doula, discussed these benefits as, "I believe that it's having that outside person that's not going to have a judgment. That you can share your real, raw emotions with and know that no matter what decision you choose to make, they're still going to be there... to be able to help you find the right clinic... helping find funding because there's a lot of people who don't have the funding to get an abortion... explaining to somebody what's going to happen and the things after." Reagan's overview of abortion doula care benefits is important as it shows that while abortion doulas may seem to only be serving clients in a short, time-sensitive window, the benefits of their care expand to before and after a client's abortion experience. Bailey shared a specific abortion client's story, highlighting the benefits of doula support before, during, and after a procedural abortion, "My client was 24 or 25 weeks along and we had to travel to Maryland because I think the cut off in Georgia is 20 weeks or 22 weeks [at the time]... we raised the money to pay for the Airbnb and all the things. I helped them fundraise to be able to cover the abortion and lodging and travel and all that, and then I also served as their abortion doula. It was a two-day procedure, so I traveled with them and then we were in the Airbnb together. I went to the clinic with them -I couldn't go in because COVID, but I was basically in the waiting room for the entire two days. They [the abortion providers] let me come in during the actual procedure... and hold my client's hand. And then the aftercare as far as making sure that the anesthesia wears off okay and that they have enough food and water and things like that. I made a belly oil... to rub on their belly and cabbage leaves on their breasts where it felt uncomfortable or felt painful and then I followed up a couple of weeks later." Bailey's client's story highlighted the wide range of benefits that abortion doula care offers clients during their abortion experience, especially when facing restrictions that force inter-state travel. From navigating those restrictions, raising funds, and even physically supporting where possible, the benefits are impactful and crucial to ensuring a client has access to a safe and timely abortion. Alex also shared an experience supporting an abortion client and what the benefits of doula care looked like, "I think being able to process is really important, like being able to just take time and space to process. And sometimes that looks like saying nothing and literally saying nothing. I don't think that my client and I spoke much at all that night, like with everything that we were doing in the space and we sat together. She got a back massage from me... We did yoga, we painted, we created a fort in the living room and engulfed ourselves in things that were stress-relieving and comforting. I think it's having a container to process and hold emotion." These stories highlight the ways in which abortion doulas are able to effectively meet the needs of their clients and improve their overall abortion experiences. --- Abortion doula challenges and solutions Accessing and providing abortion doula services do not come without challenges. When asked to describe the challenges clients may face in accessing their services, abortion doulas overwhelmingly agreed on three major challenges: affordability of services, lack of awareness, and abortion stigma. --- Financial challenges Doulas explained that one of the main challenges, especially for clients who need to pay out-of-pocket for their abortion, was finances. Due to the inability of clients to afford both an abortion and a doula for that abortion, many abortion doulas in this study provided their services pro bono. Imani, a long-time abortion doula, discussed this in more detail, "The major challenge, I would say, is just them [the client] being able to pay for it... the client's ability to afford it, to pay for it, and to count it as a necessity... it's tough... like I said, every abortion doula client that I've had was pro bono... and of course I did that so that I can get the experience, but also because the need was there and I don't like to turn people away just because they can't pay." This challenge to afford abortion doula services was even more difficult when considering the cost of an abortion procedure and particular client circumstances. Reagan highlighted the factors contributing to the issue of funding by stating that "... a lot of young people don't have, like, an extra $250 to $500 or whatever laying around, especially if they've already had to access care related to the thing. Like if they've needed to go and get an abortion... I think it's definitely financial because I know right now, if I got pregnant, I wouldn't be able to afford a doula. And I am one." Reagan points out that most people, even doulas, would not be able to afford an abortion procedure and doula support. This is a major challenge to accessing abortion doula support, especially for low-income, young, or otherwise impacted clients. --- Lack of awareness Another main challenge was lack of awareness of abortion doula services. Abortion and full-spectrum doula, Mira, described this challenge in the context of the client accessing care, "... most people who are getting abortions aren't looking for abortion doulas. That's the big thing... it's not a common practice, it's not something that's easily advertised or sold as a service." Abortion doulas then speculated that providers were also unaware of abortion doulas and their potential benefits. Lisa discussed abortion provider lack of awareness as, "I've never spoken with providers who provide abortion services. I'm not sure that it's in their lexicon of what an abortion doula is... when you even say the word 'abortion do

Background: The work of full spectrum doulas (i.e., non-medically trained care workers offering support before, during, and after pregnancy including abortion)-is increasingly important as abortion access decreases across the U.S. Few studies have examined the work of community-based doulas in restrictive abortion settings or how they might further incorporate full spectrum care. As part of the community-engaged mixed methods Georgia Doula Study, this analysis examines the scope of work of community-based doulas regarding full spectrum and abortion services, doula opinions on full spectrum and abortion work, and potential barriers and facilitators for full spectrum doula care in metro-Atlanta, Georgia. Methods: From October 2020 to February 2022, the team recruited 20 communitybased doulas with 8 who provide full spectrum services including abortion. Surveys covered demographics, doula scope of work, family planning attitudes, and abortion stigma. Survey data were analyzed using descriptive and bivariate statistics. In-depth interviews further explored those topics. They were de-identified and thematically analyzed using a semi-deductive approach. Results: The findings are organized around five themes: (1) doulas of all kinds center reproductive autonomy; (2) abortion doulas play important roles in reproductive autonomy; (3) doulas have mixed feelings about contraceptive counseling; (4) abortion doulas provide diverse services carrying numerous benefits in a stigmatized environment; and (5) abortion doulas experience challenges including stigma but they offer solutions. All but two doulas in this study were interested in learning how to incorporate contraception and abortion services in their current scope of work, and most participants supported the role of full spectrum doulas. Conclusion: This analysis highlights the experiences of abortion and full spectrum doulas, reactions of the larger doula community to those services, and facilitators and barriers to full spectrum doula care in a restrictive abortion setting. There are urgent needs and opportunities for full spectrum doulas to offer life-protecting services to pregnant people across the U.S. and globally. Coordination efforts for U.S. abortion care post-Roe v. Wade must include community-based doulas, who are largely open to aiding abortion clients through education, connection to care, and emotional support.

afford a doula. And I am one." Reagan points out that most people, even doulas, would not be able to afford an abortion procedure and doula support. This is a major challenge to accessing abortion doula support, especially for low-income, young, or otherwise impacted clients. --- Lack of awareness Another main challenge was lack of awareness of abortion doula services. Abortion and full-spectrum doula, Mira, described this challenge in the context of the client accessing care, "... most people who are getting abortions aren't looking for abortion doulas. That's the big thing... it's not a common practice, it's not something that's easily advertised or sold as a service." Abortion doulas then speculated that providers were also unaware of abortion doulas and their potential benefits. Lisa discussed abortion provider lack of awareness as, "I've never spoken with providers who provide abortion services. I'm not sure that it's in their lexicon of what an abortion doula is... when you even say the word 'abortion doulas' they [abortion providers] would probably say, 'It's not anything I've ever heard'." Abortion provider lack of awareness can impact the abortion experience of clients, especially when looking for ways to be supported during their abortion experience. Even more challenging is the lack of awareness that doulas and birth workers have regarding the ability to support clients during abortion experiences. Alicia, a doula interested in providing abortion services, described her first time meeting an abortion doula as, Lack of awareness also led to misconceptions of abortion doula support by non-abortion doulas. Annie, a birth and postpartum doula who expressed interest in learning more about abortion doula support, talked about the volunteering she does related to abortion, "I do volunteer at a place... it's technically an anti... I teach classes, I don't do the counseling side of it because they're a prolife clinic. But they gave me little tidbits and things like that, I'm not trying to convince them [clients] not to have an abortion, so we don't necessarily align there." Faith-based doulas, like Taylor, also expressed an interest in abortion doula work but only after the abortion experience under the assumption that abortion patients will struggle with their decision: "It [abortion doula work] is something that I'm interested in. I, obviously as a Christian, I don't agree with abortion. But I would like to be in a professional place and be able to assist if somebody is struggling after what happened... after they made that decision, something like that." --- Abortion stigma Misconceptions around what abortion doulas do like those highlighted in the previous section, stem from larger abortion stigma. Abortion ban policies, such Texas's SB 4 and SB 8 bills and Georgia's embryonic cardiac activity (estimated 6 weeks) abortion ban following the Supreme Court decision to overturn Roe v. Wade, perpetuate abortion stigma. Several doulas reflected on the impact of restrictive bans on their doula services. Imani stated, "... with all the legislation that's being passed... maybe trying to figure out the workarounds and making sure that we don't get in trouble or sued. How we will be able to help people and not endanger our own selves... I'm really concerned about that. I don't want toif we [Georgia] turn into Texas, I don't want to be sued by some random John walking down the street for $10,000 because of my job." Georgia also has a history of restrictive abortion bans (e.g., mandatory counseling, mandatory waiting period, and at first a 22-week limit now brought down to the estimated 6 weeks) that impact the way that abortion doulas interact with clients and abortion providers. Lisa explained, "... there are very few providers that could give any information or even would give any information for fear of retribution or backlash on abortion services, especially here in Georgia." Survey results indicated that stigmatizing attitudes, beliefs, and actions about abortion (SABAS) were low with a mean of 22.29 out of an 18 to 40 scale (Table 4), where higher scores indicate more stigmatizing attitudes, beliefs, and actions about abortion. Abortion doulas reported slightly lower mean SABAS than other kinds of doulas (20.8 vs. 23.1), but these differences were not statistically significant (t =.65, P =.53) At the same time, survey results revealed a relatively high overall abortion provider stigma scale (APSS) score with a mean of 24.00 out of a 17 to 27 scale (Table 4). Abortion doulas reported moderate disclosure management (mean score of 10.86 out of a 7 to 15 scale), low to moderate discrimination (5.86 out of a 5 to 7 scale), and moderate resistance and resilience (mean of 7.00 out of a 4 to 11 scale) (Table 4). When doulas reflected on the possible stigma perpetrated by the larger doula community, most believed that their doula community was accepting of abortion doulas. However, some like Annie felt there were negative perceptions of abortion doulas: "Probably not well... because a lot of doulas are, although some doulas are very open, I think a lot of doulas come from like upper middle-class families that are... you know. They just wouldn't do that in our area." This stigma was not just felt from the doula community, but also from the participant's larger community of friends, family, and spiritual leaders. Regan described, "I got a phone call from my spiritual teacher, "Oh my gosh, you cannot say that! You cannot say that you're promoting abortions!". And I said, I'm not promoting anything! I am saying, if you are in that situation, I am here to help." Despite stigma felt by abortion doulas, participants described their desire to continue working in the abortion space as both a doula and advocate. Alex described this desire in the context of their work as both an abortion and birth/postpartum doula, "... there are just too many reasons that abortion care should be accessible. You're not going to change my mind about that. And I think what really confuses people with me in particular is when I go from saying that abortion care should 10,000% be accessible, and I'm like, oh, yes, but natural birth should also be 10,000% accessible... I can be pro-abortion and also be pro-birth." In stating that doulas can work both in abortion and birth services, Alex and other abortion doulas once again expressed that the doula's role is to support a person's reproductive health experience even in the face of considerable stigma. When asked about how about how doula work can improve in Georgia, many acknowledged the stigma and obstacles to healthcare that many pregnant people face in the United States. Alex states, "There's an active attempt to rid our country of the ability to end a pregnancy or to have an abortion. And that is very scary. I think that abortion care is going to be looking different soon and again, like I started off saying, I think that abortion care and sexual reproductive health care is honestly something that should be community based. It's not something that has to happen in a hospital or medical setting... you don't have to go through all the obstacles of getting health care... for something that could be very vulnerable... they [clients] deserve to be respected through that and held with integrity." This need for change is echoed in other doula's responses. While this question is asked with the intention of seeing how doulas can best support their clients, some doulas envisioned doula work to fully empower clients to make the decisions necessary for their sexual and reproductive health. Bailey describes this vision of how doula work can change as, "... people want to take control of their own health. I think people know that doulas are important, and doulas are great, and people also want to take back their own health and we need to think about what are the ways we can equip people to do that." --- Discussion The Georgia Doula Study is a unique community-engaged participatory action research project that explores abortion doula care from the perspectives of all types of doulas in a restrictive abortion context. This mixed methods study identified important themes and recommendations for improving practice and policy in the increasingly restrictive U.S. abortion landscape. Lessons learned from this study can be widely applied to restrictive abortion settings globally. To date, the majority of abortion doula literature discusses clinicbased abortion doulas and their in-clinic services; the current study fills an important gap by focusing on community-based abortion doulas. Previous studies primarily focused on how in-clinic abortion doula support can mitigate pain and emotional discomfort during first trimester procedural abortions (14,16). Participants in this current study described the abortion doula support they provide primarily outside of clinic settings. This included supporting clients before, during, and after abortion with securing funds, providing information, talking through all of the options, physical support, and post-abortion care at home. Our findings align with and augment recently published media articles and commentaries discussing the impact of abortion doula services, typically in response to issues such as COVID-19 and the proliferation of abortion restrictions in the U.S (31)(32)(33). Some argue that community-based abortion doula services can overcome stigma and restrictions by providing factually correct educational materials to their clients and supporting them in finding accessible and safe abortion. Internationally, lay community health workers have already been shown to provide informational support and procurement of pills for self-managed abortion (34). COVID-19 has made it even more necessary for community care workers like doulas to provide support during a potentially isolating and stigmatizing abortion experience, especially in areas where restrictive abortion laws are being implemented (33). Moreover, studies about abortion restriction impacts on marginalized communities-like the reproductive justice community-led Georgia Medication Abortion study with Black and Latinx women-emphasize the importance of abortion doulas in educating and supporting disadvantaged pregnant people to access safe abortion care (35). Most of the participating doulas endorsed abortion care as one way to support pregnant people's reproductive autonomy through an often-stigmatized reproductive health decision. Non-abortion doulas expressed interest in supporting abortion clients, but were not currently doing so. However, it was unclear if this was due to lack of awareness (about opportunities to get trained and provide care) or stigma surrounding abortion work. In the future, doula training and certifying organizations must include abortion and full spectrum support in the scope of work. Similarly, efforts to coordinate abortion care nationally must include community-based abortion and full spectrum doulas, who are connecting patients to information and care. Given the changing post-Roe landscape, abortion and full spectrum doulas are increasingly vital resources for people accessing abortion, especially in restricted and criminalized settings like Georgia. In the U.S. and globally, restrictive abortion policies embody, exacerbate, and enact abortion stigma, which is felt not just by abortion patients but also providers and-the current findings would suggest-doulas (28,36,37). This study is the first to measure stigmatizing abortion attitudes of doulas using the SABAS (26) as well as the abortion provider stigma felt by abortion doulas using the APSS (27). Our results show that, overall, doulas do not have stigmatizing attitudes, beliefs, or actions about abortion which suggests they are supportive of their clients, regardless of pregnancy outcome. On the other hand, the moderate to high abortion provider stigma scores suggest that abortion doulas are experiencing stigma, particularly in the form of disclosure management more so than overt discrimination. This suggests that abortion doulas are having to carefully decide when and how to disclosure or hide their abortion work, despite their resistance and resilience against stigma. In discussing how to improve full spectrum doula care in Georgia and beyond, many abortion and full spectrum doulas spoke about doula work in general needing to evolve to maximize client autonomy in making reproductive health decisions. Specifically, this could include teaching clients how to "doula themselves" or empowering abortion clients, especially, with the information and skills to be their own advocates. This overarching need to reevaluate the role of doula work in the hypermedicalization of reproduction is critical and has been previously discussed in both the gray and scientific literatures (8,38). Notably, volunteer abortion doula collectives have been instrumental in supporting the abortion experiences of people throughout the U.S., regardless of age or economic background (39, 40). While study participants did not report being a part of any such collective, many expressed the desire to connect with other full spectrum/abortion doulas, especially as restrictive abortion policies are enacted. As the movement towards full spectrum and abortion doula services continues, it will be important for doula training and certifying organizations, abortion doula collectives, and doula policy advocates to be intentional about how they serve abortion clients. --- Limitations and delimitations The current study has a number of limitations, which must be considered when interpreting the results and implications. First, this is a qualitative study with 20 doulas and therefore is not intended to be generalized to broader populations or to prove causality. Second, the recruitment strategies-primarily through the doula stakeholder steering committee and abortion clinics in metro-Atlanta-might have introduced sampling bias, but there is no standard list of all doulas in the metro area and, therefore, a more systematic recruitment process was not feasible. This study's approach allowed the team to leverage partnerships with community-based organizations and abortion providers. Finally, at least one doula did not participate in the in-depth interviews about abortion and full spectrum doula care-and it is possible more doulas like them never began the study-because of antiabortion sentiments. It is therefore possible that our results do not reflect the full range of doula perspectives on abortion and full spectrum care but rather the perspectives of doulas who were comfortable answering questions about abortion. --- Recommendations and conclusions The practice implications of this study include (1) increased awareness of and funding for full spectrum doula care, (2) organizational support for existing full spectrum doula collectives across the U.S., (3) engagement of all doulas in full spectrum care through increased opportunities for training in abortion care and contraceptive counseling, and (4) abortion de-stigmatization efforts at the community-level. The doula community and general public need to better understand what full spectrum doula care is and how to access abortion doula support. Additionally, financial support (e.g., from abortion funds, insurance companies, private donors) is needed so clients can pay for abortion doula services or to facilitate abortion doulas offering pro bono services while still being compensated for their skills and labor. Full spectrum doula collectives exist across the U.S., but more funding and organizational support are needed to ensure their sustainability and reach (8,39). Such collectives could serve as a space to train doulas in abortion and contraceptive services as well as a space to be in community with other doulas that are interested in ensuring reproductive autonomy for their clients, regardless of pregnancy outcome. Doula training and certifying organizations must work to include abortion and contraceptive counseling in their scope of education for all doulas. By supporting all clients through the entire spectrum of reproductive health experiences, doulas can ensure that clients feel adequately supported in their full reproductive autonomy. Finally, abortion de-stigmatization efforts are needed at the community level broadly and within the doula community, specifically. Supportive interventions like the Providers Share Workshop (which has been tested domestically, in Latin America, and in Africa) could also reduce the stigma load on abortion doulas in the U.S. and globally (37). This study also highlights important lessons and potential opportunities for future research. Primarily, this study demonstrates the value and importance of community-engaged participatory action research, especially in the realm of abortion and contraception care. Second, future studies need to further explore the perspectives of clients who are served by abortion and full spectrum doulas. Understanding how clients view and value abortion doula care would inform how abortion doula support can meet ever-changing needs in the years to come. Third, future studies must explore full spectrum doula care in rural areas and with immigrant communities. Finally, it is also important to recognize that abortion and full spectrum doula care in the U.S. will continue to rapidly evolve given that federal abortion protections were overturned and statelevel abortion bans like Georgia's can now be enacted. In particular, studies from the U.S. and globally have shown that selfmanaged abortion using medication can be safe and effective given the right amount of support including from doulas and community health workers (34,41,42). Abortion doulas can offer pivotal emotional, informational, logistical, and physical support during abortion, even in restricted settings and in this new era. EAM and SN provided research mentorship to AL and AS throughout data collection and analysis including training in qualitative and quantitative methods. EAM and SN provided comments and edits on the first draft of this manuscript and during manuscript revision. All authors contributed to the article and approved the submitted version. --- Data availability statement The de-identified data supporting the conclusions of this article will be made available by the authors upon request, without undue reservation. --- Ethics statement The studies involving human participants were reviewed and approved by Emory Institutional Review Board (IRB). Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. --- Author contributions EAM conceptualized the Georgia Doula Study and secured funding. AL, DT, and AS conducted all surveys, interviews, and qualitative data coding. AL wrote the first draft of this manuscript. --- Conflict of interest EAM works as a consultant for the community-based organization co-leading the Georgia Doula Study. The remaining 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/fgwh.2023.966208/ full#supplementary-material.

Background: The work of full spectrum doulas (i.e., non-medically trained care workers offering support before, during, and after pregnancy including abortion)-is increasingly important as abortion access decreases across the U.S. Few studies have examined the work of community-based doulas in restrictive abortion settings or how they might further incorporate full spectrum care. As part of the community-engaged mixed methods Georgia Doula Study, this analysis examines the scope of work of community-based doulas regarding full spectrum and abortion services, doula opinions on full spectrum and abortion work, and potential barriers and facilitators for full spectrum doula care in metro-Atlanta, Georgia. Methods: From October 2020 to February 2022, the team recruited 20 communitybased doulas with 8 who provide full spectrum services including abortion. Surveys covered demographics, doula scope of work, family planning attitudes, and abortion stigma. Survey data were analyzed using descriptive and bivariate statistics. In-depth interviews further explored those topics. They were de-identified and thematically analyzed using a semi-deductive approach. Results: The findings are organized around five themes: (1) doulas of all kinds center reproductive autonomy; (2) abortion doulas play important roles in reproductive autonomy; (3) doulas have mixed feelings about contraceptive counseling; (4) abortion doulas provide diverse services carrying numerous benefits in a stigmatized environment; and (5) abortion doulas experience challenges including stigma but they offer solutions. All but two doulas in this study were interested in learning how to incorporate contraception and abortion services in their current scope of work, and most participants supported the role of full spectrum doulas. Conclusion: This analysis highlights the experiences of abortion and full spectrum doulas, reactions of the larger doula community to those services, and facilitators and barriers to full spectrum doula care in a restrictive abortion setting. There are urgent needs and opportunities for full spectrum doulas to offer life-protecting services to pregnant people across the U.S. and globally. Coordination efforts for U.S. abortion care post-Roe v. Wade must include community-based doulas, who are largely open to aiding abortion clients through education, connection to care, and emotional support.

INTRODUCTION The Minangkabau are an ethnic group originating from West Sumatra, Indonesia, known for the strong "'Merantau'" tradition in their culture. 'Merantau', or going elsewhere to gain new experience and knowledge, has become an integral part of Minangkabau's identity (Navis, 1984). 'Merantau' was not an easy process. It is a transition from a familiar environment to an unfamiliar one, often involving different cultures and customs. In this case, adaptability is crucial. Acculturation refers to the process of learning and adapting to a new culture, including language, social norms, values, and behaviors (Berry, 1997). Understanding the process of acculturation in the context of 'Merantau' is crucial, especially in today's era of globalization. As migration between regions and countries increases, it becomes increasingly important to understand how individuals and communities adapt to new cultures (Ward, Bochner, & Furnham, 2001). In the context of Minangkabau, this research aims to understand how people with a strong 'Merantau' tradition adapt to the culture of the immigrant country. Minangkabau 'Merantau' traditions are deeply rooted in their culture and history. According to Abaza (1998), 'Merantau' is not only seen as a physical journey, but also as a spiritual and intellectual journey. The 'Merantau' people of Minangkabau are expected to gain new knowledge and experiences to bring back to enrich their communities. In this context, 'Merantau' became an integral part of the cycle of knowledge and learning in Minangkabau society. Despite its importance, little research has been done on how the Minangkabau people in the country adapted to immigration. This study attempts to fill this gap by examining how the Minangkabau people adapt to a new culture and retain their cultural identity. Using the Minangkabau proverb "Nan sakuduang jadi saruik, nan salapeh jadi kambang" as a theoretical framework, this study aims to provide new insights into the dynamics and adaptive processes of 'Merantau' culture (Navis, 1984). Previous research on ''Merantau'' (migration) and acculturation has covered everything from what drives migration (Dwiyanto and Pradiptyo, 2002) to the impact of migration on individuals and communities (Abaza, 1998). In the context of Minangkabau, previous research explored how 'Merantau' traditions influenced cultural identity and social structure within Minangkabau communities (Navis, 1984). Although previous studies have provided valuable insights, there are still gaps that need to be filled. In particular, there has been very limited research on how the Minangkabau people in the country have adapted to immigration and retained their cultural identity. Furthermore, previous studies tend to focus on the macro perspective without considering the dynamics of individual experience and acculturation at the micro level. This study aims to fill these gaps by examining how Minangkabau people adapt to a new culture and maintain their cultural identity. Using the Minangkabau proverb "Nan sakuduang jadi saruik, nan salapeh jadi kambang" as a theoretical framework, this study aims to provide new insights into the dynamics and adaptive processes of 'Merantau' culture. The main goal of this study was to understand how the Minangkabau people in the country adapted to their migration. In this context, acclimatization is understood not only as a process of learning and adapting to a new culture, but also as a process of preserving and defending cultural identities. Therefore, this study aims to examine how the Minangkabau people shuttle between the two cultures and how they carve out their place in the immigrant country. To achieve this, the study used the Minangkabau proverb "Nan sakuduang jadi saruik, nan salapeh jadi kambang", which translates to "the one becomes the protector and the other becomes the ornament". This proverb provides a solid framework for understanding how the people of Minangkabau adapted to and contributed to the new society. Therefore, this study seeks to provide new insights into the dynamics of the 'Merantau' culture and adaptation processes in the Minangkabau context. To achieve the objectives of this study, we employed a mixed methods including literature review and participant observation. A literature review was conducted to understand the context and background of the Minangkabau culture and the 'Merantau' tradition. Participatory observation was conducted in several Minangkabau communities in the country of immigration to better understand the daily dynamics and the ways in which acculturation occurs in practice. This approach allowed us to gain a comprehensive insight into how the Minangkabau people of the country adapted to their migration in the context of the proverb 'Nan sakuduang jadi saruik, nan salapeh jadi kambang'. This article is divided into several main sections to better understand the research. Following this introduction, this article provides a literature review providing theoretical background and prior research on acculturation in the 'Merantau' and Minangkabau contexts. The next section looks at methodology and explains the approaches and methods used in this study, including literature review and participant observation. In the Results and Discussion section, the findings are presented and discussed within the context of the theoretical framework and previous research. The paper concludes with an executive summary that highlights the findings and provides implications for future research. --- B. LITERATURE REVIEW Migration and Minangkabau Cultural Identity: In his book "Alam Terkembang Jadi Guru: Adat dan Budaya Minangkabau," Navis (1984) provides a profound portrayal of Minangkabau culture and the tradition of migrating. He emphasized how 'Merantau' has shaped the cultural identity of Minangkabau and how they preserve and defend this identity in the land of migration. Cultural Adaptation and Migration: In his article "Immigration, Acculturation, and Adaptation," Berry (1997) There have been many studies conducted on migration and cultural adaptation, but research specifically focused on how Minangkabau people adapt in the land of migration remains limited. Most previous research has concentrated on the economic, educational, and social impacts of migration, with little exploration of how Minangkabau individuals adapt to the new culture and preserve their cultural identity. Additionally, previous research has tended to focus on macro perspectives, neglecting the experiences of individuals and the dynamics of cultural adaptation at the micro level. This research seeks to fill this gap by exploring how Minangkabau people adapt to the new culture and maintain their cultural identity. Using the Minangkabau proverb 'Nan akuduang be saruik, nan salapeh be kambang' as a theoretical framework, this study aims to provide new insights into the dynamics of 'Merantau' culture and the process of adaptation. The research also strives to explore individual experiences and the dynamics of cultural adaptation at the micro level, an aspect often overlooked in previous studies. Thus, this research contributes to the literature on migration and cultural adaptation, while offering fresh insights into the experiences of Minangkabau people in the land of migration. --- C. RESULT AND DISCUSSION The first prominent aspect is cultural adaptation and identity. Minangkabau people who migrate show strong abilities to adapt to the new culture while preserving their cultural identity. They can navigate between two cultures and create a space for themselves in the land of migration. This aligns with the Minangkabau proverb 'Nan akuduang becomes saruik, nan salapeh becomes kambang,' which means 'one becomes a protector, the other an ornament'. Dual Roles: Minangkabau people who migrate often assume dual roles as guardians of the Minangkabau culture and participants in the new culture. They strive to preserve and defend Minangkabau customs and traditions while actively participating and contributing to the new culture. Impact on the Community: Migration has a significant impact on the Minangkabau community in the land of migration. Migrants bring new knowledge and experiences, which they use to enrich their community. They also contribute to the local economy through remittances. Utilizing Community Networks and Resources: Migrants demonstrate strong abilities in leveraging community networks and resources to aid their adaptation process. They often rely on family and the Minangkabau community in the land of migration for support and assistance in various aspects of life, from seeking employment to navigating the new culture. Innovation and Adaptation: Migrants show a strong capacity for innovation and adaptation in their new environment. They often create new ways to preserve and maintain Minangkabau customs and traditions within the context of the new culture. For example, they may adapt Minangkabau rituals and ceremonies to accommodate the needs and constraints of the new environment. Promoting and Preserving Minangkabau Culture: Migrants play a crucial role in promoting and preserving Minangkabau culture in the land of migration. They often serve as cultural ambassadors and strive to promote understanding and appreciation for Minangkabau customs and traditions among the broader community. Minangkabau people who migrate also demonstrate a strong ability to uphold their cultural values despite being far from their homeland. Values such as communal cooperation (gotong royong), matrilineal customs, and the importance of education often remain integral parts of their identity even in significantly different environments. This illustrates how Minangkabau individuals can maintain cultural cohesion while in the land of migration. Migrant Minangkabau people also show their ability to make significant contributions to their new society. They often bring new skills, knowledge and perspectives that enrich the culture and community of their new environment. This demonstrates how migration can serve as a bridge between different cultures and societies, facilitating cultural exchange and interaction. This research shows that migration is not just about physical movements but also about the transfer of knowledge, ideas and culture. Migrant Minangkabau people carry with them Minangkabau knowledge and culture while also learning and absorbing knowledge and culture from their new society. Thus, migration can be seen as a two-way process involving learning and sharing, adaptation, and change. Migrant Minangkabau people also demonstrate how they utilize technology and social media to maintain connections with their original community and share their experiences in the land of migration. The use of technology not only facilitates communication and social interaction but also enables them to preserve and strengthen their cultural identity. This research shows that migration significantly impacts the identity of individuals and Minangkabau communities. The process of cultural adaptation often involves renegotiating identities and roles, which can affect how Minangkabau people understand themselves and their community. This illustrates how migration can serve as a catalyst for reflection and identity change. The research also indicates that migration can have a significant impact on gender dynamics within the Minangkabau community. The process of cultural adaptation and changes in the environment often influence gender roles and status, which can affect how gender is understood and advocated for within the Minangkabau community. This research shows that migration has a significant impact on individuals and the Minangkabau community, affecting various aspects of their lives, from cultural identity to gender dynamics. Minangkabau people who migrate demonstrate a strong ability to adapt to the new culture while preserving their cultural identity, often assuming dual roles as guardians of Minangkabau culture and participants in the new culture. They also leverage community networks and resources to aid their adaptation process and bring new knowledge and experiences that enrich their community. Additionally, they exhibit the ability to innovate and adapt in the new environment, creating new ways to preserve and maintain Minangkabau customs and traditions. Furthermore, they play a crucial role in promoting and preserving Minangkabau culture in the land of migration, and migration serves as a bridge between different cultures and societies, facilitating cultural exchange and interaction. This conclusion illustrates how migration is not just about physical movements but also about the transfer of knowledge, ideas and culture, and how this process can influence the identity of individuals and communities. The Minangkabau proverb 'Nan Sakuduang becomes saruik, nan salapeh becomes kambang' provides a strong framework for understanding the findings of this research. This proverb, which means 'one becomes a protector, the other an ornament,' reflects how Minangkabau people who migrate often assume dual roles as guardians of Minangkabau culture and participants in the new culture. This is consistent with the findings of this research, which demonstrates that Minangkabau individuals who migrate show a strong ability to adapt to the new culture while preserving their cultural identity. Previous research by Suryadi (1995) and Blackburn (2004) also supports these findings. Suryadi (1995) shows how migration has influenced changes in the social structure and cultural values of the Minangkabau, while Blackburn (2004) explores how migration affects gender roles and status in the Minangkabau society. Both studies demonstrate how migration can serve as a catalyst for change and adaptation, which aligns with the findings of this research. Furthermore, this research also shows that migration is not just about change and adaptation but also about preservation and conservation. Minangkabau people who migrate not only adapt to the new culture but also strive to preserve and maintain Minangkabau customs and traditions. This illustrates how the proverb 'Nan akuduang jadi saruik, nan salapeh jadi kambang' can serve as a guide for Minangkabau individuals in navigating between different cultures and identities. The proverb 'Nan Sakuduang becomes saruik, nan salepeh jadi kambang' also reflects how Minangkabau people who migrate leverage community networks and resources to aid their adaptation process. As shown by the research of Dwiyanto and Pradiptyo (2002), migration often involves the formation and utilization of strong social and economic networks, which can assist in the process of adaptation and integration into the new society. In this context,'saruik' or protector can be seen as a symbol of these networks and resources, which help preserve and maintain the cultural identity of the Minangkabau in the land of migration. This proverb also reflects how the Minangkabau people who migrate contributed to their new society and culture. As shown by Hadiz's research (2004), migration often involves active participation in the new society and culture, whether in terms of economy, politics, or social aspects. In this context, 'kambang' or ornaments can be seen as a symbol of these contributions and participation, which enrich and beautify the new society and culture. This proverb illustrates how migration can serve as a two-way process involving learning and sharing, adaptation, and change. As shown by Shiraishi (1997) and Bruinessen's (1995) research, migration often involves the exchange of knowledge and culture, which can influence how Minangkabau people understand and interact with the world around them. In this context,'saruik' and 'kambang' can be seen as symbols of this two-way process, reflecting how Minangkabau people navigate and adapt to different cultures and societies while preserving and maintaining their cultural identity. The proverb 'Nan akuduang so saruik, nan salapeh jadi kambang' also reflects how the Minangkabau people who migrated uphold their cultural values even when far from their homeland. As shown by Navis'(1984) research, values such as mutual cooperation (gotong royong), matrilineal customs, and the importance of education often remain integral parts of their identity despite being in vastly different environments. In this context,'saruik' or protector can be seen as a symbol of these values, which help maintain cultural cohesion in the land of migration. Additionally, this proverb reflects how the Minangkabau people who migrated made significant contributions to their new society. As shown by Abaza's (1998) research, they often bring new skills, knowledge, and perspectives that enrich the new society and culture. In this context, 'kambang' or ornament can be seen as a symbol of these contributions, which enhance and adorn the new society and culture. The proverb also illustrates how migration can have a significant impact on gender dynamics within the Minangkabau community. As shown by Nilan's (2008) research, the process of cultural adaptation and environmental change often influences gender roles and status, which can affect how gender is understood and advocated for within the Minangkabau community. In this context,'saruik' and 'kambang' can be seen as symbols of these dynamics, reflecting how Minangkabau people navigate and adapt to social and cultural changes while preserving and maintaining their cultural identity. --- D. CONCLUSION This article has explored how the Minangkabau people migrated to adapt to a new culture while preserving their cultural identity, within the context of the proverb 'Nan akuduang becomes saruik, nan salapeh becomes kambang'. The research findings indicate that migration is not just about physical movement, but also about the transfer of knowledge, ideas and culture. Minangkabau people who migrate demonstrate a strong ability to adapt to a new culture, contribute to their new society, and uphold their cultural values, often taking on a dual role as guardians of Minangkabau culture and participants in the new culture. This conclusion highlights how the proverb 'Nan Sakuduang so saruik, nan salapeh so kambang' can serve as a guide for Minangkabau people in navigating between different cultures and identities. It also shows how migration can act as a bridge between different cultures and societies, facilitating the exchange and interaction of cultures. Therefore, this research provides new insights into how Minangkabau people adapt and change in the context of migration, and how they are able to maintain and preserve their cultural identity amidst these changes and challenges.

This article focuses on immigration in Minangkabau culture and how Minangkabau people assimilate in foreign lands. Using the Minangkabau proverb "Nan sakuduang jadi saruik, nan salapeh jadi kambang" as a theoretical framework, this study examines how the Minangkabau people maintain and preserve their culture while contributing to and assimilating into the new society Identity ("nan sakuduang jadi saruik"). It ('nan salapeh jadi kambang'). Research methods included a literature review, in-depth interviews, and participatory observation of Minangkabau communities in multiple resettlement sites. The results of this study show that despite the challenges and obstacles, the Minangkabau people successfully navigated and adapted to a new culture without losing their own cultural identity. This study provides new insights into immigrant cultural dynamics and adjustment processes in the context of Minangkabau, and has the potential to make a significant contribution to broader cultural and social research.

Background Human trafficking is a crime that involves extreme forms of exploitation, which often leaves survivors with enduring physical and psychological scars [1,2]. The most commonly accepted definition of human trafficking is found in the UN Convention Against Transnational Organized Crime, which emphasizes that trafficking involves the coercion and/or deception of individuals for the purposes of exploitation, including for "sexual exploitation" and "slavery or practices similar to slavery." [3]. While the term'slave-like practices' in the protocol includes trafficking for marriage, there remains little empirical evidence or conceptual clarity about this abusive phenomenon [4], which is often only associated with the "mail order bride" business from low and middle income countries to North America and Europe [5]. The sale of women for marriage has a long history in China. After the Communist Party gained power in 1949, they instituted policies to redefine social, gender and family relationships, including abolishing rampant female trafficking and prostitution. As a result, there appeared to be no further officially recognized cases of trafficking in women [6,7] until the introduction of the free market economy and the rapid rise in migration in the late 1970's [6,8]. The main underlying factors thought to influence the trafficking of women for marriage into China include patriarchal structures and China's onechild policies. Patriarchal structures, such as the widespread expectation for men to marry and produce a male offspring for the continuation of the family line has met with a dramatic increase in bride prices since the pre-1978 era. As a result, Chinese men who are pressured by their family to marry, but lack sufficient financial or other assets, are often not considered socially desirable partners for women [9,10]. The one child policy, paired with the cultural preference for sons, has resulted in a skewed sex ratio in rural China and its impoverished regions [11]. The number of marriageable women in rural Chinese villages has further declined because a large number of women have migrated to more developed coastal areas of eastern China for work or better marriage prospects [11]. The numerous men who are unable to find wives and the social problem this creates for their families receives considerable sympathy from villagers and cadres, who accept practices that involve the purchasing of a bride against the bride's will and therefore would be unlikely to report them to police [11]. Additionally, in rural areas, when a marriage is arranged by parents, a brideto-be's consent may not be considered necessary and many will not see the difference between paying a 'bride-price' versus buying a wife. [8,12]. In Vietnam, poverty, unemployment, patriarchal structures and a surplus of Vietnamese women in rural areas in the past due to years of war are tied to a cultural expectation for single women to marry, which seem to fuel the trade in women for marriage to China [11,13]. The uneven socioeconomic development between China and Vietnam make cross-border activities and migration attractive, particularly because crossing the border only requires a boarder pass versus a passport [13]. Furthermore, in rural Vietnam, women are expected to marry at a relatively early age, yet because it can be difficult for Vietnamese women to find attractive husbands, marriage abroad is viewed as a viable option [13]. There is a history of marriage between Chinese men and Vietnamese or Burmese women, which sometimes includes bride-kidnapping, a practice often accepted by communities, leaving kidnapped brides to fend for themselves. [9,11]. Despite its high profile in news reporting and international policies, empirical evidenceboth quantitative and qualitative -on trafficking of women into forced marriage is scarce. One qualitative study investigates the trafficking of Bangladeshi girls as wives to North India, focusing on interviews with women trafficked ten to 20 years ago. This study illustrated the numerous ways children were sold knowingly or unknowingly into marriage, highlights their hard lives and their difficulties to reintegrate upon return-if they were able to leave [14]. Two other empirical studies, an ethnographic study and a quantitative survey of migrants, each with an unidentified number of women experiencing forced marriage explored the trafficking into forced marriage of North Korean women fleeing to China. None of the women in these studies planned to marry Chinese men but were rather recruited immediately after they crossed the border because of their likely vulnerability [10,15]. A handful of studies also explore the "Mail order bride" business of women from Eastern European, Russian, and South East Asian to North America and Europe, however, most of this work relies on desk-based assessments websites, newspaper reports or legal cases rather than empirical work [5,16]. To our knowledge, only two quantitative studies have examined the trafficking of women as wives from Vietnam to China, to date. The first study included 13 women who were trafficked for marriage [17], and the second study used respondentdriven sampling of women locally known as having been trafficked and included 213 women. However, the latter research initially included both trafficked women and any woman who had migrated to China, married and might have been trafficked. Therefore it is difficult to differentiate between trafficked women and those who migrated for marriage or to discern experiences of those who were trafficked [13]. Despite the high visibility of trafficking for marriage in newspapers and international reports, empirical evidence is rare. While reports have hypothesized about push and pull factors for bride-trafficking within and to China, there remains scant evidence on what women experience during these situations and what hopes and concerns they have after they return in terms of their health, well-being and families. This study is one of the first to provide the socio-economic characteristics of women trafficked into forced marriage and in posttrafficking services and to describe their experiences before, during and after their trafficking experience. --- Methods This study is a sub-study of 51 Vietnamese women and girls as young as 14 in post-trafficking services in Vietnam who were sold into marriage in China. This sub-study uses data from a larger observational crosssectional study investigating the health of men, women and children in post-trafficking services in Cambodia, Thailand, and Vietnam [1]. Within the larger study, trafficking for marriage was only observed among respondents from three post-trafficking services in Vietnam (40 women in the shelter Lao Cai, seven in the shelter Lang son and four in the shelter Peace House). Participants were a consecutive sample of clients of post-trafficking services. Trained interviewers conducted face-to-face interviews with all participants within their first 2 weeks of admission to the services after offering their informed consent. Individuals were excluded from the study if trained caseworkers deemed them too unwell to participate. The research teams followed a strict ethics protocol based on the WHO Ethical Recommendations for Interviewing Trafficked Women, ensuring voluntary and confidential participation, assurance that declining participation would not affect their access to services, minimization of distress and referral offers for health or other reported problems [18] In the standardized survey, women were asked about their socioeconomic background, pre-trafficking exposures, experiences of violence, physical and mental health, and future plans and concerns. The questionnaire was translated into Vietnamese and refined through group discussions with International Organization for Migration counter-trafficking teams, further revised through pilot-testing, and reviewed after back-translation into English. It measured symptoms of anxiety and depression with the Hopkins Symptoms Checklist and posttraumatic stress disorder with the Harvard Trauma Questionnaire [19][20][21]. A cutoff of 1.75 was used for measuring anxiety [22] and 2.00 for post-traumatic stress disorder [23]. We excluded item 12 (sexual interest) from the depression scale because of sensitivity in cases of sexual abuse and because participants were often residing in shelter situations; therefore, we used 1.625 as the cutoff for symptoms indicative of depression, instead of the standard 1.75 cutoff [21] and assuming that each item made a similar contribution to the overall score. Physical and sexual violence was measured by a modified tool of the WHO international study of domestic violence [24] which has been supplemented by items victims of trafficking commonly report to local service providers. Participants were asked about health problems experienced in the past 4 weeks and variables were coded as positive for people who reported severe levels ("extremely" and "quite a lot"). Given the lack of empirical research, especially quantitative knowledge and tools, participants were also able to give open ended responses in addition to set response categories to questions concerning recruitment, reasons for leaving, return, reintegration, concerns and hope for the future. Qualitative quotes are used to illuminate the context of existing categories or to highlight the existence of different reasons or situations than those captured by the survey tool. --- Statistical analysis The analysis is focused on women who were trafficked for marriage from Vietnam to China. Two women in the dataset who were trafficked within Vietnam and to Indonesia were not included into the following analysis. The analysis calculated proportions for all variables. Associations between symptoms of anxiety, depression and PTSD with specific aspects of their trafficking experience are assessed using Fisher exact tests. The analysis was conducted with Stata (Version 13). The study summarized the answers and used direct quotes given in the open-ended questions on reasons for leaving, hopes upon return and concerns. --- Results Of the 51 women in this sample, 15 (29.5%) were minors at the time of the interview and 18 (36.7%) stated that they were already married before they were trafficked to become wives in China. Nineteen women (63%) had children at the time of the survey. Table 1 provides further details on participant's socio-demographic characteristics. Sexual and/or physical violence was experienced by eight (16%) women prior to trafficking, with five women (10%) reporting to have been forced to have sex and five (10%) reporting physical violence. --- Reasons for leaving, recruiter and trafficking knowledge before Based on responses to the open-ended questions, it became clear that only one woman knew that she would marry a Chinese man before she left home. The other 50 women each believed they were agreeing to leave home for different reasons and the majority had not planned to migrate or even travel to China. Some women said they were recruited by being invited for a drink or a cup of water and then woke up in China, others were offered a job, travel or outing or simply a lift to a destination. Deception was a common recruitment tactic, as indicated by the following quotes: "My lover deceived me to go to meet his parents". "A stranger induced me to go to China to buy clothes". "I was deceived to find a job in Lao Cai province". Women reported that they were deceived by: friends (n = 13); relatives, including for example, their aunt (n = 3), boyfriend (n = 2), and husband (n = 1); someone they knew (n = 2); and strangers (n = 12). "My Vietnamese husband deceived me and trafficked me to China". The woman who reported that she was asked to marry in China stated later in the survey that she was not given accurate information about her situation there. The majority of the women (n = 44, 86%) never had identity or travel documents, and of the seven who did, five (71%) reported that the documents were confiscated during the trafficking situation. Women who wanted to leave home opted to migrate because: they knew others who left and earned money (n = 9, 17.0%); they did not earn enough money in their job (n = 6, 11.3%); or could not find a job nearby (n = 3, 5.7%); or they needed money to support children (n = 2, 3.8%). Two women said they were abducted (3.8%). Other reasons included: to earn money to pay for medical care for ill family member; experiencing violence at home; no livelihood or house to live in; and having a boring life and seeking adventure. Although most reported having been deceived by someone, more than half of the women blamed themselves for getting into the trafficking situation (n = 27, 53%). A few women also blamed others, including: their parents (2%); other family members (n = 5, 10%); a friend (n = 5, 10%); a boyfriend (n = 4, 8%); an acquaintance from the village (n = 5, 10%); an acquaintance not from home (n = 2, 4%); a broker (n = 7, 14%); and someone they did not know before (n = 33, 65%). Others were also blamed, such as: a husband; an agency; and a kidnapper. Half of the women (n = 25, 49%) reported they had heard about human trafficking before leaving home. --- Experiences and living conditions during the trafficking process The majority of women were trafficked for more than a year (n = 33, 66%), with four women having been trafficked for two or more years. Seventeen women (34%) were trafficked for less than 100 days, with seven trafficked for less than 1 month. Women trafficked as brides were in the trafficking situation longer than individuals who were trafficked into other sectors (e.g., sex work, domestic work, fishing, factory work, etc) [1]. While all women in this study were trafficked to be wives, 11 women were also exploited in other sectors while in the trafficking process, including prostitution (n = 4, 8%), domestic work (n = 2, 4%), agriculture (n = 2, 4%), and cleaning and factory work (n = 1 in each, 2%). Only two of those 11 women (18%) were paid for this work. Only four women (8%) spoke Mandarin fluently, but it is unclear if they learnt the language during their trafficking experience or whether they were fluent beforehand. Most women reported extremely restricted freedom, with 73% (n = 37) stating they were never free to do what they wanted or to go where they wanted and 13.7% (n = 7) said that they were'seldom' free. For ten women (20%) restrictions were extreme, as they were physically locked in a room. Nearly all women (n = 46, 90%) reported physical and/ or sexual violence while in the trafficking situation, with 86% (n = 43) stating they were forced to have sex, including the two 14 year-old girls. A majority (n = 31, 61%) reported they were physically abused, as described in Table 2. Husbands were the main perpetrators of physical violence (n = 42, 91%) and sexual abuse (n = 40, 93%), followed by traffickers, with 41% (n = 19) perpetrating physical violence and 7 % (n = 3) sexual abuse. Two women (4.3%) reported physical violence by their employer. Additionally, women reported physical violence perpetrated by a client, a brothel security staff, a father-in-law and a motorbike taxi driver (n = 1 each, --- Escaping and end of the trafficking situation The majority of women (n = 43, 84%) had attempted to escape the trafficking situation. Women were able to leave their circumstances because they either: ran away and escaped (n = 36 71%); got help from neighbors or people in the surroundings (n = 6, 12%); or were released by their husband or his family (n = 3, 6%). In this study, 42 (82%) women received help from the police, border guards or government officers. One woman also recounts that other trafficked wives worked together to flee: "I contacted two people who were in the same situation and we planned to escape". It is unclear at what stage the police help the women, as it is notable that 30 women (59%) spent time in detention before returning home, with five (10%) spending up to 7 days, 11 (22%) between 8 and 32 days, nine (18%) between one and 3 months, and five (10%) more than 3 months in detention. Eight women indicated that they did not try to escape, explaining they were: afraid of being killed (n = 5); feared revenge and violence (n = 4); feared arrest (n = 3); did not know the language (n = 3); and were afraid of getting lost (n = 3). Two women reported that they were harmed when they tried to leave previously, two did not have identity documents and three were prevented from leaving the compound because they were locked in a room or confined. Two women were also deterred because they had no money or prospect of livelihood upon return (n = 2), one feared harm to her families if she left (n = 1) and another feared she would be kidnapped to become a sex worker (n = 1). One woman did not want to leave her Chinese children behind. --- Health post-trafficking Of the 51 women, 24 (47%) had symptoms of depression at the time they were interviewed, 15 (29%) reported symptoms of anxiety and seven (14%) symptoms of PTSD. Two women (4%) reported having tried to commit suicide in the previous month and one (2%) harmed herself physically. As presented in Table 3, symptoms of depression, anxiety and PTSD are significantly associated with experiences of physical violence during the trafficking experience. Women are also more likely to show symptoms of anxiety and PTSD if they were locked into a room while trafficked. In the 4 weeks prior to the interview, participants reported experiencing severe ("quite a lot" or "extremely") physical pain or illness, including: dizzy spells (n = 9, 18%); headaches (n = 11, 22%); dental problems (n = 1, 2%); nausea or indigestion (n = 7, 14%); back pain (n = 12, 24%); skin problems (n = 4, 8%); extreme exhaustion (n = 4, 8%); memory problems (n = 2, 4%); and persistent coughing (n = 1, 2%). At the time of the interview, three women (6%) aged 15, 16 and 19 said they never have had sex and did not experience sexual violence during their trafficking situation. Seven (16%) women stated that they were pregnant at the time of the interview and ten (22%) women reported a pregnancy during their trafficking situation. Seven women stated they had an intended termination of a pregnancy during the trafficking situation. --- Future plans and concerns When asked about their future plans or worries, most women stated that they would like to live with their parents or other members of their family of origin after leaving the shelter (n = 39, 77%). "I want return home to reunite with my family and then find a job to have money for my child's studying". Nine women (18%) said they want to live with their former spouse, one explaining for example: "I want to return home to live with my husband and children, have a job and bring up my children". One woman wanted to live at her work location and the others did not know. The fear of their traffickers and their associates (n = 38, 75%) was one of women's main concerns, stating, for instance "Fearing the trafficker come back to retaliate against me". Fear was followed by feelings of guilt or shame (24%, n = 12); worries about earning money and having a job to pay debts (n = 11, 22%); their own mental health (n = 11, 22%); and their physical health (n = 8, 16%). A strong sense of shame and fear of traffickers has been previously described in a qualitative study of women returning from wife trafficking in China, because being trafficked to China is associated with sex work, loss of virginity and forced marriages in Vietnam [25]. Three women also mentioned that their main concerns were their children and husbands in China, about whom they are either thinking or to whom they want to return, with one woman planning to obtain the necessary legal documents to live with their husband and children in China noting: "I want to return to live with my parents and ask for legal documents to come back to China to live with my husband and children in China". The remainder of the women clearly saw their future in Vietnam, reporting hopes such as: securing a job (n = 34); going home (n = 33); earning enough money (n = 18); bringing up their children and unborn babies (n = 17); studying and obtaining vocational training (n = 11); marrying and having a family (n = 9); living with their parents (n = 6); being able to support their families (n = 3); and buying a home (n = 1). "I hope to have money, have family and job to bring up my coming baby (the victim is pregnant)". --- Discussion To the best of our knowledge, our findings represent the largest study sample to date of women trafficked for forced marriage from Vietnam into China and one of the only studies that specifically investigated survivors' health. The characteristics of women in this study are similar in terms of age, educational and employment status to those of Duong's et al.'s study of Vietnamese women who were considered to be trafficked in their community and consisted of women who migrated voluntarily or were trafficked into China for marriage [13]. In our study, half of the women (n = 24, 49%) were single and had never been married before they left home. In comparison, in a study of North Korean women trafficked for marriage to China, there was a higher percentage of women who were married and had children before they were trafficked [10]. The rate of physical and/or sexual violence (16%) reported by the women pre-departure is lower than the prevalence rate of 32.7% for physical and/or sexual violence found in a populationbased study by Vung et al.'s [26] in rural Vietnam of 32.7%. This difference might be due to the relatively young age of women in our study. Unlike previous studies, women in this study were mainly deceived and did not know that they would be married to a Chinese man. Reasons for this difference might be the different sampling strategies. In Duong et al., women were also recruited into the study who explicitly went to China for marriage but found the situation there to be very different to what they expected or had been promised, highlighting the difficulty of making a clear cut distinction between a woman who is considered trafficked and a woman who finds herself in an abusive marriage to which she initially agreed [13]. In the study by Blanchet et al. about Bangladeshi girls trafficked to North India for marriage, not all girls knew that they would be'sold' into marriage, although the majority of them were aware that they would be married to a North Indian man. In addition, it was mainly their parents who had agreed to their marriage, as they were still under marriage age. Among women fleeing North Korea to China, none seem to have known that they would be trafficked and sold into marriage when they decided to leave North Korea [10,27]. This is in stark contrast to women who participate in mail order bride businesses to Western countries, who agree to marry a foreign spouse initially, but might become trapped in abusive marriages [5]. The profile of traffickers described by women in this study is similar to that of other studies, as traffickers were frequently female and close or distant relatives or from the same social network as the trafficked women or complete strangers [13]. While they were trafficked, women in this study experienced extremely high levels of violence (90%), including sexual violence, mainly by their husbands and traffickers. Other research has also highlighted this, noting the extremely high prevalence of physical and sexual abuse that women experienced by their Chinese husbands and families. They attributed this to the fact that many Chinese men who resort to marrying trafficked women suffer from mental health problems, aggressive behavior, and substance abuse [10,13]. North Korean women who were forced to marry Chinese men reported that husbands exerted additional control by threatening to report disobedient wives to immigration police, wellaware that the women feared repatriation and harsh-potentially fatal-consequences for themselves and their families in North Korea [27]. The studies of Korean women trafficked to be wives have also highlighted the systematic abuse by traffickers who rape and physically assault women to control them and make them compliant. Women are restricted in their response as they are anxioius to avoid detection by the Chinese police [10]. Nonetheless, it was interesting to find that a few trafficked wives in this study managed to escape the trafficking situation because they were released by their husbands. This is not entirely unusual, as other research has suggested that some Burmese women who were trafficked to be wives in China were permitted by their Chinese husbands and his family to return to Burma after the birth of their first child [9]. It was not uncommon for women in this study to be pregnant or leave behind a child or children in China, a fact that worried many of them. Duong et al.'s study explains in detail the legal complications associated with having a child that is not registered as Vietnamese [13], while other studies add that Chinese authorities do not repatriate Chinese born children of North Korean women when they are sent back [15] or highlight the potential stigma upon return when women had been trafficked into marriages with a partner of a different faith [14]. Trafficked women have to cope with these issues upon return, in addition to potentially strong symptoms of depression, post-traumatic stress disorder and anxiety, plus physical pains and illnesses, as identified in this study. The findings of this study have to be considered in light of several limitations. Although this study represents the largest sample size of a study investigating trafficking for marriage, the sample size was still too small to investigate significant patterns of association beyond descriptive analyses. As human trafficking is a criminal activity, its scope is difficult to explore and representative samples nearly impossible to achieve. The study is based only on clients of post-trafficking services, inclusive only of women who managed to return to Vietnam and receive assistance by a shelter. Data were not collected directly from women in China, which poses an important limitation that should be addressed in future research. The study was also limited because instruments to measure mental health symptoms were not diagnostic and have not been validated with trafficked wives before, although all scales had a high reliability for all three outcomes. Also, the study relied on selfreported data from women trafficked for marriage. Answers could therefore be influenced by the wish to give socially desirable answers, as well as shame about having been deceived into these situations. As this study was part of a larger study on human trafficking, some aspects could not be explored and need to be investigated in future studies on wife trafficking, such as to which locations in China women were trafficked or if women left children behind. The responses women gave to open-ended questions suggest the limitations of current survey tools, which need to be further developed to gain a greater understanding of this subpopulation. Nonetheless, our findings point to important issues that have rarely been considered in discussions on wife trafficking, such as women's particular social and health care needs after being trafficked for forced marriage. Medical assessment, especially psychological support, should be included in all post-trafficking services. Services should also consider types of support women who opt to return home might want to foster safe and sustainable reintegration. Our study also indicates that special assistance (e.g., health, legal) might be needed for women who are pregnant or have had children with their Chinese husbands. Importantly, intervention research is urgently needed to identify feasible and effective psychological support approaches to help women recover from their complicated past and look forward to a more promising future. Their children will also need targeted support as some of them may be stateless, having been born in China without registration. --- Conclusion There can be little doubt that bride-trafficking is, at its core, a profound expression of gender discrimination. It is a criminal abuse that is driven by deeply embedded social norms that accept, even promote, the concept that women can be treated as commodities. While our research clearly shows the need to support women who fall prey to this crime, these findings also strongly call out for sustained efforts to shift current gender norms towards the equal value and participation of women in society. --- Availability of data and materials The dataset analysed in the current study are not publicly available due to the sensitive nature of the research topic but are available from the authors (Dr Ligia Kiss and Cathy Zimmerman) on reasonable request. --- Authors' contributions HS designed and conduced the secondary data analysis and wrote the first draft of the paper. LK and CZ designed the original study, which was conducted with JK and DTD. All authors contributed to the analysis and commented on the manuscript. All authors approve the final version of the manuscript. --- Ethics approval and consent to participate The study was approved by the ethics committee of the London School of Hygiene and Tropical Medicine and the Hanoi School of Public Health in Vietnam. It complied with a strict ethics protocol based on the WHO Ethical Recommendations for Interviewing Trafficked Women [18]. --- Consent for publication Not applicable as no individual details are published. --- Competing interests The authors declare that they have no competing interests.

Background: Bride-trafficking has been a growing phenomenon in Southeast Asia, particularly in China, where one-child policies have resulted in demographic imbalances favoring males. Yet, empirical evidence about women and girls sold into marriage in China remains sparse. Methods: This study describes the experiences of 51 Vietnamese women and girls as young as 14 in post-trafficking services who were sold into marriage in China. A consecutive sample of individuals from five services in Vietnam were invited to be interviewed within the first 2 weeks of admission. It is part of a wider dataset for research on the health of men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam, the largest study to date on human trafficking and health. We calculated proportions for all variables and conducted bivariate analyses using Fisher Exact Tests for their associations with mental health disorders symptoms. Results: Before leaving home, 31% (n = 15) participants were married. Participants reported high levels of sexual violence (n = 43; 86%) while trafficked and59% (n = 30) spent time in detention before returning to Vietnam. Once in post-trafficking care 52.9% (n = 27) reported probable depression, anxiety or post-traumatic stress disorders (PTSD), two women (4%) attempted suicide in the past month and 38 (75%) remained afraid of their trafficker. Ten (22%) became pregnant while trafficked, and seven (16%) were pregnant at the interview. Conclusions: The cross-border bride trade between Vietnam and China raises complex policy issues, including questions about detention and immigration rights and strategies for supported return processes, including maternal and child health services. As the repercussions of China's absent female population will persist, Vietnam and China must grapple with the political and social conditions to implement prevention strategies, and resources for women who fall prey to this cross-border bride trade.

Introduction Given the ubiquitous nature of digital use among teens, adolescents, and emerging adults, it is perhaps unsurprising that technology is increasingly manifesting in their romantic and sexual relationships, including sending sexual texts, pictures or videos via digital mediums (sexting) [1][2][3]. Among emerging adults, smartphone ownership is estimated at approximately 95% [4,5], and data suggest that the vast majority are utilizing texting or social media on a daily basis [6,7]. Although early sexting prevalence estimates were widely variable based on methodological differences (2%-78%) [1,[8][9][10][11], several reviews and current data suggest that sexting behavior among emerging adults is statistically normative, with current individual study estimates suggesting that more than 50% of college students have sent a sext and at least 60% had received a sext [3,[12][13][14]. Recent meta-analytic data examining 50 studies and more than 18,000 emerging adults suggests slightly lower rates, with approximately 38% reporting sending a sext and 42% receiving a sext [15]. Additional findings indicate that roughly 48% of the combined samples reported reciprocal sexting, with publication date operating as a moderator such that more recent studies evidenced a higher prevalence of reciprocity of sexts [15]. These data align well with meta-analytic data on sexting behaviors among younger teens and adolescents, which suggest that both age and publication date were moderating factors associated with sexting, indicating that as individuals get older and as technology use has become more universal, sexting has increased [16]. The increase in availability of mobile devices, in tandem with the development of apps that reportedly enable private and convenient sharing of digital content (e.g., Snapchat), may have increased the accessibility and motivation for engaging in sexual behavior mediated through technology, including sexting, in the 10+ years since the advent of the smartphone. Because sexting was initially largely conceptualized as a potentially risky behavior among emerging adults, much of the existing research has focused on the association between sexting and a range of risk factors, including unprotected sex, STI diagnosis, substance use, sexual coercion, pornography use, risky internet use, and psychological distress [1,3,[17][18][19][20][21][22][23][24][25][26]. An additional area of concern related to sexting is the potential for coercion and aggression in interpersonal relationships that this behavior may afford. This is particularly important to consider given the high rates of intimate partner aggression (IPA) among emerging adults. IPA is a prevalent and serious public health concern that peaks in incidence among emerging adults, with current estimates suggesting that 20%-37% experienced physical aggression, and upwards of 70% experienced in-person psychological aggression [27][28][29]. Further, there are ample data to suggest that sexual coercion and aggression is common in this population, with current estimates suggesting approximately 13% of undergraduate students experience sexual victimization, with females being more likely to experience sexual aggression compared to males [30]. While several studies have examined aggression that occurs online among emerging adults (cyber dating abuse) [31], with some finding associations between the experience of cyberaggression and sexting [32,33], there has been only limited research examining the interactional relationship between in-person IPA and sexting behaviors. Morelli and colleagues [34] found that among moderate and high sexters, rates of IPA perpetration and victimization rates were higher, both in-person and online. There are also some data to suggest that sexting may be an additional mechanism through which sexual violence occurs. For example, in their sample of teens, Kernsmith, Victor, and Smith-Darden [35] examined the relationship between in-person sexual coercion and coercive sexting victimization and perpetration. Their data suggested that, compared to non-victims, victims of coercive sexting were at significantly higher risk of at least one form of in-person sexual coercion from their dating partner [35]. Similarly, Titchen and colleagues [36] demonstrated that teen sexting is associated with in-person sexual abuse in dating relationships, and other research involving incarcerated men has shown a relationship between sexting and sexual violence perpetration [37]. Data examining the interplay of IPA and sexting with emerging adults specifically suggested that IPA was significantly positively associated with sexting coercion [38]. Recently, Ross, Drouin, and Coupe [17] examined the relationship between different types of IPA and sexting coercion, particularly the cumulative effects of these experiences on mental health symptoms. The findings of this study suggested that individuals who experience IPA, sexual coercion, and sexting coercion in combination tend to experience the most severe psychological and sexual problems, compared to those who experience IPA alone. This suggests a pattern in which sexting coercion is presenting a cumulative risk, in combination with IPA, that contributes to increased psychological distress above and beyond the severity of the individual aggression experienced [17]. Although these data provide preliminary support suggesting a relationship between in-person IPA and sexting behavior, additional research is necessary to examine how in-person IPA impacts the experience and perceived consequences of sexting for emerging adults. Research examining risk behaviors has predominated the literature in sexting; considerably less research has focused on the potential consequential benefits of sexting [39]. Some data suggest that individuals perceive sexting as a way to continue to connect in a relationship, particularly during college when partners may be separated [10,40,41]. Additionally, researchers have shown that sexting is associated with increased sexual satisfaction [42] and relationship satisfaction [40,[43][44][45], though this may vary as a function of attachment style and gender. Recent latent profile analyses involving Americans and Canadians in cohabiting relationships [42], however, showed that nonsexters did not differ from those who sexted often (frequent and hypersexters) on relationship satisfaction, and sexters also fared worse in terms of other relationship markers, such as conflict, ambivalence, and attachment security. Other researchers have examined expectations and motivations for sexting and found that, particularly for men, emerging adults noted positive expectancies more often than negative expectancies and often cited motivations including flirtation, fun, sexual explorationand sexual initiation [10,42]. Among adults, Doring and Mohseni [46] found that, among those who had sexted, the perceived positive outcomes significantly outweighed perceived negative outcomes, and half of participants perceived no negative effects of sexting. Considerably less research has been conducted on the perceived consequences of sexting within the context of a particular relationship, which may be more illuminative in exploring the contexts in which positive outcomes are most likely to occur. Drouin, Coupe, and Temple [14] examined how relationship context (casual versus committed) may affect the perceived consequences of sexting. Although approximately 50% of the total sample reported positive or neutral outcomes related to sexting, this varied by gender and relationship type. In general, those in non-committed relationships and women reported fewer positive and more negative consequences than did those in committed relationships and men. However, this body of research is limited by the scope and depth of the positive consequences that were evaluated. For example, Doring and Mohseni [46] measured positive perceived outcomes through a general question ("How far has sexting had a positive impact on you?"), and Drouin, Coupe, and Temple [14] noted only emotional and sexual connection as possible "positive" consequences. This is a consistent limitation across a range of studies examining perceived positive outcomes of sexting [41]. As sexting becomes increasingly normative among this population, it is important to more systematically examine the range and context of potential desirable sequelae of sexting, as well as the various contextual and historical events that may contribute to the manifestation of sexting behavior, including IPA. Several theoretical explanations have been offered to help understand human behavior generally, and coercive and aggressive behavior specifically. Bell and Naugle [47] developed an integrated, contextual model of IPA that drew heavily on existing research and behavioral theory, which postulates that the consequences of behavior are important predictors of future behavior. More specifically, behavior that results in reinforcing consequences is expected to be more likely to occur again in the future, whereas behavior that leads to punishing consequences is anticipated to occur less frequently in the future. Previous research examining IPA consequences has demonstrated that perpetration is often influenced by reinforcing consequences, which may explain, in part, the perpetuation and stability of aggressive behavior over time and across contexts [48,49]. There are also data to suggest that perpetrators of aggression, particularly dating aggression, are unlikely to experience punishment as a result of their behavior [49,50]. Of particular interest here is the role of negative reinforcement in maladaptive relationship behaviors, such that behaviors increase in the future, but do so by reducing negative affect, getting their partner to cease a behavior, stopping an argument, or assuaging guilt. These processes may simultaneously increase behavior, but represent potentially problematic relationship dynamics that should be addressed. To date, this theoretical model has not been applied to the understanding of coercive sexting, but the extant literature provides sufficient justification for its application beyond IPA. While the initial research on sexting has been foundational to our understanding of this technology-mediated phenomenon, further research is necessary to understand how individual variables affect sexting behaviors. Critically, much of the initial research on sexting fails to differentiate between consensual and nonconsensual sexting behavior [1,[10][11][12]14,20,38,51], or explore the nuances of consensual sexting. In a recent qualitative study, Roberts and Ravn [7] found that participants articulated the subtle, tricky, and sometimes unclear process of ensuring consent in sexting, and the ambiguity inherent in the practice. Further, online sexting guidelines in popular media sources often advocate for consent in sexting [52], and yet there has been little empirical research examining consensual sexting in particular. While the research on sexting is relatively nascent, it is critical to differentiate sexting behaviors that are coerced, unwanted, or nonconsensual from those that occur in consensual interactions. Even in a systematic review entitled, in part, "Consensual Sexting among Adolescents" [9], an analysis of the studies included and the nature of the questions does not necessarily indicate consensual sexting (e.g., "Have you ever sent a sexually suggestive nude or nearly nude photo or video of yourself to someone else?") [11]. It is possible that the sending of this explicit material is not consensual, but could be influenced by partner pressure, coercion, or threats. Limited research has examined the role of unwanted but consensual sexting (i.e., willing engagement in technology-mediated sexual behavior that is unwanted). In one study with young adults [53], more than half of the sample indicated that they had engaged in unwanted sexting, and cited various motivations for doing so, including foreplay, flirtation, to fulfill the partner's needs, and, for some, to avoid an argument. Other research has found that receiving unwanted sexts or sending consensual but unwanted sexts independently predicted a range of psychological symptoms, including depression, anxiety, stress, and lower self-esteem [54]. Recent research examining consensual, active sexting further demonstrated that even in this "consensual context", approximately one third of participants reported pressure to sext, and sexting was consistently associated with poorer mental health outcomes for women specifically [55]. This further points to the need to continue to examine the psychological and coercive elements of sexting that is specifically identified as consensual. In order to continue to advance the field, research needs to be conducted to determine the possible behavioral, interpersonal, and relationship consequences of sexting behavior when it exists in the context of a consensual interaction. As speculated by leading researchers in this field, sexting may represent a normal extension of sexual development for technologically-immersed adolescents and emerging adults [7,15,52,56], and researchers have even advocated for "safe sexting" educational curricula [57]. This "normalcy discourse" [9] may suggest that sexting is a healthy expression of sexual desire and exploration of sexual desire among emerging adults. On the other end of the spectrum, sexting that is unwanted or coerced could represent an extension of IPA and sexual violence. If we are to better understand the nature of sexting, including the potential benefits and risks of sexting, it is critical to differentiate sexting that occurs in a normative, consensual context from that which does not, by examining it on its own. It is also imperative that we examine how an individual's historical experiences, including IPA, affect an array of consequential outcomes of sexting, even when it is considered by the sexter to be consensual. Therefore, the current project was designed to comprehensively examine a range of potential positive and negative consequences of sexting in the context of a consensual sexting episode. Because the data examining the consequences of sexting is limited, particularly related to positive outcomes, we sought to systematically and comprehensively examine those consequences within existing behavior analytic models of human behavior. Further, because it is possible that certain life experiences or circumstances, including history of IPA victimization, may contribute to unique vulnerabilities related to sexting, this research also examined how an individual's victimization history differentially impacted the context and consequences of consensual sexting. Based on the extant literature, we hypothesized: Hypothesis 1 (H1). Emerging adults, both men and women, would report that, despite labeling their sexting experience as consensual, they experienced coercion and pressure to sext. --- Hypothesis 2 (H2). Significant positive associations would occur between sexting coercion and all forms of IPA. --- Hypothesis 3 (H3). Individuals reporting IPA victimization, as compared to those who did not report IPA victimization, would report different consequences from their sexting experiences, including higher rates of overall punishing consequences, as well as negative/positive punishment (H3a), and lower rates of overall reinforcement, both positive and negative (H3b). --- Methods --- Participants Undergraduate students (N = 536; 77.2% female) were recruited from psychology courses at a large, public, Midwestern university to participate in the present study. To be eligible, participants were required to be at least 18 years of age at the time of the study and report that they had "sent a consensual sext (a sexually explicit picture or video through any technological medium)" in their adult life. Participants' mean age was 19.00 years (SD = 1.67; range = 18-36), and most identified as heterosexual (86.6%). Consistent with the demographics of the university, most students identified as Caucasian (87.9%), with 7.3% of the sample identifying as Hispanic/Latino. Academically, most students were freshmen (67.1%), followed by sophomores (20.1%), juniors (8.6%), seniors (3.4%), and one person identifying as "Other". The majority of participants (59.3%) reported currently being involved in a dating or intimate relationship. --- Procedure All procedures and methods were reviewed and approved by the research ethics board at the university associated with the first author. Participants were recruited between February 2019 and March 2020 through an introductory psychology research portal that provided a brief description of the study and the eligibility requirements, and participants received class credit for signing up and participating in the study. Interested and eligible participants were provided with a link to an online survey website (e.g., Qualtrics) that used encryption to maintain participant confidentiality. The survey was designed to be completely anonymous, IP address collection was disabled, and no personally identifying information was collected. Following completion of the online informed consent documents, participants were provided with a series of measures to complete. At the conclusion of the study, participants were provided with the name, email address, and phone number of the first author in the event that they experienced distress resulting from the research. They were also provided with a list of local and campus referrals for domestic violence and counseling services. --- Measures Demographics. Participants indicated their age, academic standing, dating, sexual, and sexting history, ethnicity, gender, and sexual orientation. Sexting Experiences. Using an open-response format, participants reported the number of different people to whom they had ever sent a sext (defined as "a sexually explicit picture or video through any technological medium (text message, Snapchat, Instagram, Messenger, or any other application) the number of different people from whom they had received a sext, the estimated lifetime prevalence of sexts sent and received, and the age at which they had first sent and received sexts. Sexting Context. In order to direct participants to think about a specific instance and relationship context in which they had sent a consensual sext, participants were instructed to "Think about the most recent person with whom you sent a consensual sext (sexually explicit picture or video message) through any technological medium." They were asked to describe the degree to which the person was known to them (not well, a little, fairly well, very well), how long they knew them, the gender of the person with whom they sexted, the nature of the sext (sexually suggestive but clothed, nearly nude, nude, picture or video of sexual act or masturbation), and the age at which they sexted this person. They also indicated the type of relationship in which this sexting occurred: friends with benefits, one-night stand, fuck buddy, booty call, cheating partner, committed partner, someone they knew only online, or a casual dating partner. Sexting Consequences. To measure the consequences of consensual sexting, an in-depth questionnaire was designed to gather comprehensive information on the context and dynamics surrounding the specific episode of consensual sexting. The questionnaire was conceptualized from a functional analytic perspective and was modified from existing interviews assessing contextual variables in intimate partner violence [49,58]. To provide an inclusive and widespread analysis of possible consequences framed within behavioral theory, a range of various possible outcomes and their potential operant functions were included. This included questions related to a range of potential positive reinforcers resulting from the sext, both at the individual and relationship level (e.g., "After you sent the sext, did your partner seem more emotionally connected to you?"). This subscale included 24 items. Nine items were included that captured possible individual and relational negative reinforcing consequences, reflecting avoidance or escape of aversive outcomes that might increase the likelihood of sexting in the future (e.g., "Did you feel less lonely after sending the sext?"). A total reinforcement subscale was created by summing scores from the positive and negative reinforcement subscales. Finally, we included a range of potential punishing consequences, which presumably would decrease future sexting activity. These included items such as "Did you feel ashamed after sending the text?" and "After you sent the sext to your partner, did you find that you were less satisfied with your relationship with your partner?", again, assessing potential punishers at the individual and relationship level. Though these 28 items were conceptualized to capture both negative and positive punishers, for ease of interpretation they were collapsed into one punishment subscale. The internal consistency of all subscales was good (positive reinforcement, <unk> = 0.940; negative reinforcement, <unk> = 0.830; reinforcement, <unk> = 0.945; punishment, <unk> = 0.932). The items that comprised this measure are listed in Appendix A, Tables A1 andA2. IPA. The Revised Conflict Tactics Scale (CTS2) [59] is one of the most commonly utilized measures examining IPA and has demonstrated good reliability and validity in prior research. This 78-item measure assesses physical, sexual, and psychological aggression that has occurred in the past year. Participants indicated how frequently they had perpetrated and been victimized by each behavior on a 7-point scale ranging from 0 (this never happened) to 6 (more than 20 times). Variety scores were calculated [60] to provide count data on perpetration and victimization of each form of IPA in the past year. Dichotomous variables were also created to reflect the occurrence or non-occurrence of perpetration and victimization for each type of IPA in the past year. In the present study, only the victimization subscales were utilized. Consistent with prior literature, internal consistency estimates of the variety scores for each subscale were adequate (psychological victimization <unk> = 0.745; physical victimization <unk> = 0.885; sexual victimization <unk> = 0.660). Sexting Coercion. A modified version of the 34-item Sexual Coercion in Intimate Relationships Scale (SCIRS_S) [61] was utilized to measure sexting coercion in their current or most recent intimate relationship. The measure differentiates between different types of coercive acts in sexting and has been used in other research to assess sexting coercion [17]. Participants were presented with a series of potentially coercive acts (e.g., "My partner persisted in asking me to send them a sexually explicit picture or video, even though I did not want to") and asked to rate this on a 6-point scale ranging from 0 (act has not occurred) to 5 (act occurred 11+ times). This measure includes a total score, as well as subscales that examine coercive acts in which gifts or benefits are withheld or threatened to be withheld (Resource Manipulation: RM), coercive acts related to the couple's relationship and access to sexting (Commitment Manipulation: CM), and threats to pursue relationships with other people if sexting does not occur (Defection Threat: DT). Cronbach's alpha for this measure was 0.910 for the total score, and good for all subscales (RM <unk> = 0.928; CM <unk> = 0.924; DT <unk> = 0.945). --- Results --- Sexting Experiences and Gender All participants included in the sample reported a history of sending at least one sext and 94% of the sample also reported a history of receiving a sext. Within the entire sample, the average number of sexts sent to another person was 33.15 (SD = 38.06) and the average number of sexts received from another person was 43.96 (SD = 47.93). The average age of sending a first sext was 16.57 years old (SD = 1.69) and the average of receiving a first sext 16.15 years old (SD = 6.94). On average, participants reported receiving sexts from approximately six different people (M = 6.12; SD = 5.89) and sending sexts to about four different people (M = 3.69; SD = 3.33). Within their most recent consensual sexting relationship in which they sent a sext, the average number of sexts sent was 41.28 (SD = 108.43) and the average number of sexts received was 36.94 (SD = 102.22). In terms of relationship context, 52.4% of the sample stated that their sext was sent to a casual dating partner, whereas 47.6% reporting sexting in the context of a committed relationship. Table 1 provides a summary of sexting consequences for the entire sample. Men and women did not differ significantly in number of sexts sent and received, age of first sexting activities, and number of people engaged with in sexting activities. Table 1 provides a summary of gender differences in sexting consequences. Women reported experiencing significantly more punishing consequences after sexting (M = 6.08, SD = 6.52) than men reported (M = 4.58, SD = 5.54), t(229.34) = -2.52, p = 0.01. No other significant gender differences in sexting consequences were identified. --- Relationship between Sexting Experiences and IPA Approximately 57% of the entire sample reported a history of psychological IPA victimization in the past year. Additionally, 17.2% of the sample endorsed a past year history of physical IPA victimization and nearly 32% of the sample reported experiencing sexual IPA victimization in the past year. The average number of IPA acts experienced in the past year was 1.41 (SD = 1.47) for psychological IPA victimization, 0.49 (SD = 1.32) for physical IPA victimization, and 0.61 (SD = 1.00) for sexual IPA victimization. Men and women did not differ significantly in their reporting of victimization experiences for any IPA form. Individuals with a history of psychological IPA victimization reported being younger when receiving (M = 15.75, SD = 1.78) and sending (M = 16.38, SD = 1.69) their first sexts relative to those without a psychological IPA victimization history (M = 17.15, SD = 11.74; M = 16.96, SD = 1.65), t(451) = 1.98, p = 0.048 and t(479) = 3.68, p = 0.00, respectively. Participants with a sexual IPA victimization history also reported being younger when sending their first sexts (M = 16.26, SD = 1.68) relative to those without a sexual IPA victimization history (M = 16.77, SD = 1.68), t(479) = 3.19, p = 0.00. Additionally, those with a sexual IPA victimization history reported sending (M = 4.43, SD = 3.52) and receiving (M = 7.28, SD = 6.16) sexts with a larger number of people than those without a sexual IPA victimization history (M = 3.08, SD = 2.98; M = 5.17, SD = 5.45), t(298.43) = -4.22, p = 0.00 and t(297.47) = -3.62, p = 0.00, respectively. Those with and without a history of physical IPA victimization did not differ in number of sexts sent and received, age of first sexting activities, or number of people engaged with in sexting activities. --- Relationships between Sexting Coercion and IPA Approximately half of the sample (49.2%) reported consenting to send sexts when they actually did not want to, on at least some occasions. Nearly 28% of the sample said they felt at least a little coerced about sending the first sext in their most recent consensual sexting relationship, with 41.8% of participants stating that they felt some pressure to send the first sext. Beyond the first sext, 22% of the sample said that they felt pressured or coerced to send sexts on other occasions. Table 1 provides a summary of means and standard deviations for the entire sample's total SCIRS_S scores and each of the SCIRS_S subscale scores, along with comparisons between men and women on SCIRS_S total and subscale scores. No gender differences in SCIRS_S scores were identified in the sample. Men and women did not differ significantly in how often they consented to sending a sext when they did not want to nor the extent to which they felt pressured or coerced when sending the first sext in their most recent consensual sexting relationship. Those with a physical IPA victimization history were more likely to report feeling coerced to send the first sext in their most recent sexting relationship (M = 1.60, SD = 0.94) than those without a physical IPA victimization history (M = 1.37, SD = 0.75), t(120.10) = -2.18, p = 0.03, and those with a sexual IPA victimization history reported greater pressure to send the first sext in their most recent sexting relationship (M = 1.58, SD = 0.94) relative to those without a sexual IPA victimization history (M = 1.76, SD = 0.91), t(353.70) = -1.99, p = 0.048. As reflected in Table 2, SCIRS_S total and subscale scores were positively correlated with all forms of IPA victimization. Tables 3-5 summarize comparisons in SCIRS_S total and subscale scores between those with and without IPA victimization histories. Those with a physical or sexual IPA victimization history, relative to those without a physical or sexual IPA victimization history, had higher SCIRS_S total and all SCIRS_S subscale scores. People with a psychological IPA victimization history reported higher SCIRS_S total, SCIRS_S-RM, and SCIRS_S-CM scores than those without a psychological IPA victimization history. --- Relationships between Sexting Consequences and IPA Tables 3-5 summarize differences in sexting consequences based on IPA victimization history. Across all three forms of IPA victimization, those with an IPA victimization history reported experiencing more negative reinforcing consequences after sending a sext than those without an IPA victimization history. Those reporting a physical and sexual IPA victimization history also reported experiencing more punishing consequences after sending a sext compared to those without a physical or sexual IPA victimization history. Compared to those without a sexual IPA victimization history, those with a history of sexual IPA victimization reported greater overall reinforcing consequences after sending a sext. --- Discussion As electronic sexual communication has become more commonplace, researchers have explored the positive and negative correlates and outcomes of sexting. Overall, these studies have shown that sexting more frequently in relationships is related to sexual satisfaction [42], and in some cases, relationship satisfaction [40,[43][44][45]; however, sexting is also related to myriad of negative correlates, including conflict, ambivalence, and insecure attachment patterns [42]. Moreover, and more relevant to the current inquiry, sexting, especially unwanted or coerced sexting, has been found to relate to negative psychological symptoms, dating violence, offline sexual coercion, and IPA e.g., [34,35,42,54]. At the same time, a separate line of research has examined motivations for and outcomes of sexting, finding that most individuals have positive expectations regarding the outcome of sexting and do so for fun, flirtation, or to initiate sex [10,20]. Additionally, most individuals report more positive than negative immediate outcomes of sexting [14,46]. Hence, a duality exists whereby the motivations, expectations, and immediate outcomes for sexting are reported to be mostly positive, but relationship correlates are often negative. In this study, we combined and expanded these lines of inquiry to examine the extent to which IPA is associated with coercive sexting experiences and also whether those who experience IPA, compared to those without a recent IPA history, differ in their experiences of positive and negative consequences of sexting. Finally, unlike previous studies, we specified examined coerced sexting and positive and negative consequences within the context of sexting experiences that participants deemed consensual. In our sample of sexters, sexting was common-young adults reported sending an average of 41 sexual pictures or videos to their last relationship partner alone. Additionally, we found that both IPA and coercive sexting were common in our sample, with more than half of participants (57%) reporting some type of IPA history (psychological IPA was most common), almost half (49%) reporting that they had felt coerced to sext, and one quarter (28%) reporting that they felt pressured into sending the first sext in their last consensual sexting experience. The high rates of both IPA and sexting coercion were not unexpected; they align with previous research on both the prevalence of IPA and sexting coercion [17,38]. The presence of pressure and coercion within sexting episodes characterized as consensual was also expected (supporting our H1), and this finding gives some context to the previous literature on coercive and unwanted sexting [38,53]. Namely, it suggests that at least some of the coercive sexual experiences, and perhaps even some deemed traumatic to these participants, were considered consensual acts. Unexpectedly, gender differences did not emerge with regard to IPA or sexting coercion, which was somewhat inconsistent with previous research. For example, recent data found that women were 2.49 times more likely to be pressured to sext, and 5.06 times to be threatened related to sexting [55]. Our data did not suggest such gender differences, perhaps due to measurement and methodological differences. From a research perspective, this finding suggests that more delineation and nuance is warranted in investigations of unwanted and coerced sexting, exploring the ways in which consent, coercion, and unwanted sexual behavior manifest across sexting episodes and/or different relationship types. Meanwhile, in terms of practical implications, these findings suggest that more discussion and education is necessary regarding the definition of sexual coercion and the negotiation of consent within online sexual experiences, as it is a complicated process [7]. Clearly, teens and young adults need to be equipped with communication and negotiation strategies to help them recognize and resist sexual coercion online, particularly because sexting episodes that are deemed coercive are likely to cause individuals (especially women) trauma both at the time they happen and in future, when the coerced party looks back on the event [38]. This could perhaps be embedded within sexual education in the form of "safe sexting" lessons [57] or even in health classes as part of a module on healthy relationship communication patterns and sexual harassment. Regarding our second hypothesis, as predicted, the experience of all types of IPA victimization (psychological, physical, and sexual) in the last year was significantly related to all subscales of coercive sexting in the current or most recent relationship. Moreover, those who experienced these different forms of IPA were significantly more likely than those who did not experience these forms of IPA to report nearly every type of sexting coercion (with the exception that was there was no difference in experiences of defection threat among those who did and did not experience psychological IPA). Our findings support previous research suggesting that coerced sexting is related to partner victimization [34,35,42,54,55] and again reinforce the idea proposed by Ross et al. [17] that sexting coercion be considered part of the construct of IPA. As partner victimization and coercive control extend to digital formats, it will be important to reconceptualize common definitions of IPA and sexual harassment to include digital violence. Additionally, it may be important for advocates to provide education to individuals that digital mechanisms might be used to perpetrate different types of partner aggression, including stalking, sexual aggression, sexual harassment, physical aggression (in

Recent empirical data suggests that the majority of adolescents and emerging adults utilize digital technology to engage with texting and social media on a daily basis, with many using these mediums to engage in sexting (sending sexual texts, pictures, or videos via digital mediums). While research in the last decade has disproportionately focused on the potential risk factors and negative consequences associated with sexting, the data are limited by failing to differentiate consensual from non-consensual sexting and account for potential influences of intimate partner aggression (IPA) and sexting coercion in these contexts. In the current study, we assessed the positive and negative consequences associated with sexting, using behavioral theory as a framework, to determine the relationship between an individual's personal history of IPA victimization and the perceived consequences. Undergraduate students (N = 536) who reported consensual sexting completed a series of measures examining their most recent sexting experience, including perceived sexting consequences, and their history of sexting coercion and IPA. Results suggested that those reporting a history of any type of IPA victimization endorsed more negative reinforcing consequences after sending a sext, and those with a history of physical or sexual IPA victimization endorsed more punishing consequences after sending a sext than those without such history. Additionally, experience with IPA was found to be positively correlated with perceived pressure/coercion to send a sext. The implications of these data for research, policy, prevention, and intervention are explored.

IPA victimization (psychological, physical, and sexual) in the last year was significantly related to all subscales of coercive sexting in the current or most recent relationship. Moreover, those who experienced these different forms of IPA were significantly more likely than those who did not experience these forms of IPA to report nearly every type of sexting coercion (with the exception that was there was no difference in experiences of defection threat among those who did and did not experience psychological IPA). Our findings support previous research suggesting that coerced sexting is related to partner victimization [34,35,42,54,55] and again reinforce the idea proposed by Ross et al. [17] that sexting coercion be considered part of the construct of IPA. As partner victimization and coercive control extend to digital formats, it will be important to reconceptualize common definitions of IPA and sexual harassment to include digital violence. Additionally, it may be important for advocates to provide education to individuals that digital mechanisms might be used to perpetrate different types of partner aggression, including stalking, sexual aggression, sexual harassment, physical aggression (in the form of threats), and psychological aggression. Hypothesis three, related to the different consequences of sexting based on history of IPA victimization, was partly supported. Those who reported physical and sexual IPA victimization perceived more punishing consequences overall, as anticipated. These findings were particularly salient for females, as they were more likely to identify punishing consequences, compared to males. These findings provide an additional context for examining prevailing data with regard to gender differences in sexting. While some research has noted that males and females engage in sexting at similar rates [14,16], it appears that the experience of sexting may differ across gender, further necessitating a more nuanced approach to prevention and education. These data suggest that despite commonly identified motivations of fun, flirtation, and relationship satisfaction, particularly for those with a history of physical or sexual victimization, these motivations may not be the reality of their experiences. Rather, it appears that they are more likely to experience undesirable outcomes of consensual sexting, including regret, embarrassment, trauma, and shame, compared to their non-victimized counterparts. Additionally, recent research examined the interrelationship of sexting and online sexual victimization, and found that for females specifically, these experiences were correlated with poorer mental health [55]. These negative experiences are similar to the undesirable consequences reported by individuals who engage in unwanted sexting [54] and suggest that sexting coercion, unwanted sexting, and the experience of IPA are intertwined in complex ways. Interestingly, those who had experienced any form of IPA victimization (psychological, physical, or sexual) reported significantly more negatively reinforcing sexting experiences than those who had not experienced those forms of IPA. With regard to the negative reinforcement effects, this finding aligns somewhat with Drouin and Tobin's [53] findings that some women (those who were anxiously attached to their partners) were more likely to engage in unwanted sexting because they wanted to avoid an argument with their partner. In both the current research and this previous study [55], the removal of an unpleasant stimulus served to increase a sexting behavior that was either unwanted or considered coercive. Although removal of an unpleasant outcome is not inherently bad from a behavioral perspective, those who are pressured into sexting to avoid an argument or discord with a partner may be more likely to experience regret or trauma, especially if the sexting was considered coerced [38]. This finding has important implications for prevention and education efforts, as it further emphasizes the need to explore issues of coercion and pressure in sexting, and ensure that if a person chooses to engage in the sharing of sexual images, this is done for relationship and individual enhancement (i.e., positive reinforcement), rather than to alleviate guilt or partner pressure. Finally, our finding that those who experience sexual IPA victimization are also significantly more likely than those who do not experience sexual IPA to have positive sexting consequences overall highlight the dualistic nature of sexting, in general: it is motivated by both positive (to some) and negative (to some) feelings, and can have both positive and negative consequences. However, it is important to note that those who experience sexual IPA victimization appear to have more of this duality in their experiences, which poses a clinical challenge in that it may be difficult to make individuals cognizant of the punishments from sexting if their behaviors are also being reinforced in some way. --- Limitations and Future Directions The results of this study provide an important contribution to the understanding of consent and perceived consequences (both positive and negative) related to sexting. However, these results should be interpreted in light of their limitations. First, the relative homogeneity of our sample may limit the generalizability of our results. All participants were college-attending and a majority identified as heterosexual and/or Caucasian, which prevented any analysis on how the nature of consent and consequences of sexting may vary as a function of race, culture, or sexuality. Some research has determined that online and long-distance dating may be more prevalent in non-heterosexual relationships; however, the impact of sexting in these relationships has yet to be explored [62,63]. Additionally, this sample was recruited from a psychology course research pool that was predominately composed of female students, further limiting the generalizability of our results and our ability to detect gender differences in sexting, sexting coercion, and IPA. Second, the cross-sectional nature of this study renders analysis of temporal relationships between variables and causal hypotheses impossible. Specifically, we were unable to assess whether a causal relationship between experience of IPA and perceived consequences of sexting exists. Third, all variables were collected via self-report measures which introduced the potential for socially desirable responding. Studies have indicated that sexting is relatively stigmatic in our current social and legal environment, with some even referring to sexting as a potential deviant behavior [64,65]. It is possible that participants may be less likely to report some sexting behaviors due to the high level of stigma they may experience. Future studies should statistically control for potential socially desirable responding when possible. Finally, results should be interpreted in light of the limitations of the measures employed in this research. The use of a measure of sexting consequence that has not been validated in this population is a limitation, and future research on the psychometrics of this measure as well as with other populations is necessary. Additionally, while the CTS2 is widely used within the field of IPA research, this is a behaviorally specific measure that fails to adequately address motivation, context, or consequences of IPA. The internal consistency of CTS2 items measuring sexual coercion has been found to be weaker than the internal consistency of the CTS2 items assessing psychological and physical IPA [66], which may have impacted the current study's findings. Within the current study, the internal consistency of the CTS2 sexual coercion subscale was lower than the other CTS2 subscales, with the internal consistency of this subscale being particularly low for men (<unk> = 0.46), relative to women (<unk> = 0.68). Poor internal consistency for the CTS2 sexual coercion subscale could have impacted detection of true but unknown gender differences in sexual IPA victimization rates. Future research in this field should consider the addition of other measures to more broadly assess forms of IPA, especially sexual IPA victimization, and determine contextually-specific features of IPA and sexting coercion. While our data provide an initial examination of the perceived consequences for consensual sexting, future research is necessary to continue to understand the nuances of coercion, IPA, contextual control, and gender in sexting scenarios for emerging adults. In the current sample, there were no differences between men and women on rates of IPA, including sexual victimization and sexting coercion. While some previous research has found similar rates of sexual victimization in dating samples e.g., [67], future research should further elucidate whether these findings endure in samples with higher rates of gendered sexual victimization. Additionally, future research should consider comprehensive examination of perceived consequences across relationship type, including casual sexual relationships, and the interrelationships with IPA. While this inquiry was outside the scope of the current project, other research has demonstrated differences in consequences across relationship type [14], and integration of these methods would improve our understanding of coerced sexting in a range of contexts. Finally, this research should be examined in light of existing research on sexual harassment, both in terms of the overlap between this construct and sexting coercion and IPA, and to determine how sexual harassment differs from sexting coercion in self-identified consensual contexts. This research would greatly expand the complexity of our understanding of sexting in the range of contexts, situations, and relationships in which it occurs, and lead to more informed education and prevention efforts. In summary, critical to our inquiry was the use of a behavioral framework to categorize sexting consequences. To our knowledge, this is the first time this framework has been applied to sexting behavior; however, the use of this framework allowed us to delineate sexting consequences in ways that may help us better understand why individuals engage in sexting within different relationship contexts. Overall, our findings suggest that even in the context of consensual sexting, coercion and pressure is often present, particularly for those who have experienced coercion in other contexts. Our data further emphasize the interrelationship between IPA and sexting coercion, which has important implications for the conceptualization of aggression that occurs in relationships, as well as educational efforts. Our data suggest that while individuals with a history of some forms of IPA victimization report more punishing consequences, they also report reinforcing consequences, particularly negative reinforcement. These data provide a critical context in which to recognize the complexity of sexting and sexting coercion, and the potential outcomes of such sexting for some individuals. While behaviors maintained via negative reinforcement are not inherently problematic, it is worth considering, and educating, individuals on whether their sexting is rooted in achieving desirable outcomes or alleviating unpleasant emotional or relationship states. Particularly in light of recent conceptualizations of sexting as a developmentally normative behavior, it is worth challenging adolescents and emerging adults as to the reasons and motivations for sexting, to ensure that such behavior is not grounded in problematic interpersonal and intrapersonal processes. + indicates that it was originally conceptualized as positive punishment.

Recent empirical data suggests that the majority of adolescents and emerging adults utilize digital technology to engage with texting and social media on a daily basis, with many using these mediums to engage in sexting (sending sexual texts, pictures, or videos via digital mediums). While research in the last decade has disproportionately focused on the potential risk factors and negative consequences associated with sexting, the data are limited by failing to differentiate consensual from non-consensual sexting and account for potential influences of intimate partner aggression (IPA) and sexting coercion in these contexts. In the current study, we assessed the positive and negative consequences associated with sexting, using behavioral theory as a framework, to determine the relationship between an individual's personal history of IPA victimization and the perceived consequences. Undergraduate students (N = 536) who reported consensual sexting completed a series of measures examining their most recent sexting experience, including perceived sexting consequences, and their history of sexting coercion and IPA. Results suggested that those reporting a history of any type of IPA victimization endorsed more negative reinforcing consequences after sending a sext, and those with a history of physical or sexual IPA victimization endorsed more punishing consequences after sending a sext than those without such history. Additionally, experience with IPA was found to be positively correlated with perceived pressure/coercion to send a sext. The implications of these data for research, policy, prevention, and intervention are explored.

Introduction Currently, 88 million tonnes of food are wasted in the European Union (EU-28) every year. This represents 173 kg per capita or 20% of the EU's annual food production, and is projected to increase by 40% by 2020 if no action is taken. Over 50% of this food waste occurs at the household level (Stenmarck et al. 2016), a pattern seen across many developed regions (Gustavsson et al. 2011;Buzby et al. 2016). The causes of food waste are complex and operate at a number of inter-related levels in the supply chain (High Level Panel of Experts (HLPE) 2014; Mena et al. 2014;Parfitt et al. 2010). Actions taken upstream in the food supply chain may affect the amount of waste produced downstream, including households. For example, manufacturers in conjunction with retailers may set expiry dates, in particular best before dates, very conservatively (Priefer et al. 2016). Evidence suggests that even small increases in shelf life could result in a significant reduction in food waste at the household level (WRAP 2013b(WRAP, 2015)). There are therefore valid questions about the extent of responsibility that households have for the food waste they produce or efficacy in reducing it. In particular, recent sociological research has highlighted how food waste is simply a consequence of everyday life and the constraints faced by modern households (Evans 2011(Evans, 2012)). However, other research suggests that there are inter-related behaviours, over which households have control that are associated with lower levels of food waste (WRAP 2013a; Quested et al. 2013). As regards the household behaviour towards food waste, the Waste and Resources Action Programme (WRAP) monitors nine key behaviours on a regular basis which are believed to lead to lower levels of household food waste: planning meals in advance, checking levels of food in cupboards prior to shopping, making a shopping list, storing meat and cheese in appropriate packaging, storing all fruit (except bananas) in the fridge, using the freezer to extend the shelf-life of food, portioning rice and pasta, using up leftovers, and using date labels on food (Quested et al. 2013). Different types of households cite different reasons for wasting food; for example young professionals tend not to plan meals, whereas young families report being sensitive to dates and cook too much (WRAP 2007). More evidence is required to understand the antecedents of these behaviours and therefore how behaviour might be changed. This research will focus on one of these behaviours, the use of date labels on food. The European Union (EU) labelling requirements for food products are currently specified in Regulation (EU) No 1169/2011 (European Union 2011). This regulation contains the list of mandatory food information to be included in all food labels from December 2016 onwards. The list includes the date of minimum durability or the 'use by' date. The regulation also specifies the way it shall be expressed as well as for which products it is not required such as fresh fruit, wines, alcoholic beverages, salt, sugar, etc. Most pre-packed food requires the date of minimum durability or 'best before' date and only for the case of food products with potential microbiological hazards is the 'use by' date required. Therefore, after the 'use by' date a food product shall be deemed to be unsafe in accordance with Article 14(2) to (5) of Regulation (EC) No 178/2002. Dissimilarly, the 'best before' date refers to quality issues distant to food safety ones. A number of authors reported the current food date labelling system as a barrier to the management of food from both food waste and food safety perspectives (Priefer et al. 2016;Broad Leib et al. 2016;Rahelu 2009;Food Standards Agency (FSA) 2016; TNS European Behaviour Studies Consortium (EBSC) 2014). Most recently, evidence from the USA indicates that simplifying and clarifying expiry date labelling could be one of the most cost-effective ways to reduce food waste (Broad Leib et al. 2016). This research seeks to build on these findings by analysing the extent to which knowledge of the difference between 'best before' and 'use by' dates and the frequency of date label checking affect the use of date labels on food (such as willingness to eat non-perishable foods when a best-before date is missing) across socio-demographic groups and across the Western, Eastern and Mediterranean EU-28. The reason for estimating the model in these three regions is due to the fact that, while date labelling in EU countries follows food Regulation (EU) No. 1169/2011 of the European Parliament and Council, each country transitions from a different regime and the speed and type of rollout of the legislation across countries may affect the level of date labelling knowledge of their citizens. The EBSC eightcountry study (2014) found Finland and UK respondents to be more knowledgeable than those from other countries. However, no clear north-south patterns were identified. Jo <unk>rissen et al. ( 2015) compare food waste behaviours in Italy and Germany and conclude that attitudes towards the handling of and regard for food are more influenced by social class and educational level than by nationality. In terms of linking date labelling knowledge and behaviour to food waste prevention, there are significant differences across the EU-28 (European Environment Agency 2015). As highlighted through this research, the relationship between knowledge and behaviour is affected by a range of attitudinal and social factors, and is linked to the different ways of shopping and cooking. The way country effects play out for food waste needs to be better understood (EBSC 2014) and this research attempts to add to the current evidence. The research is structured in five sections: subsequent to the introduction, the next section describes the research hypotheses and the conceptual model, followed by the presentation of data and methods, discussion of results and conclusions. --- Research hypotheses and conceptual model To understand the influence of date label understanding on date label usage, a conceptual model (Fig. 1) was developed to describe part of the household reasoning process that supports food waste generation. Namely, it attempts to identify the influence of date marking in the decision-making process concerning food waste generation taking into account socio-demographic characteristics, understanding of date labelling and behavioural control aspects such as the perceived need for clearer information about date labelling and frequency of checking date labels. The conceptual model is consistent with the following research hypotheses based on findings from the food waste literature: Hypothesis 1 Socio-demographics (age, education and occupation) have an influence on (a) date marking understanding; (b) behavioural control regarding the appropriate use of date marking; and (c) behaviours associated with lower food waste. A number of studies have indicated that socio-demographic characteristics have an influence on knowledge and use of date labels (WRAP 2011;Broad Leib et al. 2016;EBSC 2014;van Boxstael et al. 2014). WRAP (2011) found that older respondents paid less attention to date labels than younger respondents in the UK. This may be related to the fact that older people have learnt to trust and use their senses instead of labels better than younger generations; however it may appear to be in contradiction with the established evidence regarding the stronger food safety perceptions of the adult consumers as compared to the younger ones (Sanlier 2009). Younger respondents are found to be more likely to misinterpret 'best before' date labels-believing them to be indicators of food safety and using them as a risk indicator-and thus more likely to discard food past the date on the label (Broad Leib et al. 2016). On the contrary, older respondents were more likely to misinterpret 'use by' dates-believing them to be indicators of food quality, and potentially exposing themselves to a food safety risk. This is consistent with results of other studies which found a negative relationship between the age of consumers and the amount of food waste generated (Quested et al. 2013;Van Garde and Woodburn 1987;Watson and Meah 2012;Visschers et al. 2016). A recent study of eight European countries found that young male consumers had the best knowledge on these issues, even though overall 'best before' dates were misinterpreted more often than not by all categories of consumers (EBSC 2014). A Belgian study found that more than two thirds of respondents knew the difference between 'best before' and 'use by' (Van Boxstael et al. 2014). They found that older respondents (65?) were more familiar with date labelling overall, and in contrast to the WRAP (2011) study, 'best before' was better understood by younger respondents whereas 'use by' was best understood among the older respondents. However, it should be noted that the Belgian study only asked respondents to indicate their subjective knowledge with the question ''Do you know the labels 'use by' and 'best before'?'' The difference between the results of the above-mentioned studies indicates that, although socio-demographics seem to have an influence on the knowledge of and use of date labelling, there is mixed evidence about the sign of their effects. Employment status is another socio-demographic factor found to have an impact on household food waste (WRAP 2014). Specifically, those households where the main earner was retired were less likely to throw food away when past the date on the packaging. While there is a relationship between age and retirement, employment status still had a statistically significant effect when age was controlled for. Gender has not been found to have a significant effect on consumers' knowledge of date labels (Van Boxstael et al. 2014;WRAP 2011), though women were shown to be marginally more aware that 'use by' marking had food safety implications (no statistical significance was reported) (WRAP 2011). However, in wider food waste studies some gender differences have been observed. For example, WRAP (2014) found that more avoidable food and drink waste was reported by women in the kitchen diary measures of food waste. Mallinson et al. (2016) also found that one of the clusters (''Kitchen Evaders'') reporting high levels of food waste included a high proportion of young women. This finding was supported by Visschers et al. (2016); however here the composition of the female respondent's households tended to be the driving factor. They concluded in fact that specific household situations could override strong intentions, attitudes and norms to reduce food waste. The ''Kitchen Evaders'' cluster of Mallinson et al. (2016) was also the cluster with the lowest reported level of education, with the majority not having studied beyond A-level. Higher levels of education seem to be associated with waste of certain types of foods, e.g., fruits and vegetables (Visschers et al. 2016). However, it is not clear to what extent this might reflect differences in purchasing patterns. Hypothesis 2 Date labelling understanding has an influence on frequency of use of date labels and behaviours associated with lower food waste. Adding to the effect of socio-demographic factors on both knowledge/ understanding of date labels and use of date labels, it was also hypothesised that understanding of date marking influences the frequency of use of date labels and other behaviours associated with lower food waste. Both WRAP (2011) and van Boxstael et al. (2014) found that understanding (objective or subjective knowledge, respectively) of date labelling does not necessarily result in correct or more frequent usage of date labelling. For example, van Boxstael et al. (2014) found that only 49.3% of their respondents took date labels into account when deciding whether or not to eat a food product compared to the 69.6% who reported knowing the difference between date labels. They also found significant variation by product type in the date label usage to assess edibility. Similarly, Rahelu (2009) reported that consumers do not treat different food groups in the same way. In a similar vein, WRAP (2011) found differences in the use of date labels by product type; however their analysis outlined a complex array of factors such as attitudes, values, habits, risk perception and trust, which potentially affected the relationship between knowledge and behaviour. Factors such as trust in or perceptions of labels (Broad Leib et al. 2016) as well as the role of habit and repeat purchasing (FSA 2016) are important. This may mean that, while consumers may know the difference between date labels, they might not consider it necessary to check the date label either at the point of purchase or at home since they develop a sense of how long the product lasts. Outside the food waste literature there have been a number of studies across environmental (Kaiser and Fuhrer 2003;Redman and Redman 2014;Peschel et al. 2016), health (Wardle et al. 2000;Worsley 2002;Grunert et al. 2010) and food safety (Meysenburg et al. 2014) fields that have shown that objective or declarative knowledge is a necessary but not sufficient condition for behaviour. For example Peschel et al. (2016) found that, while less knowledge might make one less likely to make an environmentally friendly choice, better knowledge might not make one significantly more likely to choose it either as people tend to balance between factors such as price and the environment. Kaiser and Fuhrer (2003) and Redman and Redman (2014) also found limited impact of objective or declarative knowledge alone and argued that it needed to converge with other domains of knowledge (procedural, social, and effectiveness) in order to affect behaviour. A Food Standards Agency (FSA) (2016) survey on food labelling issues reported that consumers considered retail food labelling information in a 'needs-based behaviour' and that the most frequently checked information when purchasing food was the 'use by' or 'best before' information. However, many authors reported that the current food date labelling system with different types of date marking can generate confusion among consumers (Rahelu 2009;NRDC 2013;FSA 2016;Priefer et al. 2016). The FSA (2016) report also noted that respondents stated internal conflicts between not wishing to take health risks by ignoring date labels and not wanting to waste food. Hypothesis 3 Perceived behavioural control (need for clearer information on date labelling and frequency of checking date labels) has an effect on behaviours associated with lower food waste. According to Ajzen and Madden (1986) and numerous other authors, perceived behavioural control will influence behaviour directly and/or indirectly through behavioural intentions. Visschers et al. (2016) emphasised the relevance of perceived behavioural control on food waste behaviour. They found that perceived behavioural control was one of the most important predictors of the amount of food waste per household member. However, evidence from WRAP (2007,2011) suggested that frequency of use or sensitivity to date labels was not a straightforward way of identifying low food wasters from high food wasters. This is because there seem to be behaviours associated with high date sensitivity (e.g., food planning and shopping) that combined may result in lower waste; equally there are behaviours associated with low date sensitivity or frequency of checking such as a willingness to eat leftovers or food past its date, which may also be associated with lower food waste (WRAP 2011). Similarly, Visschers et al. (2016) found that, with regard to consuming leftovers, consumers with more positive attitudes and norms regarding food waste reduction and with lower risk perceptions about consuming leftovers showed a higher intention to reduce food waste as well as reporting less food waste. The behaviours related to lower food waste measured by the Flash Eurobarometer 425 (European Commission 2015) are about consuming food after or without knowing the 'best before' date or eating products after they have been open for more than the recommended number of days. It was therefore hypothesised that those who check dates most frequently, i.e., appear to be more sensitive to dates, would be less likely to exhibit the behaviours analysed. 3 Data and methods --- Data The data used in this research were extracted from the Dataset Flash Eurobarometer 425: Food waste and date marking (European Commission 2015). The Eurobarometer survey was carried out by the TNS Opinion and Social through face-to-face interviews of citizens in the 28 Member States of the European Union, with an average sample size of 950 observations. The variables included in the analysis are: • socio-demographic variables (age, education, occupation); • understanding of 'best before' and 'use by' labels on food products; • perceived need for better and clearer information on the meaning of 'best before' and 'use by' dates indicated on food labels; • frequency of checking the 'use by' or 'best before' dates on food labels when shopping and preparing meals; • food waste behaviour, i.e., use of senses instead of labels to decide whether to eat or throw away food (e.g., non-perishable foods from own kitchen cupboard with no 'best before' date indicated on the label which were not bought recently; or food products which must be used within a certain number of days after opening and are past that); and stated need for 'best before' dates on nonperishable foods, such as rice, pasta, coffee or tea. Table 1 presents a description of the latent variables and the corresponding indicators included in the SEM models. Figure 2 shows that more than half of the consumers interviewed in each of the three groups always look at 'use by' or 'best before' dates on food labels when shopping and preparing meals, and a fifth up to a quarter of consumers check dates on a frequent basis. These results are in line with those reported by the FSA (2016) survey. Regarding behaviours, Fig. 3 shows that in the absence of date labels more than 60% of respondents in each group feel confident to use their own senses to assess the safety of the product before consuming it, with Western Europeans being the most, and Mediterranean consumers the least confident. However, in the presence of date labels and outside the period of time during which the product must be used after opening, a lower percentage of consumers choose to consume it (Fig. 4). The same ranking as in Fig. 3 and similar differences between the three groups apply. This may indicate that Mediterranean and Eastern European consumers may be more risk-averse to food safety issues and/or less sensitive to food waste than Western Europeans. Figure 5 shows that Mediterranean and Eastern European consumers have a stronger need for date labelling information than Western Europeans in order to perform their food consumption decisions (the same ranking as for the previous two behaviours applies; however a much higher difference is shown between the groups). The aforementioned statistics may indicate a lower tendency to generating food waste as a result of date labelling evaluation in Western Europe as compared to Eastern and Mediterranean Europe. --- Methods Structural equation models (SEM) with observed and latent variables were used to estimate the influence of these determinants on stated food waste behaviour in three groups of countries-Western Europe (France, Belgium, Netherlands, Germany, Luxemburg, Denmark, Ireland, Great Britain, Finland, Sweden, Austria), Eastern Europe (Czech Rep, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia, Slovenia, Bulgaria, Romania, Croatia) and Mediterranean Europe (Italy, Greece, Spain, Portugal, Cyprus, Malta). As each variable might influence behaviour and intentions both directly and indirectly (through their effect on other variables in the model, which subsequently Fig. 4 a-c Some food labels indicate that, once opened, a product must be used within a certain number of days. If you have not used up the product within the time indicated on the label, what do you usually do? ('use it if the product looks all right and the packaging is not damaged'). Responses for Western, Eastern and Mediterranean subsamples Fig. 5 a-c In future, if you no longer found 'best before' dates on other non-perishable foods, such as rice, pasta, coffee or tea, how would you respond? Responses for Western, Eastern and Mediterranean subsamples directly influence behaviour), the variance explained by the model is higher than when other methods, e.g., regression analysis, are used. The model consists of two parts: the measurement model (which stipulates the relationships between the latent variables and their component indicators), and the structural model (which describes the causal relationships between the latent variables). The model is defined by the following system of three equations in matrix terms (Jo <unk>reskog and So <unk>rbom 2007): The structural equation model: g 1<unk>4 Bg <unk> Cn <unk> f The measurement model for y: y 1<unk>4 K y g <unk> e The measurement model for x: x 1<unk>4 K x n <unk> d where g is an m*1 random vector of endogenous latent variables; n is an n*1 random vector of exogenous latent variables; B is an m*m matrix of coefficients of the g variables in the structural model; C is an m*n matrix of coefficients of the n variables in the structural model; f is an m*1 vector of equation errors (random disturbances) in the structural model; y is a p*1 vector of endogenous variables; x is a q*1 vector of predictors or exogenous variables; K y is a p*m matrix of coefficients of the regression of y on g; K y is a q*n matrix of coefficients of the regression of x on n; e is a p*1 vector of measurement errors in y; and d is a q*1 vector of measurement errors in x. The models were estimated using the Diagonally Weighted Least Squares (DWLS) method and the statistical package Lisrel 8.80 (Jo <unk>reskog and So <unk>rbom 2007). We combine Prelis to calculate the asymptotic covariance matrix (Muthe <unk>n 1984;Bollen 1989) and Lisrel to compute test statistics for the estimation of the significance of causal relationships (Jo <unk>reskog and So <unk>rbom 2007). The DWLS estimation method is consistent with the types of variables included in the model (ordinal and categorical) and the deviation from normality in these variables (Finney and DiStefano 2006). The models were validated using absolute (root mean square error of approximation and goodness of fit index), incremental (adjusted goodness of fit index, non-normed fit index, normed fit index, relative fit index, comparative fit index and incremental fit index) and parsimonious (normed Chi square) goodness of fit (GoF) indicators (Hair et al. 2006). An acceptable level of overall goodness-of-fit does not guarantee that all constructs meet the requirements for the measurement and structural models. The validity of the SEM was assessed in a two-step procedure: the measurement model and the structural model. Model selection was performed through a nested model approach, in which the number of constructs and indicators remained constant, but the number of estimated relationships was changed iteratively. --- Results and discussion As mentioned in the method description section, the first step of the analysis consisted of a measurement model where the indicators (11) presented in Table 1 form the latent variables (7). The main parameters to test for the robustness of the constructs, convergent validity and internal consistency (composite reliability, internal consistency reliability, extracted validity and discriminant validity) resulted in acceptable values for all constructs following Hair et al. (2006). In addition, the model meets the wider acceptance goodness-of-fit standards for the confirmatory model. Results of the measurement model are not reported due to length limitations. The second step of the analysis consisted of the structural equation model. Instead of performing a multi-country analysis for the structural model, we grouped the 28 countries in the aforementioned three groups and then estimated SEMs for each group. The model explains 18, 15 and respectively 10% of the variance in the behaviour associated to date labelling evaluation in the three models. The model has excellent fit according to the measures of absolute, incremental and parsimonious fit (Hair et al. 2006). The main goodness-of-fit (GoF) indicators (estimated and recommended values) for the estimated model are presented in Table 2. Additional testing of the appropriateness of the models was achieved by comparing each of the estimated models with three other models that acted as alternative explanations to the proposed models in a competing-model strategy using a nested model approach. The results across all types of goodness-of-fit measures favoured the estimated model in most cases. Therefore, the accuracy of the proposed models was confirmed and the competing models were discarded. After assessing the overall models and aspects of the measurement models, the standardised structural coefficients were examined for both empirical and theoretical implications. Table 3 presents the standardised total effects between the latent variables in the model. All relationships in the three models are statistically significant. The path diagrams for the estimated SEM models are presented in Fig. 6. The results support the research hypotheses in the three models. Date label understanding has a negative impact on behaviour explaining a consistent fifth of the variance in the three models. Its effect on behaviour is direct and indirect through the frequency of date label checking, with which it has a significant positive relationship. The findings might indicate that consumers with a higher level of date label understanding are more likely to make regular use of date labels and less willing to consume foods without 'best before' dates or foods outside the period of time during which they must be used after opening. While the first relationship is as expected, it is less clear why consumers who understand the meaning of 'best before' labels are reluctant to disregard the absence of these labels on foods. This may be explained through the composition of the behavioural construct, which also includes an indicator with food safety implications (consumption of products which must be used within a certain number of days after opening and are past that). Frequency of date label checking has a strong significant negative effect on behaviour explaining between a fifth and almost a third of the variance in the three models. This might indicate that consumers checking date labels regularly are less willing to consume food products which are not date-marked. The perceived need for clearer information associated to date labelling has a significant effect on behaviour explaining up to a quarter of the variance and showing a large difference in effect magnitude and sign between the three models. Its impact on behaviour is direct and indirect through date label understanding and frequency of date label checking. The findings suggest that people with a stronger need for clearer labelling information are in the habit of checking date labels and are more likely to understand the limitations of the current date labelling. The need for information to build stronger behavioural control leads to better interpretation of labels and lower food waste. The different relationship sign in the three models requires further investigation. As regards socio-demographics, with the exception of education, which does not influence behaviour in the Mediterranean model, all variables have significant effects on behaviour, albeit of very different magnitude between the three models. The effect of occupation on behaviour is direct and indirect through the perceived need for clearer date labelling information. This might suggest that consumers with better occupational status (and implicitly higher income/socio-economic group) are more likely to perceive the limitations of the current date marking and require clearer information, and are also more likely to exhibit behaviours associated with lower food waste. A limitation of this research is the low variance explained by the models, which is due to the fact that many established influences (e.g., food safety perceptions) on the specific behaviours analysed here were missing from the survey questionnaire. --- Conclusions Household food consumption has been regarded as a key point in food waste generation and significant efforts by e.g., Food and Agricultural Organization of the United Nations and the European Commission have been directed to assist consumers in reducing food waste. However, there is more to be done as the majority of the current food waste mitigation initiatives together with the EU legislation tackle the food waste conundrum from a waste management perspective. Date labelling influences the selection of food at the point of purchase and its subsequent consumption and most likely has a strong effect on consumers' decision of what to eat or throw out. Our research analysed the influence of date label understanding among other factors (socio-demographics, date label understanding, need for clearer date labelling information and frequency of date label checking) on a number of specific behaviours associated with lower food waste. Our results suggest that the frequency of checking and understanding of date labels are the main determinants of behaviour in all regions analysed (Western, Eastern and Mediterranean Europe). However, differences between the three EU regions emerge in terms of the importance of date labelling for consumption decisions. Such differences may stem from the institutional, regulatory and policy framework, public information campaigns and food culture in these countries. Building on the limitations of this study, future work should incorporate the role of food safety and risk perceptions, which would increase the variance explained in the analysis. Consumers have become less knowledgeable of the characteristics associated to safe and good quality food and rely increasingly on food label instructions, which may indicate insufficient control on food safety matters. The positive relationship found between the stated level of date label understanding and the perceived need for further information on date labelling might indicate the need for changes in date labelling and for targeted communication strategies consistent with existing policy initiatives across the European Union. This is consistent with the current views of EU policy makers and national institutions, e.g., WRAP, which have proposed new guidance on the application of date labels including a flexible implementation of the date of minimum durability while maintaining strict food safety principles (WRAP 2017).

This research analyses the impact that the level of understanding of date marking (among other influences) has on the food waste behaviour of consumers in the European Union focusing on a comparison between European Union countries. The data were extracted from the Dataset Flash Eurobarometer 425: Food waste and date marking (European Commission in Flash eurobarometer 425: food waste and date marking, European Commission, Brussels, 2015) and structural equation models to estimate the strength of these influences on behaviour. The results show that socio-demographics (age; education; occupation); behavioural control (perceptions regarding the need for better and clearer information about 'best before' and 'use by' date labelling on food products; frequency of checking date labels when shopping and preparing meals); and understanding of 'best before' and 'use by' labels have significant effects on behaviours related to lower food waste (use of senses instead of labels to decide whether to eat or throw away food e.g., nonperishable foods from own kitchen cupboard with no 'best before' date indicated on the label which were not bought recently; or food products which must be used within a certain number of days after opening and are past that; and the need for 'best before' dates on non-perishable foods, such as rice, pasta, coffee or tea). The stated understanding of date labelling is a key influence in all models and explains a consistent fifth (ceteris paribus) of the variance in behaviour.

Introduction Even though receiving newcomer migrant pupils in schools is not a new phenomenon, many education systems grapple with finding adequate schooling arrangements that foster a sense of belonging and inclusion. We use the term 'newly arrived migrant pupils' to signal primary school aged children who recently arrive to Austria for a variety of reasons, and who, at the moment of entering school, are at risk of social and educational exclusion due to a language mismatch between the language of schooling and their own linguistic repertoires. Student identities that might be tied up with aspects of transnational movement, such as migration, refuge, and asylum, seem to be subsumed under the concept of being someone who is an 'insufficient German language-speaker.'As there is no clear-cut policy definition of newcomer pupils, we trace how students become addressed through the program of German support classes and courses, initiated by the Austrian education ministry. This program is a dual approach to provide extensive learning opportunities for German in fixed classes or flexible courses. A residential status of any kind is no pre-requisite. Instead, all students can be screened for insufficient German proficiency based on an'Austria-wide, unified and standardized test procedure'. 1 While most foreign-born citizens in Austria are Germans, these language measures apply largely to students whose mother tongue is not German and who have migrated to Austria as refugees. The strongest increase in migrants was observed between 2011 and 2015 in the category of'refugee migrants' from Syria (90.3%) and Afghanistan (76.6%) (Statistik Austria, 2021, p. 27-28). Forced migration was interrupted by the Covid-19 pandemic 2020/21 and then again accelerated by the war in Ukraine at the beginning of 2022. Among EU countries, Austria currently holds the 11th highest migration quota (Statistik Austria, 2021, p. 36). While a sense of belonging is a key component for all students in educational inclusion and wellbeing (Theron and Liebenberg, 2015;Blignaut et al., 2022), the development of this feeling is a challenging journey for newly arrived migrant pupils. In particular, issues of linguistic and cultural misrepresentation, unequal learning opportunities and outcomes, stereotyping, discrimination and racism still occur in schools (Council of Europe, 2017;UNESCO, 2018;Szelei et al., 2019Szelei et al.,, 2021a,b),b). Moreover, educational research and practice often approaches migrant students through a deficit lens focusing on'shortcomings' related to the language of schooling instead of recognizing the full scope of rich knowledge they possess (Stevens, 2009;Szelei et al., 2021a,b). In Austria there are tendencies of migrant students' overrepresentation in lower qualifying schools: most students who do not speak German as their first language are placed in special schools (Sonderschule). 2 Hence, in 2019, migrant students were twice as likely to be segregated in special schools due to being labeled with a learning disability than they were likely to attend an academic secondary school which qualifies students for accessing higher education 1 BMBWF (2024). https://www.bmbwf.gv.at 2 In Austria there are nine different types of special schools that educate students with a certain special needs profile (learning, visibly impaired, blind, audibly impaired, deaf, motor physically impaired, speech impaired, behavior (schwererziehbar), severely impaired). It is important to note that students whose mother tongue is not German have often qualified for special schools because of special educational testing procedures that require a certain German language proficiency. Therefore, government publications highlight that "German language proficiency is NOT AT ALL (sic!) a reason for referral to special schools" (AMS/Arbeitsmarktservice (Labor Market Service), 2017, p. 13). Placing a majority of migrant students in special schools evokes the impression that multilingual children are more likely to be less educable than native kids and it also creates a generation of migrant children that cannot easily participate in the labor market because attending special schools does not qualify for vocational training. (Statistik Austria, 2019, p. 46). Zooming in on the parameter of heritage languages, most four-and five-year-old children who do not speak German as a mother tongue, speak Turkish or Bosnian/ Croatian/Serbian (BCS) (Ibid.,p. 47). Students who represent either of these two language groups are twice as likely to be found in special schools than in mainstream primary education (Ibid.). Furthermore, 73% of students with a Turkish background as well as 80% of students from Syria, Afghanistan and Iraq are more likely to continue secondary education at a school that does not award the matura degree. 3 They either attend special schools, which do not award any graduation diploma that qualifies for further studies, or vocational schools (Statistik Austria, 2023, p. 46). In the context of these structural inequalities, teachers' classroom pedagogies are key in creating the context for newly arrived migrant pupils to feel belonging (Vansteenkiste et al., 2020;Lang and Garc<unk>a, 2023). Therefore, in this article, we approach belonging as a pedagogical concept (Edgeworth and Santoro, 2015;Comber and Woods, 2018;Dadvand and Cuervo, 2019), and as a pathway to potentially reducing inequalities for newcomer migrant pupils (DeNicolo et al., 2017). While much research confirms that positive interpersonal relationships with teachers, and teachers' actions that provide social care are cornerstones of belonging for newcomer migrant youth (DeNicolo et al., 2017;Amina et al., 2022;Martin et al., 2023;Sutton et al., 2023), less research focuses on how teachers' instructional strategies to organize curricular learning set conditions for (un)belonging. This is an important link to further investigate since some studies note that newcomer migrant students may feel socially connected to their schools, and at the same time, detached from curricular learning in the classroom (Amina et al., 2022). Therefore, educational policy and school practitioners continue to face the dilemma of how to support curricular learning, which predominantly happens in the language of schooling, while creating an environment that builds on the diverse cultures, languages and knowledges that pupils bring to teaching and learning (Omidire, 2019;Hudson et al., 2020). While this dilemma is often presented in policy discourses as a clash between two incompatible educational missions, studies with newcomer youth show that both are important for being able to develop a sense of school belonging (Anderson et al., 2023;Martin et al., 2023). These insights indicate that the policy dilemma may reflect an artificially juxtaposed binary, and that both need to be addressed in teachers' classroom practices. For this reason, we will analyze teachers' instructional strategies of curricular learning in the classroom with a particular attention to opportunities for German language learning and expression of own cultural and linguistic identities and knowledges. Furthermore, across Europe, language support systems in school education are highly fragmented. Education systems have been implementing different models for enhancing the language of schooling (e.g., separate reception classes for newcomers, pull-out classes, individual support in or out of the mainstream classroom, etc.), but their outcomes in terms of inclusion remain highly debated (Rodr<unk>guez-Izquierdo and Darmody, 2019;Gitschthaler et al., 2021;Tajic and Bunar, 2023). Over the years it has become evident that it is 3 The matura degree is comparable to a high school diploma which enables graduates from secondary education to attend academic higher institutions. not simply a physical allocation of students in the same mainstream class that would solely indicate inclusion, and that more integrated models may also create a sense of (un)belonging or exclusion (Eloff and Kgwete, 2007;Du Toit et al., 2014;Szelei et al., 2021a;Tajic and Bunar, 2023). Therefore, 'together or separate?' is a question to be posed in any structural model of language support through a close examination of how teachers' classroom instructions of curricular learning set conditions for belonging. Consequently, the aim of this study is to provide further insights into pedagogies as vehicles of (un)belonging for newcomer migrant pupils through analyzing teachers' instructional strategies of curricular learning in the classroom, and in the context of two different institutional language support models. We present findings from classroom observations with four teachers in two primary schools in Austria that organized German language support for newcomer migrant pupils in two distinct ways. School 1 implemented pull-out classes, whereas School 2 used a model of individualized learning for all students in the mainstream classroom. Similar to other studies in this regard (Tajic and Bunar, 2023), our aim here is not to determine which language support model is'more effective' for belonging, but we rather regard these structures as underpinning contexts of teachers' classroom practices. We ask: How do teachers organize curricular learning in the classroom for newly arrived migrant students to provide German language support? How do teachers' instructional strategies provide opportunities for cultural and linguistic selfexpression? What are the similarities and differences between classroom practices operating within different models of German language support? Our study offers empirical insights to further nuance understandings of pedagogies of (un)belonging for newcomer migrant pupils particularly related to curricular learning in the classroom. While we point to crucial differences in how classroom practices enabled German language learning in view of belonging, findings also show that even 'innovative' and 'new' pedagogical norms seemed to be rooted in 'old' cultural and linguistic norms that uphold monolingualism and monoculturalism. Recommendations are given in order to expand narrow notions of belonging in educational policy and practice. 2 Theoretical perspectives and literature review --- Belonging among newly arrived migrant pupils in schools While the definitions of 'belonging' are numerous and divergent, we here approach it as a pedagogical concept (Edgeworth and Santoro, 2015;Comber and Woods, 2018;Dadvand and Cuervo, 2019), manifesting in educational relationships (Martin et al., 2023) in the classroom context as teachers organize curricular learning. Edgeworth and Santoro (2015), p. 423 call the 'pedagogies of belonging' teaching practices that construct all students as belonging to a school community. Teachers are key actors in this since they design and enact (un)belonging in the classroom via their curricular, pedagogical, and social practices (Edgeworth and Santoro, 2015;Comber and Woods, 2018;Dadvand and Cuervo, 2019;Anderson et al., 2023). In other words, teachers' pedagogical decisions and practices in how they organize social and curricular learning may set conditions for newcomer migrant students to feel (un)belonging (Comber and Woods, 2018;Picton and Banfield, 2020). For example, allowing newcomer migrant students to socialize during lessons, flexibly grouping them with many of their peers, promoting the use of home languages and actively stopping cases of peer discrimination play a crucial role in belonging (DeNicolo, 2019;Picton and Banfield, 2020;Lang and Garc<unk>a, 2023). Furthermore, the importance of cultural and linguistic recognition, positive relationships with peers and teachers, and a school environment free from bullying and discrimination has been repeatedly evidenced in previous research (Due et al., 2016;DeNicolo et al., 2017;Wissing et al., 2019;McInerney, 2022;Martin et al., 2023;Sutton et al., 2023). Moreover, while many studies shed light on rather the social aspects of belonging, schools are not only contexts of socialization, but also, curricular learning. As Comber and Woods (2018) note, the concepts of learning and belonging are closely intertwined in a school context, in how knowledge is produced, and how students connect with their peers and teachers. Therefore, academic belonging (Lewis and Hodges, 2015;Pendergast et al., 2018), a sense of belonging to a learning community, or to a place where curricular learning occurs is equally important when conceptualizing school belonging. As such, creating a sense of social bonding and a learning environment where all students are seen as capable learners and newcomer migrant students have the opportunity to experience and show their academic skills and success are equally important (Edgeworth and Santoro, 2015;Picton and Banfield, 2020). Academic belonging is, however, often overlooked in the literature capturing the experiences of newcomer migrant students. Highlighting this discrepancy, Amina et al. (2022) find that newcomer migrant students felt much connected during social activities in out-ofclassroom settings in schools, but felt yet 'invisible' and alienated during subject lessons in the classroom. For this reason, we aim to add more empirical insights into how curricular learning is organized in the classroom and discuss instructional strategies through the lens of belonging. In particular, we analyze how German language support is organized and how students' cultural and linguistic repertoires are addressed in teacher-enacted classroom instruction. Inevitably, single classrooms and teachers are often embedded in structures of inequalities (Picton and Banfield, 2020) and rigid pedagogical norms that may be difficult to overcome only by individual teacher's actions. For example, in Lang and Garc<unk>a's (2023) study, while a teacher was able to create a more inclusive classroom environment, the dominance of the language of schooling, and the privileged status of speakers of dominant languages were not possible to negotiate by micro-level actions in the classroom. Monolingualism and monoculturalism are deeply rooted ideologies that often permeate pedagogical actions and teachers' beliefs in the classroom in Austria and elsewhere around the world (e.g., Gogolin, 1991;Santoro and Forghani-Arani, 2015;Alisaari et al., 2019;Szelei et al., 2019;Herzog-Punzenberger et al., 2020;Gitschthaler et al., 2021;Szelei et al., 2021b). Yet migrant students take up agency to find or create ways to belonging in a new school environment (DeNicolo et al., 2017;Dryden-Peterson, 2022). Therefore, we here situate teachers' pedagogies in their structural contexts as well as within the teacher-pupil relationship in the classroom. In particular, we focus on the language support models and the cultural and language norms that newly arrived migrant pupils inhabit in the classroom and trace pedagogies of (un)belonging. As noted above, the organization of language support models remains a dilemma in policy and practice across Europe. CCrul et al.'s (2019) comparative study of different language support systems find that a swift transition to mainstream classrooms increases chances for newly arrived migrant students' academic success, and staying in separated classes for an extended amount of time usually leads to absenteeism and drop-out. While scholarly studies are in favor of more integrated models in general, previous research also highlights that it is not only the structural model of language support that solely define greater inclusion, and that any organizational model may present with inherently contradictory practices characterized by the simultaneous presence of exclusion and inclusion (Terhart and von Dewitz, 2018;Fejes and Dahlstedt, 2020;Szelei et al., 2021a,b;Tajic and Bunar, 2023). Furthermore, while policy and practice strongly emphasize the need to finding'solutions' to best support the language of schooling, the maintenance of home languages is somewhat overlooked (Rodr<unk>guez-Izquierdo and Darmody, 2019). As noted above, these dilemmas that policy-makers and school practitioners articulate are overly one-sided, and newcomer migrant youth emphasize the importance of both being able to effectively learn the language of schooling while seeing one's cultural and linguistic knowledges reflected in schools (Anderson et al., 2023;Martin et al., 2023). In the past, Austria has grappled in different ways with its growingly diverse student population. While formerly, the spirit of 'foreigner pedagogy' (Ausländerpädagogik) prevailed, intercultural education has taken its place over the years and fostered the spirit of a more democratic engagement with the 'other'. Formerly, migrant students in Austria were educated in their native languages and received religious education according to their own faith as it was expected that these students would return to their home countries when their parents' 'guest labor contracts' ran out. These practices were common in the 1970s and 1980s. In the meantime, 'foreigner pedagogy' has received great criticism as it was assumed to be segregationist. 'Foreigner pedagogy' blamed school failure on presumably lower cultural, cognitive, and financial capital prevalent among migrant families, instead of taking into view discriminatory practices found in schools and other institutions of governance and power. Today, intercultural education is deemed a pedagogical paradigm that applies to the general Austrian core curriculum. Hence, 'a specific pedagogical task of the primary schools arises where it can enable intercultural education for children with German and those without German as a mother tongue' (Lehrplan der Volksschule, 2005, p. 8). While this 'task' goes beyond language acquisition, integration policies continue to exercise intercultural education through the priority of German language skills. The 2018/19 school year has seen the introduction of an intense linguistic strategy that the country applies to achieve swift integration of newcomer migrant students to its mainstream educational institutions. Formerly, children received extra German lessons, called Besonderer Förderunterricht Deutsch (BFU) as a pull-out mechanism during the regular teaching schedule. As a response to poor testing results of migrant students and the influx of refugee children since 2015 (BMBWF, 2019, p. 4)-according to the Conservative government of <unk>VP (Austrian People's Party) and FP<unk> (Freedom Party Austria)-Austria decided to administer a two-track system of language acquisition that was either based on German support classes (Deutschförderklasse) or German support courses (Deutschförderkurs) (see also : Erling et al., 2022). According to students' test results, they either study 15 hours of German in a separate class unit of German learners or in a course that offers 6 h of German, taking place parallel to regular lessons (BMBWF, 2019, p. 7). These German support classes contain students of different year groups, class units and even types of schools. It is not a priority to foster a community spirit in the classes as the strategy highlights (BMBWF, 2019, p. 25). As it is only a temporary arrangement, it is comparable to an intensive training class in which developing a sense of belonging receives less attention than language progress. It must also be noted, though, that the Austrian education system continues to place attention on migrant students' first languages as part of the regular teaching schedule. Currently, 26 languages are offered across Austria to support students in acquiring their mother tongues, including Arabic, Chinese, Dari, Pashto, Persian, Hungarian, Somali etc. (BMBWF, 2019, p. 22). This multilingual strategy is geared toward 'promoting a multilingual identity development'. 4 Which languages are offered in which types of schools, however, remains a highly localized responsibility that we cannot currently judge in terms of success rates and effects on children's wellbeing and sense of belonging. However, it can be inferred that many children in Austria have experiences with different language promotion strategies with strongly varying access to these and levels of engagement. However, as one in seven students has a parent that was born outside of Austria and one in four speaks a different language than German at home (Gruber, 2019, p. 147), it can be summarized that linguistic diversity is an integral part of Austria's student population and a common phenomenon for teachers. --- Research objective and questions The overall aim of this study is to examine how teachers' instructional strategies of organizing curricular learning in the classroom set conditions for pedagogies of (un)belonging. More specifically, we ask: • How do teachers organize curricular support in the classroom for newly arrived migrant students to support German language development? • How do teachers' instructional strategies provide opportunities for cultural and linguistic self-expression in the classroom? • What are the similarities and differences between two classroom practices operating within two different German language support models? conducted qualitative school research in Austria. We select a subsample of two public schools for the sake of this article since (1) they taught newly arrived migrant students, and in general, a culturally and linguistically diverse student population (2) they opted for different models of language support that offered unique opportunities to explore in terms of how teachers navigate these structures. Fieldwork was conducted by the first two authors at different timepoints between 2017 and 2018. The key method applied during fieldwork was classroom observation. We here understand observation as 'the act of perceiving the activities and interrelationships of people in the field setting through the five sense of the researcher', and 'noting down' these perceptions 'for scientific purposes' (Angrosino, 2007;p. 37 and p. 54). The aim of observations is to delineate and understand patterns or trends reflected in individual behaviors or social practices related to the research questions (Angrosino, 2007;Given, 2008). Here, we aimed to discern teachers' instructional strategies when organizing curricular and social learning for newly arrived migrant students in given cultural and linguistic norms of classroom pedagogies, as precursors of pedagogies of (un)belonging. The advantage of being an observer in these settings is that we were able to take note of instructional strategies of learning in the classroom, and how language support models were interpreted by educators through phrasing and enactment of instructions as well as how students responded to these pedagogic interventions that were employed by their teachers. We performed observations in two distinct ways. The first author followed an ethnographic approach (Erickson, 2004): she participated in classroom scenarios and became integrated in students' activities, such as reading with them, checking their homework, and being called on by the teacher. The second author maintained some distance from the classroom interactions and pursued a qualitative observational study (Given, 2008). Hence, the second author conducted observations aiming at the least disruption of classroom interactions possible. She often stayed in the back of the classroom or at a point where she had a broad view on the learning environment. Her role as a researcher was made clear to the whole class. She also took up informal conversations with teachers and pupils during the breaks. During the observations the authors made in-situ notes that they then wrote out, following the principles of thick descriptions, into fieldnotes and analytical memos (Emerson et al., 1995). We also documented information that the school provided about itself through its online presence, the way it decorated its representative spaces like the entry hall or the classroom walls (Wagner, 2021). They were enriched by interviews with educators, teaching assistants as well as school leadership. The names used in this article are pseudonyms. The two authors, conducting fieldwork, are not native to the schools' neighborhoods. However, one shares the language of classroom instruction, and the other was a second language learner of German at the time of research, such as the students that we focus on in this piece. By combining the data that the two separate studies provided, the authors generated diverse insights into the language and social practices in the classroom which have become an integral part of Austrian teaching and learning settings. The initial findings were then presented to author 3 and 4 who are affiliated with different language groups and gave their feedback on the findings presented here. Author 1 and 2 have both been teachers before and, therefore, must remain cautious of'surface familiarity with the classroom,'as Erickson writes, in order to still be able to'make the familiar strange and visible' (2010, p. 323). --- Data analysis and interpretation We each amassed a substantial amount of data that we then interpreted through the principles of analyzing ethnographic data (Erickson, 2004). While our methods of observation were different, both our fieldnotes speak to the 'the full range of activities and social situations that take place in the setting' with regard to language use, language policies, cultural and language habits of the schools that we visited (Erickson, 2010, p. 321). Therefore, we combine our data for the sake of bringing in two angles into the analysis of classroom activities pertaining to the same issues of language policies and (un) belonging in the classroom. For both studies we follow what Frederick Erickson recommends as to go from 'whole to part' meaning to engage with data in the way it naturally appears in social interactions and then to zoom in on the microscopic detail of the given situation (Erickson, 2004, p. 491). Therefore, we have read the entire material several times to become familiar with the whole dataset. Then, we identified data that reflected practices and routines of German language support, cultural expression and home languages in teachers' classroom practices. We have moved from descriptive analysis to theoretical analysis (Angrosino, 2007) as we first developed a thorough descriptive understanding on the reported and observed practices, and then we identified patterns across the dataset. The identification of patterns happened via comparing and contrasting teachers' instructional actions, pedagogical activities and interactions with students in the classroom, as well as statements made about the same issues in the interview material (Angrosino, 2007). The identification of patterns happened by following the logic of the research questions (teachers' instructional strategies regarding German language support and cultural and linguistic diversity in the classroom), and patterns were identified as those chains of events, interactions and statements that typically described the teachers' practices during the time of this fieldwork. We have first identified these patterns in the two school settings separately, and then contrasted and compared them to be able to respond to research question 3. Finally, we have reviewed these findings altogether (similarities and differences in teachers' instructional strategies) by interpreting them through the pedagogical concept of belonging. This means that we have interpreted the patterns found in the empirical material in terms of how they informed theoretical understandings on pedagogies of (un)belonging. We organize the findings sections as per three theoretically driven categories, namely: 1. (Un)Belonging as marking 'fitness' to the mainstream classroom 1. (Un)Belonging as creating cultural (in)visibility 3. (Un)Belonging as creating language hierarchies. We narrate the findings of each category by giving holistic descriptions of thickly contextualized events and statements. Erickson recommends to look for 'the biggest shifts in activity within the interactional occasion as a whole' (Ibid.). We identified patterns as they were formed by repeated corresponding chains of events, interactions and statements. We narrate specific events that we identified as a sensible unit of interaction that spoke to the patterns we observed as a whole. This was how we decided which entities to portray and highlight in this article. --- Research context and schools Both schools were situated in an Austrian city and provided primary education to over 200 students, respectively. School 1 was located in the outskirts of the city in a predominantly low-income area. The school reflected high diversity in terms of students' migration trajectories and cultural and linguistic backgrounds. It pursued a system of pull-out classes for German language support whereby newly arrived migrant students stayed for their assigned mainstream classes for some subject lessons, and then pulled out to attend German support classes. The concept of 'pushand pull-out' has been referenced widely as a way to describe strategies that schools apply to move students into different settings, thereby exercising pressures that we seek to critically examine here (Jordan et al., 1994;Demo et al., 2021, p. 2). In this school, Wagner interviewed and observed (50 hours) two teachers (Kate and Amy) of the same class. It was a fourth-grade group of 19 children in which two pupils spoke German as their mother tongue. The other classmates spoke a variety of different languages from English, BSC, Turkish to Arabic. Some students had recently arrived, while others had parents who were born abroad but had completed their mandatory education in Austria. The group was educated under the strategic program of the 'English classes' meaning that all students received extra English language input. As a group that was considered academically driven, students studied regular lesson content in German while some students had support German classes and all of them did extra work in English. This way, the school hoped to add a level of expectation and curricular advantage that would enable higher performing groups to stand a better chance at academic secondary education. The school in which Szelei conducted research (School 2), was situated in the center of the same Austrian city in a predominantly middle-high income area. More than half of the pupils came from homes where another language than German was spoken. Out of the families coming from abroad, about half were families with a high formal education degree, and the other half were illiterate, according to the school principal. This school implemented their own innovative pedagogy whereby each student followed their own personal learning plans during curricular learning, facilitated by two classroom teachers. Here we specifically analyze classroom practices in School 2 with regards to newly arrived migrant students. In School 2, supporting the development of German language for newly arrived migrant students was directly integrated within the classroom setting via personal learning projects, therefore, no pull-out classes were implemented. Thus, School 2 was unique to explore, since this type of language support model is barely ever considered, nor analyzed in scientific studies due to their overwhelming absence in public schooling. Additionally, School 2 organized English subject learning in all classes, as well as launched some Italian-German bilingual classes within the school. Szelei conducted interviews and observations (20 hours) with two teachers (Christine and Paul) of one multigrade class of altogether 22 children. This class was selected as about half of the students spoke other languages than German at home. At the time of observations, two children were newly arrived migrants from Syria (1 and 2 years in Austria), and another 6 had parents coming from countries other than Austria (England, Russia, Armenia, Mongolia and Turkey). This class followed the German language curriculum as language of instruction, and was not part of Italian-German schooling. --- Findings --- (Un)belonging as marking 'fitness' to the mainstream classroom In seeking responses to research question 1, patterns regarding teachers' instructional strategies of German language support were related to how practices included and marked newly migrant students as fitting or unfitting into regular teaching norms in the classroom. The two classrooms we observed presented with two fundamentally different approaches in this regard. In School 1, teaching practices followed a traditional teachercentered approach that presented with the norms of teaching the same curriculum, and emphasized the importance of students advancing in the same pace and time. When it came to German, the language of regular instruction, the school policy, as advertised on its website, advocated for a strict German-only policy on its premises and educators were adamant about adhering to this rule during classes as well as during recess. Structured language support for newcomers took place in pull-out classes while the rest of the group continued with regular class work. While there was ritualized language support offered to the fourth graders, it was at times difficult to tell what were the criteria for being entitled to German language support. Throughout the observations, a practice of arbitrary allocation of students to BFU lessons emerged with a certain vagueness of the rationale about who and when could attend these lessons. 'The lesson starts. The German support teacher comes in and reads out the names of six girls. They have to get up immediately and follow the teacher out of the room for extra German class. The girls protest but the German teacher raises her voice and says she doesn't want to hear any complaining. The girls leave the room. (Fieldnote, March 3, 2017)' Protest against leaving the mainstream classroom indicated students' discomfort with this teacher-made decision that may have occurred for a variety of reasons. For example, the students may have preferred to stay with their classmates/classroom teachers or German language support lessons might have been less engaging than learning in the mainstream classroom. In any case, teacher decision on the allocation of particularly these six pupils was not clarified, neither negotiated with the pupils involved. Even though the pupils somewhat resisted the teacher's decision, in this moment there seemed to be no room for dialog with the pupils about their learning trajectories regarding BFU, or explaining why the teachers believed this was an adequate instruction for these pupils. This arbitrariness of pupil allocation to BFU and vagueness of who and when qualifies for German language support is further evidenced by the following scenario that occurred between Amy (teacher) and Aicha, a Kurdish-Austrian pupil who struggled with her German exams although she had a good command of the language in general. 'The teacher for extra German enters the class, eight children will work with her today. The class teacher tells me and the German support teacher to give her numbers between one and 19. According to these numbers that we call out in turn, the names of the children are determined who will accompany her.... The kids watch us while they hear the number and the teacher checks in the students' list whose name is linked to the given number. After the names are called, the respective students get up and follow the teacher out of the room. The rest of the class receives special puzzles and riddles today to practice spelling and arithmetic. Aicha has difficulties. Her teacher pulls up a chair and sits next to Aicha to check on her. Aicha reads out loud: "A bird lives in the birdcage. " She stops, turns around and looks for help. She turns back to her worksheet and asks: "Is there sand in a birdcage?" The teacher says: "Yes, so the shit can be better soaked up. " Aicha talks in a very loud voice. The teacher shouts back: "Not so loud!" Aicha finishes reading the text. The teacher says: "One task is no task, do the next one. " (Fieldnote, June 29, 2017) In this fieldnote, pupil allocation happened via a lottery of numbers between one and 19. This type of selection adds to the arbitrary nature of pupil allocation, as well as indicates a possibly rather generalized German language support curriculum over a pupilcentered approach. While eight pupils have been chosen randomly, Aicha was not among them during that lesson. Her chance of having structured instruction and support to acquire German language proficiency then had to wait until the next week. As Aicha stayed in the mainstream classroom, she received a worksheet exercise for reading and comprehension, while the rest of the class worked on something completely different. Amy monitored Aicha's work, and teacher instruction seemed to be also restricted to the worksheet exercise. The practice of random allocation of pupils to BFU support lessons raises questions about who is entitled to receive this type of German language support. Kate explained that because her group was academically higher performing than other groups in this school, her students were only entitled to extra German lesson once a week. They also had a commitment of keeping these support groups small, so teachers had to decide who got to profit from this service each week, and not everyone could take this opportunity every week. Other groups

Even though receiving newcomer pupils in schools is not a new phenomenon, many education systems grapple with finding adequate schooling arrangements that foster belonging and inclusion. Over the years, policy-makers and school practitioners seem to echo recurring dilemmas in terms of what language support models may promote optimal inclusion, and whether and how to support the language of schooling while also building on students' cultural and linguistic repertoires. In this article, we present classroom observations from two Austrian primary schools that implemented German language support in two distinct ways. School 1 implemented pull-out classes, whereas School 2 used a model of individualized learning for all students in the mainstream classroom. Utilizing the cultural-linguistic aspects of 'belonging' in pedagogical enactments, we analyze how teachers' instructional strategies to organize curricular learning for newly arrived migrant pupils set conditions for pedagogies of (un)belonging in the classroom. Findings show that pedagogies of (un)belonging seemed to be formed via chains of patterned interactions, activities and utterances based on three key logics: marking students' 'fitness' to the mainstream classroom, creating cultural (in)visibility, and as creating language hierarchies. While the two classroom practices remarkably differed in how they enabled German language learning and fitting to mainstream pedagogical norms, both seemed to uphold monolingualism and monoculturalism. Recommendations are given in order to expand narrow notions of belonging in educational policy and practice.

, June 29, 2017) In this fieldnote, pupil allocation happened via a lottery of numbers between one and 19. This type of selection adds to the arbitrary nature of pupil allocation, as well as indicates a possibly rather generalized German language support curriculum over a pupilcentered approach. While eight pupils have been chosen randomly, Aicha was not among them during that lesson. Her chance of having structured instruction and support to acquire German language proficiency then had to wait until the next week. As Aicha stayed in the mainstream classroom, she received a worksheet exercise for reading and comprehension, while the rest of the class worked on something completely different. Amy monitored Aicha's work, and teacher instruction seemed to be also restricted to the worksheet exercise. The practice of random allocation of pupils to BFU support lessons raises questions about who is entitled to receive this type of German language support. Kate explained that because her group was academically higher performing than other groups in this school, her students were only entitled to extra German lesson once a week. They also had a commitment of keeping these support groups small, so teachers had to decide who got to profit from this service each week, and not everyone could take this opportunity every week. Other groups had four or five BFU hours a week, she said, because on average those students were less proficient in German than the pupils in her class. This structural condition presented remarkable challenges for Amy's and Kate's work in the mainstream classroom. Kate noted: 'almost nobody was a German native speaker and so it would be much nicer if we had a lot more BFU lessons or more teaching assistants because it is often challenging linguistically. However, our group is not as bad compared to the other groups.'On the other hand, School 2 implemented a specific pedagogical model in which each student followed their own individual learning plans, facilitated by two teachers. The classroom environment was rich in diverse learning materials, objects and tools to facilitate learning, and the students could freely choose where (inside the classroom or outside on the corridor) and how they worked during the lessons. The teachers' role was to provide individual support and scaffold the learning of each student based on individual needs and learning plans. This personalized learning support was rooted in the school's vision on viewing all children as unique individuals, therefore, the specific cases of newly arriving migrant students were equally regarded as a part of universal uniqueness. Therefore, newly arrived migrant students were not seen as extraordinarily different, since individual differences were at the core of normalized pedagogical actions in this school. Christine and Paul appreciated cultural and linguistic diversity since, in their views, it created a richness for children, but also a demanding pedagogical task for teachers. For instance, 'I think it's for all children a positive thing. But for teaching it's more difficult, of course. But as we do personal learning, it's just another point more to do.'Christine 'It's a lot of work, we have to say it. It's really a lot of work, it costs much of time, but you should. If you really want this, you have to do this.'Paul. The teachers had strong academic expectations toward each student, and while they were highly flexible in how students reached their learning goals, students were expected and facilitated to progress quickly. Christine and Paul regarded newly arriving migrant pupils as capable of reaching the same goals as any other pupil in class. They strongly focused on reaching high level reading and comprehension skills in German, as well as that newcomer migrant pupils were able to get along in everyday life and social interactions in German. School 2's approach to personalized teaching-learning meant that there was no single way of teaching curricular content. Instead, Christine and Paul's mainstream classroom was characterized by the facilitation of multiple individual learning paths instead of one-way frontal teaching. Whole-class moments remained for starting the day with morning circles and for other social activities, but not directly for curricular learning. The next fieldnote shows how this personal learning is organized and scaffolded by Christine in the case of Adam, a newly arrived refugee pupil from Syria. Adam has lived in Austria for less than a year and just started schooling a couple of weeks ago in Christine and Paul's classroom, therefore, was new to the school, German language, and Austria in general. 'Christine noticed that Adam was wondering around, not knowing what to do. Christine stepped next to him. 'Spielen? (Playing?)' Adam asked Christine, pointing to the animal objects on the shelves. 'Not playing, working' said Kathrin. 'Take a small mat. Ok, let us sit' and they went out to the corridor. Kathrin wrote words on pieces of paper and put them on the mat. Adam went back and forth between the animal display and the mat, and organized the objects around the words. For example, he took a tree and put it next to word Baum (tree), a pig next to the word Schwein (pig), and so on. As Adam was getting on well, Christine went to circle around other children in the corridor. As she left, Adam stopped working. Christine noticed, returned and asked questions to learn the new words about animals in German. She explained the words in simple German sentences, using the objects. Then she put new cards on the mat with the categories 'animals' 'people' and so on written on them. Christine then explained that in German some words start with lower-case letters, and some with capitals. Now Adam's task was to write the names of the objects organized in columns (animals, people, plants, etc.) with the correct spelling. Adam went back to the classroom to fetch his notebook, sat on the mat and started copying the words independently.'(Fieldnote). In this fieldnote, Christine scaffolded Adam in learning new vocabulary and spelling in German. We witness a moment of curricular teaching-learning in which Adam stayed within the'mainstream' classroom setting, however, here'mainstream' was characterized by each student getting on their own tasks. In this context, Adam did not stand out as very different with his German language skills. In fact, parallel spaces were created for all students where they could study according to their own agenda, scaffolded by the teachers. This way, the curriculum became multi-faceted and personalized to pupils' needs (subjects, levels, learning material and Frontiers in Education 08 frontiersin.org resources) in the same educational space. Consequently, Adam's personal curriculum fit into the class schedule without disrupting existing teaching-learning norms, since teaching according to individual needs was the 'new norm'. Adam was also active in the learning process as he worked with objects and attempted to write independently. Autonomy was not established right away, but with Christine's initial guidance and monitoring, Adam was able to be engaged in the task independently toward the end. This moment seems powerful in enabling German language learning and belonging to a learning community. The student was provided ample materials as well as teacher guidance to develop German language skills. The student was also regarded as a capable learner and was expected to work, just as anyone else in the classroom. Importantly, no labeling or separated instruction took place based on German language proficiency, and it was the responsibility of the classroom teacher to support newly arrived migrant pupils, rather than specialized personnel. --- (Un)belonging as creating cultural (in) visibility Responding to research question 2, we also identified patterns regarding how students' own cultural repertoires and identities were reflected in teachers' classroom practices. At the level of symbolic recognition, we observed in both schools a general appreciation of cultural diversity, and symbols of diversity made visible in the entry halls (e.g., 'welcome' had been written on papers decorated by students and fixed on a rope that was hung across the entry hall in School 1, and flags of different nationalities were hung up in the hall of School 2). However, the two classroom practices differed in how explicitly they addressed students' cultural repertoires in classroom activities. At School 1, Kate explained that last year, the school had put on an event where each year group was asked to design a cook book with recipes that the students wanted to contribute to the book. Other groups had presented traditions and customs on posters. And yet another group presented dances. Kate remembered that students were showing these different projects to each other throughout the past school year. She regretted that this year there was little time for valuing each other's origins and remarked: 'I am sorry that we have so little time for these projects. Because they have such linguistic weakness, everything takes so much longer and but we need that time to teach the core curriculum. And if you constantly go on trips and do little projects, time is missing elsewhere. And that's a shame. Because I have the feeling that from a social standpoint they really need that but time is missing. It's this vicious cycle.'While German language support was important in order to communicate content, it seemed that teachers were also aware of the social aspect of learning together in which cultural diversity could be brought in for real progress to take place. Amy confirmed that the project 'My roots' had taken place during which students practiced a greeting in each respective language and a song, accompanied with slideshows that the students had prepared. Students were proud of their identity, Amy stressed. She felt it was important that students felt at home in Austria: 'These are their roots but their homes are in Austria now.'In School 2, Christine and Paul also placed great emphasis on children feeling empathy, socializing with and caring for each other. Therefore, another pattern that reflected their instructional practices were activities performed as a group. For example, Christine and Paul started the day with a morning circle activity where they went through the routines of the day, and the teachers also set aside time in their weekly curricular plan to address social and emotional competence development via group activities and games. Social interactions among students also occurred during the lessons, for example, when students finished with their own tasks and have chosen to help another student or join another free activity (e.g., reading or playing educational games). Depending on the students' personal learning objectives, it was possible to work in pairs or in groups during curricular learning, but learner autonomy and individual ability to tackle tasks remained of foremost importance. However, cultural diversity played a hidden part in these moments of social activities. During the time of this fieldwork we have not observed any strategies that directly addressed cultural diversity as the focus of teaching-learning instruction. However, teachers noted that they took up conversations about different cultural habits, and that via social interaction and group activity, mutual cultural exchange occurred between children which was seen as a positive reality within these schools. For example:'And for her [a new student] now, as she is not so long in Austria, it's sometimes difficult to understand that [habits in Austria]. But it's not a problem that we are talking about. And so, the children from Austria learn that in another culture it's another habit. But that's not a problem! It's a thing you need to talk about, but you learn much things from another culture.'Christine The learning environment, on the other hand, contained some cultural artifacts, for example, there were flags from different countries hung in the main hall, and the classroom itself had some representation of different countries in books, maps, globes, and a flag flipbook that children could freely use to interact with and learn from. The next moment shows how Adam, after having finished his personal task during curricular learning, picked up the flag flipbook and engaged with his peers in social interaction.'Adam and three other boys sat in the reading corner, comfortable on pillows, browsing books and objects around them. Adam looked at a flipbook that consisted a flag of a country on each page. He started a game with the other boys around him. He showed a flag to them and ask in German 'What is this?', and the other boys guessed. Adam was very confident taking a leading role and guiding this interaction himself. When someone guessed well, Adam gave a point by pointing to the person with his hand and showing the number of points on his fingers. He flipped lots of flags: Albania, Norway, Italy, Bulgaria, Estonia, Finland, Bosnia-Herzegovina, Germany, Belgium, Greece and so on. When the three boys hesitated, Adam helped by telling the first letter of the country. 'R...' he said. 'Russia?' asked the boys. 'Ro...' Adam continued. 'Romania!' 'guessed the boys finally correctly. Fieldnote Frontiers in Education 09 frontiersin.org In this fieldnote, Adam and his classmates engaged in a moment of social interaction born out of their own interests, and the learning environment and materials that Christine and Paul provided in the classroom. The children spontaneously and autonomously engaged in learning associations between flags and countries around the world while interacting with each other. Notably, Adam took lead despite being new to the German language, and was able to navigate the whole social scenario by using hand gestures, simple German sentences, and the tool of the flipbook. Therefore, Adam had the opportunity to be positioned as a successful learner and organizer of social moments. While it would have been possible to strengthen cultural exchange through this moment, students' own knowledges and experiences with cultural belonging and migration remained uncovered. Neither the teacher demonstrated explicit actions against peer discrimination and racism, but rather focused on prevention via the above described social activities. These practices may signal that, if learning instruction does not address cultural diversity explicitly and via a direct collaboration with newly arrived migrant students, it remains hidden in dominating pedagogical norms of the classroom. --- (Un)belonging as creating language hierarchies The third key node was how classroom practices reflected linguistic diversity, and particularly, students' home languages. In this regard, we have found two patterned practices across the two classroom settings. One was related to explicitly addressing and valuing the maintenance of home language in out-of-classroom activities, and, on the other hand, reinforcing the domination of German and English. At School 1, fostering students' home languages seemed to be as important as learning German. The fourth graders had access to heritage language lessons provided by the school on its own premises for those who wanted to learn Turkish and Bosnian/Serbian/Croatian. These lessons were offered in the afternoons so that the rest of the students could go home. Amy was convinced that lessons in heritage languages were very important also with regard to learning German: 'Native lessons in Bosnian, Serbian, Croatian are every Friday afternoon and Turkish is usually in the afternoon as well, it depends on the schedule. And that is also received well [by the students]. In my opinion, children who attend native lessons also do better in German. There are great differences between speaking and writing. Children who do not speak clearly can still write relatively well. So they do learn the technique [of the language].'Hence, this 'double approach' worked in the students' favor, in Amy's thoughts. Placing both attention on the students' home languages while studying German in general education and occasionally through extra German support classes was a remarkable pedagogical vision in School 1 regarding linguistic diversity. However, heritage language instruction occurred out of the mainstream classroom, performed by heritage language teachers, and mainstream classroom teachers seemed to build little on students' home languages during curricular learning in the classroom. Teachers in School 2 were also appreciative of students' home languages, and they have also closely considered students' language backgrounds when designing German curricular learning. However, home languages were rather seen as in how they may influence the acquisition of German learning, and similar to School 1, little explicit visibility was provided during classroom instruction. In School 2, home languages were one part of student diversity, and therefore, did not seem to receive a more accentuated attention in the development of pedagogical vision than any other dimension of diversity. Therefore, both classroom practices seemed to focus on German language through a monolingual approach during classroom instruction, as well as the domination of English emerged. While English is a subject that students in Austria study as a regular subject lesson during primary education, the involvement of English was not restricted to those hours in the classes we observed. In both schools, students received lessons in English as a foreign language and English language was somewhat present in the daily classroom interactions too, and regarding it more organically as part of the general curriculum. At School 1, English received a special place in the curriculum. While it was the mother tongue of a handful of students from Central Africa, it was, unlike Kurdish or Bosnian/Serbian/Croatian, interwoven throughout the school day. On some mornings, the teachers practiced a routine of reading out the date of the day in English. In other instances, students had to open their German textbooks and the teachers announced page numbers in English. Some of the books in the 'book corner' were in English and students were encouraged to flip through them in their free time. English was treated as a language of prestige that received attention during the prime hours of the schedule. Other home languages remained compartmentalized for afternoon education. Amy explained the reasons behind her group being an 'English class' and linking it to their general abilities to perform higher than the other students in the school: 'We are an established 'English class.'So we offer an extra focus on English because the students seemed to have shown during their entry exams into the school that they were capable of learning yet a third language.'Students were encouraged to use English as a general education language which placed some of the students at an advantage while others remained with their mother tongue in the afternoon classes. While the reading corner had English classics like the 'The very hungry caterpillar' by Eric Carle, there were no Turkish or Bosnian/ Serbian/Croatian books. German and English were to be spoken and practiced communally in written and spoken word, while other languages remained a private endeavor. Similarly, in the classroom of Christine and Pauline at School 2, there was a student with English as home language, however, there were many others with other languages. Apart from English as a foreign language lesson, Christine and Paul also used English occasionally during classroom interactions, for example, in the morning circle. 'The students and teachers set in a circle on the mat in the middle of the classroom and talked about the date of the day, the season, and the weather. Paul leads the activity by posing questions to all students, and calling on them to answer. He also calls children to the whiteboard to write the date, and select the right pictograms for the weather. With each answer, Paul asks for the reply also in While the prominence of English was not as established as in School 1, a hierarchy of languages in curricular learning was also evident in School 2. English has somewhat entered daily interactions, and other classes of the school received structural bilingual education in Italian-German. This approach is somewhat contradictory to the school's vision on valuing each aspect of a student, but home languages becoming rather invisible when focusing on German, Italian, and English as named languages in curricular learning. --- Discussion In this study we explored teachers' instructional strategies in classroom practices that were underpinned by two different models of German language support. We specifically analyzed instruction in terms of German language support, cultural expression and the use of home languages in curricular learning, and we have identified similarities and differences between two classroom practices. Focusing on the cultural and linguistic aspects of belonging in curricular learning, (un)belonging as a pedagogical construct seemed to emerge from a chain of instructional strategies that marked newly arrived migrant students' 'fitness' to the mainstream classroom, created cultural (in)visibility, and language hierarchies. The two classroom practices presented remarkably different approaches in how they organized German language support in or out of the mainstream classroom, and consequently, how newly arrived students were marked as belonging or not belonging to predominating pedagogical norms. Importantly, School 2 did not only provide 'belonging' by physically placing newly arrived students in the same classrooms as others, but by changing its entire pedagogical approach for all students in which everyone followed their own learning paths as the new norm of the mainstream. Similarly, it is not only the pull-out mechanism of German language support that deemed students unbelonging to the mainstream classes, but teachers having to arbitrarily decide who benefit from that learning support, and who remains physically included yet marked in the unchanged mainstream classroom. These empirical insights to better understand the role of pedagogical enactments related to providing adequate learning opportunities in the language of schooling, which newly arrived students elsewhere report to be key in achieving a sense of belonging. While the two classroom practices were largely different in how they organized German language support, they were somewhat similar in their pedagogical uptake of students' cultural and linguistic knowledges, identities and experiences. By making cultural diversity rather invisible or pushed to tokenistic activities -food and festivals (Meyer and Rhoades, 2006), these schools seemed to give lesser chances for newly arrived migrant students to see their backgrounds and experiences reflected in curricular and social learning in the classroom. While surface level insight into a given country through songs, recipes, dances, and phrases, or random cultural exchange via social interaction was noted, students' authentic relationships with their transnational identities remained in the background. This finding corresponds with many others that report similar tendencies (e.g., Szelei et al., 2019), however, we importantly correspond here with studies on belonging, and add that this cultural (in)visibility may have a direct impact on students' feelings of (un)belonging. Furthermore, both schools seemed to opt for following'monolingual principles' (Gitschthaler et al., 2021, p. 5) which (Hornberger and Johnson, 2014) make out as teachers exhibiting political power over their students. Monolingualism was reflected by emphasizing German language acquisition through German-only instruction, and by establishing the dominance of German and English (School 1), German, Italian and English (School 2), while home languages remained pushed to out-of-classroom activities. Home languages occasionally entered the classroom via tokenistic activities or by paying attention to students' backgrounds when designing tasks for German language development. Tied to the monolingual approaches adopted by the two schools studied are language hierarchies. Schooling practices in both schools reflect unconscious hierarchies of languages, positioning the German and English languages as more valued and ethically minoritized languages or migration-induced multilingualism as less valued (Von Esch et al., 2020;Putjata and Koster, 2023). Across the two schools, the domination of German and English was evident. In School 1, English was tied into the curriculum and teachers had stacked the 'book corner' with books in English even if none of the interlocutors was'Anglo.'Similarly, in School 2, English use was explicit in interactions albeit occasionally. This points to linguistic hierarchies and separate spaces for different languages especially minoritized languages within these schools (Young, 2014). This conscious or unconscious promotion of some languages over others deserves attention as past studies indicate that teachers' multilingual practices can negatively affect the development of multilingual children and their educational success (Gomolla, 2017;Putjata, 2018Putjata,, 2019) ) while truly embracing multilingualism such as employing translanguaging practices in classrooms can have positive affects for students' well-being and belonging (Duarte and van der Meij, 2018). How teachers teach and the professional choices they make in the classroom setting are tied to their language ideologies and cultural beliefs. In a recent study of teachers' beliefs and attitudes about multilingualism (ideas about the value of different languages and their role in everyday teaching and learning processes) in the German state North Rhine-Westphalia, (Putjata and Koster, 2023) found that despite differences in school language policies, professional biographies and multilingual upbringings, teachers in monolingual and bilingual schools reproduced monolingual normative perceptions. Even teachers at bilingual schools focusing on European languages deem migrationinduced multilingualism as less important. Turning from the European level back to the state-level, the Austrian Federal Ministry for Education, Science and Research (Bundesministerium für Bildung, Wissenschaft und Forschung) evaluated the implementation of the German support model, presented in this piece, in October 2022 (see: Spiel et al., 2022). In this report, survey data from 93 schools and 693 participants, including German language support teachers (167), principals (80) as well as primary school teachers (446) responded to the questionnaire (2022, p. 7). The report comes to the following conclusions: It is of paramount importance that educators who provide German support classes and courses are actually trained in teaching German as a second language. In fact, the survey highlights that German support should only ever be taught by 'experts in German as a second language' (p. 22). None of the practitioners, showcased in this text, were specificallytrained to work with children who were in the process of acquiring German language skills. Moreover, schools seem to be asking for more flexibility to handle how long students can remain either in German support classes or courses. German support classes and courses were generally considered negatively by the respondents who preferred 'integrative instead of segregated' education of multilingual students (Ibid. 2022, p. 22 and p. 25). This finding reflects some of the discontent that students expressed in our materials who protested against being pulled out of the mainstream classroom and indicates that teachers are sensitive to their students' unease around temporary segregation. The evaluation also shows that research participants preferred smaller groups and more flexibility when it comes to the number of hours that students spent in separate settings. Looking ahead, then, we want to advise to strive less for a unified approach to newly arriving students as these approaches perpetuate disparities among children and produce high levels of fragmentation in the way that children may feel a sense of belonging to their new environments, as we have shown in this study. Instead, we suggest a flexible approach that focuses on the individuals at hand and allows teachers of German as a second language to foster communal as well as linguistic practices, that are suitable for the specific setting. In closing, we want to point to the strengths of this study which include the extensive use of direct observations, prolonged engagement at the sites of study, linguistic diversity in the researchers conducting the data analysis and a clear delineation of the place of research. In terms of limitations, the study may have benefited from more extensive details on biographical variables in the child participants, such as initial levels of German-language proficiency, adverse childhood events prior and during migration and socio-economic status. Additional data collection and analysis on written language proficiency in child participants may also have been insightful. Nonetheless, the study contributes to complex and nuanced understandings of the phenomenon of classroom pedagogies and curricular support for newcomer migrant pupils in schools. The study also connects the notion of 'belonging'/'(un)belonging' to the micro-decisions that teachers make in classrooms on a daily basis. Furthermore, the study forefronts the importance of visible inclusive practices, yet it simultaneously agitates for increased sensitization on the underlying curricular dynamics that constitute an inclusive learning environment. Visible inclusive practices, such as the content of 'Welcome' posters and the portrayal of national flags, are evident in the schools in this study. This can be expanded to also include celebrations such as diversity days, regularly reviewing learning materials and learning basic conversational phrases in a multitude of languages. For example, poems, rhymes, songs, dance and music, from a variety of cultures, as well as audio-taped books in a variety of first languages can be used as resources that reflect the interests and perspectives of all students. Through these materials, characters from different places around the world can be introduced to children in non-stereotypical roles. In terms of building language proficiency, bilingual dictionaries can be developed based on these materials and used to address many different experiences that children in the given classroom may relate to. Eventually, it is left to point out that Austrian schools have been highly diverse for decades and even centuries, and that newly arriving migrant students simply indicate how valuable an approach to valuing this diversity could be. Instead of reshuffling classrooms and reinventing a course structure, we want to end with the question addressed at policy and practice alike: What would a curriculum look like in which linguistic and cultural diversity was the norm and not an inconvenience? The current study traced classroom pedagogies of (un)belonging in Austrian schools, and while not generalizable, the findings may potentially resonate in schools around the globe. Migration is a continued, global phenomenon and the pedagogies, and concomitant experiences of (un)belonging found in this study, may be present elsewhere, too. --- Data availability statement The datasets presented in this article are not readily available because the data remains under EU privacy protection policy for research with vulnerable individuals. Requests to access the datasets should be directed to edite.eu. --- Ethics statement The studies involving humans were approved by Research Executive Agency (REA). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. --- Author contributions --- 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.

Even though receiving newcomer pupils in schools is not a new phenomenon, many education systems grapple with finding adequate schooling arrangements that foster belonging and inclusion. Over the years, policy-makers and school practitioners seem to echo recurring dilemmas in terms of what language support models may promote optimal inclusion, and whether and how to support the language of schooling while also building on students' cultural and linguistic repertoires. In this article, we present classroom observations from two Austrian primary schools that implemented German language support in two distinct ways. School 1 implemented pull-out classes, whereas School 2 used a model of individualized learning for all students in the mainstream classroom. Utilizing the cultural-linguistic aspects of 'belonging' in pedagogical enactments, we analyze how teachers' instructional strategies to organize curricular learning for newly arrived migrant pupils set conditions for pedagogies of (un)belonging in the classroom. Findings show that pedagogies of (un)belonging seemed to be formed via chains of patterned interactions, activities and utterances based on three key logics: marking students' 'fitness' to the mainstream classroom, creating cultural (in)visibility, and as creating language hierarchies. While the two classroom practices remarkably differed in how they enabled German language learning and fitting to mainstream pedagogical norms, both seemed to uphold monolingualism and monoculturalism. Recommendations are given in order to expand narrow notions of belonging in educational policy and practice.

INTRODUCTION Crime is increasingly transnational, stressing the need for coordination among all stakeholders to uphold the global security order. Interpol, as an international organization, provides a platform that allows police forces to work directly with their counterparts across national borders, even with countries that do not have diplomatic relations (Murphy, 2023;Tsai et al., 2022;Watson, 2023). Human slavery can be traced back hundreds of years. Even in today's era, where human rights are globally recognized as fundamental, modern slavery remains in the form of human trafficking. Human trafficking (THB) is an international organized crime worth billions of dollars, affecting every region worldwide. Victims are traded across countries and territories through fraud, threats, or coercion. Traffickers use sophisticated methods to target and exploit vulnerable populations for personal gain, disregarding human dignity and life. (Bossard, 2022;Bowersox, 2022;Go<unk>dziak, 2021;Nordquist, 2022;Tsai et al., 2023;Watson, 2023;). Trafficking in human beings is a crime that occurs worldwide and affects millions of people every year. Trafficking in human beings is a form of modern slavery that involves the recruitment, transportation, transfer, shelter, or acceptance of a person using the threat or use of violence, fraud, or abuse of power or vulnerable position for exploitation. Exploitation can be sexual exploitation, forced labor, or other forms of exploitation (Ara & Khan, 2022;Han et al., 2022;Kennedy, 2022;Recknor et al., 2022;Shah, 2021). The problem of human trafficking is not a new challenge facing countries worldwide. The victims of exploitation generally come from an unfortunate economic background, leaving them trapped in difficult economic conditions and eventually using various means, including illegal activities that violate human rights (Albanese et al., 2022;Bartilow, 2022;Dilmore, 2022;Lazzarino et al., 2022;). According to the Human Trafficking Report 2022 (see figure 1), there has been a significant decline in human trafficking figures from 2018 to 2021. In 2019, the number of recorded victims was 118,932, while in 2021, it reached 450,000 victims and 300,000 suspects, with perpetrators detected throughout the country. Over 23% of global human trafficking occurs in Africa (Sprang et al., 2022;Yansaneh, 2020). According to the 2018 Global Slavery Index, an alarming 9.2 million people in Africa endure modern slavery, constituting nearly one-quarter of global human trafficking cases. This emphasizes the pressing and critical nature of the issue on the continent (Abioro & Akinyemi, 2022;Obokata, 2019;Pendery, 2022;Yansaneh, 2020). Africa acts as a significant source region for individuals trafficked to other areas, particularly Western Europe and the Middle East. However, internal and regional trafficking also prevails within the continent, especially in Sub-Saharan Africa. Women and children are disproportionately affected, forming a significant portion of Sub-Saharan Africa's victims. They face exploitation in various industries, including agriculture, domestic work, prostitution, and forced military service (e.g., child soldiers). Estimates indicate that 3.7 million people in Africa are enslaved or forced laborers, generating approximately $13.1 billion annually for the Sub-Saharan region alone (ILO, 2014). Shockingly, perpetrators often include individuals known to the victims, such as close family members, relatives, or even friends. The notion that human trafficking is a crime mostly committed by men is disproved by the fact that 50% of human trafficking criminals in Africa are women (UNODC, 2014). It has also been established that organized criminal gangs are involved, which makes people trafficking operations more complex and deadly. Various industries, including domestic employment, prostitution, labor in gold mines, organ transplantation, and the shipment of illicit narcotics, are involved in human trafficking crimes (Idowu, 2022;Motseki, 2022;Ogunniyi & Shoroye, 2021;Umukoro, 2021). --- Figure 2. West Africa Map Source: https://www.istockphoto.com/id/vektor/peta-afrika-barat-dengan-perbatasan-negara-negara-bagian-gm1469665528-500798213 The West African region has long experienced high population migration rates, creating a market for human traffickers. However, human trafficking is described as a form of modern slavery. It is the result of a combination of factors, including gender inequality, economic instability, and political conflict, all common in West African countries. The role of states and law enforcement in West Africa is not optimal in providing technical tools, human resources, and references to deal with criminal groups operating as transnational syndicates (Abioro & Akinyemi, 2022;Judge & Doherty, 2022;Motseki, 2022). In addition, cultural factors, political instability, institutional inefficiency, and poor economic conditions in the West African region aggravate the situation. No African country fully meets the minimum standards of the Trade and Violence Protection Act (TVPA) for the eradication of human trafficking. This condition requires cooperation between African countries and Interpol as a more sophisticated and experienced law enforcement entity (Abodunrin et al., 2021;Bosard, 2022;Hackett, 2022;Jagoe et al., 2022;Shoroye, 2021). Interpol cooperates with law enforcement agencies in Africa through several mechanisms. In addition to identifying human trafficking crimes in the African region, Interpol actively enhances the capacity of relevant stakeholders in Africa, including the security, governance and legal sectors. Interpol actively collaborates with African law enforcement agencies, significantly boosting their capacity in security, governance, and the legal sector. The West Africa THB Project, executed by Interpol from September 2020 to September 2023, involved impactful rescue operations like Operations Weka and Weka II, alongside Operation Priscas. Operation Weka, led by Interpol, successfully rescued nearly 500 trafficking victims and apprehended 195 suspects during its implementation from March 28 to April 2, 2021. Operation Priscas, directed by Interpol in targeted criminal organizations exploiting individuals, resulting in the rescue of 90 victims and the detention of 15 alleged traffickers, including 56 children forced into labor in homes, open marketplaces, and gold mines (Hounmenou & O'Grady, 2021;Mutasa, 2021;news.detik.com, 2022;). This research delves into a crucial gap in existing knowledge: Interpol's specific strategies for strengthening regional networks to combat human trafficking in West Africa. While research often examines Interpol's overall role and initiatives in the region, it rarely dives deep into the network-building tactics employed. This is particularly important given the evolving nature of human trafficking in West Africa. As social, economic, and political conditions change, so too must the strategies employed to combat this complex and dynamic crime (Motseki, 2022;Nordquist, 2022). Therefore, this research seeks to answer the following key questions: (1) What specific strategies does Interpol employ to improve regional networks in its fight against human trafficking in West Africa? (2) Do these strategies effectively combat human trafficking in the region? If not, what factors hinder their effectiveness? In the end, the researchers hope that this study can contribute a significant insight to the issue of human trafficking and how related parties should handle it. --- METHOD The qualitative descriptive analysis method is an analytical technique that focuses on understanding a problem, context, complexity, subjectivity and group interaction. Thus, researchers should gradually seek to understand social phenomena by comparing, imitating, cataloging and grouping objects of study (Anggito & Setiawan, 2018;Creswell, 2014;Helaluddin & Wijaya, 2019). In this study, journal analysis aims to pay attention to the main essence of research that has been published by scientific resources, then combine it with the ideas of the analyzer. The researchers then provide a brief and descriptive statement of the journal to make the content more effective, clear, and useful. Qualitative research in the field of international relations involves in-depth analysis of one or several specific cases, such as regional conflicts, diplomatic negotiations, or foreign policy of a country and is carried out as a whole to the subject of research (Peterson & Peters, 2020;Rosyidin, 2019;Viskupi<unk>, 2021). Where there is an event that is used as a key instrument in research, such as reviewing international treaty documents, news, foreign policy and diplomatic reports, then the results of the approach are described in written words from empirical data to be obtained (McCourt, 2019;Viskupi<unk>, 2021;Rosyidin, 2019). In addition, qualitative data is described descriptively using research instruments, data reduction, data presentation, and conclusion drawing (Anggito & Setiawan, 2018;Creswell, 2014;Rosyidin, 2019). --- RESULTS AND DISCUSSION The Importance of Interpol's Role in Tackling Transnational Crime Founded in 1923 by 20 countries, Interpol aimed to enhance global police cooperation against transnational crime. Its origins trace back to the first International Congress of the Criminal Police in Monaco in 1914, discussing international crime collaboration and prevention techniques. Interpol uniquely shares legal and law enforcement information globally (Delpirou, 2022;Lacy, 2023;Milani, 2023;Yorke, 2023). Transnational crime in West Africa involves illicit networks operating across borders, exploiting weak governance and economic disparities. Crimes include drug trafficking, human trafficking, arms trafficking, and money laundering (Delpirou, 2022;Helpingstine, 2022;). In 1923, Vienna hosted a pivotal moment in the fight against international crime as Dr. Johannes Schober, President of the Vienna Police, led the second International Congress of the Criminal Police. With delegates from 20 nations, this congress resulted in a landmark resolution on September 7th, giving birth to the International Criminal Police Commission (ICPC), later known as Interpol. Rooted in the shared goal of aiding police forces across borders, Interpol established core objectives, including direct information exchange, joint capture of criminals, combating counterfeiting, and fingerprint identification. This historic initiative laid the foundation for an influential organization, a beacon of international cooperation in the face of global crime (Delpirou, 2022;Dryjanska, 2022;Helpingstine, 2022;Kenny et al., 2022;Lacy, 2023;Yorke, 2023). Interpol maintains political neutrality and operates within the legal framework of various countries. Its official name is the International Criminal Police Organization, an intergovernmental organization. Interpol has 195 member countries tasked with assisting police forces worldwide in collaborating to make the world safer. Interpol allows police officers from different countries to share and access crime and criminal data while offering a wide range of technical and operational support (Tsybulenko & Suarez, 2022;Williamson, 2022;). The Interpol General Secretariat carries out and coordinates day-to-day activities. Interpol's staff consists of police officers and civilians. Its headquarters are located in Lyon, France, with a global office complex for innovation based in Singapore and several satellite offices located in various regions around the world (Hough, 2020;Hufnagel, 2021;Kemp, 2021;Tsybulenko & Suarez, 2022). In the Interpol network, each member country relies on staffed by national police officers, serving as a crucial link to the General Secretariat and other NCBs. Annually, the Interpol General Assembly convenes representatives to make pivotal decisions on pressing matters. Facilitating seamless communication, Interpol's I-24/7 system serves as a secure bridge between countries, offering real-time services and database access. Beyond communication, Interpol provides extensive investigative support, from forensics to global fugitive location. The organization also plays a vital role in training, conferences, and capacity-building initiatives, empowering law enforcement against evolving global threats like terrorism, cybercrime, and organized crime (Delpirou, 2022;Nordquist, 2022;Zhang, 2022). --- Interpol's strategy to combating human trafficking in West Africa The UNODC and NAPTIP collaborated on a report covering global trafficking incidents from 2016 to 2019, highlighting West Africa's prominence in identifying trafficking victims. Out of 4,799 victims in 26 Sub-Saharan African nations, 3,336 were found in West Africa, including 2,553 children. Forced labor, constituting 80% of victims, spans sectors like agriculture and mining, where victims endure hazardous conditions with minimal or no pay. Minors, easily manipulated and unaware of their victimization, often feel protected by their exploitative "employers". Globally, nearly 20% of trafficking victims are children, contributing to the ongoing challenge of labor exploitation and modern-day slavery, particularly in the African region (Clark, 2020;Ford, 2015;Gill & McKinnon, 2021;Handrahan, 2022;Hounmenou & O'Grady, 2021;Maluleke et al., 2022;Mutasa, 2021;Sprang et al., 2022;UNODC, 2022;Yingwana et al., 2019). Interpol will continue to play an important role in combating human trafficking in West Africa and worldwide. In other words, it has supported law enforcement agencies in West Africa, both from resource and technical, financial aspect. Sharing expertise, funding, legal knowledge, psychology, technology, and field operations through alliances with Interpol and other countries help strengthen responses to transnational trafficking in persons. Through joint efforts and shared goals, countries in West Africa seek to address the external threats posed by human trafficking and protect the rights and well-being of victims (Bowersox, 2022;Cunha et al., 2022;Koegler et al., 2023;Kvartalnov, 2021;McCourt, 2019;Murphy, 2023;Tsai et al., 2022;Umukoro, 2021;Watson, 2023). --- istockphoto.com/id/vektor/peta-afrika-dengan-perbatasan-negara-negara-bagian-gm1469665502-500798197 The United Nations Office on Drugs and Crime (UNODC) presents a troubling scenario of human trafficking in a recent report covering 148 countries and over 95% of the global population. Developed in collaboration with the National Agency for the Prohibition of Trafficking in Persons (NAPTIP), the report draws on official data from 2016 to 2019, highlighting West Africa's alarming trend of identifying more trafficking victims than other Sub-Saharan regions. Shockingly, of the 4,799 victims identified in 26 Sub-Saharan African nations, 3,336 were in West Africa, including a heartbreaking 2,553 children. UNODC's findings underscore the pervasive issue of forced labor, affecting approximately 80% of victims in West Africa (Gill & McKinnon, 2021). Labor trafficking casts a long shadow across industries like agriculture, mining, and fishing. Victims are trapped in a web of exploitation, forced to endure grueling hours and hazardous conditions for scant or no pay (Clark, 2020;Ford, 2015). Minors are especially vulnerable. Their innocence makes them easy targets, often unaware they're caught in a web of crime. Deceptive "employers" offering food and lodging can mask the reality of exploitation, leaving children believing they're protected (Handrahan, 2022;Gill & McKinnon, 2021;Maluleke et al., 2022;Mutasa, 2021;). Tragically, children comprise roughly 20% of all global victims. The African continent, according to ILO data from 2022, bears the highest burden of labor exploitation, feeding into the persistent specter of modern slavery. This grim reality underscores the urgency of combating this heinous crime (Hounmenou & O'Grady, 2021;UNODC, 2022). Understanding the dynamics of exploitation varies among African countries is often solely with prostitution or sexual exploitation, while other nations encompass diverse forced marriage and involvement in armed conflict. These perceptions stem from social, cultural, political, and legal traditions, impacting fragmented approaches to combating human trafficking and hindering regional law enforcement cooperation. Countries lacking legislative frameworks are more vulnerable, as criminals exploit weak law enforcement. In Africa, over half of trafficking victims face forced unions, with about 63% coerced into marriage without consent, leading to domestic servitude, sexual exploitation, and abuse. Conflict-affected countries with limited security access become hotspots for human trafficking, particularly in Sub-Saharan Africa, where 73% of cases were reported in 2020(borgenproject.org, 2020;Botha & Warria, 2021;Handrahan, 2022;ILO, 2021;Motseki, 2022;Nguyen et al., 2022;Obokata, 2019;UNICEF, 2020;UNODC, 2022). --- Figure 4. Global Report of Trafficking in Person 2022 Source: UNODC, 2022 Human trafficking remains shrouded in uncertainty in certain nations, notably Libya and Somalia, as indicated by the 2018 Trafficking in Persons report. Ongoing conflicts in these regions hinder accurate assessments of trafficking levels, making detection and combat challenging amidst the absence of authority and law enforcement. Somalia, facing persistent humanitarian crises and security issues for 17 years, struggles to address trafficking due to ongoing conflicts. The U.S. State Department's Watch List includes 19 countries, recognizing their efforts, though imperfect, to align with the Act's criteria, emphasizing the crucial role of state authorities and the need for international cooperation, particularly with organizations like Interpol, to combat human trafficking (Bartilow, 2022;borgenproject.org, 2020;Dilmore, 2022;Neikirk & Nickson, 2023;Nordquist, 2022;Yansaneh, 2020). --- Interpol Actively Bolsters the Capabilities of West African Law Enforcement in Their Fight Against Human Trafficking In certain regions of Africa, traffickers exploit the lack of security and law enforcement capacity, contributing to high rates of trafficking crimes. Interpol addresses this issue by offering training, databases, and operational support to enhance global law enforcement agencies' capabilities in detecting and investigating these crimes. Recognizing the challenges faced by African law enforcement and government stakeholders, Interpol aims to develop their capacity, fostering organization and unity in combating traffickers. The ongoing Trafficking Human Being (THB) in West Africa Project, running from September 2020 to September 2023, focuses on training activities in Benin, with the goal of equipping Interpol's law enforcement and judicial actors with enhanced capabilities to investigate and prosecute human trafficking cases (Cuhna et al., 2022;Delpirou, 2022;Jesperson & Henriksen, 2022;Obokata, 2019;Ogunniyi & Idowu, 2022;Tsybulenko & Suarez, 2022;Yansaneh, 2020). In 2022, Interpol collaborated with West African police forces in various Trafficking in Human Beings (THB) crime investigations. In March, Togolese police and Interpol rescued victim from erotic abuse, reuniting her family. Identified during Operation WEKA II in February, she had disappeared from Ouagadougou in January. In November, law enforcement agents, with Interpol's assistance, freed an eight-year-old boy held for ransom by other migrants for a year. Coordinated efforts in Algeria led to the capture of the kidnapper. Operation Priscas in December targeted criminal organizations involved in human trafficking and child abuse, resulting in the rescue of 90 individuals and the apprehension of 15 suspected traffickers, including 56 victims exposed to sexual exploitation and forced labor in open markets, families, and gold mines (Lockyer, 2020;Ho<unk>dy<unk>ska, 2021;Murphy, 2023;Ogunniyi & Idowu, 2022;Yansaneh, 2020). A continuous communication among stakeholders in the African region is essential. Interpol is working to facilitate this coordination center with support from EU donors through the West African Police Information System program (Ogunniyi & Idowu, 2022;Yansaneh, 2020). The program's goal is to improve communication and cooperation amongst law enforcement agencies in the West African region by doing the following: First, give West African police officials access to crucial law enforcement data from regional national criminal databases, boosting criminal identification and assisting with existing investigations. Improve analysis of regional transnational organized crime and terrorism, as well as knowledge of crime coming from and passing through West Africa. Third, promote judicial and law enforcement authorities' cooperation on criminal cases in the area, the European Union, and globally (Udezi, 2023;Nordquist, 2023;Ogunniyi & Idowu, 2022;Yansaneh, 2020). Interpol, in collaboration with regional police forces, has conducted numerous operations to combat human trafficking and migrant smuggling. Operation Priscas, among others, has been notable, with recent initiatives like Operation Weka and Weka II between 2021 and 2022. Operation Weka, occurring from March 28 to April 2, 2021, led to the successful rescue of nearly 500 trafficking victims, including children, and the identification of about 760 undocumented migrants. Authorities from 24 participating countries exchanged intelligence to dismantle criminal networks, with Spain, Sudan, Benin, Morocco, Algeria, Portugal, and Congo being key contributors (Ogunniyi & Idowu, 2022;Yansaneh, 2020). This operation vividly demonstrates the close link between migrant smuggling and human trafficking, especially during a global health crisis, where vulnerable groups seek to avoid hardship while criminal networks prioritize profit. The arrests made during Operation Weka also involved charges related to other crimes, including document falsification, theft, drug offenses, and environmental pollution (www.interpol.int, 2021). Interpol's I-24/7 communication network plays a vital role in enhancing global law enforcement cooperation. Each national police data system, linked to Interpol through their national central offices, facilitates officers in examining and sharing official national data worldwide. This interconnectedness allows for efficient identification of connections between criminal behavior and suspects, contributing to more effective transnational crime and terrorism combat in West Africa and globally. Interpol's involvement in THB crime investigations includes examples from 2022, such as the rescue of an adolescent girl from sexual exploitation and the successful apprehension of a kidnapper, highlighting the organization's commitment to operational support and technical resources (Albanese et al., 2022;Lazzarino et al., 2022;Ogunniyi & Idowu, 2022;Yansaneh, 2020). --- Operation Sahara North Africa and Sahel To combat migrant smuggling and human trafficking in North Africa and the Sahel. Resulted in the rescue of over 2,000 migrants and the arrest of over 100 smugglers. --- Operation Weka East and Central Africa To combat human trafficking and migrant smuggling in East and Central Africa. Resulted in the rescue of over 500 victims and the arrest of over 50 traffickers. --- Operation Storm South and Southeast Asia To combat human trafficking and migrant smuggling in South and Southeast Asia. Resulted in the rescue of over 1,000 victims and the arrest of over 100 traffickers. --- Operation Mekong River Southeast Asia To combat human trafficking in Southeast Asia. Resulted in the rescue of over 1,500 victims and the arrest of over 200 traffickers. --- Operation Libertador Latin America To combat migrant smuggling and human trafficking in Latin America. Resulted in the rescue of over 3,000 migrants and the arrest of over 200 smugglers. --- Operation Mare Nostrum Mediterranean Sea To rescue migrants and refugees crossing the Mediterranean Sea in unseaworthy vessels. Resulted in the rescue of over 150,000 people. --- Source: Results of researcher data analysis, 2023 In the presented Table 1, Interpol's collaboration in Africa involves multiple stakeholders, including state actors like the United States (through the Bureau of Narcotics Affairs and International Law Enforcement) and international organizations such as the United Nations, Europol, the International Organization for Migration, Frontex, the OSCE Office for Democratic Institutions and Human Rights, and the Inter-Agency Coordination Group against Trafficking in Persons (ICAT). This collaborative effort, acting as a "gap-filler," addresses the inadequacies in West Africa's security and law enforcement. The involvement of various stakeholders becomes crucial as state and law enforcement agencies in the region face challenges in providing the necessary technical tools, human resources, and references to combat transnational criminal syndicates operating with multi-billion-dollar criminal activities, often due to the region's low social, cultural, and economic conditions (Abioro & Akinyemi, 2022;Delpirou, 2022;Neikirk & Nickson, 2023;Yansaneh, 2020). The alliance's purpose is to enhance the security of its members or promote shared interests globally (Bowersox, 2022;Nosenko, 2022;). Faced with complex political, economic, social, and cultural conditions, West African nations, alongside Interpol, find eradicating national and transnational crime challenging. Special attention and adapted strategies are crucial. In social and cultural aspects, promoting gender equality and women's rights remain priorities (Lacy, 2023;Yorke, 2023). In politics and security, the West Africa THB Project aids surveillance, especially at trafficking-vulnerable border points. Strengthening security through programs like WAPIS is vital, fostering quick responses. West African nations form alliances with Interpol and others to combat human trafficking, sharing insights, experiences, and resources (Ferreira, 2022;Helpingstine et al., 2022;Hough, 2020;Judge & Doherty, 2022;Kyatalnov, 2021;Orsini, 2022;Perdery, 2022;Poku & Therkelsen, 2022;Umukoro, 2021). --- CONCLUSION Interpol's strategy for combating human trafficking in West Africa focuses on prevention, investigation, prosecution, protection, and international cooperation. The organization empowers law enforcement agencies through training, operational support, and victim and witness protection. Awareness-raising initiatives contribute to a collective understanding of these crimes. However, the research has limitations, such as focusing only on INTERPOL's role and not addressing other actors like the government, civil society organizations, and victims. Future research should focus on qualitative and quantitative methods to better understand the situation and conditions of human trafficking in West Africa.

The main problem in this study is the human trafficking practices in West Africa. Trafficking in human beings is a serious transnational crime involving blackmail, exploitation, and forced labor. Victims of human trafficking are often forced to work in modern slave industries, such as prostitution, agriculture, and manufacturing. They can also experience physical and psychological violence. Human trafficking has many root causes, including poverty, gender inequality, and conflict. Research methods use qualitative descriptive approaches with data analysis techniques that focus on understanding a problem, context, complexity, and subjectivity to more detail about the data source. Results: Interpol's role and initiatives have saved hundreds of victims of human trafficking in West Africa. The organization has been a valuable partner for governments and law enforcement agencies in the region in combating human trafficking crimes and rescuing victims. Interpol's efforts to rescue victims of human trafficking in West Africa are critical to combating this crime. By raising awareness, identifying victims, disrupting trafficking networks, and providing support to victims. Interpol recognizes the urgent need to facilitate interstate police cooperation in addressing transnational crime, regional security and resilience.

conducted in San Francisco, Los Angeles, and New York, African-American and Latina transgender women were at significantly higher risk for HIV infection compared to their white counterparts (Clements-Nolle et al., 2001). Increased HIV risk among transgender women has been linked to a variety of behavioral factors, including high prevalence of sex work (Operario, Soma & Underhill, 2008;Nemoto, Operario, Keatley, Han & Soma, 2004), increased rates of unprotected anal sex (Garofalo et al., 2005;Nemoto et al., 2004), and high rates of sex under the influence of alcohol or drugs (Bockting et al., 1998;Garofalo et al., 2005). Engagement in these high-risk behaviors has been linked to the stigma experienced by transgender women (Bockting et al., 1998). Some research has specifically linked stressful life circumstances and sexual risk-taking, finding that exposure to stressful events is associated with a variety of unhealthy behaviors, including highrisk sexual behavior and substance use (Johnsen & Harlow, 1996;Lang et al., 2003;Semple et al., 2009). In past studies of transgender women, high rates of discrimination predicted unsafe sex (Bockting, et al., 2002), as did low self-esteem and history of victimization (Garofalo et al., 2005). At the same time, research on resilience to stress highlights several important factors that may assist stigmatized individuals in coping with discrimination and other stressful life situations. Social support has been demonstrated to act as a buffer against stress, blunting its negative effects and facilitating more effective coping (Cohen & Willis, 1984;Cohen, 2004). Supportive friendships have been demonstrated specifically to reduce the association between stressors and sexual risk-taking (Brady et al., 2009). Unfortunately, stigmatized individuals may sometimes avoid social relationships, and lower levels of social support have been found to mediate the relationship between stigma and both psychological and physical functioning (Larios, David, Gallo, Henrich, & Talavera, 2009). In one study of transgender women, lack of social support emerged as an independent predictor of high-risk sexual behavior (Garofalo et al., 2005). Another factor that has been associated with enhanced coping in the face of difficult life events is stress-related growth, defined as perceptions of positive personal or life-changes associated with stressful events (see Calhoun & Tedeschi, 2006;Linley & Joseph, 2004, for reviews) Perceptions of stress-related growth have been associated with a host of positive psychological outcomes, including decreased depression and increased emotional well-being (Helgeson et al., 2006). In addition, stress-related growth has been associated with positive health behaviors, including decreased alcohol and substance use (Millam 2004;Millam 2006), improved medication adherence (Weaver, 2005), and increased physical activity (Littlewood et al., 2008). However, little research has been conducted on perceptions of stress related growth among transgender women, or on its potential impact of risk behavior in this population. Religious behaviors and beliefs have also been identified as important components of resilience to stress. Using religious behaviors and beliefs as part of coping with negative life events has been associated with less depressive symptoms, higher self-esteem, improved cognitive functioning, and better life satisfaction (Pargament, Koenig, Tarakeshwar, & Hahn, 2004;Park, 2006;Yakushko, 2005). In accordance with evidence suggesting that religion can be used to counter experiences of stigma or discrimination, some lesbian, gay, bisexual, and transgender (LGBT) individuals use religious behaviors and beliefs (e.g., prayer, meditation, attending worship services), as a means to counter the oppression they feel based on their stigmatized identities (Love et al., 2005;Bockting & Cesaretti, 2001;Fullilove & Fullilove, 1999). However, religious affiliation may be a double-edged sword for some LGBT individuals. Religious institutions that stigmatize homosexual, bisexual, or gender non-conforming identities may actually increase mental health problems for LGBT individuals with strong religious beliefs or affiliations with these institutions (Fullilove & Fullilove, 1999;Love et al., 2005). The present study is an attempt to examine the relationships among three factors that might protect against sexual risk-taking among transgender women: social support, stress-related growth, and religious behaviors and beliefs. Often, investigations of HIV risk in this population focus on factors that promote risk behavior; in contrast, this analysis focuses on three factors identified in the literature as promoting resilience to stressful life events and preventing unhealthy behavior. Specifically, our analyses were designed to examine both bivariate and multivariate associations between each of these three factors and high-risk sexual behavior among transgender women, as well as explore the interactions among these factors in determining risk. --- Methods --- Participants Seventy-five (75) transgender women (biological sex male; gender identity female) were recruited from New York City and Northern New Jersey. Participants were predominantly women of color, Latina (45.3%) and Black (34.7%), and ranged in age from 18 to 56 (M=35.37, SD=10.48). Participants reported low levels of education (72% had GED's or had not completed high-school), low personal income (68% reported making less than $30,000 per year), and 46.7% were unemployed. Half of participants (50.7%, n = 38) reported being HIVpositive. In terms of medical gender affirmation treatments, 93% of participants reported taking hormones; 35% (n = 26) reported silicone injections in their breasts (13.3%), face (20%) or buttocks (24%); 21.3% (n = 16) reported facial surgery, and 6.7% (n = 5) had their testicles removed. All participants reported having a penis. --- Procedure Participants were part of a research study designed to test the effectiveness of a 4 week workshop series which addressed many life concerns of transgender woman (e.g. feelings of isolation, sex work, HIV risk, physical/hormonal bodily changes). Transgender women of color served as peer outreach workers to recruit potential participants. These women attended programs, bars, and night clubs that service transgender women. The peer outreach workers provided potential participants with a brief description of the project and a recruitment card with the study tag line "Interested in sharing about your experiences with your 'Girlfriends?' " and project contact information. Interested women then called in to screen for eligibility. Participants came in for baseline assessments in February 2008, followed by the 4 week workshop series, and then completed 3 month follow-up assessments. Participants received $40 for each assessment. Current analysis utilized the baseline assessment data only. All procedures were approved by the Institutional Review Board of Hunter College. --- Measures Participants completed a series of validated measures using an Audio Computer Assisted Self Interview (ACASI). ACASI uses both computer and voice recordings so that the participant hears (through headphones) and sees (on the screen) each question and response choices. ACASI has been found to be an effective interview method for people of diverse educational backgrounds and decreases the effect of reading ability on internal validity (Gribble et al., 2000;Turner et al., 1998). Additionally, ACASI administration has been found to improve self-report of sensitive topics (Gribble et al., 2000;Williams et al., 2000). Religious Behaviors and Beliefs-The Religious Behaviors and Beliefs Scale (RBB; Connors, Tonigan, & Miller, 1996 ) consists of thirteen items measuring religious activities, both past and present. The first question ask participants to identify which best describes their religious beliefs (e.g. Atheist, Agnostic, Unsure, Spiritual, Religious). Then, six questions ask participants about religious behavior over the past year (e.g.: "For the past year, how often have you done the following: Thought about God?") on a 8 point Likert scale 1 (Never) to 8 (More than once a day). The last six questions ask participants about lifetime engagement in the same 6 behaviors: Never=1, Yes, in the past but not now=2, or Yes, and I still do=3). Alpha coefficients reflecting internal consistency was.81 for the total scale. Higher scores indicate high levels of religious behaviors and beliefs. Multidimensional Scale of Perceived Social Support-The Multidimensional Scale of Perceived Social Support (SS; Zimet, Dahlem, Ziment & Farley, 1988) consists of twelve questions measuring participants' perceived social support. Questions were on an 8 point Likert scale ranging from 1(very strongly disagree) to 8(very strongly agree). Participants were asked questions such as "there is a special person with whom I can share my joys and sorrow". Alpha coefficients were strong,.93, for internal consistency. Responses were summed with higher scores reflecting high social support. Stress-Related Growth-The Stress-Related Growth Scale (SRG) created by Roesch, Rowley, and Vaughn (2004) was adapted for this study. Participants were asked how much they felt they had learned about themselves from being transgender-women on three subscales (growth in mature thinking, emotional growth, and religious growth). Twenty-nine questions were asked reflecting each subscale. Questions such as "Being a trans woman: I learned to look at things in a more positive way (mature thinking), I learned better ways to express my feelings (emotional growth) and I developed/increased my faith in God (religious growth)" were measured on a 3 point Likert scale ranging from 1(not at all) to 3 (a great deal) with a strong internal consistency Alpha coefficient of.87. Each subscale also had strong Alpha coefficients; mature thinking =.90, emotional =.88, religious =.87. Participant scores were summed, with higher scores presenting higher levels of religious growth. Perceived Stigma and Stigma Concealment-Two subscales (personalized stigma and disclosure) of the Perceived Stigma and Stigma Concealment Scale originally designed for HIV-positive persons (Berger, Ferrans & Lashley, 2001) were adapted for this study, consistent with previous adaptations of this measure for use with lesbian, gay and bisexual populations (Frost, Nani & Parsons, 2007;Grov, Parsons & Bimbi, 2009). The personalized stigma subscale asked participants 10 questions that measured perceived societal attitudes and possible consequences of being transgender (Alpha coefficient,.92). The disclosure subscale, alpha coefficient,.83, measured participants' concealment and disclosure of their transgender identity utilizing 10 questions. Participants were asked questions (e.g. "I regret having told some people that I'm transgender") on a 4 point Likert scale ranging from 1( Strongly Disagree) to 4(Strongly Agree). Scores were summed with higher scores indicating more perceived stigma and concealment. Sexual Behavior-Participants were asked to indicate their number of sexual partners, types of sexual partners (e.g., main partners, casual partners, sex work partners, trade partners), and types of sexual behaviors (e.g., oral sex, anal sex, protected, unprotected) in which they engaged in the last 3 months. To create a variable that represented the highest risk of potential HIV transmission or infection, we created a composite variable that represented the total number of unprotected anal sex act with non-main partners (including casual partners and/or partners with whom money, drugs, or other goods were exchanged for sex) in the past 3 months. Participants reported an average of 4.3 unprotected anal acts with non-main partners in the past 3 months (SD = 22.4), but this variable was significantly skewed (range: 0-178, median = 0, IQR: 0-2). As a result, we conducted subsequent analyses using a dichotomous variable indicating any unprotected anal sex with a non-main partner in the past 3 months (1 = Yes; 0 = No). --- Statistical Analyses The data were examined in a three-step process. First, because of the high prevalence of HIV in this sample, comparisons were made on all study variables by HIV-status (chi-square for dichotomous variables and t-tests for continuous variables). There were no differences in scores on any study variables by HIV status, so this factor was not included in further analyses. Second, bivariate analyses, including both zero-order and partial correlations, were run to investigate the association between psychosocial measures and unprotected sexual behavior. Third, based on the findings from bivariate analyses, hierarchical logistic regression was conducted to examine the relative predictive power of religious behaviors and beliefs, social support, and religious growth in predicting high risk sexual activity among this sample of transgender women. --- Results --- Bivariate Relationships among Study Variables Correlational analyses were computed to examine relationships among the outcome variable (unprotected anal sex with a non-main partner in the past 90 days) and religious behavior/ beliefs, social support, stigma, and stress-related growth. As shown in Table 1, there were a series of significant associations among study variables. However, social support and religious stress-related growth were the only two variables with significant associations with unprotected anal sex. Because of the high degree of intercorrelation among other study variables, partial correlations were conducted to assess the association between study variables and unprotected anal sex, controlling for social support and religious growth. Controlling for social support and religious stress-related growth, a significant partial correlation was demonstrated between religious behaviors and beliefs and unprotected anal sex, r =.26, p <unk>.05. No other variables demonstrated significant zero-order or partial correlations with high risk sex. --- Significant Predictors of High Risk Sexual Behavior A logistic regression analysis was conducted to assess the relative predictive power of the three variables associated with high risk sex in bivariate analyses: religious behaviors and beliefs, religious stress-related growth, and social support. Step one of the regression analysis assessed the main effect of these three predictors as a set, and the second step included their two-way interactions. As is shown in Table 2, the three predictors as a set accounted for 24% of the variance in unprotected anal sex, and each of the three variables was a significant independent predictor. Every standard deviation increase in religious stress-related growth was associated with a 37% decrease in the odds of unprotected sex (p <unk>.05) and every standard deviation increase in social support was associated with a 4% decrease in the odds of unprotected sex (p <unk>.05). A standard deviation increase in religious behaviors and beliefs was associated with a 6% increase in the odds of unprotected sex. In the second step, the two-way interactions among study variables accounted for an additional 13% of the variance in the model. All three simple effects (i.e. effects associated with Step 1 predictors) were maintained, although the coefficients for stress-related growth and social support were reduced slightly and the coefficient for religious behaviors and beliefs was increased slightly. In Step 2, these simple effects indicate the impact of each predictor at mean levels of the other two (Jaccard & Turrisi, 2003). For example, at mean levels of both stress-related growth and social support, each standard deviation increase in religious behaviors and beliefs is associated with an almost 7% increase in odds of unprotected sex. In terms of interaction variables, the only significant predictor in Step 2 was the interaction between social support and religious behavior and beliefs. In order to interpret this small but significant interaction effect, participants' scores on both social support and religious behaviors and beliefs were dichotomized based on a median split. The percentages of participants who engaged in unprotected anal sex was compared for each of the four categories: high religious behavior and belief/high social support; high religious behavior and belief/low social support; low religious behavior and belief/high social support; low religious behavior and belief/low social support. As shown in Table 3, the percentage of participants who reported unprotected anal sex was highest among participants with low levels of both religious behaviors and beliefs and social support (50% of these participants reported unprotected anal sex). However, the percentage of participants who reported unprotected sex was lowest among those who reported high levels of social support but low levels of religious belief/behavior (14%). In fact, among individuals with high levels of social support, unprotected sex was less likely among participants with low levels of religious behaviors and beliefs (14%) compared to those with high levels of religious behaviors and beliefs (35%), <unk> 2 = 4.85, p <unk>.03. --- Discussion The purpose of this paper was to examine the role of religious behaviors and beliefs, social support, and stress-related growth in predicting high-risk sexual behavior of transgender women. In bivariate analyses, both social support and religious stress-related growth were significantly inversely related to unprotected anal sex, such that higher scores on these scales were protective against risk behavior. In contrast, there was a positive correlation between religious behaviors and beliefs in this sample, such that higher scores on this scale were associated with significantly increased odds of unprotected sex. However, these simple main effects must be interpreted in light of an interaction effect identified in the multivariate model. The interaction between religious behaviors and beliefs and social support was also a significant predictor of unprotected sex, and post-hoc analyses indicated that high-risk sex was least likely among individuals with high-levels of social support but low levels of religious behaviors and beliefs. These data have important implications for understanding factors that might protect against HIV risk for transgender women. First, greater religious stress-related growth was associated with lower odds of unprotected sex, and this effect was not qualified by an interaction effect with the other variables. Across multiple studies, stress-related growth has been associated with decreased depression and greater positive well-being (Helgeson et al., 2006), as well as with positive health behaviors (Littlewood et al., 2008;Millam 2004;Millam 2006;Weaver, 2005). In this sample, religious stress-related growth was the only subscale of the larger stressrelated growth scale to emerge as a significant predictor of sexual risk behavior. This finding is surprising, as all three stress-related growth subscales were highly intercorrelated, and as we might predict both the emotional and mature-thinking subscales to be associated with lower likelihood of risk-taking. We offer two potential explanations for this finding. First, it is possible that any impact of emotional stress-related growth and mature thinking stress-related growth on sexual risk-taking is mediated by social support. In other words, both types of stressrelated growth may make social relationships easier and more likely to occur, but their independent effects are not strong enough to make them significant predictors in their own right. In contrast, religious stress-related growth is positively correlated with social support, but its effects seem independent from it. Instead, it appears that translating the stresses associated with being a transgender woman into a stronger religious identity allows these individuals to avoid sexual risk-taking as a negative coping strategy. These findings fit well with past research on religious coping, which finds that religious and spiritual beliefs provide a framework for thinking about negative experiences or stressful events that lessens distress (Laubmeier et al., 2004). In addition, religious beliefs themselves have been found to lead to better health practices (Benjamins, 2006). Interpretation of findings related to social support and religious behaviors and beliefs is more complex, given their interaction in the multivariate model. The importance of social support is not a surprising finding, and it underscores the extent to which social relationships promote healthful behavior for marginalized populations. In contrast, given average scores on social support and religious stress-related growth, higher scores on religious behaviors and beliefs were associated with increased sexual risk-taking in our sample. This finding stands in sharp contrast to the majority of literature on the positive effects of religious coping, which finds a positive association between health behaviors and religious practice and belief (Gardner et al., 1995;Koenig et al., 1997;Strawbridge et al., 1997;Wallace & Forman, 1998). Organized religion is believed to confer a sense of group identity, provide a network of individuals with similar beliefs, and provide an overall supportive environment for healthful behavior (George et al., 2002). However, any findings related to both social support and religious behaviors and beliefs must be interpreted with caution, in light of the significant religious behaviors and beliefs by social support interaction. On the one hand, these data suggest that religious beliefs and behaviors moderate the role of social support on risk behavior. For individuals with high levels of religious behavior and beliefs, social support does not appear to significantly impact risk; rates of unprotected sex among those who are low in social support (36%) are almost identical to rates among those who are high in social support (35%). However, for those with low levels of religious behaviors and beliefs, rates of unprotected sex are significantly reduced for those with high levels of social support (14%), compared to those with low levels of social support (50%). One interpretation of these findings would be that social support becomes most important in the absence of other institutional or structural resources. When individuals lack religious behaviors and beliefs, social support can significantly reduce vulnerability to risk taking. At the same time, it is important to consider the interaction effect in its alternative interpretation: social support moderates the impact of religious behaviors and beliefs on risk behavior. When social support is low, religious behaviors and beliefs play an important role in decreasing the risk of unprotected sex. But when social support is high, the impact of religious behaviors and beliefs appears to be reversed, with high levels of religious behaviors and belief associated with much higher rates of unprotected sex, compared to low levels. Both interpretations underscore two findings: 1) rates of unprotected sex are highest (50%) when both social support and religious behaviors and beliefs are low; and 2) rates of unprotected sex are lowest (14%) when social support is high, but religious behaviors and beliefs are low. It is not surprising that participants who reported the highest rates of unprotected sex were those with neither high levels of social support nor strong religious behaviors and beliefs. Research suggests that some stigmatized individuals isolate themselves from social settings and relationships in an effort to avoid situations in which their stigma might be activated (Corrigan & Mathews, 2003;Lee & Craft, 2002;Miall, 1986;Link, Mirotznik, & Cullen, 1991). This pull toward social isolation is even more powerful among individuals with a concealable stigma, that is, a stigma that may not be immediately apparent to others, but is at risk of being discovered (Pachankis, 2007). For many transgender women, their gender identity may be experienced as a concealable stigma, reducing their ability to seek out and sustain relationships and institutional resources that can provide them with adequate levels of social support. Indeed, our data demonstrated a strong negative correlation between stigma and social support. Interestingly, however, stigma was not associated with unprotected sex in our sample, even after controlling for social support. Although we did not assess it in the current study, it is possible that stigma may be more strongly associated with mental health outcomes for this population, while social support is more strongly associated with behavioral outcomes. The finding that participants who reported the lowest rates of unprotected sex were those with high levels of social support but low levels of religious behaviors and beliefs is more difficult to understand. As noted above, most studies demonstrate a positive association between religious affiliation or practice and health behavior (Gardner et al., 1995;Koenig et al., 1997;Strawbridge et al., 1997;Wallace & Forman, 1998). When considered in light of the protective simple main effect of religious stress-related growth, these data may suggest a more complicated relationship between internal and external aspects of religion for transgender women. Internal aspects of religious beliefs, similar to those measured by the religious stressrelated growth scale, appear to be protective against risk behavior. For some transgender women, however, institutionally-based religious behavior may be more difficult. As discussed above, some religious institutions are intolerant of gender non-conforming individuals, and may actively discriminate against transgender women and/or gay, lesbian, or bisexual individuals. In this context, strong religious behaviors and beliefs may conflict with a transgender identity, causing depression, anxiety, and other psychological factors associated with high-risk sexual behavior. In the absence of other forms of social support, such religious institutions may provide a modicum of protection against risk taking. But the transgender women with the lowest rates of unprotected sex (those whose social support was high, but religious behaviors and beliefs were low) may have been able to garner a social support network outside of a religious structure that might promote negative beliefs about their transgender identity. The measures collected in this study are insufficient to provide a true test of this hypothesis; future research is needed into the complex relationship between religion and risk behavior among transgender women. Several limitations of the present study bear mention. First, these data are drawn from a larger study piloting a 4-week workshop series. Although these data were collected prior to the first workshop, it is likely that transgender women who are willing to participate in such a workshop series differ significantly from those who are more difficult to recruit or engage for this type of project. Additional research is needed into the role of these factors among a more representative sample of transgender women. Second, the small sample size in this study prevents us from conducting more complex analyses, such as path analysis or structural equations modeling, that might allow us to better tease apart the relationships among study variables. For example, the status of medical gender affirmation treatments among transgender women may be related to risk, social support, and religious behaviors and beliefs. Further research is needed to address these critical interactions. And third, our analyses do not include information regarding substance use among our participants. There was little variance in substance use among participants in our sample, and almost 40% reported no substance use in the past 3-months, preventing us from conducting complex analyses with this factor. Research suggests that substance use is an important factor in determining unprotected sex among transgender women (Sevelius et al., 2009) and may be used to cope with stigma and other stressors associated with being transgender (Hughes & Eliason, 2002;Nemoto et al., 2004;Sausa, Keatley, & Operario, 2007). This study was designed to focus on potentially protective factors, but future research should investigate the interaction between protective factors and those that might exacerbate risk-taking in this population. Despite these limitations, findings from this study have several important implications for the development of HIV prevention interventions for transgender women. First, these data support the development of a "strengths-based approach" to risk reduction for this population, which draws on the potential for social support -most likely in the form of peer support -to reduce sexual risk behavior. Peer support, defined as support from a person who has "experiential knowledge of a specific behavior or stressor" (Dennis, 2003), has been demonstrated to improve affect, reduce negative health behaviors, and improve disease management. In addition, peer support has equivalent or stronger positive effects on the individual providing support. Providing peer support has been associated with improved quality of life, self-esteem, self-efficacy, decreased risk of mortality, and improved health outcomes. Reciprocal peer support among individuals who share similar stressful circumstances has the unique ability to combine the benefits of providing and receiving peer support. Peer support theories both within HIV (Marino, Simoni, & Silverstein, 2007) and across other chronic illnesses (Gussow & Tracy, 1978;Whittemore, Rankin, Callahan, Leder, & Carroll, 2000) focus on the potential for peer social support to reduce stigma and increase social acceptance and emotional wellbeing. Second, these data underscore the importance of interventions that promote spirituality and the transformation of struggles associated with stigma and other stressors into perceptions of religious stress-related growth. Interventions that focus on strengthening spiritual components of the self have been successful in the treatment of addiction, and have been demonstrated to be associated with decreased HIV risk behavior (Margolin et al., 2006). And third, these data suggest the importance of community-level interventions that educate religious institutions about the transgender community. Improving the ability of religious beliefs and behaviors to act as facilitators of risk-reduction, rather than as barriers to it, is critical to the long-term health and wellbeing of transgender women. --- Table 1 Bivariate Correlations Among Study Variables --- Biographies

Transgender women completed questionnaires of religiosity, social support, stigma, stress-related growth, and sexual risk behavior. In a multivariate model, both social support and religious stressrelated growth were significant negative predictors of unprotected anal sex, but religious behaviors and beliefs emerged as a significant positive predictor. The interaction between religious behaviors and beliefs and social support was also significant, and post-hoc analyses indicated that high-risk sex was least likely among individuals with high-levels of social support but low levels of religious behaviors and beliefs. These data have important implications for understanding factors that might protect against HIV risk for transgender women.

Introduction Feminism was introduced to China during the May Fourth period, and has been around for nearly 100 years. However, to this day, there is still a long way to go before "equality between men and women" in a substantive sense. And gender discrimination against women, especially in the workplace, is still common. Labour market discrimination is depicted by the gender level. This is the issue with job discrimination on the basis of gender. [1] It is now a social fact that women are marginalized and treated differently in the workplace, making them one of the underrepresented groups there [2]. This is primarily seen in the following areas: First, the entry bar; despite the fact that both men and women have an equal amount of human capital, businesses still favor hiring males and frequently view women as inefficient. Second, gender segregation, which refers to the practice of assigning employees to specific jobs or positions based on their gender, resulting in a glaring disparity in the distribution of occupations between men and women. Third, women often face disadvantages when promoted inside businesses because they typically rank lower in the occupational ladder than men. Fourth, the work-family conundrum. Women experience more "work-family" conflicts in daily life, and family obligations like marriage and childbirth have an impact on women's labor supply, resulting in shorter average working hours for women than for men, as well as a greater propensity to engage in informal jobs with erratic hours, instability, and no social security status. [3] The promotion of equal employment for women is of great practical significance, not only for the promotion of social equity, but also for unleashing the potential for economic and social development. Chinese women make up one fifth of all females worldwide, as noted in the 2015 White Paper on Gender Equality and Women's Development in China. In addition to demonstrating China's advancement as a civilisation, gender equality and women's progress in China have historically contributed to global peace, development, and equality. [4] Finding solutions to women's employment inequality from the perspective of policy adjustment is a useful attempt, and has profound theoretical and practical significance for achieving gender equality in the labour market, improving women's social status, enhancing social welfare and benefits, perfecting the construction of employment policies. --- Status of Women in the Workplace Based on the research study, this paper will interpret the current situation of women facing workplace discrimination from three perspectives. --- Recruitment Level For women in the hiring process, the issue of gender discrimination is particularly acute. During interviews with female applicants, inquiries like "Are you married?" and "Do you have any plans to have children?" are routinely made. Female applicants are not only required to respond to these in-depth personal questions, but they also feel obliged to be honest or face rejection. Furthermore, despite the fact that these roles are not directly related to gender convenience, many industries have the "unspoken rule" that only men are recruited or given preference over men. In these situations, female job seekers are frequently turned down even though their overall performance is superior to that of their male counterparts. --- Promotion Level Women frequently face a "ceiling" effect that keeps them from advancing to higher positions and pay. This effect is entirely dependent on gender and is unrelated to working conditions. Senior management prefers to place men in leadership positions and women in other support roles when given the same opportunity for advancement, perpetuating the stereotype that women are not "competitive, influential" managers. This unconscious selection bias makes it more difficult for women to pursue careers in the workforce. In addition, women now face a "stumbling block" in their quest for career progress related to childrearing. The age range of 23 to 40 is the concentrated peak of female fertility and the important point at which women's career development enters an upward mobility phase. --- Remuneration Level While very few women work in these high-paying sectors and businesses, a substantial number of males work in high-paying industries like finance, logistics, and the Internet, and most of them pick high-paying positions like sales and technology. And there is a large wage gap between the industries and fields, which has led to the pay gap between men and women in some respects. It's also clear that when female managers do well at work, they tend to credit timing and luck more than their own skills, and when they perform poorly in particular circumstances, discrimination against them intensifies and is met with harsh criticism and accusations. Because of this, female managers rarely receive recognition for their achievements, and the incentives they do receive are far smaller than those earned by their male counterparts. --- Causes of Sex Discrimination Faced by Women in the Workplace The causes of gender discrimination against women in the workplace are many and are summarised at three levels: corporate, social and legal. --- Enterprise Level Businesses will attempt to minimize labor costs and optimize financial gains in order to limit costs. Objectively speaking, employing men allows companies to exchange the same labour costs for a more productive workforce. Women can retire five years sooner than males under China's current retirement system, which inevitably lowers the value of women's labor. Businesses are hesitant to hire women in order to achieve their aims of increased efficiency. [5] Furthermore, businesses must incur indirect losses due to a reduction in labor skills during the maternity leave period in addition to direct expenditures like salaries, job openings and the lack of updated knowledge that may occur when women return to their jobs after giving birth. Employers will therefore avoid these expenses by restricting the hiring, placement, and advancement of women out of self-interest. Thus making women face problems such as difficulty in finding jobs, poor development, and low treatment. [4] --- Social Dimension The issue of women's employment is subject to the clash of old and new cultures. Nowadays, society and women themselves are increasingly recognising that women should pursue a certain degree of career, but the idea that "women should be in charge of the family" is still rooted in people's concepts. The whole society has formed the expectation of women's dual roles: be a office lady and a good wife [6], expecting them to create value in the market but also expecting them to take good care of their families. This concept, on the one hand, pushes women to keep moving towards market employment, but on the other hand, it also creates the social role dilemma of women's employment and childbirth, which hinders women's employment in the new era. --- Legal Aspects China's laws and regulations on protecting women's legal rights in employment are not very comprehensive. China's existing anti-discrimination provisions are scattered throughout the Constitution, the Employment Promotion Law, the Labour Law, but there is no specific anti-discrimination law. The Labour Law also makes only some provisions in principle, neither defining clearly the constituent elements of gender discrimination in employment, nor specifying the main parties responsible and the penalties to be imposed. As a result, women who encounter gender discrimination in the workplace do not have the ideal legal weapons to defend their rights. [7] 4. Recommendation --- Improvement of Relevant Laws to Promote Women's Equal Rights and Interests The legal procedures for guaranteeing equal employment for women in China can be improved in the following three areas. The introduction of a special Anti-Employment Discrimination Act. In this special law, on the one hand, the definition, criteria and classification of gender discrimination in employment should be clarified; on the other hand, clear provisions should be made on the Government's supervisory methods and duties, and the level of penalties. Improving employment laws and regulations. The wording of the existing laws on occupational taboos and special employment regulations for women during their physiological period can lead employers to misunderstandings such as "female employees are too delicate", which reinforces the stereotype that women are inferior to men. [8] In this regard, the interpretation of these laws should be gradually adjusted to omit ambiguous words and clearly define relevant terms. In short, on the basis of both special protection and gender equality, the boundaries between special protection and "equal treatment" should be clearly delineated, so as to reduce the misunderstanding of women and return to the original intention of the law to protect women. bolstering anti-discrimination policies in the workplace. Women's equal employment rights will be better protected through the creation of a specialized anti-discrimination organization like to the Equal Employment Opportunity Commission, which is akin to opening a green channel to deal specifically with job discrimination. --- Establishment of Specialised Oversight Bodies In order to promote the operability of policy implementation and the effective solution of gender equality issues, special regulatory organisations can be established. While focusing on the establishment of a special organisation to carry out the function of promoting equal employment in a phased or sustained manner, the civil society can also form some social organisations on its own initiative to further promote it. The relevant organisations from both the official and private sectors will focus on their respective functions and roles, and complement each other to jointly promote the realisation of women's equality in employment. --- Establishment of Diversified Childcare Institutions The establishment of childcare facilities by the Government can effectively alleviate the family pressure faced by women so that they can better engage in their work. For example, the Government can provide nursery schools for children aged 0-5 years and kindergartens for children aged 3-5 years, with an emphasis on educational services. There are also other child-care institutions, such as public mixed child-care centres, joint child-care centres, family-run child-care institutions, early education centres, and so on, to meet the different forms of child-care needs of parents. --- Government Encourages Enterprises to Create a Family-Friendly Employment Environment Encouraging gender equality only through government action is insufficient; businesses must take greater responsibility as well. Enterprises are an important part of the market economy and are the main carriers of employment for families of childbearing age, so they must actively fulfill their corresponding social responsibilities in promoting equal employment for women. The Government shares the costs of childcare for female employees borne by enterprises through economic measures such as compensation and incentives. First, the Government should apply tax incentives, such as tax deductions and exemptions for business enterprises that pay the usual benefits to female employees during the period of childbirth and breastfeeding; second, the Government should draw a certain percentage of fiscal revenues for matching support for the payment of maternity insurance by enterprises, changing the burden of maternity insurance from that of the enterprise alone to that of society as a whole, in order to alleviate the pressure on the enterprise's financial resources. --- Conclusion Childbearing is a natural physiological attribute of women, and employment is an economic and social attribute of women, both of which are inseparably united in order to form contemporary women in the full sense of the word. Firstly, in order to completely eliminate discrimination against women in the workplace, laws and policies pertaining to this issue must be strengthened. Secondly, policy orientation between the State and women's individual interests must be coordinated; thirdly, it is necessary to intensify the formation of family support policies to provide solutions for women to balance their work and family; and finally,to achieve complete equality between the sexes in all economic and social domains, the concept of gender must be more integrated throughout society. In order to establish full equality between the sexes in all economic and social arenas, it is also required to increase the integration of the social idea of gender in society at large. Without gender equality in society as a whole, it is difficult to maintain gender equality in individual areas. Therefore, women's equal employment should be based on the continuous promotion of gender equality in society as a whole in order to be stable and long-lasting. Therefore, in promoting equality between men and women and fulfilling the commitment to gender mainstreaming, we should update the mindset of social groups in terms of behavioural patterns. However, behind the institutional deficiencies are the deficiencies in the values of public policymaking-the lack of sufficient attention to the plight and needs of vulnerable groups. Therefore, in formulating laws to protect women's equality in the workplace, it is necessary to consider women's interests from the perspective of their needs.

Nowadays, many women are discriminated in the workplace because of their gender. Equal employment for women is at the centre of this study, and the dynamic equilibrium between the reproductive policy and the related supporting policies, especially the public service policy, together constitute the policy background to the issue of women's employment, while at the same time the social has some negative evaluation of women's employment. At present, China's traditional labour division model of "men focusing on the outside and women focusing on the inside" has been turned into a labour participation model in which females devote themselves to both work and family, i.e., internal and external labour participation, while men still continue to "focus on the outside" one-dimensional labour model. The increase in women's labour force participation rate has, on the contrary, put women in a more unequal situation. This paper first describes the current situation of gender-based discrimination against women in the workplace in terms of three aspects: recruitment, promotion and pay. It then analyses the causes of these phenomena and looks for ways to address them to better protect women's equal rights in the workplace.

Background Globally, the importance of using contraceptives to regulate fertility has been recognized [1]. This is a key aspect of the reproductive health of women who wish to space or limit childbearing. A useful measure of the gap between women's reproductive desires and the provision of health services is the estimation of unmet need for contraception. This indicator refers to women who wish to space or limit births but who do not use contraceptive methods to achieve this [2][3][4][5]. This indicator is important not only because it informs and guides contraceptive services, but also because it shows how far a country has ensured compliance with the reproductive health rights of its population. In Latin America and the Caribbean, there was a large increase in contraceptive use between 1970 and 2010 and a decrease in unmet need for contraception [4]. As Bongaarts states [6], as countries move forward in the demographic transition, the level of unmet demand for contraception drops. Mexico has witnessed a significant reduction in fertility rates since the mid-1970s, declining from 7 children per woman at that time to 2.21 children per woman in 2014 [7,8]. This decline was largely due to the work of public health services that provided contraception in all regions of the country. The proportion of married or inunion women using contraception rose from 30% in the mid-1970s to 72.3% in 2014 [7]. These changes occurred in combination with other important social phenomena: increasing urbanisation, expansion of schooling -especially of women-, and greater participation of women in the labour market, which, together with the introduction of modern contraceptive methods, allowed women to limit their family size [9]. However, once this rapid fall in fertility had been observed, these contraceptive policies were reduced as it was believed that the decline in fertility and the increased use of contraception use would continue. Since 2000, however, progress made regarding contraceptive prevalence and unmet need for contraception has stalled. This is combined with recent changes in sexual and reproductive behaviours, observed in an earlier sexual debut among women, an increasing gap between sexual initiation and union, and an increase in the desire to limit childbearing at earlier ages. Therefore, while there has been an increase in the proportion of women who wish to space and limit childbearing, a stagnation in contraceptive supply programmes has been observed. In addition, another unresolved issue related to the decline in fertility has been the persistence of differences between socioeconomic groups [10]. Hence, there is the need to investigate the level of unmet need for contraception in Mexico and also to identify the factors that further hinder the use of contraceptives to meet the reproductive desires of women. The indicator of unmet need for contraception has been widely used in developing countries, especially in those countries that have participated in the Demographic and Health Surveys (DHS) programme. It is a complex measure, which has international comparisons, and whose algorithm has changed over time. Since 2012, a revised version has been used which has gained consensus [3,4]. Mexico has conducted a similar survey to the DHS named the National Survey of Demographic Dynamics (Encuesta Nacional de la Dinámica Demográfica -ENADIDin Spanish). Unlike the DHS surveys, the ENADID did not initially include all the questions necessary for the construction of the indicator of 'unmet need'. However, in 2014, for the first time, ENADID included all of the questions needed to estimate the indicator that could be compared internationally. In addition, as has been recently proposed, the indicator can be calculated not only for married women, but also for sexually active unmarried women [4,11,12], and with the information from ENADID 2014, it can be estimated for Mexico. Thus, the objectives of this article are to estimate the levels of unmet need for contraception among married women and never married women, and to explore the factors associated with unmet need for contraception to space or limit births. --- Methods --- Study design Secondary data analysis was conducted. The data comes from a 2014 cross-sectional national demographic survey of Mexico that is a random sample with national, state level and urban-rural representativeness, collected by the National Institute of Statistics and Geography (Instituto Nacional de Estad<unk>stica y Geograf <unk>a -INEGIin Spanish). The sample included 101,389 households. In each selected household, all women aged 15 to 54 were interviewed [13]. The completion rate was 87% (2.9% had incomplete interviews and 9.2% had no response) [13]. For this analysis, the observation unit is women of reproductive age from 15 to 49 years, in a union (formal or consensual) and 'never in union' women who had had sex in the 3 months prior to the survey, totalling 56,797 cases. --- Setting Mexico is a middle-income country, located in Latin America, with over 119 million inhabitants according to the Intercensal Survey of 2015, and has an annual population growth rate of 1.4% [14]. The population is mostly urban, and only 21% is considered as rural, i.e. living in localities of fewer than 2500 inhabitants [15]. The country has a young population, with 9 people of working age for each person aged 65 and over [16]. In Mexico, the increase in schooling has been notable, but it still shows lags and serves as an indicator of social strata [17]. Considering the population of 15 years and older, women had on average 9 years of schooling and men 9.3 in 2015 [14]. In 1974, an article in the constitution was changed regarding fertility regulation. It established that couples had the right to decide how many children they wanted and when to have them. This legislation is still valid at the present time. Family planning services have been established through public health services. Mexico offers a range of different access to health services, all supervised by the Ministry of Health, but with differences in the quality of service. Affiliation to the health system (denoted as Social Security of Health Services) is not determined by need, but by a person's job. Workers employed in the formal labour market (those who are paid a salary and pay taxes to the government) are insured by the government through different types of health insurance, depending on whether the employee works for the private sector (IMSS) or public sector (ISSSTE, and other government health services for employees of the army, navy, etc.). Belonging to the Social Security System is compulsory for employees in the formal sector, where a percentage of the employee's salary is deducted to pay for it. Employees also have the right to private health insurance paid out of their own pockets, which can be costly. The rest of the population who are not employed in a formal job (workers in the informal and agricultural sector, or unemployed) can receive services from the Ministry of Health (Secretar<unk>a de Salud -SSAin Spanish) through the state health services and also from IMSS-Prospera (which serves the uninsured rural population) or the "Popular Insurance" (Seguro Popular -SPin Spanish). The latter is a new public health insurance scheme for low income groups and those enrolled in it access health services through the SSA [16]. As for health services coverage, in 2013, Mexico was considered to be the country with the lowest service coverage of the OECD countries: bed density was 1.6 beds per thousand inhabitants, and there were 2. 2 practising doctors and 2.6 practising nurses per 1000 population [16]. --- Statistical analysis The main variable is unmet need for contraception, which is divided into need for spacing and need for limiting births. For this estimation, it was also necessary to consider women who were using contraception to space or limit fertility and those who did not need to use contraceptives either because they want to have children or were infecund. This last group, made up of 11.5% of all women of reproductive age, was excluded from the statistical model. We compared women who were currently using contraception for spacing with those women who were not using contraception but who wished to delay their next birth for at least two or more years (unmet need for spacing). We also compared women who were currently using contraception to limit their fertility with those women who did not want any more children but were not using contraception (unmet need for limiting). Hence, the first dependent variable was "unmet need for spacing" with values of "0" for women who were using contraception to space and "1" for women who wanted to wait at least two years to have a child but were not using contraception. The second dependent variable was "unmet need for limiting", with values of "0" for women who were using contraception to limit their fertility, and "1" for women who did not want more children and were not using contraception to limit their fertility. For our study, current users of contraception included those using both modern and traditional methods. Associated factors in our study included 5-year age groups, marital status, urban-rural residence, education, region of residence, number of live births, and access to health services. Age was grouped in five years ranging from 15 to 19 years up to 45-49 years. We defined "women in union" as women in formal marriages and consensual unions. "Never in union women" consisted of women who, at the time of the survey, had never been married or in a consensual union. We excluded from the analysis women who had formerly been in a union due to the small numbers of cases. Sexually active women referred to women who had had sex in the 3 months prior to the date of the survey. Type of residence (urban or rural) used the official Mexican definition -'rural' referring to localities with fewer than 2500 inhabitants. Education consisted of two categories: women with less than 10 years of schooling (basic compulsory education in Mexico) and women with 10 or more years of schooling. Mexico is not officially divided into regions so the 32 states were grouped according to the percentage of the population in poverty reported by The National Council for the Evaluation of Social Development Policy (Consejo Nacional de Evaluación de la Pol<unk>tica de Desarrollo Social -CONEVAL-in Spanish) for the year 2014 [18] with the exception of Mexico City, which was considered as a region alone because it is very different to the rest of the country (lower fertility, more infrastructure, more health services, more educated population, and ranked as the region with the second lowest poverty rate by CONEVAL). The regions were therefore ranked as follows: Region 1: Mexico City; Region 2: States with less than 40% of population in poverty -Nuevo León, Baja California, Sonora, Coahuila, Baja California Sur, Querétaro, Colima, Chihuahua, Aguascalientes, Jalisco, Quintana Roo, Tamaulipas, Sinaloa; Region 3: states with between 40% and less than 65% of the population in poverty -Nayarit, Durango, Campeche, Yucatán, Guanajuato, San Luis Potos<unk>, Tabasco, México, Morelos, Zacatecas, Hidalgo, Veracruz, Tlaxcala, Michoacán, Puebla and Region 4: with 65% or more of their population living in poverty -Guerrero, Oaxaca, Chiapas. The covariate of number of births was grouped as 0 children, 1, 2, and 3 or more children. We coded access to health services in four categories according to the quality of service from lowest to highest as follows: no social security health services (the worst scenario), partial access to public health services (workers in the informal sector covered by the public health services SSA and those enrolled in the Seguro Popular), full access to public health services (fully employed workers in the formal sector with access to IMSS/ISSSTE/or other similar services) and private health services. STATA 13 (StataCorp., College Station, Texas, USA, 2013) was used for the analysis and all data was weighted. An analysis of the proportion of women with met need and unmet need for spacing and limiting considering marital status was conducted. Multivariable analysis was performed running binary logistic regressions to examine the relationship between "unmet need" (for spacing or for limiting) and independent variables. Separate models for each dependent variable were used. Before conducting the analyses, the multicollinearity between covariates was assessed using polychoric correlations, adjusting to re-scale marital status and social security into ordinal covariates. Highly correlated variables (number of live births) were removed from the models. Confidence intervals of 95% were calculated and p <unk> 0.05 was considered statistically significant. --- Ethics This study is based on secondary analysis of publicly available data; hence no ethical approval was required from our institutions. No permission is required to access and use these datasets; they are freely available. --- Results The sample population consisted of 51,758 women in union and 5039 women never in union who were sexually active in the three months prior to the survey. Of the total number of women never in union interviewed (29,375), 17.2% reported having had sex in the three months prior to the survey, a subgroup to be considered in this study according to the definition of unmet need for contraception. To give evidence of the increasing proportion of women in need of contraception in recent years, we compared the percentage of women who had had sexual intercourse before age 20 for older and young cohorts. For the cohorts who were 40 to 44 years at the time of the survey, the proportion who had had sexual intercourse before the age of 20 was 52.9%. This percentage increased to 61.3% for the cohort aged 20 to 24 years at the time of the survey. This data is informative at aggregate level and is not included at the individual level in the model. The age distribution of the women in the study reflected the demographic composition of the country, with a mean age of 33. 5 years (SD <unk> 8.9). Most of the women were urban (77%), with schooling less than 10 years (61%), and 15% had no health insurance. Table 1 presents the overall estimates of unmet need for contraception by subgroup of population. The overall prevalence for unmet need for contraception was 11.5% for women currently in union (6.4% for limiting and 5. 1% for spacing) and 28.9% for sexually active women never in union (8% for limiting and 20.9% for spacing). Among women currently in union, 57.4% were using contraception to limit and 15.2% to space. Among sexually active women never in union, 19.8% were using contraception to limit and 43.8% to space. The descriptive results showed, as expected, that younger women, both currently in union and never in union, use contraceptive methods more for spacing, and older women use contraception more for limiting. Among married women, there were no major differences in unmet need for contraception regarding urban-rural residence or schooling, but there were differences between those with no health insurance and those who have it, with the former group having almost doubled the level of unmet need for contraception than the latter. The number of children was also significant with those without children having a greater need for contraception for spacing compared to those with three or more children. Among sexually active women never in union, those who resided in rural areas, those who had lower levels of education and those with no children had the greatest unmet need for contraception for spacing. Table 2 shows the results of the first logistic regression model with variables associated with unmet need for spacing. After controlling for age, marital status, urban-rural residence, schooling, region of residence and access to health service, the likelihood of having unmet need for spacing increased for younger women compared to older women (OR 6.8; CI: 2.95-15.48), never in union women compared with those currently in union (OR 1.6, CI: 1.40-1.79), those with lower schooling than those with higher schooling (OR 1.4, CI: 1.26-1.56); those living in region 4 (OR 1.9; CI: 1.52-2.49) compared to region 1. Women were less likely to have unmet need for contraception for spacing if they had full access public health service (OR 0.8, CI 0.66-0.88) than those who did not. Table 3 shows the results of the second logistic regression model with the variables associated with unmet need for limiting. After controlling for age, marital status, urban residence, schooling, region of residence and access to health services, women were more likely to have unmet need for limiting if they were younger (OR 6.3; CI: 4.73-8.27), never in union (OR 3.0, CI: 2.47-3.54), lived in a rural area (OR 1.2, CI: 1.07-1.32), have less schooling (OR 1.13; CI: 1.02-1.26) and resided in region 4 (OR: 1.5; CI: 1.23-1.93) compared to women who use contraceptive methods to limit their fertility. Women were less likely to have unmet needs for limiting if they had some type of access to health service (private OR: 0.5; CI: 0.37-0.77; full public OR: 0.7; CI: 0.57-0.75; partial public OR: 0.83; CI: 0.72-0.95). Note: For the total 100% of women currently in union, women who are infecund and want to have children account for 11.9%. For the total 100% of never in union women who have been sexually active in the previous 3 months, women who are infecund and want to have children account for 7.5% --- Discussion Unmet need for contraception is an important health problem for women in Mexico. Our study found that the level of unmet need for contraception among married women was not very high (11.5%), and was similar to the estimated level for Latin America, reported for 2010 at 10.5% [4]. Additionally, the use of contraceptive methods was widespread among Mexican women as a whole. However, the analysis showed important differences regarding sociodemographic characteristics and demonstrated that new reproductive desires and sexual behaviours are not being accompanied by appropriate public contraceptive policies. Age was the most significant variable in both models (spacing and limiting). Young women, both currently in union and never in union, had difficulty using the contraceptive methods they required according to their reproductive desires, both for spacing and for limiting, and therefore, had a high probability of having unintended pregnancies. Recent estimates indicate that in Mexico 38 out of 1000 women of reproductive age have had clandestine abortions as a result of not having the necessary contraceptive methods [19]. Inconsistent use of contraceptives is also a problem experienced by young women [20]. The second most significant variable was marital status, where women never in union had a much greater unmet need for contraception than women currently in union. The country's family planning services were originally designed exclusively for married women, and despite evidence of increased sexual initiation prior to marriage, the need for contraception has not been met adequately for the younger population [7]. Women living in the country's poorest region, which is the region with the highest proportion of indigenous population (Region 4), have greater unmet needs for both spacing and limiting compared to women residing in the capital of the country. This finding clearly shows that services are insufficient in those areas of the country where women have traditionally had the highest fertility rates, but now have a greater desire to space and limit births. As previously reported [7], having health insurance reduces the unmet need for contraception both to limit and to space. One characteristic of contraceptive use by Mexican women is that they tend to be sterilized at an early age. Thus, in the age group 30-34 years, sterilization ranks highest in contraceptive methods used, and ranks second for the 25-29 years age group [7]. Since performing sterilizations require medical facilities, having medical insurance to cover the medical procedure will make a difference. The ORs of the second model (need to limit), reflect that having any type of access to health service significantly reduced unmet need for contraception (for limiting). In the Latin American region, there has been a high use of sterilization [1], and although the level varies by country, Mexico is in the group of countries that uses this method the most [21]. A limitation of the study is that the estimation of unmet need for contraception did not consider the particular efficacy of different contraceptive methods. Women who used both modern and traditional methods were defined as having met needs, even though some methods are inefficient in the prevention of pregnancy [4]. However, this limitation has little weight in the case of Mexico, as only 4.2% of the women in this analysis use traditional methods (4.2% of currently married and 4.1% of never married women who were sexually active). --- Conclusions This research has shown the urgency of focussing on the country's young population in terms of contraceptive services. Younger women, both currently in union and never in union, had the highest unmet needs of contraception for spacing and limiting. This points out to the need to redesign the country's contraceptive programmes. Previous research has shown that well-organized family planning programmes have a direct and indirect impact on reducing unmet need for contraception [4,6]. In Mexico, priority should be given to providing contraceptive services to the young population in general, as well as to women in the poorest region of the country. --- Availability of data and materials The datasets analysed during the current study are available in the INEGI repository, http://www.beta.inegi.org.mx/proyectos/enchogares/especiales/ enadid/2014/. --- Authors' contributions FJ and CG conceived the study and wrote the manuscript. GMP contributed to the data analysis and manuscript drafting. FJ supervised the data analysis. All authors reviewed and approved the manuscript. --- 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: Worldwide, the importance of contraception to control fertility has been recognized. A useful indicator of the gap between reproductive preferences and the provision of contraception is "unmet need for contraception". The aims of this paper are to estimate the levels of unmet need for contraception among married and single women, and to explore factors associated with unmet need for contraception for spacing and limiting births in Mexico. Methods: We used the Mexican National Survey of Demographic Dynamics 2014, using a sub-sample of 56,797 sexually active women aged 15-49 years who were either currently in union or who had never been in union to estimate the prevalence of unmet need for spacing and limiting births. We applied multivariable binary logistic regressions to examine the relationship between unmet need for spacing and limiting considering associated factors. Results: Unmet need for contraception was estimated at 11.5% among women in union (6.4% limiting; 5.1% spacing), and 28.9% for women never in union (8% limiting; 20.9% spacing). In the logistic regression for unmet need for spacing, the likelihood was statistically significant associated with younger women (OR = 6.8; CI = 2.95-15.48); women never in union (OR = 1.6; CI = 1.40-1.79); low levels of education (OR = 1.4; CI = 1.26-1.56); and residing in poor regions (OR = 1.9; CI = 1.52-2.49). Those with full access to public services were significantly less likely to have unmet need for spacing (OR = 0.8; CI = 0.66-0.88). In the logistic regression for unmet need for limiting, being younger (OR = 6.3; CI = 4.73-8.27), never in union and sexually active (OR = 3.0; CI = 2.47-3.54); with less schooling (OR 1.13; CI: 1.02-1.26); rural residence (OR = 1.2; CI = 1.07-1.32); and residing in poor regions (OR = 1.5; CI = 1.23-1.93) were factors positively associated with this unmet need. Women with private health services were the least likely to have unmet need for limiting (OR = 0.5; CI = 0.37-0.77). Conclusions: Younger women currently in union and never in union had the highest unmet needs of contraception for spacing and limiting. The results from this study suggest that in Mexico family planning services must prioritize the contraception needs of all young women, both in union and not in union, with appropriate and suitable services to cover their needs.

. Introduction Data in social and behavioral studies often show multilevel structures (Bryk and Raudenbush, 1992). The multilevel structure may be purely hierarchical (or nested). In a purely hierarchical structure, lower-level units belong to one and only one higher-level unit. A canonical example of strictly nested data is found where students (at level 1) are nested within classrooms (at level 2), and classrooms are nested within schools (at level 3). A pure hierarchy as such may no longer hold when lower-level units belong to two or more types of higher-level units at the same level. This kind of situation yields a socalled cross-classified structure. An example of cross-classified data can be found where students (at level 1) are nested within schools and neighborhoods simultaneously (at level 2). Students who live in the same neighborhoods may not attend the same schools, and students who attend the same schools may be drawn from different neighborhoods; therefore the schools and neighborhoods are not nested but crossed. If lower-level units belong to two or more higher-level units of the same type, the data show a multiple membership structure, rather than crossed; for example, students attend more than one classroom (multiple classroom membership) or more than one middle school (multiple school membership). We will focus on cross-classified structures, not multiple membership structures, in this paper. Standard regression models designed for single-level data typically assume that units of analysis are independent of each other. This independence assumption is violated when the data show multilevel structures due to the clustering of units, i.e., dependence among the units within the same clusters. Hierarchical linear models (HLM; Bryk and Raudenbush, 1992), also called multilevel models, have been developed to address such lack of independence and account for dependence among units within the clusters where the units are nested. To accommodate more complex dependence structures due to cross-classified clustering in data, multilevel models have been extended to cross-classified random effects models (CCREMs; Raudenbush, 1993;Goldstein, 1994;Rasbash and Goldstein, 1994). In applied settings, researchers may fail to recognize the cross-classified structure of the data being analyzed, neglecting some or all crossed factors in data analysis. However, studies have shown that ignoring crossed factors can bias variance estimates and standard errors of the regression coefficients associated with predictors (Meyers and Beretvas, 2006;Luo and Kwok, 2009;Ye and Daniel, 2017). To promote the use of CCREMs in applied research, we aim to introduce modern applications of CCREMs that may be less well-known in the literature. In particular, we will present several existing statistical/psychometric models as applications of CCREMs. Understanding these models as CCREMs can be beneficial; the flexibility of CCREMs allows researchers to extend these models to address important substantive issues by incorporating complex multilevel/cross-classified data structures, covariates, and other model structures. In addition, researchers can estimate these models and their extensions using existing software packages available for CCREMs. This means that researchers may not need to learn different software packages designed for specific models separately every time they need them. We will illustrate the estimation of the discussed CCREM applications with a freely available R package, PLmixed (Jeon and Rockwood, 2018). PLmixed is a flexible R package designed to estimate models with nested and/or crossed random effects. It can estimate standard CCREMs as well as extended CCREMs with factor structures (e.g., factor loadings). The latter type, cross-classified models combined with measurement models, may not be estimable with other widely-used R packages, such as lavaan (Rosseel, 2012) and mirt (Chalmers, 2012). Further, PLmixed extends the popular R package lme4 (Bates et al., 2015), so researchers who are familiar with lme4 syntax can use PLmixed with minimal learning efforts. For each of the applications, we provide the PLmixed syntax and an example dataset (in the manuscript and in the supplement), so that readers can easily apply and utilize the discussed models in their own research. The remainder of this paper is organized as follows. In Section 2, we give a context to establish the notation of CCREMs. In Section 3, we briefly review available software options for CCREM estimation, and provide an overview of the PLmixed package. In Section 4, we present several statistical/psychometric models as special cases of CCREMs, and then present a couple of other less well-known, but interesting applications of CCREMs. Finally, in Section 5, we conclude the paper with a summary and a discussion on limitations and future directions. ---. Model.. Setting To set up the notation, we suppose a researcher wants to study the effects of elementary schools and neighborhoods on students' math performance, where the math performance was measured based on standardized test scores (continuous) or pass/fail evaluations (binary). The researcher also wants to explore how some characteristics of schools (e.g., public vs private), neighborhoods (e.g., residential income deprivation scores), and students (e.g., student age and race/ethnicity) may be related to the student performance measure. In this case students, the level-1 units, are cross-classified by two different level-2 units, schools and neighborhoods. ---.. General formulation Let y ijk denote the math performance of student i (i = 1,..., I) who goes to school j (j = 1,..., J) and lives in neighborhood k (k = 1,..., K). I, J and K are the total numbers of students, schools and neighborhoods, respectively. We specify a CCREM for y ijk as follows: g(E(y ijk |u j, u k )) = X ijk <unk> + u j + u k,(1) where g(•) is a link function that transforms the linear predictor on the right-hand side to the conditional expectation E(y ijk |u j, u k ). Using a link function allows us to accommodate outcome variables from various distribution families. For example, if y ijk is continuous test scores and can be assumed to follow a normal distribution, an identity link function is used. If y ijk is binary (e.g., pass/fail), a logit or probit link function can be used so that the linear predictor (which ranges from -<unk> to <unk>) is mapped to a 0 to 1 scale. On the right-hand side of Equation ( 1), X ijk is a covariate matrix, each row of which corresponds to a student and each column of which corresponds to a covariate, and <unk> is a vector of regression coefficients for X ijk. The elements of the first column of X ijk are 1 when the first element of <unk> is the intercept. With no covariates and continuous math scores y ijk, the intercept is the grand mean, representing the average math scores of average students who attend an average school and lives in an average neighborhood. In Equation ( 1), u j and u k are respectively the random effects associated with the two level-2 crossed factors, schools and neighborhoods, and are assumed to be normally distributed as u j <unk> N (0, <unk> 2 school ) and u k <unk> N (0, <unk> 2 neighborhood ). Additional technical details on CCREMs can be found in comprehensive review articles, such as Fielding and Goldstein (2006) and Cafri et al. (2015). ---. Software options In this section, we provide a brief review of several existing software programs and packages for estimating CCREMs. These include HLM 7 (Raudenbush et al., 2011), MLwiN (Charlton et al., 2020), R package lme4 (Bates et al., 2015), andfunctions in SAS 9.4 (SAS Inc, 2014). Although not discussed here to conserve space, additional software options are also available, such as Mplus (Muthén andMuthén, 1998-2017), SPSS (IBM Corp, 2020), and Bayesian options such as WinBUGS (Lunn et al., 2000) and Stan (Carpenter et al., 2017). Subsequently, we describe the R package PLmixed (Jeon and Rockwood, 2018), which is selected for illustration in the present article. PLmixed can be downloaded from CRAN (https://cran. r-project.org/web/packages/PLmixed/)... Existing programs and packages... HLM HLM 7 (Raudenbush et al., 2011) is a commonlyused software program for fitting multilevel models. HLM 7 can fit two-and three-level CCREMs, using maximum likelihood estimation through the expectation-maximization (EM) algorithm (Raudenbush, 1993). For discrete outcome variables, HLM 7 estimates the models using the higherorder Laplace approximation. However, HLM 7 has limited capabilities in estimating CCREMs with more than three levels. ---.... MLwiN MLwiN (Charlton et al., 2020) is another widely-used statistical software program for fitting various types of multilevel models. MLwiN can handle both continuous and discrete outcome variables. MLwiN also allows for inconstant level-1 variance (i.e., heteroscedasticity). MLwiN implements the iterative generalized least squares (IGLS) and Markov chain Monte Carlo (MCMC) estimation procedures (Browne, 2015). Estimating CCREMs with IGLS can be computationally intensive. Thus, splitting the data into separate groups is recommended to reduce the amount of storage needed. For example, in the school and neighborhood example, if some schools only have students from certain neighborhoods, and the students from these neighborhoods do not go to other schools, these schools and neighborhoods can be treated as separate groups. However, using this trick may not always be possible in all data situations. Using the MCMC option might not be an easy route either, as fundamental knowledge about the Bayesian method would be required for proper usage of the option..... R package lme lme4 (Bates et al., 2015) is a powerful R package for maximum likelihood estimation of linear and generalized linear mixed models. For non-continuous outcome variables, lme4 utilizes the (penalized) iteratively reweighted least squares using the Laplace approximation (Doran et al., 2007). lme4 is highly flexible, allowing for many nested and crossed random effects at multiple levels. lme4 has also been used to estimate one-parameter logistic (1PL) item response theory (IRT) models (e.g., Doran et al., 2007;De Boeck et al., 2011), and their various extensions, such as IRTree models (e.g., De Boeck and Partchev, 2012). However, lme4 cannot estimate models that involve factor loadings, such as two-parameter IRT models and factor analysis models. blme (Dorie and Dorie, 2015), a Bayesian version of lme4, offers additional flexibility, but estimating complex CCREMs with factor loading structures may still be challenging with this package..... SAS. SAS 9.4 (SAS Inc, 2014) is a general-purpose statistical software program and it offers powerful procedures, such as GLIMMIX and MIXED, for fitting mixed models. GLIMMIX subsumes MIXED since it fits generalized linear mixed models, of which linear mixed models are a special case. GLIMMIX allows for accommodating complex nested and crossed random effects structures. GLIMMIX employs the restricted pseudolikelihood (RPL) estimation (Wolfinger and O'connell, 1993), a linearization-based method, as its default estimation method for models with random effects. The PRL estimation method may yield biased parameter estimates especially for binary data. GLIMMIX also offers two integral approximationbased estimation methods, the Laplace approximation and adaptive Gauss-Hermite quadrature, but the latter may be computationally inefficient for estimating complex CCREMs. ---.. R package PLmixed PLmixed extends the lme4 package to estimate extended generalized linear mixed models with factor structures. PLmixed implements a profile maximum likelihood estimation approach (Jeon and Rabe-Hesketh, 2012), taking advantage of the lme4 estimation and the optim function (Byrd et al., 1995). PLmixed follows lme4's syntax structure, and therefore, minimum learning may be required to utilize PLmixed for users who are already familiar with lme4. To illustrate what PLmixed can do, let us return to the example used in Section 2.1. Suppose the researcher has tracked the students at multiple time points, and is interested in how the effects of schools change over time. For simplicity, assume the students did not change their school membership and residential areas (neighborhoods) during this time. In this longitudinal measurement context, we can extend the CCREM specified in Equation ( 1) as follows: g(E(y itjk |u jt, u k )) = X itjk <unk> + <unk> t u jt + u k, (2 ) where y itjk indicates the i-th student's performance measure at time t (t = 1,..., T) in school j and neighborhood k. Here the new parameter <unk> t is introduced to model the weight of the school random effect u jt at time t. The weight parameters <unk> = (<unk> 1,..., <unk> t,..., <unk> T ) ′ tell us how the impacts of schools on the students' math performance change over time. For identification purpose, one of the weights is fixed at 1 as a reference point (e.g., <unk> 1 = 1). Since the weight parameter <unk> t is multiplied by random effect u jt and indicates the size/direction of the relationship between the outcome measures across time and the random effect, they can be seen as factor loadings as in the factor analysis framework. For example, <unk> t is the factor loading of the random effect u jt (or latent variable or factor) on the t-th outcome variable y itjk. In IRT, factor loadings are also called item slopes or item discrimination parameters. These factor loadings are not estimable with lme4. The main function of the PLmixed package is PLmixed. The basic arguments of PLmixed function are identical to lme4's glmer function's main arguments: formula (a twosided linear formula that describes the model), data (a data frame containing variables in formula), and family (a GLMM family to specify the distribution of response variable). To estimate factor loadings, three new arguments are introduced: load.var (a vector of variables correspond to lambda and factor), lambda (the factor loading matrix), and factor (a list of factor names in lambda). We will further illustrate the usage of the PLmixed function in the following section through several CCREM applications. Of note, Rockwood and Jeon (2019) demonstrated the applications of PLmixed in the context of complex measurement and growth models, providing additional technical details of the profile likelihood estimation. We refer interested readers to Rockwood and Jeon (2019) for additional information. ---. Applications In this section, we introduce several applications of CCREMs. We will first present several measurement models and methods as special applications of CCREMs. We will then introduce a couple of interesting CCREM applications that may be less well-known in applied research. For each of the applications, we first give a brief summary of the discussed models or methods. We then describe how to fit the models using PLmixed with an example dataset and briefly discuss the estimated results... Measurement models and methods... Random item-e ect IRT models.... Background IRT models describe the relationship between categorical item responses and the latent variable(s) to be measured with the test. The one-parameter logistic (1PL) model, also known as the Rasch model (Rasch, 1960), can be written for binary response y ij to item i given by person j as follows: logit(P(y ij = 1 | <unk> j )) = <unk> i + <unk> j,(3) where <unk> j indicates person j's level on the latent variable or construct of interest; respondents are typically assumed drawn from a population distribution, assuming <unk> j <unk> N (0, <unk> 2 ). <unk> i is the item intercept parameter representing the easiness level of item i. The 1PL model can also be seen as a two-level multilevel model with item responses at level 1 and respondents at level 2, where <unk> j indicates person random effects and <unk> i indicates item fixed effects. The 1PL model can therefore be estimated with multilevel modeling packages, such as the R package lme4 (Bates et al., 2015). The 1PL model is extended to the two-parameter logistic (2PL) model by additionally accommodating the item slopes, or factor loadings <unk> i : logit(P(y ij = 1 | <unk> j )) = <unk> i + <unk> i <unk> j,(4) The item slope parameters <unk> i are multiplied by the latent variable <unk> j <unk> N (0, <unk> 2 ), similar to Equation (2). For identifiability, one of the item factor loadings are fixed at 1 (or <unk> = 1). The 2PL model can be seen as a two-level multilevel model with a factor structure. Thus, PLmixed can estimate this model, while lme4 cannot. Van den Noortgate et al. (2003) presented an extended 1PL IRT model that assumes both respondents and items are random samples from the respective population distributions, therefore considered as random effects. This so-called, random item-effect IRT model can be written as follows: logit(P(y ij = 1 | <unk> j, <unk> i )) = <unk> 0 + <unk> j + <unk> i,(5) where <unk> j <unk> N (0, <unk> 2 ) and <unk> i <unk> N (0, <unk> 2 ) represent the respondent and item random effects, respectively, and <unk> 0 indicates the intercept. In the sense that the same set of items are given to respondents, item responses are cross-classified by respondents and items. When both respondents and items are considered random effects, as in Equation ( 5), the model can be seen as a CCREM with no covariates. Under the CCREM framework, the random item-effect IRT model described above can be easily extended with person and item covariates. For example, logit(P(y ij = 1 | <unk> j, <unk> i )) = <unk> 0 + x P j <unk> P + x I i <unk> I + x P,I ij <unk> P,I + <unk> j + <unk> i,(6) where <unk> P is a vector of regression coefficients for x P j, a vector of person j's characteristics (e.g., gender and motivation level). <unk> I is a regression coefficient vector for x I i, a vector of item i's features (e.g., item length and cognitive complexity). <unk> P,I is a vector of regression coefficients of x P,I ij, which is a vector of person-by-item interactions (e.g., whether person i's background, such as gender, interacts with item i or item i's feature). In addition, the CCREM framework allows for further expansions of the random item-effect IRT model with more complex person and item clustering structures; for example, respondents and/items are nested or cross-classified with higher-level units (e.g., respondents are cross-classified with schools and neighborhoods, and items are cross-classified with two or more cognitive functions). ---.... Illustration To show how to fit a random item-effect IRT model with PLmixed, we use the simulated data IRTsim in the package. The installation of the package and the first six rows of the data are presented below. > install.packages("PLmixed") > library(PLmixed) > head(IRTsim) sid school item sch_x stu_x y 1.1 1 1 1 -1.21 0 0 1.2 1 1 2 -1.21 0 0 1.3 1 1 3 -1.21 0 0 1.4 1 1 4 -1.21 0 0 1.5 1 1 5 -1.21 0 0 2.1 2 1 1 -1.21 1 0 The data contain 6 variables and 2,500 binary item responses from a cognitive test. The first three columns of the data are sid, school, and item, indicating student ID, school ID, and item ID, respectively. There are a total of 500 students from 26 school and 5 items. sch_x represents a continuous school-level covariate. stu_x is a binary student-level covariate. y indicates students' binary responses that takes the value of 1 if the answer is correct and 0 otherwise. Model To illustrate, we specify a random item-effect IRT model with a cross-classified structure of respondents with schools. We include student-level and school-level covariates to examine their impacts on the success probability. --- logit(P(y ijk = 1 | <unk> jk, <unk> k, <unk> i )) = <unk> 0 + <unk> 1 <unk> sch_x k + <unk> 2 <unk>stu_x jk + <unk> i + <unk> jk + <unk> k, (7 ) where <unk> 0 is the intercept, <unk> 1 is the regression coefficient for the school-level covariate, <unk> 2 is the regression coefficient for the student-level covariate. <unk> i <unk> N (0, <unk> 2 ) is the random item effect, where <unk> indicates how much the item easiness varies across the test items. <unk> jk <unk> N (0, <unk> 2 stu ) and <unk> k <unk> N (0, <unk> 2 sch ) represent the student and school random effects, respectively. Fitting the model The model can be fitted with the below PLmixed syntax: > IRT.example <unk>-PLmixed(formula = y<unk>1 >+ sch_x + stu_x + > (1|item)+(1|sid:school)+(1|school), + data = IRTsim, family = binomial) The argument formula follows Equation ( 7). The item response y is a function of three fixed-effect and three randomeffect terms. The inclusion of the term 1 indicates that the intercept of the linear predictor <unk> 0 is estimated. With sch_x and stu_x, the regression coefficients, <unk> 1 and <unk> 2, are estimated as well. (1|item), (1|sid:school) and (1|school) are the three random-effect terms. The colon between sid and school is used to indicate that the students are nested within schools. Here, the argument family = binomial means that the binomial family with a logit link function is used. Other than the default logit link, a probit link function can also be used with the syntax family = binomial(link="probit"). All results are saved in an object named IRT.example. After fitting the model, the estimated results are summarized with the summary() function. The first section of the summary echos the formula we specified, the data, and the link function. The second section presents model fit indices including the AIC, BIC, and a summary of the scaled residuals. In the Random effects section, the estimates of variances and standard deviations of the three random effects are presented. The last line of this section lists the numbers of observations, students, schools and items. These estimates indicate that about 42.7% (= 0.753/ [0.632 + 0.753 + 0.377]), 35.8% (= 0.632/ [0.632 + 0.753 + 0.377]), and 21.4% (= 0.377/ [0.632 + 0.753 + 0.377]) of the variation in the data are explained by the differences between schools, between students, and between items, respectively. In the Fixed effects section, the estimates of the fixed effects are presented. that the probability that the an average student (i.e., <unk> jk = 0) in the stu_x=0 group from an average school (i.e., <unk> k = 0) with sch_x=0 correctly answers an average item (i.e., <unk> i = 0) is about 0.577 (= 1/ [1+exp(-0.2695)]). The change in the logit that is associated with one unit increase in sch_x is 0.6963, and the corresponding standard error (SE) is 0.2062. The average difference between the stu_x= 0 group and stu_x= 1 group is 1.3874, with SE of 0.1326. The last section of the result lists lme4 optimizer, optim optimizer, the number of optim iterations, and the estimation time.... Rater e ect models.... Background Social science studies often utilize assessment by raters. In this case, raters contribute to the variance in the assessment data, and this variance due to rater effects is not related to the variation of the ratees in their performance (Scullen et al., 2000). Since rating data are cross-classified by raters and ratees, CCREMs are a natural option to address rater effects. For example, CCREMs have been used to estimate rater effects in cross-sectional data (e.g., Jayasinghe et al., 2003;Murphy and Beretvas, 2015;Lei et al., 2018;Martinez et al., 2020;Chen et al., 2021) and in longitudinal data settings (e.g., Guo and Bollen, 2013). Under the CCREM framework, researchers can differentiate rater variance from other sources of variances, and incorporate covariates to answer useful research questions. For example, a large rater variance indicates that ratings vary to a large degree across raters, implying that rater training needs to focus on improving consistency across raters (by making the scoring rubrics tighter and stricter, for instance). With covariates, one can find out whether particular characteristics of raters, ratees, and rater-and-ratee combinations may be associated with systematically higher or lower ratings. ---.... Illustration To show how to fit a rater effect model as a CCREM, we first generate a dataset that mimics the empirical data analyzed by Jayasinghe et al. (2003). The simulated data include 2,401 evaluations of 1,580 assessors on 673 grant proposals. Each assessor and proposal belongs to one of the 28 fields of study, which can be further categorized into nine general discipline panels, such as Physics and Mathematics. The first six rows of the simulated dataset are printed below. The outcome variable is the rating (rating) of a proposal (proposal) provided by an assessor (assessor) in a field of study (field). The mean and standard deviation of the ratings are 0.14 and 1.05, respectively. The number of proposals assessed by each assessor ranges from 1 to 3. The number of ratings each proposal receives ranges from 2 to 7. The numbers of assessors, proposals and ratings in the fields range from 15 to 83, from 12 to 33, and from 37 to 122, respectively. Other covariates included in the data are the gender of the assessors (assessor_gender) and the gender of the first author of the proposals (researcher_gender). For these gender variables, 0 indicates the assessor/author is a male, and 1 indicates the assessor/author is a female. --- Model We specify a three-level CCREM where ratings (at level 1) are cross-classified by assessors (raters) and proposals (at level 2) both of which are nested within fields (at level 3). In addition to the random effects of assessors, proposals, and fields, we examine the effects of the genders of assessors, first authors of proposals, and their interactions. The rater effect CCREM can then be specified as follows: y ijk |u ik, u jk, u k = <unk> 0 + <unk> 1 x R ik + <unk> 2 x P jk + <unk> 3 x R,P ijk + u ik + u jk + u k + <unk> ijk,(8) where y ijk is the rating of proposal j in field k assessor i provides. x R ik, x P jk and x R,P ijk are the assessor' gender (1: female; 0: male), first author's gender (1: female; 0: male), and the interaction between the two (1: the assessor and author are both females; 0: the assessor and author are of different genders or are both males), respectively. <unk> 0 is the intercept and <unk> 1 to <unk> 3 are the regression coefficients for the three gender-related covariates. The regression coefficient <unk> 3 of the interaction term can answer an interesting question that whether female assessors' rating on the proposals written by female authors are consistently higher or lower. The assessor, proposal and field random effects are assumed u ik <unk> N (0, <unk> 2 assessor ), u jk <unk> N (0, <unk> 2 proposal ), and u ijk <unk> N (0, <unk> 2 field ). Fitting the model The below PLmixed syntax can be used to fit the model specified in Equation ( 8). In the Random effects section, the estimates of variances are shown. Consistent with the results shown in Jayasinghe et al. (2003), assessors explain about 82% (= 0.8876/ [0.8876+0.1672+0.0254]) of the total variation in ratings, proposals explain about 15% (= 0.1672/ [0.8876+0.1672+0.0254]), and fields explain 3% (= 0.0254/ [0.8876+0.1672+0.0254]) of the variation in the data. The large betweenassessor variance tells us that improving consistency in ratings across assessors would be a useful consideration to improve the proposal assessment system. In the Fixed effects section, the estimates of regression coefficients and the associated standard errors are presented. The results suggest that female assessors on average provide lower ratings than male assessors, female authors on average receive higher ratings than male authors, and proposals written by female authors receive lower ratings from female assessors.. /fpsyg.. ---... Multitrait-multimethod models.... Background The multitrait-multimethod (MTMM) (Campbell and Fiske, 1959) models have been applied broadly in applied social science research (e.g., Lance and Sloan, 1993;Biesanz and West, 2004;DeYoung, 2006). When multiple traits (e.g., the Big Five) are measured with multiple methods (e.g., self report or peer report), MTMM models are used to differentiate method effects from trait effects. MTMM analysis helps researchers evaluate convergent and discriminant validity of the main measures; the methods designed to measure the same traits should be highly correlated, while the traits should not correlate highly with the methods. The flexible CCREM framework allows researchers to extend the classical MTMM model in a variety of ways, e.g. by adding covariates and dealing with multilevel/cross-classified data structures. These extended models can be easily estimated with a CCREM package of choice, such as PLmixed, without needing to develop a new estimation routine. ---.... Illustration To show how the MTMM model can be estimated as a CCREM, we simulate a dataset that reproduces the MTMM covariance matrix reported by DeYoung (2006). The simulated data include continuous scores on the Big Five obtained from subjects (n = 500) and three of their peers. Each subject has 20 scores, where five are self-reported and the other 15 are reported by three peers (five per peer). The five self-reported scores are measures 1-5, and the 15 peer-reported scores are measures 6-10. The first six row of the simulated data are printed below. The variable subject, measure, method, trait and peer are indicators of subject, scale, method (1: self report, 2: peer report), trait (1 = Extraversion, 2 = Agreeableness, 3 = Conscientiousness, 4 = Neuroticism, 5 = Openness/Intellect) and peer (0: self report). The last column, score, is the outcome variable. Model Figure 1 illustrates the MTMM model that we consider for this dataset. Mathematically, the model is specified as follows: y itpj |<unk> T tj, <unk> M p = <unk> i + <unk> T it <unk> T tj + <unk> M ip <unk> M p + <unk> itpj, (9 ) where y itpj represents peer p's rating to measure i on trait t of subject j. <unk> i denotes the intercept of measure i, <unk> T it indicates measure i's loading on <unk> T tj for t-th trait, and <unk> M ip indicates measure i's loading on <unk> M p, the peer rater effect. The trait latent variables and peer/rater latent variables are assumed: <unk> T j <unk> N (0, T ) and <unk> M p <unk> N (0, <unk> 2 M ). The residual term is assumed <unk> itpj <unk> N (0, <unk> 2 e ). Fitting the model To fit the above model with PLmixed, we first specify

Cross-classified random e ects models (CCREMs) have been developed for appropriately analyzing data with a cross-classified structure. Despite its flexibility and the prevalence of cross-classified data in social and behavioral research, CCREMs have been under-utilized in applied research. In this article, we present CCREMs as a general and flexible modeling framework, and present a wide range of existing models designed for di erent purposes as special instances of CCREMs. We also introduce several less well-known applications of CCREMs. The flexibility of CCREMs allows these models to be easily extended to address substantive questions. We use the free R package PLmixed to illustrate the estimation of these models, and show how the general language of the CCREM framework can be translated into specific modeling contexts.

that we consider for this dataset. Mathematically, the model is specified as follows: y itpj |<unk> T tj, <unk> M p = <unk> i + <unk> T it <unk> T tj + <unk> M ip <unk> M p + <unk> itpj, (9 ) where y itpj represents peer p's rating to measure i on trait t of subject j. <unk> i denotes the intercept of measure i, <unk> T it indicates measure i's loading on <unk> T tj for t-th trait, and <unk> M ip indicates measure i's loading on <unk> M p, the peer rater effect. The trait latent variables and peer/rater latent variables are assumed: <unk> T j <unk> N (0, T ) and <unk> M p <unk> N (0, <unk> 2 M ). The residual term is assumed <unk> itpj <unk> N (0, <unk> 2 e ). Fitting the model To fit the above model with PLmixed, we first specify the factor loading lambda matrix according to the diagram (Figure 1). Rows of the lambda matrix correspond to the measures, and columns correspond to the latent variables. For identification purpose, we fix the first loading of each lambda matrix to 1. Note that as measures 6-10 are peer-reported, the first five elements of the rater effect latent variable (i.e., the last column of the lambda matrix) are zeros. NA represents unknown parameters that are to be estimated. > lambda <unk>-rbind(c(1, 0, 0, 0, 0, 0), + c(0, 1, 0, 0, 0, 0), + c(0, 0, 1, 0, 0, 0), + c(0, 0, 0, 1, 0, 0), + c(0, 0, 0, 0, 1, 0), + c(NA,0, 0, 0, 0, 1), + c(0,NA, 0, 0, 0, NA), + c(0, 0,NA, 0, 0, NA), + c(0, 0, 0,NA, 0, NA), + c(0, 0, 0, 0,NA, NA)) The full PLmixed syntax can be specified as follows: > MTMM.example <unk>-PLmixed(score<unk>0 + as.factor(measure) + + (0+E+A+C+N+O|subject) + + (0+rater|peer), + data = as.data.frame(MTMM.data), + lambda = list(lambda), load.var = "measure", + factor = list(c("E","A","C","N","O","rater"))) The 0 is included to ensure no intercept is estimated. We use as.factor(measures) to estimate measure-specific intercepts. The five trait latent variables are named E, A, C, N and O. As assumed, these latent variables are correlated and vary across subjects. If independence is assumed among the trait latent variables, the syntax would be specified as The first section of the results echos the formula, and the second section shows model fit indices. The Lambda section shows the estimates of factor loadings and the corresponding standard errors. The negative loading of measure 10 on the latent variable O indicates that the peer-reported scores are negatively associated with Openness/Intellect, suggesting that these peerreported scores of measure 10 should be closely examined as they do not seem to properly measure the target latent variable Openness/Intellect. Following the factor loading section, the Random effects section lists the estimates of variances of all latent variables, and the correlations of the five traits. In the Fixed effects section, measure-specific intercepts are presented. In the last section, information about lme4 optimizer is listed.... Generalizability theory.... Background Generalizability theory (G-theory) is a statistical framework for evaluating the generalizability (or reliability) of measurements (Shavelson and Webb, 1991). In G-theory, observed scores are decomposed into additive effects of multiple facets (i.e., sources of variations). If levels of a facet in a measurement design are viewed as random samples from the universe of all levels, or if researchers would like to generalize beyond these observed levels, this facet is a random facet. In contrast, if all possible levels of a facet are included in the design, or if there is no need for generalization, this facet is treated as a fixed facet. Gtheory includes two types of studies, the generalizability study (G study) and the decision study (D study). In a G study, variances associated with the facets are computed. In a D study, different generalizability coefficients are constructed, using the variance estimates computed from the G study. A generalizability coefficient is analogous to a reliability coefficient, while it depends on which facets are considered random. Vangeneugden et al. (2005) utilized a linear mixed model framework to estimate G-theory models, so that different kinds of generalizability/reliability coefficients can be derived from the estimates of variances. Choi (2013) and Choi and Wilson (2018) presented a generalized linear latent and mixed modeling approach (GLLAMM) (Skrondal and Rabe-Hesketh, 2004) to combine G-theory and IRT. Jiang (2018) and Jiang et al. (2020) showed how generalizability variance components from univariate and multivariate generalizability theory can be estimated within the linear mixed model framework with general-purpose R packages. ---.... Illustration To illustrate how a G-theory model can be estimated and extended as a CCREM, we analyze the Brennan.3.2 dataset from the gtheory R package (Moore, 2016). The dataset contains scores of 10 persons' performance on 3 tasks, each of which is rated by 4 raters (i.e., the classical person<unk>[rater:task] design). The first six rows of the data are printed below. > install.packages("gtheory") > library(gtheory) > head(Brennan.3.2) Task Person Rater Score 1 1 1 1 5 2 1 2 1 9 3 1 3 1 3 4 1 4 1 7 5 1 5 1 9 6 1 6 1 3 The outcome variable is the score (Score), which ranges from 1 to 9. The 10 persons (Person) complete all three tasks (Task). Raters (Rater) 1 to 4 assess task 1, raters 5 to 8 assess task 2, and raters 9 to 12 assess task 3. Model In this person<unk>(rater:task) design, there are five sources of variation: persons, tasks, raters, person-task interactions and residuals. The data show a cross-classified structure where the scores are cross-classified by persons and raters, which are nested within tasks. We specify the G-theory model as a CCREM as follows: y ijk |u jk, u k, u ik = <unk> 0 + u i + u jk + u k + u ik + <unk> ijk,(10) where y ijk is person i's score on task k by rater j, u i <unk> N (0, <unk> 2 person ) represents the person random effect, u jk <unk> N (0, <unk> 2 rater ) is the rater random effect, u k <unk> N (0, <unk> 2 task ) is the task random effect, u ik <unk> N (0, <unk> 2 person<unk>task ) is the persontask interaction random effect, and <unk> ijk <unk> N (0, <unk> 2 e ) is the residual term. Fitting the model The PLmixed syntax to fit this model is displayed below. The summary of the estimated results is shown below; only the Random effects and Fixed effects sections are listed to conserve space. The reliability coefficient above is fairly low (consistent with the result from the gtheory package). This means that it would be difficult to generalize subjects' scores over different raters and tasks, calling for further investigation on the assessment data... Other applications... Social network analysis.... Background Social network analysis (SNA) examines how individuals are connected and how social connections influence individuals and their behaviors (Otte and Rousseau, 2002). A number of methods and techniques have been developed for social network analysis, such as stochastic actor oriented models (SAOM) (e.g., Snijders, 1996Snijders,, 2017)), exponential random graph models (ERGM) (e.g., Holland and Leinhardt, 1981;Frank and Strauss, 1986;Cranmer and Desmarais, 2011), and latent space models (e.g., Hoff et al., 2002;Sewell and Chen, 2015). CCREMs have also been utilized to study social network connections and dependencies among individuals generated due to their social networks. For example, Tranmer et al. ( 2014) considered individuals' ego-nets (of size 2 and 3) as their classification structures and applied a CCREM to account for the dependencies due to the network structure. They found that ignoring network dependencies as such would bias the estimates of fixed and random effect parameters in the model. De Nooy (2011) analyzed reviews/interviews among 40 literary authors and critics in the Netherlands during 1970-1980. The network model adopted in this study can be viewed as a CCREM in the sense that the model viewed review/interviews were cross-classified by authors and critics. Koster et al. (2015) showed that the multilevel formulation of the Social Relations Model (SRM) (Snijders and Kenny, 1999) could be estimated as a cross-classified Poisson model. The SRM as a CCREM partitions the total variance in social network data into variance components contributed by multiple sources. ---.... Illustration To illustrate how a CCREM can be used for social network analysis, we analyze a dyadic network dataset used by Koster et al. (2015). The data were collected in a village of indigenous Ye'kwana horticulturalists with eight households in Venezuela. These eight households lead to 28 dyads. The first six rows of the data are printed below: The outcome variable is the total number of meals (sharing) provided from one household (giver) to another (receiver). Each giver-receiver pair defines a relationship (relationship). Note the relationship variable is directed, meaning that the values may not be the same for household A-B and B-A pairs. Other covariates are the distance between households (distance), the genetic relatedness between households (kinship), and an association index which is a measure of interactions between each pair of households (association). Model The number of meals y ij that household i gives to household j is assumed to follow a Poisson distribution with mean <unk> ij, i.e., y ij <unk> Pois(<unk> ij ). For simplicity, we consider no covariates and specify a Poisson CCREM as follows: log(<unk> ij ) = <unk> 0 + g i + r j + u |ij| + <unk> ij,(11) where <unk> 0 is the intercept, g i and r j represent the giver and receiver random effects, respectively. The two random effects are assumed to be independent with g i <unk> N (0, <unk> 2 giver ) and r j <unk> N (0, <unk> 2 receiver ). We further decompose the relationship random effects into two parts: u |ij| represents the symmetric (undirected) relationship random effect, with u |ij| <unk> N (0, <unk> 2 dyad ). The |•| is used in the subscript to indicate that this effect is symmetric, meaning that it takes the same value within each dyad. e ij is the asymmetric (directed) relationship random effect, with <unk> ij <unk> N (0, <unk> 2 relation ). This effect is asymmetric, meaning that the value of e ij can be different for each observation within a dyad. Covariates at the giver, receiver and relationship levels can be also incorporated into the model. Fitting the model The network model described above can be fit with the below PLmixed syntax. We show below the Random effects and Fixed effects sections of the estimated results. With the variance estimates of the random effects, we can quantify the contribution of each variation source to the total variance. For example, the amount of total variation attributed to the givers is 0.549 (= 1.8853/[0.2401 + 1.1990 + 0.1060 + 1.8853]); that is, givers explain 54.9% of the total variation in the data. In contrast, receivers explain only 3.1% of the variance (0.031 = 0.1060/[0.2401 + 1.1990 + 0.1060 + 1.8853]). The outcome variable is the math scores (score) of a student (student) who was born in an origin country (origin) and took the PISA test in a destination country (destination). The mean and standard deviation of scores are 503 and 98, respectively. Each combination of the origin and the destination countries defines an immigrant community (community). Since not all origin countries are presented in all destination countries, the data contain 67 (instead of 13<unk>35 = 455) different immigrant communities. The number of students in each of the communities ranges from 90 to 144. Model In this example, students are cross-classified by countries of origin and destination. The communities indicate the originby-destination combinations. To differentiate the three types of contextual effects on students' math scores, we specify the following CCREM model: y ijk |u j, u k, u jk = <unk> 0 + u j + u k + u jk + <unk> ijk,(12) where y ijk represents the math score of student i's, who was born in country j, took the test in country k and lives in the immigrant community defined by the origin and destination countries. <unk> 0 is the intercept, u j <unk> N (0, <unk> 2 origin ) and u k <unk> N (0, <unk> 2 destination ) are the origin country and destination country random effects, respectively, and u jk <unk> N (0, <unk> 2 community ) is the community random effects, as specified as the cell effects (cells created by origin and destination country classifications). <unk> ijk <unk> N (0, <unk> 2 e ) is the residual term. Fitting the model The above model can be estimated with the PLmixed syntax below: Elements in the formula argument correspond to the terms in Equation ( 12). The 1 represents the intercept, and (1|origin), (1|destination) and (1|origin:destination) are the three random-effect terms. Below we display the Random effects and Fixed effects sections of the estimated results. The Random effects section lists the variance estimates of random effects. Here origin:destination indicates the community random effects specified as the cell effects. The results suggest that the immigrant community, the country of origin, and the country of destination explain 5.4% (= 511.2/[511.2+803.2+681.4+7459.7]), 8.5% (= 803.2/[511.2+ 803.2 + 681.4 + 7459.7]) and 7.2% (= 681.4/[511.2 + 803.2 + 681.4 + 7459.7]) of the total variation in the math scores, respectively. It is interesting that the country of origin still has influence immigrant students' math scores, and the students' immigrant community shows as large influence as the destination county on immigrant students' math outcomes. ---. Concluding remarks In this article, we aim to introduce some modern applications of CCREMs for social science studies. We presented some existing models and methods widely used in applied research as applications of CCREMs. These applications and their connections to CCREMs might have been shown in the literature by different authors in separate studies. However, to our best knowledge, these different applications have not been reviewed, discussed, and integrated together in a single paper. We want to stress again the usefulness of understanding the connections between different models that serve for seemingly different purposes within the CCREM framework. As discussed earlier, those models can easily be extended to accommodate complex clustering and covariate structures in the data for any units of analysis. Further, the models presented in this paper can be integrated when desirable under the unifying framework that CCREM offers. For example, the rater effect model can be combined with the random item-effect IRT model, and/or with the multitrait-multimethod model, and/or the G-theory model. As another example, the model presented for a study of country of origin and destination may be extended with a measurement model such as the two-parameter IRT model. Without having these perspectives, researchers may need to develop their own estimation routines every time there is a need for such models, which can be inefficient, time consuming, and unnecessary. It may be worth commenting that the flexibility and generality of the CCREM framework come with a cost in the sense that researchers need to understand the CCREM framework, and translate the general language of the CCREM framework into the specific modeling contexts of choice, which may not be an easy task. The current article is written to help remediate such a challenge by providing a practical guide to the CCREM and its applications. Lastly, we chose the R package PLmixed to illustrate the estimation of the discussed models. PLmixed is a convenient choice as it is freely available and it can estimate all of the models presented in this paper and many of their combinations. Of note, when no factor structures are involved, the models presented in this paper can also be estimated with the R package lme4. But when factor loadings are included, lme4 can no longer be used. In addition, an important future line of work is to compare PLmixed with other packages specialized for specific models as well as other general-purpose software programs in terms of the model specification and estimated results. Further, it would also be useful to conduct rigorous simulation studies to compare the performance accuracy of different software packages for estimating different CCREM applications introduced in this paper. Author's note SH is currently an Assistant Professor at Indiana University Bloomington. MJ is an Associate Professor at the University of California, Los Angeles. --- Data availability statement The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author. --- Author contributions SH and MJ drafted the manuscript. Both 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. --- Author disclaimer Opinions are those of the authors alone and do not necessarily reflect those of the authors' home institutions.

Cross-classified random e ects models (CCREMs) have been developed for appropriately analyzing data with a cross-classified structure. Despite its flexibility and the prevalence of cross-classified data in social and behavioral research, CCREMs have been under-utilized in applied research. In this article, we present CCREMs as a general and flexible modeling framework, and present a wide range of existing models designed for di erent purposes as special instances of CCREMs. We also introduce several less well-known applications of CCREMs. The flexibility of CCREMs allows these models to be easily extended to address substantive questions. We use the free R package PLmixed to illustrate the estimation of these models, and show how the general language of the CCREM framework can be translated into specific modeling contexts.

Background Young fatherhood is a public health issue that, in terms of research, has slowly come out of the shadow of adolescent pregnancies over the past recent years. Studies of urban adolescent males found rates of fatherhood to be between 10-30% before the age of 19 or 20, 1,2 which were similar to estimates of 14-24% by age 21 or 22 years from large nationally representative studies. 3,4 Males who become fathers during adolescence tend to be on average 2 to 3 years older than the adolescent girls they impregnate. 5 Adverse outcomes of young fatherhood are varied and long-lasting. Similar to adolescent mothers, young fathers report lower self-esteem, lower perceived social support from friends and the community, and lower general life satisfaction after birth of the child. 6 Young fathers report significantly more academic problems and less years of education than nonfathers and older fathers. 7,8 Compared to childless young men, young fathers were more likely to commit delinquent acts such as theft, trespassing, assault, be called into court, and be more involved with problem behaviors such as alcohol and drug use. 1,9 By age 30, more men who became fathers by age 22 were found to be living in public housing, receiving government benefits, working as manual laborers, and unemployed than nonfathers. 7 However, adversity was not faced only by men whose sex partners gave birth upon impregnation. Higher psychological distress scores had been noted by age 25 among those who had impregnated a partner by age 21 than those who did not experience impregnation by age 21. 10 Additionally, psychological distress was just as high among young men who became fathers as it was among those whose adolescent partners' pregnancies ended in abortion. 10 Several familial factors have consistently been shown to be associated with young fatherhood. Mother's age at first birth is negatively associated with young fatherhood. 4,7,[11][12][13] Sons of adolescent mothers have almost three times the risk of becoming a father by age 20 compared to those with older mothers, 13 with each one-year increase in mother's age at first birth estimated to reduce her son's odds of becoming a father by age 21 by 15%. 4 Young fathers also tend to grow up in households of low socioeconomic status (SES), particularly single young mother households. 3,7,11 The heightened risk of young fatherhood in single mother households could be due to several reasons. Firstly, through social learning, sons of young single mothers might not only view young parenthood as normative behavior; but with the constant absence of their own fathers throughout the young men's lives, they might also regard pregnancies as the mother's responsibility and not the father's. 14 Secondly, single mother households have also been found to experience the most financial struggles out of all family structures. 15 Part of the reason behind such disparity could be that young single mothers also tend to report low academic achievement. 16 As a result, children from such families not only have less resources and opportunities available for them, but they also have less parental academic expectations, all of which could lead to the children's own low academic abilities and achievement. 17 Sociologists have suggested that young men with limited education and employment opportunities might view fatherhood as a marker of manhood that emphasized sexual prowess. 18 Another explanation could be the low parental monitoring within such households. 19 For example, Hofferth & Goldscheider 4 found that young men who reported low parental monitoring had 75% increased odds of fathering by age 20 compared to those who reported higher parental monitoring. Involvement in problem behaviors might partly attribute to the increased risky sexual behaviors that led to the young pregnancies. [20][21][22] Gambling, particularly problem gambling, is another problem behavior that has been found to be strongly associated with low SES, substance use, delinquency, and risky sexual behaviors. 23-26 The Diagnostic and Statistical Manual of Mental Disorders (4 th ed.; DSM-IV 27 ) describes problem gambling as a continuous or periodic loss of control over gambling behavior; it is marked by irrational thinking and erroneous cognitions, a preoccupation with gambling and with obtaining money to gamble, a continuation with gambling despite adverse consequences and an inability to stop gambling despite a desire to do so. Furthermore, according to the Problem Behavior Theory, which states that problem behaviors often co-occur among adolescents and young adults, 28 adolescent males who are problem gamblers could also exhibit more risky sexual behavior. Hirschi and Gottfredson 29 also suggested that the lack of self control explains the tendency of an individuals' engagement in various types of addictive behaviors. Numerous studies have found impulsivity to be positively associated with adolescent gambling and problem gambling. 30,31 Likewise, impulsivity has been found to be associated with increased risky sexual behaviors during adolescence. 32,33 Additionally, adolescent problem gamblers report taking significantly more sexual risks than adolescent nongamblers. 34,35 Risky sexual behavior, in turn, increases the odds of fatherhood by young adulthood. 36 However, there does not appear to be any research exploring the co-occurrence of young fatherhood and adolescent gambling. The current study aims to describe the relationship of adolescent gambling behavior with young fatherhood among a sample of predominantly low-income, urban, African American males while adjusting for many of the other risk factors and behaviors found to be associated with young fatherhood in previous studies. We hypothesize that young fatherhood will occur more often and at an earlier age if they are involved in gambling activities during early adolescence. --- Methods --- Sample The data came from the Johns Hopkins Center for Prevention and Early Intervention Cohort 3 project, 37 a study initiated as a randomized prevention trial targeting academic achievement and aggression. Cohort recruitment occurred in Fall 1993 at nine urban primary public schools, primarily located in western Baltimore, MD (n=678, mean age=6.2 years, 53% male). Within each school, there were three 1 st grade classrooms, which were randomly divided into one control and two intervention classrooms. Teachers in the control classrooms provided the usual curriculum while teachers in the intervention classrooms implemented either classroom behavior management strategies or enhanced parent-school communication. 37 While the intervention only lasted for one year, the cohort was followedup annually. Of the original cohort of 678 students, approximately 80% were successfully followed up during each assessment that took place between the ages of 17 and 22 years. The current study used data from the 294 male participants who provided any data on fatherhood and gambling behavior, which were both first assessed in the age 17 (2004) interview. Eighty-one percent of the original male cohort had information on both key variables; there were no differences by race, percentage receiving subsidized lunches, or intervention condition between the study sample and the original sample of 362 males (p values>.05). As seen in Table 1, the majority of the 294 participants were African Americans (86%), and 70% received free or reduced-price lunches (a proxy for low SES). Half of the sample had been raised by a single caregiver. Approximately 20% of the participants were high-school dropouts. Study protocols were approved by institutional review boards (IRB) of Johns Hopkins University. --- Measures Young Fatherhood (assessed annually between 2004-2009)-Self reports of fatherhood were collected via the question: "Have you ever gotten someone pregnant, including current pregnancies, still births, miscarriages, or live births in which the baby later died?" Nearly three-fourths (72%) of those acknowledging having impregnating someone reported this in more than one interview. Participants were then asked to provide their age the first time they had impregnated someone; to limit recall bias the age provided at the first acknowledgement was used. Those who reported having impregnated a sex partner by age 20 were classified as "Young Father" and those who reported no impregnations by age 20 were classified as "Nonfathers." For time to event type analysis, if a participant reported impregnating a partner and his age at first impregnation was missing, we imputed his age at the time of the first assessment survey with the positive impregnation report as a conservative proxy of age at first impregnation (7.5% imputed). --- Adolescent Gambling (assessed in 2004, 2006, 2007.)-The South Oaks Gambling Screen-Revised for Adolescents (SOGS-RA) assessed gambling behavior when participants were between the ages 16-19 years. The SOGS-RA is a 12-item adaptation of the adult orientated SOGS, that assesses gambling behaviors and problems in the 12 months preceding the interview using wording of items and response options that reflect adolescence gambling behavior at an age-appropriate reading level. 38 The scale correlates with gambling activity (r=0.39), gambling frequency (r=0.54), and the amount of money gambled in the past year (r=0.42). 38 The Cronbach's alpha is.86 for males. 38 Those who reported not having gambled in the past 12 months are classified as 'nongamblers'. Gamblers who scored 0-1, which meant they had essentially had no gambling problems, were classified as'social gamblers' and those with a score of 2 or more were classified as 'problem gamblers'. 39 Others have found that adolescents with a few problems (i.e., 2-3 problems) are very similar to those with more problems. 40 Participants were classified based on their highest score at any of the data waves. --- Conduct Disorder (assessed annually between 2000-2004)-The Conduct Disorder module of the Diagnostic Interview Schedule for Children (DISC-IV 41 ) assessed whether youth met the DSM-IV criteria for a past-year diagnosis of early conduct disorder. Endorsement of at least three self reported symptoms, such as having ever shoplifted, in the past year was needed to be classified as a case of current conduct disorder. A youth was classified as having conduct disorder if they met criteria during any of the age 13-17 interviews. --- Alcohol and Illegal Drug Use (assessed annually between 2000-2004)- Questions from the Monitoring the Future National Survey 42 collected self-reports of pastyear use of alcohol and illegal drugs (marijuana, crack cocaine, cocaine, heroin, inhalants, and ecstasy). These sections of the interview were completed using Computer Assisted Personal Interview (CAPI) to enhance truthful reporting. A youth indicating use in any of the interviews conducted between ages 13-17 was classified as an early-onset alcohol user and/or early onset illegal drug user. --- Parental Monitoring (assessed annually between 2000-2004)-The Parental Monitoring Subscale of the Structured Interview of Parent Management Skills and Practices -Youth Version (SIPMSP 43 ) assessed parental monitoring by asking youths to respond to questions such as "How often would your parents or a sitter know if you came home an hour late on weekends?" Each item within the subscale was rated on a 5-point Likert scale (1=all of the time to 5=never). The average score of the seven items indicated the overall parental monitoring level with higher scores indicating less monitoring. The Cronbach's alpha was found to be 0.62. 44 For the current study a cumulative parental monitoring level in adolescence was calculated by averaging the scores collected across ages 13-17. Three groups of parental monitoring level were next created based on tertiles of the score: High (lowest tertile), Moderate (middle tertile), and Low (highest tertile). High -School Dropout-At age 19, participants were asked "What is the last year of schooling that you complete?" Those with less than a high school diploma or GED were classified as high-school dropouts. Demographic characteristics-Race, household structure (two-parent/caregiver or single-parent/caregiver), lunch status (full-price or free/reduce-price) were collected at baseline when the sample was age 6. --- Analysis Exploratory analyses with Chi-square statistics were first conducted to uncover differences in the demographic and behavioral characteristics between Young Fathers and Nonfathers. Nelson-Aalen cumulative hazard analyses next compared the risks of young fatherhood among Nongamblers, Social Gamblers, and Problem Gamblers. Cox proportional hazards models were next fitted to examine the hazard of adolescent gambling on young fatherhood. 45 Simple Cox models first tested for the unadjusted associations between young fatherhood and each covariate (i.e., gambling status, race, household structure, lunch status, conduct disorder, alcohol use, illegal drug use, high school drop out, and parental monitoring). Next, a multivariate Cox model assessed the association between young fatherhood and adolescent gambling status adjusted for all other covariates. Due to the initial study design, models need to account for the sampling and intervention strategies (i.e. students were clustered within schools). Individuals belonging to the same cluster were likely to resemble one another due to their shared environment; and if the resemblances in outcomes among those in each cluster were ignored, the standard errors would be underestimated, inflating the Type I error. 46 As a result, a variant of the Huber-White sandwich estimator of variance was used to obtain robust standard errors and variance estimates. All analyses were performed using STATA 11.0. 47 --- Results Among the 294 males with complete fatherhood and gambling data, 41% (n=120) reported fathering by age 20. Thirty-five percent of the sample were Nongamblers (n=104), 45% were Social Gamblers (n=133), and 19% were Problem Gamblers (n=57). The three most frequent types of gambling activities were betting money on games of personal skill such as pool or basketball (Social Gamblers: 58%; Problem Gamblers: 77%), card games (Social Gamblers: 50%; Problem Gamblers: 80%), and dice games (Social Gamblers: 35%; Problem Gamblers: 61%). Among Problem Gamblers, the mean SOGS-RA score was 3.9 (SD=1.8). As seen in Table 1, significantly more Young Fathers than Nonfathers were adolescent Social and Problem Gamblers. A similar pattern was observed for subsidized lunch status, early-onset conduct disorder, early-onset illegal drug use, high-school dropout, low parental monitoring in adolescence. Figure 1 shows the Nelson-Aalen cumulative hazard curves, stratified by adolescent gambling status. The cumulative hazard of young fatherhood at a specific age indicates the hazard of the event of fatherhood at that age, conditional on not having experienced the event at the specified age. Males who problem gambled during adolescence were the most likely to become fathers by age 20, followed by those who social gambled, with those who never gambled reporting the lowest cumulative hazards (p<unk>.001). The absolute differences in cumulative hazards also grew larger with increasing age. For instance, the cumulative hazard of fatherhood by age 20 was 52.6% (95% CI=40.4%, 66.0%) among Problem Gamblers, 26.7% (95% CI=20.0%, 35.1%) among Social Gamblers, and 19.3% (95% CI=12.9%, 28.3%) among Nongamblers. Results of the unadjusted and adjusted Cox regression models are shown in Table 2. The unadjusted models fitted the bivariate associations between young fatherhood and each covariate. The adjusted model examined the relationship between adolescent gambling status and young fatherhood while controlling for race, household structure, lunch status, early-onset conduct disorder, early-onset alcohol use, early-onset illegal drug use, high school drop out, and parental monitoring. Males who reported social gambling and problem gambling during adolescence had approximately two and three times, respectively, the hazards of being a young father than those who did not report any adolescent gambling. Subsidized lunch status and high school drop out were also associated with more than a twothird increase in hazard of fathering by age 20. --- Discussion Approximately 40% of the male young adults in the current sample indicated they had impregnated a sex partner by age 20. Through bivariate associations, we found aolescent gambling (both social and problem gambling), subsidized lunches (a proxy for low SES), early-onset conduct disorder, early-onset alcohol use, early-onset drug use, low parental monitoring, and dropping out of high school to be positively associated with young fatherhood. However, after adjusting for all of the covariates, only the positive associations with both adolescent social and problem gambling, subsidized lunch status, and high-school drop out remained statistically significant. The current study used subsidized lunch status as a proxy for low SES. Its positive association with young fatherhood among the current sample of young men is consistent with past studies. 3,7,11 Many researchers have also found low SES to be associated with adolescent gambling. 26,48 Furthermore, growing up in low SES environments, individuals often experience many adversely stressful events, as evidenced by the high rates of high school dropout, incarceration, low employment, and deaths in low SES neighborhoods. 49,50 In the same predominantly African American sample reported on in this paper, Storr and colleagues 51 found gamblers to experience more events than nongamblers, and directly experiencing threatening and deviant/violent types of events was associated with problem gambling symptoms. Among male adolescents, maladaptive avoidance coping strategies have been found to be more common among problem gamblers than nongamblers. 52 Therefore, engaging in risky sexual practices and gambling activities might be coping mechanisms adolescents from low SES backgrounds use as a way to dissociate from the adverse events in their lives. According to the Problem Behavior Theory, individuals tend to engage in multiple problem behaviors, 28 which some have suggested could be due to the lack of self control. 29 Supporting the theory, studies have found gambling and, particularly, problem gambling to be positively correlated to risky sexual behaviors, such as multiple sex partners and unprotected sex, among adolescents. 34,35 Such risky sexual behaviors have been demonstrated to be antecedents to young fatherhood, [53][54][55] thus bridging the association between adolescent gambling and young fatherhood. Conversely, while the unadjusted hazard estimates of early onset alcohol and illegal drug use appeared to be associated with young fatherhood, such associations were attenuated upon controlling for the demographic and behavioral covariates. The relationship between substance use and young fatherhood could be confounded by the other covariates, such as low SES. For instance, research have shown that adolescents from low SES backgrounds and single parent households were more likely to have ever used alcohol and illegal drugs than those from high SES and two-parent households. [56][57][58][59] Furthermore, studies that have shown substance use to be associated with young fatherhood generally did not concurrently adjust for SES (e.g. 1,22,53 ). Therefore the lack of associations found between adolescent substance use and young fatherhood in the present study could reflect their true relationships. The current sample of males was predominantly low-income African Americans, a subpopulation that past research have shown to have the highest odds of becoming young fathers, and mostly likely to view young fatherhood favorably and oppose abortions as an option to unplanned pregnancies. 14,60,61 Such findings suggest that most impregnations reported by the participants ended in births. As such, another important reason to invest research into further understanding young fatherhood is for the wellbeing of the baby. Studies have found the relationship between the young parents often decline with time. 62,63 For example, Larson and colleagues 63 found that adolescent mothers who reported their child's biological father as their current boyfriend decreased from 60% one month after birth to 26% forty-two months after birth. Failure of the father to achieve ongoing intimacy with the mother also correlated negatively with paternal involvement. 62 In fact, many young, low-income African American fathers become nonresident fathers with little contact with their child(ren). 14 Because father's involvement and presence in children's lives have positive benefits for the children's adjustment and development such as academic achievement, mental health, and satisfactory intimate relationships, 7,64 it is imperative to fully understand the risk process of young impregnation so as to develop effective prevention and intervention programs for those at risk. There are several limitations to the study. Firstly, the small sample size greatly restricted the study's statistical power, which could partially explain the attenuation of associations between young fatherhood and certain covariates in the adjusted model. Secondly, the majority of the data used were based on self-reports, thus subject to recall and social desirability bias, particularly those regarding gambling, substance use, and impregnation. Another limitation associated with the male participants' self-reported data on impregnation is that many might not know they had caused pregnancies. Such potential unawareness combined with the relatively low reliability of the present study's self-report of impregnation could further attenuate the current findings. Because the self reports of age of gambling onset was available for only a small subset of the sample (n=80), the study was unable to establish the temporal sequencing of fatherhood and gambling. Thirdly, current study did not collect information regarding the participants' mothers' ages of first birth, which have been shown in the past to be associated with young fatherhood. 4,7,12,13 Similarly, the composition of the households, particularly of the single parent/caregiver households, that the participants had grown up in was not identified. Among urban African American communities, from which the current cohort was predominantly sampled, single households were generally led by either mothers or grandmothers. [65][66][67] Some studies showed that children who grew up with their grandmothers exhibited less deviance and were better adjusted than those who grew up with single mothers, 68,69 therefore the lack of distinction among the types of single households could explain the present study's lack of association between household structure and young fatherhood. Finally, adolescent gambling could be a proxy of other underlying personality traits such as impulsivity or sensation seeking, 30,31 thus suggesting that the current finding of the co-occurrence of adolescent gambling behaviors and young fatherhood only depicted a small part of a bigger picture. Future studies should focus more on the mechanisms that lead to young fatherhood, adolescent gambling, and other potential characteristics so as to gain a better understanding of the public health issue of young fatherhood. A major strength of the study was the sample, which was selected from an epidemiologically defined population representative of students in schools located in urban neighborhoods. Because urban families experience high rates of marital disruption, and single-parent/ caregiver households tend to have lower parental-monitoring, 70 youth from such families represent a highly vulnerable population at risk for adverse outcomes such as young parenthood and problem behaviors. Study findings from the current sample could be generalizable to other young men from low-income urban settings, and inform intervention researchers the needs of this population so as to shape their interventions to maximize their effectiveness. --- Conclusion Young fatherhood by age 20 was common among males who had grown up in low-income, urban settings. The current study examined the co-occurrence of young fatherhood and adolescent gambling while adjusting for several previously found risk factors. Amongst the sample of predominantly African American young men, those who reported gambling, particularly problem gambling, during adolescence had increased hazards of reporting first fatherhood by age 20. Such a result shows that there is a subpopulation of males who are at high risk for adverse outcomes such as young parenthood and problem behaviors. Only through further studies could the needs of this subpopulation be better assessed so that appropriate assistance could be delivered to better the lives of such individuals. --- Unadjusted Cox regression cumulative hazard curves for participant's age at first fatherhood by adolescent gambling status

Background-Young fatherhood is associated with various adverse outcomes. This study aims to describe the relationship of adolescent gambling with young fatherhood (by age 20) while adjusting for several young fatherhood antecedents. Methods-Data were from 294 males who have been followed for 16 years since entering first grade in nine inner city public schools (86% African Americans, 81% of the original male cohort). Self-reports of impregnation (including age) and gambling were collected during late adolescence. Nelson-Aalen curves and Cox regression models assessed the hazard of young fatherhood among adolescent nongamblers, social gamblers, and problem gamblers. Results-More Young Fathers than Nonfathers reported adolescent social (49.2% vs 42.5%) and problem gambling (28.3% vs 13.2%, p<.001). Problem gamblers were the most likely to impregnate someone by age 20, followed by Social Gamblers, then Nongamblers. Problem gambling (aHR=3.16, 95% CI=1.75, 5.72, p<.001) had the highest increased hazards of young fatherhood, followed by social gambling (aHR=1.95, 95% CI=1.30, 2.94, p=.001), high school drop out (aHR=1.75, 95% CI=1.14, 2.70, p=.01), and subsidized lunch status (aHR=1.69, 95% CI=1.01, 2.38, p=.04). Conclusion-Adolescent male gamblers, particularly problem gamblers, were more likely than their nongambling peers to become fathers by the age of 20. Such a result shows that there is a subpopulation of males who are at high risk for adverse outcomes such as young parenthood and problem behaviors. Only through further studies could the needs of this subpopulation be better assessed so that appropriate assistance could be delivered to better the lives of such individuals.

In recent decades, the issue of social exclusion has emerged and gained visibility, largely through the political discourse of supranational and national institutions, thus becoming the social issue par excellence (Castel, 1995). Since social exclusion is a recurrent and apparently consensual theme within social and political domains, it seems relevant to adopt a critical perspective with a view to defining its nature. Thus, this paper seeks to problematise the theme of social exclusion through the analysis of the counter-hegemonic perspective inherent to the micropolitics of a civil society association, founded and promoted by migrants and descendants of migrants. The paper stems from empirical data produced in the context of participatory research, conducted in Portugal, on the training and work of the expert by experience in the Cova da Moura neighbourhood, in the field of social and community work. The analysis is a snapshot of the theme of social exclusion, based on the perspective of people living and working in a working-class neighbourhood inhabited by immigrants and their descendants. The empirical data underpinning the analysis was obtained through semistructured interviews and documentation collection. The research was conducted within the scope of Education Sciences, more specifically in the field of adult education. A critical perspective was adopted, considering hegemonic discourse as an ideological instrument at the service of dominant economic, social and cultural forces, with the purpose of legitimising and perpetuating a social system based on inequalities (Canário, 2005;Freire, 1978;1980). The research focused on the analysis of alternative practices, which may be deemed counter-hegemonic. In the approach adopted, the hegemonic discourse regarding social exclusion in public policies is an obstacle to the understanding of the social world since it omits the structural and institutional factors responsible for the marginalisation, discrimination and segregation processes of individuals and groups (Canário, 2005;Freire, 1978;1980). Thus, it is important to identify and analyse the micropolitics of civil society groups to understand the issue of social inequality in its complexity. These micropolitics, coupled with the usually silenced and invisible perspective of working class individuals, migrants and their descendants, may allow for the emergence of counter-hegemonic practices and discourses, which are essential for social change (Sousa Santos, 2007). We understand discourse as organized forms of communication (verbal, written, non-verbal, visual) on a given subject, carried out in a social, political and cultural context, with the aim of informing, exposing and persuading. Discourse is a meaningproducing activity that expresses the social, cultural and ideological positions of the individuals involved, both explicitly and implicitly. The empirical data refer to the terms 'work in tandem' and 'expert by experience', the meaning of which is important to clarify. Work in tandem consists of an activity conducted by two individualsthe expert by experience and the academic expert. The expert by experience is someone with life experience in a given domain (Cavaco, 2018;McLaughlin, 2009), who has undertaken specific training, based on a reflection of their own life experience, geared towards the exercise of activities, through work in tandem. The academic expert is someone who holds an academic qualification in a given area. In the field of health and social work, the emergence of the expert by experience and the academic expert stemmed from a recognition of the complexity of the individual's intervention, experience and singularity, and power to act. Work in tandem is based on a collaborative dynamic between these two professionals who acknowledge the importance of complementarity between academic and experiential knowledge for effective interventions with other people (Cavaco, 2018). Thus, they might 'help each other, growing together in the common effort to understand the reality they seek to transform' (Freire, 1978, p. 11). The paper is structured into five parts. The first presents a brief contextualisation of the Bairros Cr<unk>ticos [Critical Neighbourhoods] Programme of the Cova da Moura neighbourhood and the Associaç<unk>o Cultural Moinho da Juventude. The second focuses on theoretical elements regarding the narrative on social exclusion. The third is related to the conceptual dimensions of micropolitics resulting from civil society initiatives, framed by the field of adult education. The methodology of the research is presented and justified in the fourth part and the fifth presents and analyses the empirical data resulting from the research. The contextual elements regarding the Cova da Moura neighbourhood and the Associaç<unk>o Cultural Moinho da Juventude came from research (the sources are indicated) and from the testimony of the participants with whom the interviews were conducted. The information on the Critical Neighbourhoods Programme came from the analysis of legal documents and research carried out in the field. In the mid-twentieth century, housing peaked in the Metropolitan Area of Lisbon, with the construction of illegal neighbourhoods in unoccupied or deprived areas on the outskirts of the city of Lisbon. The construction of poor housing and socio-cultural ghettos (Cardoso & Perista, 1994;Coimbra & Menezes, 2009) are associated with poverty and the migration phenomenon. The 'appropriation of urban space' (Cardoso & Perista, 1994, p. 102) is the result of the poverty and inequalities that condition the particular social groups in their access to housing in city centres. An individual's place of residence is a potential inequality factor, for example, in the search for employment, access to transport and public services. Individuals in this situation carry the weight of the space they occupy (Byrne, 1999). The occupation and construction of illegal neighbourhoods are evident phenomena arising from the denial of the 'right to the city' (Wildemeersch & Lages, 2018), that is, the right to affordable housing in spaces with habitable conditions, including the provision of basic physical, social and cultural infrastructures for a dignified life. The Alto da Cova da Moura neighbourhood, more commonly known as Cova da Moura, was built from the 1960s onwards through spontaneous occupation. This involved the residents' self-construction of housing and self-urbanization on abandoned private and State land. It is one of the oldest and largest areas with a migrant population within the Metropolitan Area of Lisbon. With approximately six thousand inhabitants (Gomes, 2019), the population has doubled since the 1980s. A highly significant number of the neighbourhood's inhabitants are migrants or descendants of migrants from African countries, colonised by Portugal between the fifteenth and twentieth centuries (Cape Verde, Guinea-Bissau, Sao Tome and Principe, Angola). Among the inhabitants there are also migrants and their descendants from the northern and central regions of Portugal and other countries (Eastern Europe, Brazil, etc.). The growth of the neighbourhood was concomitant with an increase in migratory movements due to factors of a social, economic and political nature (Mendes, 2008). Poverty in these individuals' homelands is one of the motives for their migration (Morrice, 2019). In addition to these factors, decolonization, war and political persecution are also reasons for migration (Mendes, 2008). The Cova da Moura neighbourhood is characterised by multiculturality, solidarity and the power to act. In the struggle for the right to decent housing, to the city, and to a 'place' (Jorge & Carolino, 2019), in recent decades its inhabitants have opposed the various attempts to demolish the neighbourhood and relocate the residents to public housing, in dispersed areas far from the city centre. The neighbourhood appears to be a place of life and belonging, self-produced by its inhabitants who call for the improvement of its infrastructures and housing conditions. In 1978, the inhabitants organised themselves collectively and elected a Residents' Committee. The collective organisation arose from the awareness of their rights to a dignified life and the need to vindicate these rights from the public entities responsible for the neighbourhood's infrastructures (running water, sewerage systems, electricity, street works, etc.). There are currently three active associations in the neighbourhood with the mission of promoting the improvement of residents' living conditions: the Social Solidarity Association, O Clube (founded in 1980); the Moinho da Juventude Cultural Association (officially founded in 1987, but active from 1984); and the Associaç<unk>o de Moradores do Bairro Alto da Cova da Moura (founded in 1996). The research presented in this paper focuses on the Associaç<unk>o Cultural Moinho da Juventude, better known as 'Moinho', a term that is adopted hereinafter. The Moinho is a non-governmental, non-profit organization, created and managed by residents located in the Cova da Moura neighbourhood. Upon its legal recognition as a Private Social Solidarity Institution, the integration of non-residents into its governing bodies became a requirement. The Moinho's intervention is anchored on a set of key pillars: interculturality, communication, joy, gender, respect for convictions, cooperation, empowerment, environment, creativity, persistence, quality, efficiency, effectiveness and solidarity. Based on these guiding principles, the Moinho promotes global and sustainable community development aimed at improving the living conditions of the neighbourhood's inhabitants through the organisation of activities in the social, educational, cultural, sports, professional, economic, legal and urbanistic fields. By way of example, the following projects designed and implemented by the Moinho are particularly noteworthy: PULO (parent training and accompaniment for families), Gabinete de apoio social [Social Support Office], Creche Familiar [Family Nursery] (nanny service, with extended opening hours for babies and children), Creche e Jardim de Infância [Nursery and Kindergarten] (for children aged between 4 months and 5 years), the Centro de Atividades de Tempos Livres [Leisure Centre] (activities and accompaniment for children and youths from 6 to 18 years of age), Cantina Social [Social Canteen] (meal services for the more financially disadvantaged members of the neighbourhood and surrounding neighbourhoods), Kova M Estudio (studio where young people from the neighbourhood produce and edit music), Cidadania Participativa [Participatory Citizenship] (community intervention project seeking to cover the population in a situation of socioeconomic fragility through a decentralised intervention in areas such as health, documentation, domestic violence, support for ex-convicts, and also to promote healthy ageing), Gabinete de Integraç<unk>o Socioprofissional [Socioprofessional Integration Office] (support and accompaniment of integrated professional and training insertion paths), Gabinete de Apoio à Documentaç<unk>o [Documentation Support Office] (formal documentation support for migrants). A significant part of the Moinho's interventions target children and youths and currently cover over 500 children and young people. The Association develops its intervention with the financial support of the State (through co-operation agreements, applications to funded and co-funded projects), with levies, the provision of services, and the support of both private and corporate sponsors, at domestic and international levels. It is often the first institution with which immigrant citizens come into contact, which reinforces and justifies the need for its action since it is a reference in this field at the national level. Through its intervention, the Moinho seeks to assume a political dimension of a critical nature, which is evident in three lines of action: firstly, its action is based on a model of integrated and sustainable local and community development, grounded on the recognition of the residents' culture, knowledge and skills; secondly, it seeks to secure the continuity of the neighbourhood in the location upon which it was built and opposes the demolition attempts of governmental bodies; thirdly, it promotes and vindicates improvements in the neighbourhood to ensure the residents' 'right to the city' (Wildemeersch & Lages, 2018) and to a dignified life. The Moinho's action, in line with the thinking of Paulo Freire (1978;1980), adopts a political and critical positioning geared towards social change and the construction of a fairer world with less oppression, through conscientization. The Moinho aims to promote the conscientization of the residents of the neighbourhood as political education, providing access to resources and stimulating critical thinking, so that they can, both individually and collectively, observe, analyse and define action and act to bring about change. The Moinho makes its policy known through goals, keystones, organisation and functioning methods, work methodologies and the lexicon used. In its practice, it seeks to ensure coherence, continuity and comprehensiveness. In the last three decades, the Moinho has promoted a diverse range of social and cultural dynamics with educational potential within the community, with families, children, young people, adults and senior citizens, and sometimes by means of intergenerational initiatives. Many of these initiatives were designed and implemented through work in tandem between an expert by experience and an academic expert. The Moinho works with experts by experience in the fields of migration, colonialism and poverty. These experts by experience are individuals who live in the neighbourhood and have undergone training, designed and implemented by the Moinho itself, with a threefold dimension: the explanation and (re)elaboration of experience and life history; the acquisition of knowledge regarding the phenomena of migration, colonialism and poverty; and knowledge acquisition and capacity building in relation to the work in tandem. The work in tandem is based on articulation, complementarity and synergy between the expert by experience and the academic expert, as well as on accompaniment. Since its foundation, the Moinho has resorted to work in tandem to promote intervention in all areas. Since 1974, several rehousing measures have been implemented with a view to demolishing these neighbourhoods through investment in public housing. Policymakers regard these neighbourhoods as symbols of deprivation, gaps and illegal construction, and they therefore do not fall within the hegemonic parameters and image of the city (Jorge & Carolino, 2019). The Critical Neighbourhoods Initiative (Presidency of the Council of Ministers, 2005) was part of a public policy initiative for cities between 2005 and 2012, implemented in three neighbourhoods in the metropolitan areas of Lisbon and Porto (Cova da Moura, Vale da Amoreira and Lagarteiro), as a pilot programme. This programme sought to ensure the continuity of state interventions for the qualification and rehabilitation of urban territories through what was deemed an integrated and innovative approach (Presidency of the Council of Ministers, 2005). The neighbourhoods of Vale da Amoreira, on the outskirts of Lisbon, and Largateiro, on the outskirts of Porto, are examples of neighbourhoods built by the State to rehouse families living in shanties. The Cova da Moura neighbourhood was built by the residents on abandoned land on the outskirts of Lisbon. As a justification for the relevance of this measure, the Resolution of the Council of Ministers, under which it was legally framed, pinpointed the three territories of the intervention as critical neighbourhoods due to the 'concentration of social problems, to the disadvantaged and disempowered populations, to the concentration of groups most vulnerable to different forms of discrimination, to the social stigma associated with them and the blocked opportunities' (Presidency of the Council of Ministers, 2005, <unk> 5). Moreover, from the legislators' perspective, these neighbourhoods represent a major risk to the quality of life and competitiveness of metropolitan areas (Presidency of the Council of Ministers, 2005). The document states that implementing measures in these urban spaces is a complex matter and that the results are not long-lasting. In this paper a critical perspective is adopted, in line with the thinking of Paulo Freire, Robert Castel and Rui Canário. It is important to analyse 'what is hidden in this discourse on exclusion and translates the social issue' (Castel, 1995, p. 13) in contemporary society. The theme of social exclusion gained popularity in the 1990s, in the context of public policies, especially in Europe (Mascare<unk>o & Carvajal, 2015). Since then, its presence has been increasingly noted in the discourse of policy makers and the media (Bouquet, 2015). This discourse is by no means anodyne, on the contrary, it might reflect political positions towards social phenomena which lead to social action in a given direction, precluding and silencing other approaches. The terms and concepts used may establish 'a linguistic action' (Guilhaumou, 2012, para. 14) influencing how the reality is understood. The discourse on social exclusion'reveals pitfalls both for sociological reflection and for political action' (Castel, 1995, p. 12). The term'social exclusion' itself is used as an umbrella to encompass the diversity of poverty in the world, in other words, the great diversity of extreme situations of individuals and groups (Castel, 1995). Since it is a term that can designate a great variety of phenomena, it does not differentiate between them, perhaps, giving rise to an amalgam (Canário, 2005). We would argue that, instead of serving as a useful mental tool for the construction of scientific knowledge, it is an obstacle to its production. In the political discourse on social exclusion, social phenomena are frequently simplified and the individuals themselves are blamed and held to account. This discourse underestimates the processes that enhance social inequality, such as the precariousness of work relationships and the fragility of social relationships (Castel, 1995). From our point of view, this narrative describes social phenomena but does not address their dynamics and causes, silencing the social and institutional mechanisms that generate social inequality and the denial of citizens' rights (Canário, 2005;Castel, 1995), which undermines an understanding of these phenomena. There is an underlying negative meaning to this political discourse which is related to a deficit or lack of something (Castel, 1995), and this may represent a threat to the social groups who find themselves in these circumstances (Canário, 2005) owing to the risk of stigmatization stemming from this discourse. Scapegoating, infantilization and segregation are functions associated with the capitalist economy which can give rise to dominant subjectivity and influence life in society decisively (Guattari & Rolnik, 1996). Although they substantiate welfare for those in situations of social vulnerability, it is important that public policies not replace or prevent the fight against its causes (Castel, 1995). The expression social exclusion has a 'paradoxical meaning in that there is nothing "outside" the social' (Canário, 2005, p. 36). This expression conveys novel language, uncritically imported from the technical and political fields into the scientific field. The term is 'an object of tautological use which, in the case of the social sciences, is an epistemological obstacle to understanding the social world' (Canário, 2005, p. 36). So, as far as Canário (2005) is concerned, the terms exclusion and inclusion should be rejected as tools for analysis, as they correspond to dimensions of the same phenomenon. In the same vein, Castel (1995) expresses reservations on using the term 'exclusion' and considers that it should be replaced 'by a more appropriate concept to name and analyse the risks and current social fractures' (p. 13). Social inequality stems from the organisation and functioning of the social structure, which is why it occurs in the 'centre of social life and not its periphery' (Castel, 1995, p. 15). From this perspective, Paulo Freire (1980) considers that marginalisation and segregation involve placing someone 'outside', 'on the sidelines', therefore, one must question 'who the author of this movement from the centre of the structure to its margin' is (pp. 73-74). In the political discourse, individuals considered marginal are defined as being on the outside of the social system, yet these people have always been on the inside (Freire, 1972). According to Freire (1972), overcoming inequalities implies changing the social structure. The social structure gives rise to situations that cause renegades in relation to whom the feeling of inferiority and incapacity has been 'emphasised' (Freire, 1978, p. 15). In Freire's view (1980), marginality is not a choice, these individuals are systematically denied the most basic rights. According to the author, by changing these structural mechanisms, generators of violence, perpetuators of poverty and multiple inequalities, 'the dehumanizing structure' could be transformed (Freire, 1980, p. 75). Individuals living in poverty and all those who are denied the most basic rights represent the dominated structures of society, deprived of the right to assume full citizenship, but who nevertheless consciously or unconsciously oppose those who trivialise and dehumanise them by treating them as worthless objects (Freire, 1980). Paulo Freire (1980) considers that transformation of the dehumanising structure involves critical intervention. This enables those who have been dominated and subjugated by an alienating power to free themselves and claim their rights with a critical conscience and spirit (Freire, 1980). The approach of contemporary political philosophy is adopted to problematise political power, among other dimensions. Policies, through power and control, assume a'social mediation function in the reorganisation of the social order, through different systems' (Junqing, 2008, p. 58). For Junqing (2008), policies can be analysed from two different, but complementary and interdependent levels, namely through macropolitics and micropolitics. Macropolitics focuses on large-scale power structures and regulation and control mechanisms, such as the organisation of the State and the mechanisms through which it exercises its power (Junqing, 2008). Micropolitics, on the other hand, is centred around small-scale power structures, as exemplified by 'the control mechanisms inherent to social activities and everyday life' (Junqing, 2008, p. 58). Through the explicitness of the micro-political level, (re)constructed discourses and practices in certain groups, communities and organisations can be identified and analysed. This approach, that integrates both macro and micropolitics, makes it possible to (re)consider policies on the basis of diversified, heterogeneous, multiple and complex social dynamics at all levels of society and daily life. The micropolitics (re)constructed by individuals and groups in everyday life might correspond 'to different forms of social integration' (Guattari & Rolnik, 1996, p. 11), and makes it possible to analyse the singularity of experiences constructed individually and collectively. Our interest in micropolitics stems from the enhancement of unique experience and subjectivity. The micropolitics of groups and social movements that fight on behalf of minorities and social causes may foster the production of new forms of subjectivity (Guattari & Rolnik, 1996). These'subjective singularization processes' (Guattari & Rolnik, 1996, p. 45), characterised by plurality and individual and collective action, can constitute resistance mechanisms against the 'general serialisation of subjectivity' process (Guattari & Rolnik, 1996, p. 45), typical of the capitalist system. Singularisation might be a disruptive process against capitalist subjectivity, asserting itself through ways of being, sensibilities and perceptions that differ from those that are more common or instituted (Guattari & Rolnik, 1996). The diversity and complexity of challenges in contemporary society seem to require an interconnection between 'public policies and the increasingly formalised initiatives of civil society' (Fleury, 2015, p. 2). It is in this sense that Fleury (2015) considers that social intervention devoid of the active participation of individuals, without considering their power to act, is a counterproductive process. According to Fleury (2015), politicians no longer hold a monopoly over policymaking in contemporary society, as citizens are increasingly concerned with action in the public sphere. Individuals develop initiatives, design instruments, experiment, validate and disseminate them, which justifies the emergence of policies resulting from civil society action (Fleury, 2015). Some civil society entities, namely associations, implement community intervention in locations set in urban peripheries, characterised by multiculturalism and predominantly inhabited by migrants and their descendants. For immigrants, the organisations established within the community are the preferred sites for adult education (Guo, 2015) through the dynamics that foster non-formal and informal education and experiential training. These organisations operate in very diverse areas and aim to promote the establishment of networks, culture and identity affirmation, and the development of a relational dimension. In addition, they try to play the role of transition institutions, functioning as promoters of immigrants' process of integration into society on the one hand, and as mediators between them and the host States on the other (Guo, 2015). Due to its historical commitment to social movements and social justice, the field of adult education is a structuring domain in the intervention of these civil society organizations. As mentioned above, this paper problematises the issue of social exclusion by analysing the counter-hegemonic perspective grounded on the policies of an association, in Portugal, facilitated by migrants and their descendants. The analysis presented in this paper is a cross-section of empirical data produced within the framework of a participatory research, conducted in Portugal, on the training and work of the expert by experience in the Moinho. Participatory research favours the construction of scientific knowledge through the 'ecology of knowledge' (Sousa Santos, 2007). Hence, this research is grounded on a recognition of the importance of dialogue and the interdependence between scientific knowledge and the popular knowledge of urban migrant populations. The study adopts the perspective that the construction of scientific knowledge results from the commitment, experience and knowledge of all the actors involved, and seeks to counteract the hegemonic tendency in which 'the particular and the local does not count, it is invisible, disposable, despicable' (Sousa Santos, 2007, p. 31). From an epistemological point of view, this participatory research is framed by the emerging paradigm since it acknowledges the twofold importance of the scientific paradigm as also a social paradigm of decent life (Sousa Santos, 1987). Against this backdrop, the study sought to involve individuals and institutions related to the issue under study, through participatory and co-constructed processes (Vaughn & Jacquez, 2020). This type of research is anchored on reflection, flexibility and interactivity (Cornwall & Jewkes, 1995). In the present participatory research, the relationships between the various agents were based on horizontality, dialogue, recognition and reciprocity. The decision to conduct this participatory research was both to ensure the construction of socially relevant scientific knowledge and to promote training processes for all those involved in order to boost each individual's power to act (Ricoeur, 2005). The empirical data presented in the paper is the result of a participatory research, conducted in the neighbourhood of Cova da Moura, with individuals connected to the Associaç<unk>o Cultural Moinho da Juventude. Various techniques were used in the participatory research, such as: document collection, participant observation, informal conversations, biographical workshops and semi-structured interviews. In the paper, the empirical data underpinning the analysis was obtained through the collection of documentation and semi-structured interviews. The collection of documents focused on the legal framework of the national Iniciativa Bairros Cr<unk>ticos programme. Three of the interviewees live in the neighbourhood of Cova da Moura and are connected to the Moinho: one of the interviewees is a founding partner of the Association and is currently involved in projects in the area of Participatory Citizenship (Matilde), the other is a young adult participating in the Association's projects (Bruno), and the third interviewee is a worker, an expert by experience and member of the Association's administration board (Berta). A fourth interview was also held with a technical staff member working at the Association, who works in tandem as an academic expert (Dalila). In the semi-structured interviews, the aim was to systematise issues that had been previously addressed in informal conversations. The semi-structured interviews were conducted according to a script, previously provided to the participants, with the following themes: neighbourhood characteristics and life, migration,'social exclusion', work in tandem and expert by experience. The interviews were guided in a flexible manner, with attention to the epistemology for listening (Berger, 2009). The empirical data underwent a thematic content analysis (Bardin, 2018). To guarantee an interpretative content analysis, the content of the interviews was organized systematically around categories (themes) and subcategories (subthemes) already included in the interview script, and around others that emerged from the data itself. In the analysis presented in this paper, the following themes and sub-themes were considered: discourses (discourses on the neighbourhood, discourses on'social exclusion'), logics and disputes (disputes over space, public policies and the work of the Moinho). The participatory research followed the ethical principles of research in the field of Educational Sciences (All European Academies, 2017; Sociedade Portuguesa de Ciências da Educaç<unk>o, 2020). The names of the interviewees are pseudonyms in order to guarantee their anonymity. The association involved was not anonymised for three reasons. First, the use of another name would not ensure anonymity, given the specific nature of its work and the terms used. Second, participatory research assumes a political dimension, which in this case aims to acknowledge and give visibility to alternative, more sustainable and fair social practices, which are usually silenced and rendered invisible. Third, the association also considers this to be an important option. This paper is the result of a collaborative writing process with all the individuals involved. The discourse and words contained within it are neither neutral nor anodyne, on the contrary, they define positions, based on representations of the world, associated with particular perspectives and purposes. The interviewees highlighted the non-neutrality and subjectivity of the discourse on the neighbourhood, which they consider valid for their perspective, but also for political and social perspective: it is very hard to characterise in general terms, mainly because I have lived here for so many years which makes an objective view difficult, but also I do not think there can be objectivity in terms of characterising a neighbourhood (Matilde). I grew up here when I was little, I don't have a very objective point of view (Bruno). This subjectivity is important to understand the neighbourhood from the perspective of those who inhabit it, who have built and continue to build it as a habitable space, and who, as a rule, do not have a voice in the public sphere. Additionally, it might allow for the visibility of counter-hegemonic subjectivities that criticize the reductive nature of the discourse disseminated in the public arena. Cova da Moura has been officially classified as a rundown, illegal and 'clandestine neighbourhood' (Graça & Paio, 2018). In political and public discourse, the neighbourhood is usually portrayed negatively, as 'critical', 'vulnerable', 'violent', 'clandestine', 'rundown', 'illegal'. The Cova da Moura neighbourhood was selected by the Iniciativa Bairros Cr<unk>ticos whose aim was to regenerate 'critical urban areas' (Presidency of the Council of Ministers, 2005, <unk>4). The respective urban areas were described on the basis of problems, needs and gaps, reinforcing the negative perspective of these territories and of their inhabitants: their concentration of social problems, the disadvantageousness and lower qualifications of their populations, the concentration of groups more vulnerable to different forms of discrimination, the social stigma associated with them and blocked opportunities (Presidency of the Council of Ministers, 2005, <unk>4). In the above discourse, the territories and their inhabitants are what constitute the social problems, without mentioning that the living and housing conditions and insufficient schooling are consequences of inequality and the asymmetric distribution of wealth, consented by the political and social systems. Furthermore, no mention is made of the positive characteristics of these territories and the people who live there. For the residents and technical staff working at the Moinho, the Cova da Moura neighbourhood is a place of life, belonging, well-being and positive long-lasting relationships: [The neighbourhood is a] living and dynamic territory, [where the person] public space is appropriated (Dalila). It's more the environment that I like in the neighbourhood. I feel at home, I feel safe, being with people who are like me, people who understand me (Bruno). For the people who have left the neighbourhood, this is their place, where they like to spend their holidays (Matilde). As far as the sense of safety highlighted by the inhabitants is concerned, they refer to the paradoxical political and social discourse surrounding the neighbourhood. A negative image has emerged from the political and social discourse surrounding the neighbourhood which is difficult to counteract. The inhabitants are aware that the discourse produced on the neighbourhood interferes with the social construction of reality. They highlight these dimensions: this is very interesting, this feeling of being safe, because people always say that this neighbourhood is dangerous, but this is the feeling the people here have, of feeling safe. I feel it too (Matilde). It's a really cool neighbourhood. It's not what you think and see on television, on the contrary, everyone is nice, everyone is cool (Bruno). These areas are deemed critical and priority cases in public policies, based on two interconnected arguments. On the one hand, it is deemed essential to promote citizenship and social cohesion, while on the other, these territories are regarded as a risk to quality of life and competitiveness in metropolitan areas. A reductionist perspective of citizenship is conveyed, as the emphasis is on social peace and economic development to the detriment of safeguarding the poorest citizens' basic rights. This is evident in the following statements: An analysis of the empirical data reveals another paradox. The political discourse interprets citizenship as a dimension of regulation, essential for social peace and for the competitiveness of territories. The interviewees highlight cultural diversity, liveliness and solidarity as important characteristics of the neighbourhood. The neighbourhood is characterised by its very young population, cultural richness, African origins, cooperation and mutual help, despite the financial hardship of its residents: it has young people with vibrant energy and great skills [...] has a liveliness that comes from Africa. Liveliness and at the same time a lot of strength, depth and a lot of humanity [...] they support other neighbours in different ways, without making a fuss, in terms of education, health, and in terms of food. [...] There is solidarity here, there is synergy. [People] have brought really valuable cultures from Africafrom S<unk>o Tome, from Cape Verde, from Angola (Matilde). the word that best describes it is solidarity [...] it gives a good characterisation of what the experience of the people who live here is like (Dalila). In this paper, only the issue of asymmetry in the 'right to the city' is addressed, namely, the right to live close to one's workplace and the city centre. The interviewees criticise the political discourse in which the residents of the Cova da Moura neighbourhood are regarded as 'excluded'. They believe it is essential to take the diversity of the situations in the neighbourhood into consideration instead of making simplistic generalisations, as may be seen below: it makes no sense (Matilde). [At the Moinho, we don <unk>t use] the terminology of social exclusion or social inclusion, not least because we understand it much more as a process dynamic [...] of feeling socially included or excluded is subjective and is not directly confined to an economic issue or a territorial issue [...] what may make me feel socially included, may be different for you [...] we often see this, people in very vulnerable circumstances, from a

The theme of social exclusion has gained visibility in recent years through political discourse. This paper problematises the issue of social exclusion by analysing the counter-hegemonic perspective grounded on the policies of an association, a civil society organization, in Portugal, facilitated by migrants and their descendants. The analysis is the result of a participatory research based on the collection of documentation and semistructured interviews. The hegemonic discourse on social exclusion was analysed through empirical data from the perspective of those who inhabit and/or intervene in a neighbourhood that is the object of public policies targeting the so-called 'excluded'. Several paradoxes were identified between the social exclusion discourse conveyed in public policies and in the micropolitics of this association. The approach, goals and working methods that characterise the micropolitics of the association may contribute to the emergence of new forms of singularisation, through adult education initiatives.

Cape Verde, from Angola (Matilde). the word that best describes it is solidarity [...] it gives a good characterisation of what the experience of the people who live here is like (Dalila). In this paper, only the issue of asymmetry in the 'right to the city' is addressed, namely, the right to live close to one's workplace and the city centre. The interviewees criticise the political discourse in which the residents of the Cova da Moura neighbourhood are regarded as 'excluded'. They believe it is essential to take the diversity of the situations in the neighbourhood into consideration instead of making simplistic generalisations, as may be seen below: it makes no sense (Matilde). [At the Moinho, we don <unk>t use] the terminology of social exclusion or social inclusion, not least because we understand it much more as a process dynamic [...] of feeling socially included or excluded is subjective and is not directly confined to an economic issue or a territorial issue [...] what may make me feel socially included, may be different for you [...] we often see this, people in very vulnerable circumstances, from a socioeconomic point of view, who don't really show that they feel particularly excluded [...] because within their own system, relationships are established and they find [...] the resources that allow them to feel included or at least not to feel excluded, both from a social and economic point of view (Dalila). Interviewees highlighted the diversity and complexity of the structural and institutional factors that generate inequalities. However, in their view, public policies have no bearing on these factors. Therefore, they regard the political discourse as contradictory since although it identifies social problems, the policies and institutions themselves generate and perpetuate inequality: the institutions are the cause of our exclusion (Matilde). because inclusion means including someone, but most of the time it's excluding, so it's exclusion [...] it's only words, they are only written [...] they are things that are written, but in practice it is only written [...] I often say to my co-workers at the Moinho -We are not politicians, the politicians are the ones who write one thing and do another (Berta). It is the inconsistency between the hegemonic political discourse and effective action that underlies her critical analysis. The interviewees highlight multiple historical, cultural, economic, political and social factors and phenomena of a structural and institutional nature that generate inequalities, such as: colonialism, poverty, violence, racism, segregation, asymmetries in the labour market (precariousness, low income), disparities in educational access and performance, difficulties in accessing information regarding rights, difficulties in acquiring Portuguese citizenship, asymmetries in the 'right to the city' (Wildemeersch & Lages, 2018), etc. It seems that, from the interviewee's perspective, these factors (re)produce and naturalise differentiated power relations which, in turn, define social and economic positions, acting as social regulation instruments with the power to decide who stays in the centre and who is relegated to the margins. The illegal origin of the neighbourhood, built on private and state property, the lack of infrastructures and urban planning, the location and real estate speculation are factors that have conditioned its legal recognition and the creation of conditions to improve the quality and stability of the lives of its inhabitants. Over the years, several projects for the neighbourhood have emerged, almost always in an attempt to rehouse and relocate the families to more peripheral areas, which has been contested and has served to strengthen the residents' fight for the 'right to the city' (Wildemeersch & Lages, 2018). The dispute over the occupation of space in the neighbourhood, which is on the outskirts of the city of Lisbon, with high real estate potential, is an obvious factor. The attempt to shift to the margins and remove from the centre, in this case, is also geographic. At the root of the difficulty surrounding the urban legalisation of the neighbourhood and its recognition by public entities, namely the Municipality of Amadora, was the intention to impose its demolition and relocate its inhabitants to other locations, further removed from the outskirts of Lisbon. In this case, in a Djunta Mô [Cape Verdean expression meaning holding hands and mutual help] of the three associations and with the support of the parish, we managed to halt the Mayor of Amadora's project in 2002, which intended to destroy 85% of the neighbourhood (Matilde). As the neighbourhood has not yet been legalised, there is always the fear of this occurring again. The evident competition for space has caused fear and distrust among the residents, as they are constantly aware of the real risk of being rehoused and the demolition of the neighbourhood: the neighbourhood used to be 47 acres. Since 2009 it is only 39.5 acres. This is a consequence of political options taken on the sly [...] I'm against that (Matilde). This reduction in the neighbourhood's space was a measure adopted at the time of its involvement in the Iniciativa Bairros Cr<unk>ticos. The 7.5 acres ceased to be part of the neighbourhood, although the residents were unaware of this. In 2011, they discovered that the Santa Casa da Misericórdia (charitable organisation), initially a partner of the Iniciativa Bairros Cr<unk>ticos project, had ceased to be a part of it in 2009, and had subsequently obtained a license to build the Continuing Care Unit, reducing the land in Cova da Moura from 47 to 39.5 acres hectares on the title deeds (Matilde). The Critical Neighbourhoods Initiative, designed to solve community problems, was used to legitimise the reduction of neighbourhood space and the construction of a service that does not serve the population: it is a political balance game between the PSD [social democratic party] and the PS [socialist party], without considering the needs of the population. The Continuing Care Unit does not serve the population (of the neighbourhood). The Nursery serves the population of the neighbourhood and is a basic need (Matilde). However, the construction plan for the Moinho nursery was cut short, even though they had land, funding and an architectural project. The residents feel that this is an injustice, which undermines the credibility of public policies: but the Mayor blocked it. He forced us to wait for the Detailed Plan within the scope of the Critical Neighbourhoods Initiative (Matilde). The promotion and enhancement of the neighbourhood's cultural manifestations is a fundamental strand of the Moinho's intervention, geared towards its official recognition and dignification, personal and identity development, and the strengthening of community spirit. This has become a means of fighting against attempts to demolish the neighbourhood and for the residents to claim their 'right to a place' (Jorge & Carolino, 2019). The Moinho prepared an application for recognition of the Kola de San Jon, a traditional Cape Verdean festivity. In this manifestation, involving music, dance, lyrics and artefacts, the facilitators recreate elements of Cape Verde's cultural tradition. As a Cultural and Intangible Heritage of Portugal since 2013, culture, in particular the Kola San Jon, has saved the neighbourhood from demolition: Those who are part of both the Kola and Batuque feel immense pride. I think the neighbourhood does too, the fact that it was published in the Diário da Rep<unk>blica [Official Gazette]. This means that the neighbourhood cannot collapse because we have Kola. (Matilde) Batuque is a musical-choreographic expression of Cape Verde's cultural heritage, which was ostracised during the period of Portuguese colonisation. The women who perform batuque, called batucadeiras, define the melody, rhythm and lyrics of the songs. These songs refer to life experiences, feelings, vindications and gratitude. The Iniciativa Bairros Cr<unk>ticos may be noted as an example which, as an instrument of city policy, was publicised as an innovative public policy. In its framing documents, the following structuring principles are mentioned: integration, sustainability and durability, cooperation, mobilisation and participation of actors, transparency, communication and articulation, intention to generate structural impacts, innovative intervention and management models (Presidency of the Council of Ministers, 2005). Although designed on the basis of accumulated experience in prior public policy interventions, in practice, this programme appears to have reproduced a technocratic and welfare-based perspective. Although the aim of this public policy was to promote participation, it was designed without the intervention of the inhabitants of the neighbourhoods, as may be deduced from the following interview excerpt. The residents presented a proposal to designate the intervention areas, which was ignored: during the Iniciativa Bairros Cr<unk>ticos project, a name that was not chosen by the residents who wanted to call it Bairros Criativos [Creative Neighbourhoods], but by a government body [...] We had proposed Bairros Criativos, but no, they opted for Bairros Cr<unk>ticos. There is a lot of creativity in our neighbourhood (Matilde). Although the legislation on the Critical Neighbourhoods Programme foresees participation, cooperation, transparency, communication and articulation, in practice this has not been the case. The initiatives have been defined and imposed on the inhabitants of the neighbourhood, without taking their perspectives and experiences into consideration: people from outside the neighbourhood were chosen to organise the meetings and prepare the projects [...] the most important decisions were made in the absence of the residents [...] the technical staff came from outside and made the decisions. We, the residents, could go to the meetings, we had a vote on behalf of the Neighbourhood Committee, but there were seven coordinators and our vote did not carry any weight (Matilde). The welfare model has been reproduced, whereby the population is the object of intervention. The attempt to impose measures that are meaningless to the residents is clear: there were three associations in the neighbourhood and the coordinators decided that they should all merge into one and paid a university professor to prepare the Ancora Project [...] this makes no sense, because that's where the wealth resides, each association has its own dynamics (Matilde). Interventions of a technocratic and welfare-based nature, taking residents as objects and infantilising them, disregarding their knowledge, traditions, cultures and problems, are highlighted in the interviewee's speeches. They use the argument based on the deficit and incapacity of the inhabitants of the neighbourhood: it had to be organised by outsiders. [...] -Ah! You don't know how to collaborate! [She also adds, in a tone of irony] One institution came here to teach us all, because we didn't know... teach us how to dialogue, how to have meetings (Matilde). The Moinho aims to promote an alternative way of working to technocratic and welfarebased models. The work in tandem between the expert by experience and the academic expert is a structuring element of the Moinho's policy and, as such, it has featured in all the initiatives since the beginning of its intervention. The work in tandem is the basis of the Moinho and is aligned with the principles of Paulo Freire and the Juventude Operária Católica [Catholic Youth Workers Movement]. Conscientization and the political dimension of the intervention are pillars of its action: The work in tandem enhances the relevance of the intervention resulting from the collaboration between the academic expert and the expert by experience, namely in terms of the actual design of intervention projects and their effective implementation (Dalila) The dialectic relationship between theory and practice, and between scientific knowledge and knowledge resulting from experience, dimensions of Paulo Freire's thinking, function as pillars in the practices of the Moinho. As characteristics of work in tandem, synergy, complementarity and the joint efforts of the expert by experience and the academic expert are particularly noteworthy. Thus, the academic expert, with his/her skills and knowledge of the international literature on the subject, formulates various hypotheses, ideas and several paths, and the expert by experience, with his/her knowledge resulting from reflected experience, try together to understand what is happening. [...] This synergistic effort is very important. (Matilde) The Moinho has implemented work in tandem in all its areas of intervention in the neighbourhood, with a particular focus on poverty, migration, and the consequences of colonialism. An example of this is the work with the batucadeiras, with those from the Kola San Jon group. These people have told the story of the importance of their culture and the repression of the colonisers before 1974 in Cape Verde themselves. [In this case,] it is because the importance of their culture was formulated, put in a context, that its recognition as Intangible Cultural Heritage became possible (Matilde). The researching, explaining and recording of individual and collective memory on the social and cultural dynamics of the Cape Verdean people was carried out with academic experts who were able to put this information on the required forms, and it was a very beautiful example. The work of the experts by experience began in 1991. [...] I didn't know anything about Kola, then I began to learn, we went looking for people in Cape Verde, an anthropologist, then little by little we managed with the support of more academic experts in Portugal (Matilde). Recognition of the experience of individuals who have lived through situations of migration and poverty and their work as experts by experience fosters integrated and sustained intervention in the neighbourhood and contributes to the fulfilment of those involved. This is highlighted by the interviewees: this is very rewarding for me and it is very important because the expert by experience has already been through certain situations, and is able to make an analysis of the experience and help others. [Through the intervention process] 'I acquired more experience [...] More knowledge. [...] I learned a lot, really a lot. I learn every day, with each of the those I do the intervention with, I learn [...] I have many success stories and that motivates me to continue, which is a sign that I am doing well and that is important (Berta). [The intervention of the expert by experience] is absolutely important and fundamental (Dalila). The experience of civil society, through the De Link Association, and the recognition of the importance of experts by experience in public policies, abroad, in the field of poverty have served as a reference and an inspiration for enhancing the work accomplished by the Moinho in the field of adult education. The design of the training framework and the recognition and validation of acquired experience occurred in the early 90s, when the Belgian managers of De Link, an institution for training experts by experience, came here. Experts by experience are officially recognised by the Belgian Government (Matilde). In recent decades, exclusion has become the main social issue (Castel, 1995). The social visibility and apparent consensus surrounding the subject has given rise to a hegemonic perspective that seems to have contributed to the neglect and silencing of alternative perspectives. The empirical data resulting from this study with actors from a civil society association reveal the complexity of the issue and some of its inherent paradoxes. The experience, knowledge and micropolitics implemented by the residents and technical staff of the Associaç<unk>o Cultural Moinho da Juventude possibly contribute to finding alternatives to the political-normative perspective underlying public policies in the field of social exclusion. Inequality, segregation and marginalisation are actions that place people and groups 'on the margins' of the established system (Freire, 1980), through oppression and the denial of human rights. The empirical data of this study may contribute to the analysis of how these movements from the centre of the structure to its periphery are (re)produced (Freire, 1980). In addition, they can also contribute to the understanding of certain pitfalls, generated by the hegemonic discourse, which affect political action and have consequences for sociological reflection (Castel, 1995). The experiences reported by the interviewees reveal the accountability, inferiority and segregation processes (Guattari & Rolnik, 1996) to which they are subject in their daily lives, due to the fact that they meet two conditions -being migrants and residents of a self-built neighbourhood in an urban periphery. As highlighted by the participants, these complex processes are (re)produced in everyday life, through discourses and practices conveyed by the instituted system, through what is said and what is silenced. Political guidelines on social exclusion focus essentially on locations, groups and individuals deemed 'excluded' or at 'risk of exclusion', are silent as regards the structural and institutional factors that generate inequalities, segregation and discrimination, as shown by the Iniciativa Bairros Cr<unk>ticos. These guidelines act on the outcomes and neglect the causes of social problems, which might largely explain their ineffectiveness. Usually, they essentially use pejorative vocabulary to name these locations and describe them on the basis of problems, without referring to resources or potential (Canário, 2005;Jorge & Carolino, 2019). From a critical perspective, the interviewees reinforce the importance of acting on the causes of inequalities and oppression, considering the interdependence of the various phenomena. They highlight the effects of colonialism, the asymmetrical distribution of wealth, problems in the labour market (unemployment, precariousness and low wages), and asymmetries in human rights. Given the complexity of social problems, it seems to us to be 'counterproductive' (Fleury, 2015) to insist on interventions that do not consider the desire, experience, knowledge and capacity of civil society to act. The Associaç<unk>o Cultural Moinho da Juventude, established and run essentially by migrants and their descendants, has an intervention experience of approximately four decades in the neighbourhood of Cova da Moura through community intervention, with a particular focus on the education and training of children, young people, adults and seniors. This work experience translates into an intervention characterised by the singularity of its purposes, principles, organisation and functioning, working methods and lexicon, thus falling within the scope of'micropolitics' (Guattari & Rolnik, 1996). Moinho's micropolitics stems from its critical approach to the hegemonic strategies and processes. In this sense, Moinho seeks to promote global and integrated interventions, based on the experiences, knowledge and culture of the neighbourhood's residents. The recognition of residents' experience and knowledge, the training of experts by experience and the work in tandem are Moinho initiatives that bring to light new approaches to intervention in relation to what has been instituted, thus rendering them singularisation processes (Guattari & Rolnik, 1996). This singularisation process, triggered and implemented by the residents of the neighbourhood, aims to promote training geared towards a critical conscience and spirit (Freire, 1980), as well as to vindicate transformation of the dehumanising structure (Freire, 1980). Moinho's initiatives are driven by the pursuit of conscientization (Freire, 1980) focused on observation, analysis and transforming action towards a fairer world, thus constituting adult education processes themselves. Its intervention reveals the importance of interdependence and

The theme of social exclusion has gained visibility in recent years through political discourse. This paper problematises the issue of social exclusion by analysing the counter-hegemonic perspective grounded on the policies of an association, a civil society organization, in Portugal, facilitated by migrants and their descendants. The analysis is the result of a participatory research based on the collection of documentation and semistructured interviews. The hegemonic discourse on social exclusion was analysed through empirical data from the perspective of those who inhabit and/or intervene in a neighbourhood that is the object of public policies targeting the so-called 'excluded'. Several paradoxes were identified between the social exclusion discourse conveyed in public policies and in the micropolitics of this association. The approach, goals and working methods that characterise the micropolitics of the association may contribute to the emergence of new forms of singularisation, through adult education initiatives.

Background: County-level vaccination barriers (sociodemographic barriers, limited healthcare system resources, healthcare accessibility barriers, irregular healthcare seeking behaviors, history of low vaccination) may partially explain COVID-vaccination intentions among U.S. adults. This study examined whether county-level vaccination barriers varied across racial/ethnic groups in the U.S. and were associated with willingness to receive the COVID-vaccine. In addition, this study assessed whether these associations di ered across racial/ethnic groups. Methods: This study used data from the REACH-US study, a large online survey of U.S. adults (N =, ) completed from January -March. County-level vaccination barriers were measured using the COVID-Vaccine Coverage Index. Ordinal logistic regression estimated associations between race/ethnicity and county-level vaccination barriers and between county-level vaccination barriers and willingness to receive the COVID-vaccine. Models adjusted for covariates (age, gender, income, education, political ideology, health insurance, high-risk chronic health condition). Multigroup analysis estimated whether associations between barriers and willingness to receive the COVID-vaccine di ered across racial/ethnic groups. Results: American Indian/Alaska Native, Black/African American, Hispanic/Latino ELP [English Language Preference (ELP); Spanish Language Preference (SLP)], and Multiracial adults were more likely than White adults to live in counties with higher overall county-level vaccination barriers [Adjusted Odd Ratios (AORs):. -. ]. Higher county-level vaccination barriers were generally associated with less willingness to receive the COVID-vaccine, yet associations were attenuated after adjusting for covariates. Trends di ered across barriers and racial/ethnic groups. Higher sociodemographic barriers were associated with less willingness to receive the COVID-vaccine (AOR:., % CI:. -. ), whereas higher irregular care-seeking behavior was associated with greater willingness to receive the vaccine (AOR:., % CI:. -. ). Greater history of low vaccination was associated with less willingness to receive the COVID-vaccine among Black/African American adults (AOR:., % CI:. -. ), but greater willingness to receive the vaccine among American Indian/Alaska Native and --- Introduction In response to the SARS-CoV-2 (i.e., COVID-19) viral outbreak, the United States (U.S.) released three effective COVID-19 vaccines in December 2020 and March 2021 (1). Despite the protection/reduction from severe morbidity offered by the COVID-19 vaccines, a significant portion of the U.S. remained unvaccinated by the end of 2021 (2). Moreover, initial COVID-19 vaccination rates varied across racial/ethnic groups. Between December 2020 and April 2021, American Indian/Alaska Native, Black/African American, Hispanic/Latino, Multiracial, and Native Hawaiian/Pacific Islander adults had lower vaccination rates compared to Asian and White adults (3). Disparities in COVID-19 vaccination uptake were not unexpected. Prior to the release of the COVID-19 vaccines, experts warned of racial/ethnic disparities in COVID-19 vaccination due in large part to the long history of racial/ethnic inequities within the U.S. healthcare system (4). In the early phase of the COVID-19 vaccination rollout, for example, healthcare facilities in metropolitan counties with higher proportions of Black residents and rural counties with higher proportions of Hispanic residents were less likely to serve as COVID-19 vaccine administration locations (5). Moreover, many individuals from marginalized racial/ethnic groups were hesitant to take the COVID-19 vaccine given their historical mistreatment by the healthcare system (e.g., historic exploitation of Black/African American and American Indian/Alaska Native populations in biomedical studies). Nationally representative surveys of U.S. adults conducted prior to the release of COVID-19 vaccines reflected these concerns. Black/African American and American Indian/Alaska Native adults, and in some cases, Hispanic/Latino adults, reported lower intentions to vaccinate compared to White adults (6)(7)(8). In many cases, individual-level factors were associated with COVID-19 vaccination intentions including beliefs about the vaccine, such as concerns over side effects and/or the rushed development of the COVID-19 vaccine (9,10). In addition to individual-level factors, public health-oriented studies examined the association between structural factors, such as county-level characteristics, and COVID-19 vaccination intentions (11)(12)(13)(14). For example, the Centers for Disease Control and Prevention (CDC) COVID-19 Response Team examined the association between COVID-19 vaccination and county-level vulnerabilities measured by the CDC Social Vulnerability Index (i.e., "SVI, " a composite measure including socioeconomic status, household composition and disability, racial/ethnic minority status and language, and housing type and transportation) (13). In the first 3 months of the U.S. vaccination program (i.e., December 2020-March 2021), counties with higher scores on the SVI had lower COVID-19 vaccination rates (13). Studies also found that counties' SVI scores were associated with individuals' COVID-19 vaccination intentions (11). These studies using the SVI highlighted the impact of social vulnerabilities on COVID-19 vaccination intentions. Additionally, public health scholars emphasized the importance of both social vulnerabilities as well as healthcare system barriers when assessing structural factors associated with COVID-19 vaccination (15). In February 2021, the CDC released a second composite measure developed by Surgo Ventures that extended the SVI (16). The COVID-19 Vaccine Coverage Index (CVAC) included U.S. county-level scores of social vulnerabilities (i.e., sociodemographic barriers captured by socioeconomic disadvantage and lack of access to information) and the healthcare system (i.e., limited healthcare system resources, healthcare accessibility barriers, and irregular careseeking behaviors). The CVAC also included each county's history of receiving various vaccines (i.e., history of low vaccination captured by histories of lower coverage and high refusal rates). Given that the CVAC is a newly developed tool, few studies have used it in the literature (17)(18)(19)(20) and studies have yet to look at the impact of the individual CVAC components on vaccine willingness. The present study linked county-level barrier scores on the CVAC with survey responses from a large, diverse panel of U.S. adults who reported their willingness to receive the COVID-19 vaccine. The study aims included examining whether (i) county-level vaccination barriers varied across racial/ethnic groups, (ii) county-level vaccination barriers were associated with willingness to receive the COVID-19 vaccine and (iii) the association between county-level vaccination barriers and willingness to receive the COVID-19 vaccine varied across racial/ethnic groups.. /fpubh.. --- Materials and methods --- Data source The present analysis used data from the REACH-US (Race-Related Experiences Associated with COVID-19 and Health in the United States) study. The REACH-US study is a cross-sectional online survey of adults living in the U.S. recruited from an existing opt-in survey panel hosted by YouGov, a non-partisan research firm. Participants completed the survey between January 26, 2021 and March 3, 2021. Participants were initially recruited to YouGov's proprietary survey panel using online advertising, email communication, and partner-sponsored solicitations (<unk>1.8 million U.S. panel members). Eligible YouGov panel members were proximity matched to the 2018 American Community Survey 1-year sample based on race/ethnicity, gender, age, education level, and language preference (English Language Preference or Spanish Language Preference for the Hispanic/Latino subgroup only). The target sample consisted of 500 American Indian/Alaska Native, 1,000 Asian, 1,000 Black/African American, 1,000 Hispanic/Latino, 500 Multiracial, 500 Native Hawaiian/Pacific Islander, and 1,000 White adults (total N = 5,500). This quota sampling method was implemented to increase diversity and facilitate comparisons across racial/ethnic groups. Eligible participants for the REACH-US study were invited by email by YouGov, completed their survey responses online, and received panel rewards and/or incentives for their participation. Once quotas were met for each racial/ethnic group, sampling weights were calculated for REACH-US study participants. Race/ethnicityspecific multivariable logistic regression models, adjusting for age, gender, years of education, and region were used to estimate probability of inclusion in the study. Propensity scores were then grouped into deciles and post-stratified on age, gender, years of education, region, language preference (Hispanic/Latino only), and 2020 and 2016 Presidential vote choice (used to correct for sampling bias based on political affiliation). This matching and weighting approach generated a final sample weight for each participant and allowed for generating nationally representative estimates within each racial/ethnic group. A complete case analysis was used in which participants were excluded if they had missing data on any study variables [countylevel vaccination barrier (CVAC) score (n = 1), age (n = 2), annual household income (n = 13), health insurance coverage (n = 8), and political ideology (n = 1)]. The final sample included in the analysis was 5,475 participants. Given that YouGov provided deidentified data to the study team, this study was considered exempt, nonhuman subjects research as determined by the Institutional Review Board at the National Institutes of Health. --- Measures County-level vaccination barriers County-level vaccination barriers were drawn from the CVAC (developed by Surgo Ventures and made available by the CDC, https://data.cdc.gov/stories/s/Vaccine-Hesitancy-for-COVID-19/cnd2-a6zw/) and linked with data from the REACH-US study using the U.S. ZIP Code reported by REACH-US study participants. The CVAC includes five themes for each county in the U.S: sociodemographic barriers (i.e., socioeconomic disadvantage, lack of access to information), limited healthcare system resources (i.e., healthcare system capacity, healthcare quality, health spending per capita and total healthcare funding per capita), healthcare accessibility barriers (i.e., cost barriers, transportation barriers), irregular care-seeking behavior (i.e., lack of a designated medical home, lack of routine care visits) and historic undervaccination (i.e., lower coverage and high refusal rates of various vaccines). Historic undervaccination is hereafter referred to as "history of low vaccination". The CVAC includes a score for the composite measure of all themes as well as scores for the individual themes. Missing data values were imputed with median values across all counties. Scores were calculated using stepwise percentile ranking and equal weighting of the themes for the composite measure and subthemes for the individual theme measures (16). Scores for the composite measure (i.e., "overall county-level vaccination barriers"), as well as the individual theme measures (i.e., "component measures") ranged from 0 to 1, with higher scores representing greater barriers. Consistent with the original coding scheme outlined in the CVAC Methodology report (16), the composite measure and the component measures were categorized as "low/medium" (i.e., counties with a barrier score <unk>0.6), "high" (i.e., counties with a barrier score >0.6 and <unk>0.8), and "very high" (i.e., counties with a barrier score >0.8). --- Willingness to receive the COVID-vaccine Willingness to receive the COVID-19 vaccine was measured using the item "Do you plan to get the COVID-19 vaccine once it becomes available?". Response options included "Definitely not, " "Probably not, " "Probably yes, " "Definitely yes, " "I have received one dose of the COVID-19 vaccine, " and "I have received two doses of the COVID-19 vaccine." Willingness to receive the COVID-19 vaccine was coded with "Definitely not" coded as 1, "Probably not" coded as 2, "Probably yes" coded as 3, and "Definitely yes, " "I have received one dose of the COVID-19 vaccine, " and "I have received two doses of the COVID-19 vaccine" coded as 4. --- Racial/ethnic group and sociodemographic covariates Participants self-identified whether they were of Hispanic, Latino, or Spanish origin (i.e., "No" or "Yes"). In addition, those who responded that they were of Hispanic, Latino, or Spanish origin, were asked to select their language preference for the survey (i.e., English or Spanish). Lastly, participants self-identified their race from the categories used by the 2020 U.S. Census. Participants who selected "Yes" to the item capturing Hispanic, Latino, or Spanish origin were included in the subgroup labeled "Hispanic/Latino" which included Hispanic/Latino participants from all gender identities. The Hispanic/Latino ethnicity, language preference, and race items were combined to create categories of American Indian/Alaska Native, Asian, Black/African American, Hispanic/Latino-English Language Preference (ELP), Hispanic/Latino-Spanish Language Preference (SLP), Multiracial, Native Hawaiian/Pacific Islander, and White. Sociodemographic characteristics used as covariates in the analysis included age in years (i.e., 18-34, 35-49, 50-64, and 65 and older), gender (i.e., man, woman, non-binary, transgender, not listed), education level (i.e., high school or less, some college or 2-year college, 4-year college, and post-graduate), and annual household income (i.e., <unk>$20,000, $20,000-49,999, $50,000-99,999, and $100,000 and over). Additionally, political ideology (i.e., conservative, liberal, moderate, not sure) and health insurance coverage (i.e., covered or not covered) were included as covariates given their previously established associations with COVID-19 vaccination intentions (21,22). Lastly, at the time of data collection, only adults with high-risk chronic health conditions were eligible to receive the COVID-19 vaccine. Given this eligibility, participants with high-risk chronic health conditions may have been more likely to have received at least one dose of the COVID-19 vaccine. Therefore, the presence of a high-risk chronic health condition was included as a covariate in the analysis. Participants reported whether they had a chronic health condition by indicating whether a medical doctor or health professional ever told them they had a chronic health condition (i.e., checking all that apply from a list of chronic health conditions). Participants' responses were coded as "high-risk" (1) or "not high-risk" (0) using the CDC guidelines on medical conditions that increased the risk for severe illness due to COVID-19 (23). --- Data analysis Descriptive statistics and chi-square difference tests were conducted in R version 4.2.1. The proportions of sociodemographic characteristics and county-level vaccination barriers were assessed in the total population and stratified by racial/ethnic groups. Willingness to receive the COVID-19 vaccine was assessed in total population and stratified by county-level vaccination barriers. Multigroup regression analyses were conducted in Mplus version 8.6 (24). Ordinal logistic regression models included the maximum likelihood with robust standard errors estimator (MLR). Given the use of the MLR estimator, the Satorra-Bentler scaled chisquare test for model comparisons was calculated using the SBSDiff package in R (25). All adjusted models included race/ethnicity (except for multigroup models in which race/ethnicity was used as a stratification variable), age, gender, annual household income, education level, political ideology, health insurance, and highrisk chronic health condition. All analyses were weighted to be nationally representative within each racial/ethnic group. --- Racial/ethnic di erences in county-level vaccination barriers Racial/ethnic differences in the prevalence of county-level vaccination barriers (i.e., separate models for the composite measure and each of the component measures) were estimated using unadjusted and adjusted ordinal logistic regression. Countylevel vaccination barriers were treated as an ordinal variable, therefore, odds ratios >1 indicated whether each racial/ethnic group was more likely to live in a county with higher barriers (i.e., higher categories vs. lower categories; "very high" vs. "high" and "low/medium"; "very high" and "high" vs. "low/medium") compared to White adults. --- County-level vaccination barriers associated with willingness to receive the COVID-vaccine The association between county-level vaccination barriers and willingness to receive the COVID-19 vaccine was estimated using unadjusted and adjusted ordinal logistic regression. Odds ratios <unk>1 indicated that counties with high (vs. low/medium) and very high (vs. low/medium) county-level vaccination barriers were less willing to receive the COVID-19 vaccine. --- Racial/ethnic di erences in associations between county-level vaccination barriers and willingness to receive the COVID-vaccine Multigroup structural equation modeling was used to examine racial/ethnic group differences in the magnitude of the associations between county-level vaccination barriers and willingness to receive the COVID-19 vaccine. Given the small sample cell sizes of specific gender categories (i.e., non-binary, transgender, and not listed), ridge estimators were used to address singularity issues (i.e., lack of variance due to small cell sizes within racial/ethnic groups). The ridge estimator included a small constant value added to the diagonal of the covariance matrix (26,27) and allowed for inclusion of all gender categories in the analysis. When gender categories were excluded from the analysis without the use of ridge estimators, results were consistent (data available upon request), therefore the model including all gender categories was used for the final analysis. All models were estimated using unadjusted and adjusted ordinal logistic regression. Fully constrained models (i.e., associations between the county-level vaccination barriers and willingness to receive the COVID-19 vaccine held equal across racial/ethnic groups) were compared to freely estimated models (i.e., associations between the county-level vaccination barriers and willingness to receive the COVID-19 vaccine allowed to vary freely across racial/ethnic groups). Model comparisons were used to assess whether allowing each association to vary freely across racial/ethnic groups resulted in a stronger model fit (i.e., a significant difference in the log-likelihood values of the two models indicated significant interactions between the county-level vaccination barrier and race/ethnicity in these models). Model comparisons that revealed significant racial/ethnic differences were further assessed by examining the race/ethnicity-stratified results of the freely estimated multigroup model. --- Results Participant sociodemographic characteristics in the total population and stratified by race/ethnicity are reported in Table 1 (unweighted estimates presented in Supplementary Table S1). --- Racial/ethnic di erences in county-level vaccination barriers In the total study population, most participants lived in counties with low or medium overall county-level vaccination barriers (64.0%), sociodemographic barriers (80.2%), limited healthcare system resources (76.0%), healthcare accessibility barriers (66.7%), and history of low vaccination (52.1%) (Table 2). Almost half of participants lived in areas with low or medium irregular care-seeking behavior (45.3%). These proportions varied across racial/ethnic groups (global chi-square difference tests and pairwise comparisons revealed significant differences in county-level vaccination barriers between specific groups (p-values <unk> 0.01)). For example, the proportions of adults living in counties with high or very high overall county-level vaccination barriers and sociodemographic barriers were higher for American Indian/Alaska Native (25.4% and 15.9%), Black/African American (25.0% and 12.0%), and Hispanic/Latino adults (ELP: 30.5% and 23.0%; SLP: 36.6% and 24.9%%) and lower for Asian (21.0% and 5.7%), Native Hawaiian/Pacific Islander (17.5% and 10.5%), and White adults (18.8% and 6.5%). Higher proportions of Native Hawaiian/Pacific Islander adults lived in counties with a very high history of low vaccination (42.5%) and high or very high irregular care-seeking behaviors (49.0% and 29.8%). After adjustment, American Indian/Alaska Native (adjusted odds ratio (AOR): 2.02, 95% CI: 1.49-2.73), Black/African American (AOR: 1.70, 95% CI: 1.37-2.11), Hispanic/Latino (ELP AOR: 3.56, 95% CI: 2.78-4.58; SLP AOR: 3.81, 95% CI: 2.95-4.92), and Multiracial (AOR: 1.63, 95% CI: 1.25-2.13) adults were more likely than White adults to live in counties with higher overall county-level vaccination barriers (Figure 1). No differences were observed between Asian, Native Hawaiian/Pacific Islander, and White adults. However, the patterns of racial/ethnic differences varied across the component barriers (Figure 1). American Indian/Alaska Native (AOR: 1.77, 95% CI: 1.26-2.50), Black/African American (AOR: 1.63, 95% CI: 1.26-2.11), and Hispanic/Latino (ELP AOR: 1.61, 95% CI: 1.19-2.18; SLP AOR: 1.42, 95% CI: 1.03-1.95) adults were more likely than White adults to live in counties with higher sociodemographic barriers. Similarly, American Indian/Alaska Native (AOR: 1.12, 95% CI: 1.52-2.06), Black/African American (2.71, 95% CI: 2.21-3.32), Hispanic/Latino ELP (AOR: 1.72, 95% CI: 1.33-2.23) and SLP Hispanic/Latino (AOR: 1.80, 95% CI: 1.39-2.33), and Multiracial (AOR: 1.29, 95% CI: 0.99-1.67) adults were more likely than White adults to live in counties with higher healthcare accessibility barriers. By contrast, Asian and Native Hawaiian/Pacific Islander adults were less likely than White adults to live in counties with higher sociodemographic barriers, limited healthcare system resources, and healthcare accessibility barriers (although the confidence intervals for some of these associations were wide). All marginalized racial/ethnic groups were more likely than White adults to live in counties with higher irregular care-seeking behavior (AORs: 1.15-5.05). This trend was similar for history of low vaccination (AORs: 1.72-3.41), except for Black/African American adults who were less likely than White adults to live in counties with higher history of low vaccination (AOR: 0.80, 95% CI: 0.64-1.00). --- County-level vaccination barriers associated with willingness to receive the COVID-vaccine In the total study population, most participants were willing to vaccinate ["Definitely yes/received <unk>1 dose": 40.1%; or "Probably yes": 27.0%)], but COVID-19 vaccination intentions varied across county-level vaccination barriers (Table 3). In counties with low/medium barriers, the proportions of those who reported "Definitely yes/received <unk>1 dose" were roughly 42%, but these proportions were lower in counties with high or very high barriers (e.g., 31.9% in counties with high sociodemographic barriers, 34.2% in counties with very high healthcare accessibility barriers). These trends were similar across all barriers, except for history of low vaccination, in which willingness to receive the COVID-19 vaccine did not significantly vary across levels of this barrier (p-value = 0.29). In the unadjusted models, participants who lived in counties with very high overall county-level vaccination barriers (vs. low/medium), were less willing to receive the COVID-19 vaccine (OR: 0.79, 95% CI: 0.66-0.94) (Supplementary Table S2). In addition, compared to low/medium barriers, those who lived in --- FIGURE Racial/ethnic di erences in odds of living in a county with higher COVID-vaccination barriers ("very high" vs. "high" and "low/medium"; "very high" and "high" vs. "low/medium"). COVID-vaccination barriers were treated as an ordinal variable. Adjusted odds ratios > indicate that the racial/ethnic group was more likely to live in a county with higher COVID-vaccination barriers compared to White adults (reference group). Weighted to be nationally representative within each racial/ethnic group. Adjusted for race/ethnicity, age, gender, annual household income, education level, political ideology, health insurance coverage, and high-risk chronic health condition. ELP, English Language Preference; SLP, Spanish Language Preference. --- Frontiers in Public Health frontiersin.org However, after adjustment, these results were largely attenuated and no longer significantly associated with willingness to receive the COVID-19 vaccine, except for sociodemographic barriers and irregular care-seeking behavior (Table 4). Those who lived in counties with high sociodemographic barriers (vs. low/medium) were still less willing to receive the COVID-19 vaccine (AOR: 0.78, 95% CI: 0.64-0.94) and those who lived in counties with very high irregular care-seeking behavior (vs. low/medium) were still more willing to receive the COVID-19 vaccine (AOR: 1.20, 95% CI: 1.04-1.39) after adjustment. --- Racial/ethnic di erences in the association between county-level vaccination barriers and willingness to receive the COVIDvaccine The multigroup analysis allowed for examining racial/ethnic differences in the predicted probabilities of willingness to receive the COVID-19 vaccine, adjusting for age, gender, annual household income, education level, political ideology, health insurance, and high-risk chronic health condition (Figure 2). Multigroup comparisons revealed significant racial/ethnic differences in the magnitude of association between history of low vaccination and willingness to receive the COVID-19 vaccine (p-value = 0.01) and marginally significant differences in the magnitude of association between overall county-level vaccination barriers and willingness to receive the COVID-19 vaccine (p-value = 0.09) (Supplementary Table S3). Apart from these differences, there were no significant differences between the fully constrained and freely estimated models for the remaining component barriers (i.e., indicating relatively consistent associations between barriers and vaccination intentions across racial/ethnic groups). Trends in the magnitudes of association for overall county-level vaccination barriers and history of low vaccination were examined in the multigroup models (Figure 3). Although confidence intervals were wide, the results revealed different patterns in the associations across racial/ethnic groups. American Indian/Alaska Native adults (high AOR: 1.64, 95% CI: 0.95-2.85; very high AOR: 1.18, 95% CI: 0.69-2.04) and Hispanic/Latino ELP adults (high AOR: 1.26, 95% CI: 0.80-1.99; very high AOR: 1.13, 95% CI: 0.73-1.74) and Hispanic/Latino SLP adults (high AOR: 1.72, 95% CI: 1.09-2.71; very high AOR: 1.53, 95% CI: 0.93-2.50) who lived in counties with high or very high overall county-level vaccination barriers (vs. low/medium) were more willing to receive the COVID-19 vaccine. Alternatively, Asian adults (high AOR: 0.67, 95% CI: 0.43-1.04), Black/African American adults (high AOR: 0.88, 95% CI: 0.66-1.18; very high AOR: 0.90, 95% CI: 0.59-1.38), Multiracial adults (high AOR: 0.93, 95% CI: 0.62-1.40; very high AOR: 0.76, 95% CI: 0.41-1.42), and Native Hawaiian/Pacific Islander adults (high AOR: 0.88, 95% CI: 0.50-1.53; very high AOR: 0.60, 95% CI: 0.30-1.21) who lived in counties with high or very high (vs. low/medium) overall county-level vaccination barriers were less willing to receive the COVID-19 vaccine. In assessing racial/ethnic differences in the association between history of low vaccination and COVID-19 vaccination intentions, American Indian/Alaska Native adults (high AOR: 1.90, 95% CI: 1.10-3.28) and Hispanic/Latino ELP adults (high AOR: 1.85, 95% CI: 1.14-3.01) living in counties with a high history of low vaccination (vs. low/medium) were more willing to receive the COVID-19 vaccine (Figure 3). Interestingly, Black/African American adults who lived in counties with a high history of low vaccination were less willing to receive the COVID-19 vaccine (AOR: 0.55, 95% CI: 0.37-0.84), yet the association was weaker and nonsignificant for Black/African American adults who lived in counties with a very high history of low vaccination (AOR: 0.94, 95% CI: 0.67-1.33). No racial/ethnic differences in the associations between sociodemographic barriers, limited healthcare system resources, healthcare accessibility barriers, or irregular care-seeking behaviors were observed after adjustment. --- Discussion This study used the newly developed CVAC to examine whether county-level vaccination barriers varied across racial/ethnic groups in the U.S. and were associated with willingness to receive the COVID-19 vaccine. In addition, this study assessed whether these associations differed across racial/ethnic groups. Importantly, this study was conducted using a large survey of U.S. adults across seven racial/ethnic groups, including substantial representation from American Indian/Alaska Native, Native Hawaiian/Pacific Islander, and Multiracial adults who are often underrepresented in national surveys. In the total study population, higher county-level vaccination barriers were generally associated with less willingness to receive the COVID-19 vaccine, yet many of the associations were largely attenuated after adjusting for covariates. The trends in the associations between county-level vaccination barriers and willingness to receive the COVID-19 vaccine varied by type of barrier and, in some cases, varied across racial/ethnic groups. Consistent with previous studies on racial/ethnic disparities by geographic region (28,29), American Indian/Alaska Native, Black/African American, Hispanic/Latino ELP and SLP, and Multiracial adults were more likely than White adults to live in counties with higher overall county-level vaccination barriers and multiple component barriers. Trends for Asian and Native Hawaiian/Pacific Islander adults varied across component barriers. --- FIGURE Racial/ethnic di erences in predicted probabilities of willingness to receive the COVID-vaccine. Adjusted predicted probabilities of willingness to receive the COVID-vaccine for each racial/ethnic group (DN, Definitely not; PN, Probably not; PY, Probably yes; DY/<unk> d, Definitely yes, already received <unk> dose of the COVID-vaccine). Weighted to be nationally representative within each racial/ethnic group. Adjusted for age, gender, annual household income, education level, health insurance, high-risk chronic health condition, and political ideology across racial/ethnic groups. ELP, English Language Preference; SLP, Spanish Language Preference. Asian and Native Hawaiian/Pacific Islander adults were more likely than White adults to live in counties with higher histories of low vaccination and irregular care-seeking behavior, but less likely than White adults to live in counties with higher sociodemographic barriers, limited healthcare system resources and healthcare accessibility barriers. The lower odds of Asian and Native Hawaiian/Pacific Islander adults living in counties with limited healthcare system resources and higher healthcare accessibility barriers may relate to disparities in rural vs. urban healthcare. For example, there is existing evidence that higher proportions of Asian and Native Hawaiian/Pacific Islander adults live in urban areas which tend to score higher on healthcare system quality and access than rural areas (30,31). Moreover, the higher odds of Asian and Native Hawaiian/Pacific Islander adults living in counties with histories of low vaccination and irregular care-seeking behavior may relate to previous evidence that Asian and Native Hawaiian/Pacific Islander adults were less likely to have a usual primary care provider compared with White adults (32). Together, racial/ethnic differences in county-level vaccination barriers suggest that healthcare system resources and access to healthcare are inequitably distributed across counties in the U.S. Furthermore, counties with greater healthcare barriers are often those with higher proportions of residents from marginalized racial/ethnic groups. Moreover, participants who lived in counties with greater overall county-level vaccination barriers and greater component barriers (with the exception of history of low vaccination) were less willing to receive the COVID-19 vaccine, which is consistent with prior analyses using the CVAC (33). After adjusting for individuallevel sociodemographic covariates, however, overall county-level vaccination barriers, limited healthcare system resources, and healthcare accessibility barriers were no longer significantly associated with willingness to receive the COVID-19 vaccine. These findings suggest that individual-level factors may have affected the association between these county-level vaccination barriers and willingness to receive the COVID-19 vaccine by serving as confounders and/or mediators in these relationships. The influence of the individual-level sociodemographic covariates on willingness to receive the COVID-19 vaccine is consistent with previous literature (22,(34)(35)(36) and further suggests that many sociodemographic characteristics associated with COVID-19 vaccination intentions vary systematically across counties in the U.S. Despite the impact of individual-level sociodemographic covariates on willingness to receive the COVID-19 vaccine, participants who lived in counties with higher sociodemographic barriers (i.e., county-level measures of socioeconomic disadvantage and lack of access to information) were still less willing to receive the COVID-19 vaccine after adjustment. These findings suggest that even after adjusting for individual-level sociodemographic characteristics, sociodemographic barriers at the county-level can affect individuals' willingness to receive the COVID-19 vaccine. In addition, irregular care-seeking behavior was also associated with willingness to receive the COVID-19 vaccine after adjustment. In contrast, participants who lived in counties with

Discussion: Future public health emergency vaccination programs should include planning and coverage e orts that account for structural barriers to preventive healthcare and their intersection with sociodemographic factors. Addressing structural barriers to COVID-treatment and preventive services is essential for reducing morbidity and mortality in future infectious disease outbreaks.

that individual-level factors may have affected the association between these county-level vaccination barriers and willingness to receive the COVID-19 vaccine by serving as confounders and/or mediators in these relationships. The influence of the individual-level sociodemographic covariates on willingness to receive the COVID-19 vaccine is consistent with previous literature (22,(34)(35)(36) and further suggests that many sociodemographic characteristics associated with COVID-19 vaccination intentions vary systematically across counties in the U.S. Despite the impact of individual-level sociodemographic covariates on willingness to receive the COVID-19 vaccine, participants who lived in counties with higher sociodemographic barriers (i.e., county-level measures of socioeconomic disadvantage and lack of access to information) were still less willing to receive the COVID-19 vaccine after adjustment. These findings suggest that even after adjusting for individual-level sociodemographic characteristics, sociodemographic barriers at the county-level can affect individuals' willingness to receive the COVID-19 vaccine. In addition, irregular care-seeking behavior was also associated with willingness to receive the COVID-19 vaccine after adjustment. In contrast, participants who lived in counties with higher irregular care-seeking behavior were more willing to receive the FIGURE Racial/ethnic di erences in adjusted associations between county-level vaccination barriers and willingness to receive the COVID-vaccine. Adjusted odds ratios of willingness to receive the COVID-vaccine for high and very high (vs. low/medium) county-level vaccination barriers for the overall study population and within each racial/ethnic group. AOR <unk> indicates that counties with high or very high (vs. low/medium) county-level vaccination barriers were less willing to receive the COVID-vaccine. Weighted to be nationally representative within each racial/ethnic group. Adjusted for age, gender, annual household income, education level, health insurance, high-risk chronic health condition, and political ideology across racial/ethnic groups. ELP, English Language Preference; SLP, Spanish Language Preference. Frontiers in Public Health frontiersin.org COVID-19 vaccine. There may be multiple explanations for this finding. One possibility is that the measure of irregular careseeking behavior partially captured relatively healthy individuals who required less routine care due to their relatively healthy status. Yet, these individuals may have been more willing to receive recommended vaccinations as found in previous research [e.g., self-rated health among U.S. adults was associated with lower likelihood of having a usual source of care, but also a greater willingness to receive recommended vaccinations (37,38)]. Given this possibility, it may be important to consider whether irregular care-seeking behavior is an appropriate measure to include in the CVAC and/or whether it is possible to capture irregular care-seeking behavior related to delays in necessary care. There were relatively few racial/ethnic differences in the associations between county-level vaccination barriers and willingness to receive the COVID-19 vaccine. These findings may suggest a generally consistent relationship between most CVAC county-level vaccination barriers and willingness to receive a COVID-19 vaccine across racial/ethnic groups. However, some notable differences included that Black/African American adults who lived in counties with a higher history of low vaccination were less willing to receive the COVID-19 vaccine and this association was significant after adjusting for sociodemographic covariates. These findings are consistent with previous studies in which both influenza vaccination and COVID-19 vaccination were lowest among Black/African American adults (39). Furthermore, these findings may suggest that factors preventing healthcare system use among Black/African American individuals prior to the COVID-19 pandemic (e.g., disparities in care, anticipated healthcare discrimination) likely contributed to similar trends in COVID-19 vaccination disparities. In contrast, in some racial/ethnic groups, higher countylevel vaccination barriers were associated with greater willingness to receive the COVID-19 vaccine. Compared to low/medium barriers, Hispanic/Latino SLP adults who lived in counties with high overall county-level vaccination barriers and Hispanic/Latino ELP adults and American Indian/Alaska Native adults who lived in counties with high histories of low vaccination were more willing to receive the COVID-19 vaccine. Given prior findings that many of the factors associated with county-level vaccination barriers in the U.S. (e.g., lack of internet access and/or limited healthcare system resources) were also associated with lower income (40), it is possible that income disparities across counties were driving these findings. Individuals in counties with greater vaccination barriers due to lower countylevel income, may have perceived greater COVID-19 risks due to economic factors (e.g., living and working conditions that increased exposure to COVID-19). These concerns may have increased their willingness to receive the COVID-19 vaccine. This potential explanation is further supported by previous evidence that Hispanic/Latino and American Indian/Alaska Native adults perceived higher COVID-19 risk compared to other racial/ethnic groups (39) and that Hispanic/Latino adults from households with lower income had greater worries about contracting COVID-19 (41). Public health interventions might partially explain why higher county-level vaccination barriers were associated with greater willingness to receive the COVID-19 vaccine among Hispanic/Latino and American Indian/Alaska Native adults. In addition, public health efforts might also explain why a high history of low vaccination was associated with less willingness to receive the COVID-19 vaccine among Black/African American adults, but not for a very high history of low vaccination. Many efforts to increase COVID-19 vaccination in Hispanic/Latino, American Indian/Alaska Native, and Black/African American communities began prior to the release of the COVID-19 vaccine (42)(43)(44). Moreover, many of these interventions focused on areas at high risk of reporting COVID-19 vaccine hesitancy. Given that the REACH-US study was conducted from January 2021 to March 2021, it is possible that the survey captured COVID-19 vaccination intentions that were positively influenced by these health communication campaigns. This potential explanation would demonstrate the benefit of targeted outreach efforts in increasing willingness to receive the COVID-19 vaccine. Several limitations should be considered when interpreting the present study findings. The sample was drawn from individuals who were not only online but also willing to participate in studies (45). Previous studies found that lack of internet access was a barrier to COVID-19 vaccination (46,47), therefore COVID-19 vaccination intentions reported by the YouGov survey panel may be higher than vaccination intentions in the total U.S. population. In addition, the study was cross-sectional, which limits the ability to make causal inferences. Moreover, the present study assessed willingness to receive the COVID-19 vaccine, yet individuals' COVID-19 vaccination intentions may not have translated into their actual COVID-19 vaccination rates. It is possible, for example, that individuals overreported their intentions to receive the COVID-19 vaccine due to social desirability, as reported in recent studies (48). Alternatively, it is also possible that individuals who intended to get the COVID-19 vaccine later encountered barriers related to limited healthcare resources and accessibility. Given that self-reported COVID-19 vaccination intentions are often higher than actual rates of vaccination (49), the associations between many county-level vaccination barriers and COVID-19 vaccination uptake may be higher than the associations observed in the present study. Lastly, the present study used the CVAC which included some limitations in its development (16). The CVAC has yet to be fully validated and some counties with missing data required imputing data at the median county levels. Despite these limitations, the present study had several strengths. The study included a large, diverse sample of U.S. adults with substantial representation of the racial/ethnic categories in the U.S. Census. Moreover, this study also considered language preference among Hispanic/Latino adults and consistent with previous studies (34), there were important differences between those who preferred to speak English and those who preferred to speak Spanish. This distinction reflects the heterogeneity of the U.S. Hispanic/Latino population on factors such as language preference (34,50). In addition, the present study focused on structural factors related to COVID-19 vaccination intentions, which have been underexplored in the literature. Studies that focus on structural barriers are particularly essential in public health interventions. Structural factors influence the distribution of public health interventions, including the ability to provide warnings and distribute treatment and protective actions within geographic areas and community structures (e.g., local businesses, schools, Federally Qualified Health Centers, religious organizations, and community-based organizations). Public health emergencies, such as responding to an infectious disease outbreak, require knowledge of the structural elements that may serve as barriers to plan accordingly for an efficient and timely response for all in the community. Although willingness to receive the COVID-19 vaccine may have underestimated actual COVID-19 vaccination uptake, the measurement of COVID-19 vaccination intentions also represents a unique strength of this study. The willingness to receive the COVID-19 vaccine captured in the present study provides a snapshot of public perceptions of vaccination prior to its public release (51). Moreover, behavioral intentions are not only good indicators of subsequent behavior ( 52), but they represent thought processes that could highlight willingness to receive the COVID-19 vaccination in the absence of barriers. These findings, especially as they relate to county-level vaccination barriers may be helpful for responding to future pandemics. There are many opportunities for future research related to the present study findings. Future studies could consider examining mediation pathways. It is possible that individuallevel differences in sociodemographic characteristics mediate the relationships between county-level vaccination barriers and willingness to receive the COVID-19 vaccine. Limited healthcare system resources or healthcare accessibility barriers, for example, may have affected individuals' chronic health conditions and/or health insurance status, which in turn, influenced their willingness to receive the COVID-19 vaccine. These mediation pathways would be particularly important for public health efforts. Future studies might also consider examining more complex decision-making processes related to county-level vaccination barriers by using open-ended items and/or qualitative methods (e.g., interviews, focus groups) to explore COVID-19 vaccination intentions. In addition, future studies could examine whether the CVAC is a better predictor of actual COVID-19 vaccination rates compared to willingness to receive the COVID-19 vaccine. If willingness to receive the COVID-19 vaccine was higher than observed vaccination uptake rates, it might suggest that structural barriers prevented individuals from receiving the COVID-19 vaccine. Furthermore, if differences in willingness to receive the COVID-19 vaccine and observed COVID-19 vaccination rates varied across racial/ethnic groups, it could suggest the need to intervene at different stages across racial/ethnic groups (e.g., increasing awareness about COVID-19 vaccine benefits for groups with lower initial COVID-19 vaccination intentions, increasing COVID-19 vaccine access for those with high COVID-19 vaccination intentions, but lower observed rates). Lastly, the study of countylevel factors associated with COVID-19 vaccination behavior raises awareness of contextual variables that could vary by county, as well as at the state and country level. Recent studies, for example, have examined how factors such as wealth, economic growth, population size, migration, and/or tourism impact COVID-19 death rates (53). These factors could be further examined as predictors of COVID-19 vaccination behavior. The present study addressed recent calls to examine the importance of structural factors in COVID-19 vaccination rates (54)(55)(56). In examining COVID-19 vaccination intentions during the early stages of the COVID-19 vaccination program, the present study provides important information on how countylevel vaccination barriers could have impacted initial COVID-19 vaccination intentions during the first year of the U.S. COVID-19 vaccination program. These findings have implications to assist in the planning of early-stage public health efforts for future vaccination interventions and may ultimately lead to infectious disease curtailment. 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. --- Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- Author contributions JRF: conceptualization, methodology, software, formal analysis, data curation, visualization, writing-original draft, and writingreview and editing. PDS: formal analysis and writing-review and editing. JR and VMM: writing-review and editing. ATF: supervision, resources, funding acquisition, and writing-review and editing. 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 --- Author disclaimer The contents and views in this manuscript are those of the authors and should not be construed to represent the views of the National Institute on Minority Health and Health Disparities, National Institutes of Health, or the Department of Health and Human Services. --- Supplementary material The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2023. 1192748/full#supplementary-material

Discussion: Future public health emergency vaccination programs should include planning and coverage e orts that account for structural barriers to preventive healthcare and their intersection with sociodemographic factors. Addressing structural barriers to COVID-treatment and preventive services is essential for reducing morbidity and mortality in future infectious disease outbreaks.

Introduction Evolutionary fitness is measured by the relative frequency of one's genes in subsequent generations. An individual can gain fitness through another organism's successful reproduction, but only if they share genes. The greater the relatedness the more the benefits of cooperation can outweigh the costs. Fitness so defined includes the successful reproduction of both the individual and their relatives into a total 'inclusive' measure [1]. Inclusive fitness theory has been vital in understanding the reproductive behaviour of numerous species, most notably the social insects but also various birds and mammals, where the role of relatives is so important that the reproductive strategy of the species is described as 'cooperative breeding' [2,3]. Hrdy [4] has argued that humans should also be classified as cooperative breeders and empirical evidence suggests that in high-fertility resource-poor settings the presence of kin is beneficial for fitness outcomes, namely child survival [5] and fertility [6,7] (though also see Strassmann [8]). Here we examine the extent to which humans in a resource-rich contemporary environment have patterns of reproductive behaviour that fit this cooperative breeding hypothesis. It should be noted that reproduction in such settings is often considered to be'maladaptive' because the abundant resources available are not converted into more offspring. There have been many attempts at reconciling evolutionary theory and low levels of fertility [9]. Two important contributions to this debate by Turke [10] and Newson et al [11] stress that the weakening of kin ties may lead to low levels of fertility, though via different proximate mechanisms: respectively, kin assistance and kin priming. Whilst these theories set out to explain fertility variance at the population level, here we apply them to explaining within population variance. We will discuss in detail the mechanisms proposed over the next two sections. We have found a limited number of empirical tests of kin influence on childbearing in low-fertility settings. What evidence that there is presents a mixed picture. Some previous studies [12][13][14] have reported that kin have a pro-natal influence on women's fertility, using a diverse array of measures of both kin and fertility. Childcare provided by relatives has also been shown to increase fertility intentions [15]. However, Hank and Kreyenfeld [16] found no effect of informal or kin-provided childcare on second birth progression in Germany. Using the same dataset we analyse here, we have previously shown [17] that having a larger number of kin in a woman's close social network reduces her age at first birth. Different considerations may apply to the decision to have a subsequent birth, so in this paper we test whether kin effects are replicated for another fertility measure: the transition to a second birth. There are also different considerations which apply to the analysis of first versus subsequent births. There is a relatively short period of time during which subsequent births are likely to occur, which is known as the 'childbearing window' [18,19], whereas women may have their first birth anytime between their teens and early 40s. Here we focus on this 'childbearing window'. We also exclude transitions to 3 rd and later births because there were too few of these births in our dataset to allow separate analyses. We chose not to analyse the transitions to 2 nd, 3 rd and later births simultaneously as the decision to continue to 3 rd and higher order births in a low fertility population is taken only by a small (and likely unusual) sub-section of the population. Therefore including these transitions may introduce noise into our analysis. We investigate two potential proximate mechanisms by which kin could exert a pro-natal influence. First, resources and practical assistance from relatives may reduce the cost of having children and thus encourage further childbearing [10]. Secondly, communications with kin could have the effect of 'priming' pro-natalism [11]. These mechanisms are not mutually exclusive but they can theoretically work independently of each other. --- Kin assistance Kin provide important assistance in resource-poor and natural fertility societies [20][21][22]. In these environments relatives can directly influence fertility by enhancing a female's health and thus her fecundity. Kin who provide resources directly to the child could also allow earlier weaning and cessation of lactational amenorrhea, which may in turn lead to shorter birth intervals and higher overall fertility. Kin assistance directed towards mothers and offspring is the mechanism given for how non-human cooperative breeders enhance the reproductive success of their relatives [2,3]. Kin assistance that helps childbearing is not confined to natural fertility populations. In resource-rich societies relatives can and do provide important resources, in the form of finances or time (i.e. spending time looking after their relatives' children), both of which could reduce the costs of reproduction. Human offspring require extraordinarily high levels of investment from others, normally their parents [23,24]. Turke [10] argues that in societies where kin provide high levels of assistance this reduces the constraints on parents' childbearing and thus leads to high fertility. Where kin support is weak then the costs are borne more by the parents and they therefore have fewer children. As noted earlier Turke's theory was put forward at a macro-level to explain population level differences in fertility but it is equally plausible that at the individual within-population level those with less kin assistance will have fewer children. For kin assistance to be useful in explaining fertility patterns it must be substantial but not universal. Is this the case in contemporary Britain? Here we will divide kin assistance into two forms: (i) financial and (ii) childcare. In terms of financial assistance from relatives, Attias-Donfut et al. [25] have shown that in contemporary Europe there are substantial financial transfers between family members. Focusing on grandparents, virtually all the families in the UK's Millennium Cohort Study reported some financial assistance from at least one grandparent [26]. Two other British datasets [27,28] showed that around 50% of grandparents report'regularly' providing financial support. There is some evidence to suggest that the level of kin's financial assistance has increased over recent years. In 1997 10% of first-time house-buyers under 30 required informal assistance to purchase their property, but by 2005 nearly 50% had assistance from 'family or friends' [29] (presumably more the former than the latter). In terms of kin providing childcare, the literature broadly shows that in the UK and other economically developed countries 'informal' childcare (childcare that is not purchased) is substantial, though not universal. For example Fergusson et al.'s [30] analysis indicates that around 45% of young children were cared for by a grandparent and 10-15% by 'other relatives'. These patterns are also seen in other studies where the provision of childcare and other resources by relatives, particularly the child's grandparents, is significant but varies considerably between sub-groups of the population [25,28,[31][32][33][34][35][36][37][38][39]. --- Kin Priming Kin priming is a potentially independent proximate mechanism that allows relatives to influence the fertility of their relatives. This idea is based on the recent work of Newson et al. [11] and a key component is that it is communication, rather than resources, that influences fertility. From an inclusive fitness perspective it will often be adaptive for relatives to provide information that encourages or primes individuals towards pro-natal sentiments and thus raises fertility. It should be noted that such priming of relatives may, or may not, be overt or conscious. On the one hand parents could explicitly attempt to persuade their adult children to provide them with grandchildren. It could also be much more subtle, with relatives raising conversation topics pertinent to childbearing, leading conversations to more pro-natal conclusions as well as indirectly encouraging decisions (regarding partnership, housing, employment etc) that are more conducive to childbearing. Such priming could in turn lead to the formation of reproductive norms that are more or less fitness maximising. For example, the acceptability of voluntary childlessness may be greater in non-kin orientated social groups than in kin orientated groups. Empirical evidence on whether kin do communicate more pronatal messages is currently rather limited. Newson et al. [40] found in role playing experiments those playing the'mother' role provided more fitness maximising messages than those playing a 'friend' role. Keim et al. [41] found in qualitative social network analysis that kin seemed to provide social pressure on respondents to have children. Axinn et al. [42] provide some evidence for direct conscious persuasion as a mother's preferences for grandchildren were correlated with her adult children's preferences for children. Waynforth, while not directly examining the content of communication between kin, found that emotional closeness and frequency of contact with maternal grandparents increased the likelihood of birth for UK women [14]. Kin priming does not require the transfer of resources, but it does require communication between relatives. To help explain variance in second birth transitions the amount of communication with kin in contemporary Britain must, like kin assistance, be substantial but also variable. This seems to be the case. Hawkes and Joshi [26] found that 65% of new mothers saw their mother 'at least' weekly and one-fifth 'daily'. It has also been estimated that 20% of British adults contact a sibling 'at least several times a week' [43]. However, frequency of contact with kin varies with numerous factors such as age [31] occupation and education [44], geographic proximity [45], ethnicity [46] and local area deprivation [27,47]. In summary, there may be two proximate mechanisms, kin assistance and priming, through which kin could influence a female's transition to second birth. In this analysis we will attempt to distinguish between the effects of these two mechanisms. Our a priori prediction is that both kin influence indicators will have a pro-natal effect on fertility. --- Methods Our data come from six waves of the British Household Panel Study (BHPS) conducted between 1992 and 2003. The BHPS is a multipurpose longitudinal dataset that is broadly representative of the British population, though results should not be taken as strictly representative of the population of Great Britain as it was not possible to fit a satisfactory weighting (full documentation of question wording, data collection methods etc is available at http://www.iser.essex.ac.uk/survey/bhps). We restricted our analysis to females as the household clustering of the survey means that male and female respondents were often partners and so their fertility was highly correlated. There are also well known reporting problems with male fertility [48]. We used discrete-time event history analysis with the dependent 'event' being a second birth [49,50]. This technique divides a respondent's recorded time into spells, which in this case last for two years. Surveys were conducted annually but not all variables were collected during every survey. For example, the key kin priming indicators were only collected every other year. A respondent entered the dataset once her first child was born. She exited the dataset in four ways i) her second child was born, ii) she reached 45 years of age, iii) she reached 10 years since first birth without an additional birth (we removed observations after this point as the probability of ever having a second birth becomes very low), or iv) she reached the end of the data collection period without having a second birth (i.e. she was right-censored). Multivariate binary logistic regression models were then fitted for predictors of the occurrence of a second birth. Event history analysis has long been regarded as a good technique for understanding birth progressions [51] since it allows for both time-varying covariates and censorship in the dataset. An assumption of this technique is that the covariates have proportional hazards across the time period under analysis. We broadly confirmed this assumption is valid for the models presented here. This and the other sensitivity analyses mentioned but not shown are available on request from the authors. --- Dependent variable The dependent event variable used was whether or not a second birth occurred within a window of 9-27 months after the respondent was interviewed. A nine month lag was used to ensure that respondents were not pregnant at the time they reported on the indicators of kin priming and kin assistance. This controlled for a potential confounding effect whereby relatives may increase childcare or contact in response to pregnancy. Respondents who were pregnant (i.e. had a birth within nine months of the interview) were not included in the analysis. A cut-off of 27 months was used since relatives may change their contact and assistance over time and it would be inappropriate to attribute the influence of these indicators too far into the future. We tested the sensitivity of the analysis by changing the lag for the measurement of the event (second birth) to either 9-18 or 18-27 months after the interview. The results stayed broadly similar. --- Explanatory variables Our explanatory variables explored kin priming and kin assistance as proximate mechanisms through which kin can influence the transition to a second birth. Kin priming indicators were constructed from responses to a battery of questions asked in alternate waves of the study about the three individuals the respondent felt 'closest' to outside of their household. We will describe these individuals as 'emotionally close' to the respondent. Two key variables were constructed from the responses to this battery i) the number of relatives who were emotionally close and ii) the number of relatives who were emotionally close relatives and were also in frequently contact (defined as those who reported contacting the respondent'most days' by either 'visiting, writing or by telephone.') We tested the robustness of the findings for the kin priming variables by running the model again using different operationalisations. First, we used dichotomised versions of the variables i.e. whether the respondent had any emotionally close relatives. Secondly, we decreased the threshold for the frequency of contact to 'at least once a week'. Both of these changes produced similar results though there was a decrease in the statistical significance level. Two additional explanatory variables were constructed from this battery of questions on emotionally close individuals. We created separate variables which coded for whether a specific category of relative (e.g. mother, sister) was listed as one of these individuals, to determine if a particular relative was driving any overall effect. We also looked at emotionally close relatives' geographic proximity. We created a set of variables which combined the geographical proximity and frequency of contact for each emotionally close relative. The categories were whether the respondent had an emotionally close relative: (i) within 50 miles of respondent and frequently contacted, (ii) within 50 miles but infrequently contacted and (iii) over 50 miles from respondent (there were only 19 occasions when respondents lived over 50 miles away and also frequently contacted an emotionally close relative, so we made a single group for occasions when the relative lived over 50 miles away). Some forms of kin assistance, such as childcare and help with day-to-day activities can more easily be provided if relatives live in close proximity. Conversely kin priming can occur wherever kin live, as long as they are in contact with the respondent. So if kin assistance is the more important mechanism, then relatives who are geographically distant should have a weaker influence on the transition to a second birth. If kin priming is the more important mechanism, then frequently contacted relatives, regardless of their geographic location, should have the greater pro-natal effect. Unfortunately the questions on specific relatives and geographic proximity were not asked in one wave of the BHPS (Wave F 1996-1997) and so we have one sixth fewer observations for this part of the analysis. We looked for indicators of kin assistance. We were unable to construct a variable based upon whether kin provided financial assistance to the respondent. Surprisingly there were only 11 occasions (less than 1%) where the respondent reported receiving a payment from a non-household family member. Compared to the levels of kin financial assistance found in the papers discussed earlier, this value for mothers with young children seems implausibly low [46] [25]. We suspect this is simply measurement error on the part of the BHPS. However, many women in the BHPS did report receiving assistance with childcare from relatives. Respondents were asked ''which of the following best describes the way you arrange for your children aged 12 or under to be looked after while you are at work?'' The interviewer then recorded up to three responses from a list of eleven potential childcare categories. We created three dummy variables for different childcare types. A kin assistance explanatory variable was constructed with '1' if the respondent mentioned 'a relative' as one of these three forms of childcare and '0' if a relative was not mentioned. A second dummy variable for 'formal childcare' was constructed if the respondent mentioned 'at school', 'nanny/mother help', 'day nursery' or 'childminder'. The final 'other childcare' dummy variable combined instances of the respondent mentioning'spouse or partner', 'friend' or 'other'. These additional childcare variables were necessary to control for the effect of women using childcare per se. The reference category was set as the occasions when the respondent did not mention anyone else providing childcare. Potential weaknesses of this childcare question are that it does not capture the full extent of childcare and there could be variation in how respondents interpreted the notion of 'work'. We return to this issue in the discussion section. We did not distinguish between whether the type of childcare was mentioned first, second or third, or whether it was mentioned in conjunction with other methods (but there were only a limited number of occasions when the respondent mentioned more than one type of childcare). Respondents were only included within the dataset when they were present in a wave of data collection containing the battery of questions about individuals who were emotionally close to the respondent. If respondents were missing for one wave of data collection they were still eligible for inclusion in later waves subject to the usual constraints, such as not being pregnant with a second child. --- Control variables There are numerous factors that influence childcare provision and kin contact and these same factors could also confound any observed association with the second birth transition. First, three types of time measurement are included in all of the models. The event history analysis is based on the number of months since the respondent's first birth. Time since first birth will be associated with the likelihood of second birth due to the 'childbearing window' discussed earlier. It also captures the first born child's age and this will correlate with the nature of childcare, as older children are eligible for (pre)schooling. Secondly, the respondent's age is included, as a female7s age is associated with both her fecundity and the nature of her family and friend contacts [52]. Finally all models include dummy variables for the wave (year) of the survey to take into account calendar time, though their effect is consistently non-significant and so they are not reported. To determine whether it was an individual's general level of social attachment, rather than interactions with kin, that might be causing any observed correlations we included a measure of the number of frequently contacted emotionally close individuals (regardless of whether they were related). We control for socioeconomic confounders. Female employment increases childcare demand, and at the macro-level there is a 'U' shaped association with fertility [53]. The extent of employment is included as the number of reported hours the respondent is in paid employment (including overtime). We also control for education, as it is often shown to be associated with birth interval length [18] and is also associated with kin interactions [52] and childcare use [30,34] though see [37]. Education is included as a time-varying covariate (though in reality very few of the respondents obtained additional qualifications during the study period. For example less than 2% of those without a degree obtained one during this period). We also included the respondent's income and her proportion of household income. Income will influence the capacity to purchase formal childcare in place of informal childcare, and the opportunity costs of leaving the labour force [54]. Family networks and childcare practices also differ between ethnic-cultural groupings [55] and so does fertility [56,57]. We therefore included non-time varying controls for religious organisation membership and non-white ethnicity. We included several variables on household composition, as our kin priming variables only include non-household members. For example, having a resident partner will clearly influence fertility and it also influences grandparental childcare involvement [28]. We also controlled for the sex of the first born child. This can influence numerous parental behaviours, including fertility and childcare [58]. We included a control variable for the focal women's sibship size as this would influence the number of nonhousehold relatives who were available for inclusion within our measure of emotionally close relatives, and there is also a known correlation between the fertility of parents and offspring [59]. Scotland and Wales were over sampled in later waves of the BHPS, so we included dummy variables for both countries in the models. We also tested for significant interactions between the explanatory variables and all the socio-demographic control variables. This was because the pro-natal (or anti-natal) influence of relatives on fertility could be limited to particular sub-groups in the populations and the observed aggregate effects could mask both pro-natal and anti-natal effects. However, we did not find any consistent interactions between the socio-demographic controls and the explanatory variables that were statistically significant at the 5% level. Finally we checked for non-linear effects for each of the continuous variables and a quadratic term was included in the final model for age to control for non-linearity. No other nonlinear effects were found to be significant. All analysis was conducted using Stata. Data collection, storage and use is administered by the Institute of Social and Economic Research, University of Essex in accordance with the Ethical Guidelines of the Social Research Association. --- Results Our final dataset contains information from 594 females who had had a first birth. The earliest age at interview in the dataset came from a female who was 17 and the oldest 44. These women contribute 1115 spells of data (i.e. observations). 242 second births were captured in the 9-27 month threshold after the interview meaning that 21.7% of spells ended in a second birth. Table 1 shows the descriptive statistics for the explanatory variables. It also shows the volatility of the time varying covariates for respondents who contributed data in two or more waves, by showing the percentage of individuals who ever changed value for each covariate. Descriptive statistics for the categorical and continuous control variables are shown in Table 2 and Table 3. Column three of Table 1 shows the percentage of spells that end with a second birth 9-27 months after measurement for each of the categorical variables. The bivariate association is in the expected direction for both the kin assistance and kin priming indicators. As the number of emotionally close relatives increases so does the percentage of spells ending in a second birth (chisquare association significance p = 0.05). The same association is seen for those relatives who are also frequently contacted, though it is only marginally significant (chi-square association significance p = 0.07). Where a relative provides childcare, 25% of spells end in a second birth, which is slightly higher than when the respondent does not mention receiving childcare (21%), though this association falls outside of conventional statistical significant (chi-square association significance p = 0.17). Table 4 shows the results for the multivariate discrete-time event history models with the first three explanatory variables included separately (model one -number of emotionally close relatives, model two -number of frequently contacted emotionally close relatives and model three -whether a relative provided childcare). The results are presented as odds ratios, whereby a value greater than one indicates that this variable increases the odds of a second birth occurring 9-27 months after the interview compared to the reference category (controlling for all other variables), whilst a value less than one indicates that this variable decreases the odds of a second birth. We included all the theoretically relevant control variables in each model though it should be noted that many do not significantly predict the occurrence of a second birth. In a 'best fitting model' produced from backwards model selection, the explanatory variable's effects are essentially the same as those displayed here. Model one shows that once our control variables have been added the number of emotionally close relatives no longer significantly predicts the occurrence of a second birth. On the other hand, model two shows the number of emotionally close relatives who are frequently contacted does significantly increase the odds of a second birth. Model three shows that once the full set of controls is included when kin provided childcare statistically significantly increase the odds of a second birth. These variables all relate to relatives outside the household. In none of these models do the household composition variables significantly predict the occurrence of a second birth (i.e. having a parent or sibling in the same household). Table 5 shows a summary of the remaining models. This table only contains the results of the explanatory variables though the full set of control variables was used in all cases (we have only shown the explanatory variables because the controls provided very similar results to those already seen.) Models four and five, which include main effects for both types of explanatory variable (kin assistance and kin priming) included together in the same model. The results remain very similar and the fit of the model (pseudo r-squared) increased only very slightly (by 0.002 in Model 4 and 0.003 in Model 5), though the effect for frequently contacted relatives becomes significant only at the 10% level. It is quite possible that there is a correlation between the number of emotionally close relatives a respondent reports and whether a relative provides childcare, since relatives who provide childcare may well also be emotionally close to the respondent. Table 6 shows the bivariate association between the explanatory variables. It shows that there is little association between the number of emotionally close relatives a respondent reports and whether a relative provides childcare (Kendall's tau2b = 20.02, p = 0.47). However there is a significant, positive relationship between the number of frequently contacted emotionally close relatives and relative-provided childcare (Kendal's tau2b = 0.08, p = 0.01). We tested interaction terms between our relative-provided childcare variable and both the (i) number of emotionally close relatives and (ii) number of frequently contacted and emotionally close relatives. Neither interaction term was significant, with a very small effect size for the interaction with frequently contacted relatives. This means that there is not a significant multiplicative effect of both kin childcare provision and frequently contacted emotionally close relatives. Finally, we also analysed two other sets of explanatory variables, whether a specific relative was described as emotionally close and the geographic distance of the emotionally close relative. A summary of the results of the multivariate models are also set out in Table 5. The two most commonly cited relatives were mothers, included in 29% of spells, and sisters, included in 27%. We included the presence of a specific relative as the sole explanatory variable in multivariate models six to twelve and in all cases the presence of the specific relative was in the anticipated direction (it increased the odds of a second birth), though the effect was not statistically significant. This suggests that the aggregate effect of emotionally close relatives was not driven by the presence of one particular type of relative. Unfortunately the BHPS does not provide information on which relatives are providing childcare, so we were unable to explore this aspect further, though the literature suggests it would largely be the child's grandparents. We also analysed an interaction between geographic proximity and frequent contact with emotionally close relatives. Model thirteen shows that the geographic proximity variables are not significant. Kin who are geographically closer could more readily provide childcare, so the lack of a geographic difference adds some support to the idea that kin influence is not solely due to assistance with childcare. --- Discussion These results suggest that kin positively influence the progression from first to second birth in contemporary Britain. A second more tentative conclusion is that both proximate mechanisms, kin assistance and kin priming, are important, given that both being in frequent contact with emotionally close relatives, and having childcare provided by a relative, appeared to be associated with progression to second birth. However, only very cautious conclusions on the relative importance of the proximate mechanisms should be drawn. First, relatives who help with childcare can also encourage and prime the respondents to have an additional child. We are not able to match the relatives in the two indicators together but there is a significant bivariate association between a respondent reporting frequent contact with emotionally close relatives and a respondent reporting that her first born child is looked after by a relative, so it seems plausible that those relatives who provide childcare are also those who are emotionally close to the respondent. Secondly, the temporal relationship between kin priming and kin assistance is unclear. Are relatives in close social proximity simply more likely to undertake childcare, or does the provision of childcare bring relatives closer together? We are unable to distinguish between these two possibilities in this analysis of second birth, but we note that our previous analysis of progression to first birth found that being emotionally close to one's relatives increased the odds of birth even before relatives are able to undertake childcare for the respondent [17]. In this analysis we are using indicators of kin priming and kin assistance, and there are limitations in the extent that these concepts are fully captured. Kin priming could be induced by relatives other than the three the respondent considers particularly close at that point in time. Kin assistance can be much more substantial than simply the provision of childcare whilst the respondent is 'at work'. An additional limitation is that we are not able to properly identify which kin are important. Our dataset has relatively crude, composite kin indicators. 'Kin' are not a homogenous entity, and our indictors may mask the effects of relatives varying in their motivation and capacity to influence fertility. We do not know who is providing childcare other than that they are 'a relative'. When we tested each specific emotionally close relative (mother, sisters etc) with progression to second birth, none were significant, though all had positive effects, and nonsignificance could simply be due to an insufficient number of observations. Both our kin variables are only measured in the immediate environment. Many species, and particularly humans, have 'developmental plasticity' whereby information from earlier environments shapes the individual organism's physiological and psychological development [60,61]. During the developmental period some individuals may be more influenced by non-kin, who may instil values towards a life course that is not fitness maximising, or kin, who may induce 'family values' that are more fitness maximising. The developmental period could be important, but in this study we are only able to look at the components of kin influence in adulthood. It would be interesting for future research to look at a wider array of indicators of kin influence and in particular to also look at when kin influence has the greatest impact. Finally, we have concluded that we find some support for the hypothesis that kin have a direct influence on the fertility. An alternative explanation is that there is some unmeasured common factor which predisposes women both to remain close to their kin, and to have relatively high fertility. For example, the associations we have found could be confounded by unmeasured personality characteristics of the respondents. Nettle [62] has argued that human personality diversity, as represented in Costa and McCrae's [63] five factor (Neuroticism, Extraversion, Openness, Agreeableness and Conscientiousness) model has an ultimate adaptive function. It is ultimately adaptive for multiple personality strategies to co-exist in a population, as the optimal fitness maximising personality will depend upon the local ecology (resource availability, population density etc) and the frequency of competitors' personalities [64]. There is some evidence that personality components do influence the frequency of contact with relatives [65]. By definition low levels of Openness or Extraversion are likely to limit interactions with 'new' individuals (who are liable to be non-kin). Some personality traits do seem to be associated with some aspects of fertility, although these links tend to vary cross-culturally. For example, neuroticism is positively correlated with fertility in some populations [66,67] and negatively in other [68]. We were unable to control for personality in our analysis. It was measured in the BHPS, but only many years after most of our observations. Personality can be relatively stable across the life course, but there are circumstances, such as major life events, that are shown to be associated with changes in personality [69,70]. Indeed Jokela et al. [68] and Srivastava et al. [71] have shown that parenthood may influence personality, increasing Agreeableness and Emotionality scores. Additionally, personality development may be subject to kin influence. Parenting styles influence children's personality development [72]. So personality may not be entirely separable from kin influence. The BHPS was designed as a multipurpose survey, without our research question in mind. Many of the above limitations are products of using data of this nature. Nevertheless the BHPS is a good dataset in many other ways, providing broadly representative and longitudinal information. It has allowed us to show that there is a significant association between kin influence indicators and fertility, even after numerous socio-economic controls. We therefore argue that the key conclusion from these results is that in a resource-rich low-fertility setting the cooperative breeding hypothesis helps predict the pattern of observed fertility behaviour. A mother with a young child who scores highly on indicators of kin assistance and kin priming has a higher propensity in a given period of time following her interview to have a second birth. Kin can influence fitness in a setting where fertility is low and child survival is extremely high. Fitness is a relative measure, comparative to an organism's competitors. Indeed because children are discrete units, each additional child in a low fertility environment represents a proportionally higher increase in reproductive success than in a high fertility society. This paper complements our earlier work which showed the positive influence of kin on the transition to first births in the same low fertility population. Social scientists have long been interested in fertility and family structure [73,74]. However there has been relatively little recent research on if and how family influence fertility in resource-rich societies. Our results demonstrate the utility of a cooperative breeding perspective when seeking to understand contemporary family and fertility behaviour. --- Author Contributions Conceived and designed the experiments: PM RS. Analyzed the data: PM. Wrote the paper: PM RS.

Particular features of human female life history, such as short birth intervals and the early cessation of female reproduction (menopause), are argued to be evidence that humans are 'cooperative breeders', with a reproductive strategy adapted to conditions where mothers receive substantial assistance in childraising. Evolutionary anthropologists have so far largely focussed on measuring the influence of kin on reproduction in natural fertility populations. Here we look at the effect in a present-day low-fertility population, by analysing whether kin affect parity progression in the British Household Panel Study. Two explanatory variables related to kin influence significantly increase the odds of a female having a second birth: i) having relatives who provide childcare and ii) having a larger number of frequently contacted and emotionally close relatives. Both effects were measured subject to numerous socio-economic controls and appear to be independent of one another. We therefore conclude that kin may influence the progression to a second birth. This influence is possibly due to two proximate mechanisms: kin priming through communication and kin assistance with childcare.

Introduction The Millennium Development Goal 5, which aims to reduce persistently high maternal mortality, has propelled policies to increase facility deliveries to the forefront of national agendas in many low-income countries (Campbell et al. 2006). However, there are anecdotal reports and mounting qualitative evidence that some women experience disrespectful or abusive treatment at the hands of health providers in facilities during labour and delivery (d'Oliveira et al. 2002;Bowser and Hill 2010). Abusive treatment in a health care setting where all patients are entitled to be treated with dignity violates a woman's fundamental rights. Such treatment is also a signal of low quality of care that may adversely affect health outcomes and may deter women from coming to facilities (Kruk et al. 2009(Kruk et al., 2010)). Both of these undermine efforts to reduce maternal mortality. Accounts of women, health workers and families reveal a range of disrespectful and abusive treatment. These include physical abuse (beating, slapping and pinching), lack of consent for care (e.g. for Caesarean section or tubal ligation), nonconfidential care (e.g. lack of physical privacy or sharing of confidential information), undignified care (e.g. shouting, scolding and demeaning comments), abandonment (e.g. being left alone during delivery), discrimination on the basis of ethnicity, age, or wealth, or detention in facilities for failure to pay user fees (d'Oliveira et al. 2002;Miller et al. 2003;D'Ambruoso et al. 2005;Bowser and Hill 2010). Disrespectful treatment may be due to absent or inadequate national human rights policies and their enforcement, lack of leadership in the health system, poor standards of care in facilities, provider demoralization and shortages (Bowser and Hill 2010). Health providers in these contexts often contend with poor physical and organizational working environments, including medicine and provider shortages as well as low pay and weak supervision, which may result in demoralization and thus dehumanization of patients (Amoran et al. 2005;Bosch-Capblanch and Garner 2008;Johnson et al. 2011). The dynamics of power in health systems that strongly favour health professionals and low community engagement in health governance limit the accountability of health providers to users (Freedman 2003). In addition, long-standing patterns of poor quality and disrespectful care in a context of resource scarcity lead to their normalization in local cultures, making abusive care less visible (Bowser and Hill 2010). Finally, research from high-income countries has found that more educated women, women with past abuse and women with depression report higher rates of abuse in health care settings (Swahnberg et al. 2007). To date there have been no estimates of the prevalence of disrespectful and abusive treatment of pregnant women in health facilities in low-income countries. In this article, we assessed the frequency of disrespect and abusive experiences as reported by women during facility childbirth in eight health facilities in Tanzania. We compared two approaches for measuring prevalence-exit interviews and community follow-up surveys and examined individual and delivery-related factors associated with reports of abusive treatment. This analysis is part of a larger study, the Staha (Respect in Swahili) study, which aims to measure the extent of disrespect and abuse, examine its drivers and determinants and design and pilot interventions to combat disrespectful treatment in health facilities in Tanzania. --- Methods --- Study area and sampling The study was conducted in the Tanga Region of Tanzania in Korogwe and Muheza Districts, rural areas in the northeast corner of Tanzania. Korogwe District has a total population of 324 000 and Muheza District 341 000 (National Bureau of Statistics Tanzania and Tanzania Ministry of Planning 2006). Korogwe has 36 government health facilities (1 district hospital, 4 health centres and 31 dispensaries) and 8 private health facilities (1 hospital and 7 dispensaries). Muheza has 24 government health facilities (3 health centres and 21 dispensaries) and 6 private health facilities (1 district designated hospital, 2 health centres and 3 dispensaries). The hospital in Muheza District is non-governmental organization (NGO)owned but it is designated by the government as the main district hospital (National Bureau of Statistics Tanzania and Tanga Regional Commissioner's Office 2008; Tanga Regional Health Management Team, personal communication). The Tanga Region has an institutional delivery rate of 41.3%, which is lower than the national average (National Bureau of Statistics Tanzania and ICF Macro 2011). Eight health facilities were purposively chosen from the two study districts to be included in the study: the two district hospitals, five government health centres and one government dispensary. The two hospitals and one of the health centres in Korogwe can perform obstetric surgery. The facilities were selected to reflect the range of delivery settings in rural Tanzanian districts. Women who delivered in study facilities and were 15 years of age and older were eligible to participate. Women aged 15-17 years required parent/guardian or spousal consent. During the consent process, participants were asked whether they would be interested in participating in a followup interview in their homes 5-10 weeks postpartum. Informed consent was obtained for both surveys at the time of the exit survey. Those who agreed to follow-up interviews provided contact details which were stored in a lock box separate from other study material. We randomly sampled 60% of the participants who consented to participate in the follow-up interview and had a complete exit questionnaire for the followup survey. Participants who lived outside of the study district or in hard to reach remote areas of the district were excluded from this sample due to logistic constraints. The authors obtained ethical clearance for this study from their institutions and the National Institute for Medical Research, Tanzania. --- Instrument and survey fielding Exit and follow-up questionnaires were developed in English, translated into Swahili and back translated. The exit questionnaire included questions about demographic characteristics, asset ownership, health history, recent health care utilization, delivery characteristics, perceived health care quality and satisfaction, experiences of disrespect and abuse during delivery and future health care utilization. The follow-up questionnaire included the same questions from the exit survey about perceived health care quality and satisfaction, experiences of disrespect and abuse during delivery and future health care utilization and also included questions about health seeking behaviours for mother and baby, preferences for labour practices and measures of maternal health. Disrespect and abuse were measured by asking women whether they experienced specific events during labour and delivery. Questions were based on the disrespect and abuse categories defined by Bowser and Hill and were further adapted and validated for the Tanzanian context by the study team in formative research before this study consisting of focus group discussions and several in-depth interviews with recently delivered women. The categories were reworked as follows: non-confidential care, non-dignified care, neglect, non-consented care, physical abuse and inappropriate demands for payment. In the exit and follow-up surveys, each disrespect and abuse event was asked in a separate question. The disrespect and abuse items in the questionnaires were: body seen by others; shouting/scolding; request or suggestion for bribes or informal payments for better care; threatening to withhold treatment; threatening comments or negative or discouraging comments; ignoring or abandoning patient when in need; delivered alone; non-consent for tubal ligation; non-consent for hysterectomy; non-consent for Caesarean section; hitting, slapping, pushing, pinching or otherwise beating the patient; sexual harassment; rape and detention due to failure to pay. Although some of the items overlapped in meaning (e.g. shouting and negative comments), they were chosen to gain greater specificity of understanding of the women's experience; thus, multiple responses may represent a single abuse incident. Responses to each question were categorized as 'experienced' or 'not experienced'. A participant was labelled as having experienced disrespect and abuse during childbirth if she answered 'experienced' to one or more of the 14 questions. The exit questionnaire was administered between December 2011 and May 2012 and the follow-up questionnaire between February 2012 and June 2012. Each interview lasted approximately 45 min and was administered in Swahili. For the exit interviews, trained interviewers approached women for participation upon discharge. To account for delivery volumes, six interviewers were stationed at each of the hospitals with one interviewer stationed at each of the health centres and the dispensary. The exit interviews were held in tents outside of the health facilities to maintain privacy. The follow-up interviews were conducted inside the participants' homes by trained interviewers. Interviewers were instructed to interview the women in private without other family members present. Women were given a bar of soap and a bottle of water in appreciation of their participation after each interview. Quality of the surveys was monitored by two supervisors and by monthly monitoring visits from a data analyst based at Ifakara Health Institute in Dar es Salaam, Tanzania. --- Statistical analyses We calculated means and frequencies for a range of sociodemographic factors (age, education, marital status, socioeconomic status and parity), factors pertaining to women's health (reported low mood or depression in the past 12 months and any past experiences of physical abuse or rape) and factors related to participants' delivery experiences (delivery facility, length of stay at facility, Caesarean section, whether the woman came directly to the facility for delivery and self-reported complications during delivery). The latter variable included any of a broad array of concerns ranging from extreme pain, to excess bleeding, to headache. The frequency of separate experiences of disrespect and abuse and a single measure of any disrespect and abuse was measured for exit and follow-up samples. To measure household wealth in a non-cash economy, we used a principal component analysis (PCA), as developed by Filmer and Pritchett, based on 18 survey questions about household assets (Filmer and Pritchett 2001). The results of the PCA were divided into quintiles, with the lowest two quintiles (40%) classified as 'poor'. Independent variables were chosen based on past literature and our hypotheses of what may make women vulnerable to experiences of disrespect and abuse. For example, teen mothers frequently experience social disapproval and deliver less frequently in health facilities, which may lead to disrespect during labour (Magadi et al. 2007). Women with self-reported complicated labours may require greater assistance and thus be more likely to be treated rudely by overextended staff. Overall quality of care and satisfaction with delivery were also explored for each group of women. Response categories for overall quality of care were excellent, very good, good, fair and poor. From these, a three-level categorical variable was created: excellent/very good, good and fair/poor. Response categories for satisfaction with delivery were very satisfied, somewhat satisfied, somewhat dissatisfied and very dissatisfied. Responses were dichotomized into very satisfied and the other response choices. Chi-square tests or Fisher's exact tests were performed to compare disrespect and abuse by each experience and for any disrespect and abuse experienced as measured on exit from health facility and on follow-up 5-10 weeks postpartum. Two multivariable logistic regression models were performed with the outcome of interest as experience of any disrespect and abuse-one measured on discharge from facilities and one measured on follow-up-with robust standard errors to account for grouping of observations in facilities. The intent of the regression was to identify individual and delivery-related factors associated with reports of abusive treatment rather than to identify underlying causes of abuse, which is impossible given the cross-sectional data and the relative homogeneity of the health system settings in the study. Independent variables included demographic and health characteristics, such as age, parity, wealth (bottom 40%), history of depressed mood in past 12 months, history of abuse or rape, hospital vs health centre delivery and several birth factors. Statistical analyses were performed using Stata 12.1 (College Station, TX, USA). --- Results We invited 2520 women who had been discharged from health facilities after delivery to participate in the study. Of these, 1779 (70.60%) agreed to participate. Women were, on average, 25.86 years old (standard deviation (SD) 1<unk>4 6.3) and for 684 women (38.47%), this was their first birth (Table 1). About a fifth of the women (N 1<unk>4 360, 21.80%) had some secondary education. Although 421 (23.72%) of the women's households have electricity, 1501 (84.52%) have a mobile phone. The majority of the women in our sample delivered in hospitals (N 1<unk>4 1388, 78.02%). Of the women who participated in the exit survey, 1532 (86%) consented to participate in the community followup survey and had a complete exit survey. A simple random sample of 60% of these women was selected for follow-up, of which 782 (85.46%) were eligible for participation; 14.54% were not eligible due to logistical constraints. Of those eligible, 593 (75.83%) were interviewed. Ninety-five per cent of the women were interviewed within 8 weeks after delivery discharge. Although no significant differences were found in background characteristics, health facility factors or delivery experience comparing the full exit sample to the community follow-up subsample, there was a significant decrease in satisfaction with delivery and quality of care from exit to follow-up (Table 1). Overall, more disrespectful and abusive treatment was reported on follow-up than on exit. Nearly one in five women (N 1<unk>4 343, 19.48%) reported any disrespectful and abusive treatment during their childbirth experience on exit and 167 women (28.21%) reported any disrespect and abuse on followup (Table 2). The most commonly reported experiences of disrespect and abuse were shouting or scolding (N 1<unk>4 153, 8.71% on exit; N 1<unk>4 78, 13.18% on follow-up), ignored when needed help (N 1<unk>4 139, 7.93% on exit; N 1<unk>4 84, 14.24% on follow-up) and threatening or negative comments (N 1<unk>4 93, 5.28% on exit; N 1<unk>4 68, 11.54% on follow-up). Chi-square tests showed significant increases in the reporting of disrespect and abuse on follow-up compared with exit for our measure of disrespect and abuse (P 0.001), and the categories of non-dignified care (P 0.001), neglect (P 0.001), physical abuse (P 1<unk>4 0.012) and inappropriate demands for payment (P 1<unk>4 0.042). The specific experiences of disrespect and abuse that significantly increased from exit to follow-up were shouting or scolding (P 1<unk>4 0.002), threatening or negative comments (P 0.001), ignored when needed help (P 0.001) and physical abuse (P 1<unk>4 0.004). Table 3 shows results from separate multivariable logistic regression models with any experience of disrespect and abuse on exit and on follow-up as the outcomes of interest. Full data for analysis were available for 1613 women on exit and 546 women on follow-up. On exit, women who attended secondary education or greater (OR: 1.34, 95% CI: 1.05-1.71), those with a first birth (OR: 1.26, 95% CI: 1.00-1.59), those who reported low mood in the last 12 months (OR: 1.27, 95% CI: 1.00-1.62) and those who reported ever being physically abused or raped (OR: 2.29, 95% CI: 1.44-3.64) were more likely to report experiences of disrespect and abuse and women who were married were less likely to report experiences of disrespect and abuse (OR: 0.72, 95% CI: 0.58-0.89). In terms of delivery experience factors, women who reported that they had any complications during delivery (OR: 1.69, 95% CI: 1.29-2.22) and who stayed in the facility for delivery for less than 1 day (OR: 1.35, 95% CI: 1.07-1.70) were more likely to report experiences of disrespect and abuse, whereas women who came directly to the facility (OR: 0.51, 95% CI: 0.42-0.60) for delivery were less likely to experience disrespect and abuse. In the follow-up survey, women who had four or more births (OR: 0.58, 95% CI: 0.39-0.87) and those with Caesarean sections (OR: 0.66, 95% CI: 0.51-0.86) were less likely to report any experiences of disrespect and abuse. Poor women (OR: 1.80, 95% CI: 1.31-2.47) and those who reported low mood at the time of the exit interview (OR: 1.62, 95% CI: 1.23-2.14) were more likely to report any experiences of disrespect and abuse on follow-up. Similar to exit data, women who attended secondary education or greater were more likely to report disrespect and abuse (OR: 1.48, 95% CI: 1.10-1.98). --- Discussion We found that 19% of women interviewed immediately postpartum reported experiencing at least one form of disrespectful or abusive treatment during facility delivery in northeastern Tanzania with the frequency rising to 28% 5-10 weeks after delivery. The most commonly reported incidents in both waves were being ignored when they needed help, shouting and scolding and negative comments. Between 3% and 5% of women reported being slapped or pinched and 4-5% of women reported delivering alone. These figures are some of the first systematic measures of abusive practices in health facilities and indicate a worrisome picture of the quality of care for Tanzanian women in labour and delivery. They confirm findings of the qualitative literature in the field (Moyer et al. 2014). The reported frequency of disrespect and abuse varied by time of the interview. Reporting was substantially higher in the community survey 5-10 weeks after delivery than in the exit survey done on facility grounds. This may be due to courtesy bias-reluctance to disappoint researchers by giving negative ratings, particularly if the interviewers are perceived to be associated with the clinic. Despite reassurance from the research team, women may also have been concerned that providers would learn of their responses. Women's perception of their birth experience also changes over time. Although newly discharged mothers are likely to be relieved to have given birth safely and may feel grateful to the facility, they may re-evaluate their experience in subsequent weeks. They may also be more inclined to share negative delivery experiences in their own home than on health facility grounds. On the other hand, women may have poorer recall of specific incidents at 5-10 weeks. Although it is possible that there was upward bias in reporting disrespect and abuse on follow-up due to hearing the questions a second time, we do not believe this was large as frequency of reporting of related variables did not similarly rise. Indeed women's overall satisfaction and quality ratings for the delivery declined over time-nearly twice as many women reported only fair or poor quality on follow-up as on exit survey. This finding is consistent with higher frequency of disrespect. Other studies have documented a lower level of satisfaction with facility care in household surveys compared with exit questionnaires (Glick 2009). Three items in particular were reported much more frequently in the community follow-up than on exit: being ignored, threatening or negative comments and slapping or pinching. Of these, the first two are more general in nature. In a study of the reliability of patient reporting of hospital medical errors, Bjertnaes and colleagues (2013) found that more general items, such as staff forgetting to convey important information, had lower test-retest reliability than more specific questions such as receiving a wrong diagnosis-i.e. were prone to be reported with different frequencies over time. Future qualitative research should explore how women's assessments of care, including disrespectful or abusive care, evolve over time. Women with secondary education were more likely to report disrespect and abuse in both waves of data. This is likely due to a combination of higher expectations of care quality and greater empowerment to report abuse. Self-reported depression in the year prior to delivery increased the frequency of reporting disrespectful treatment during labour in both the exit and follow-up interviews. In the second wave, poor women (in the lowest 40% of wealth) were nearly twice as likely to have experienced disrespect, possibly due to class-based discrimination and providers' belief that poor women have less power and thus less recourse to the complaint process (Fonn et al. 2001). Other research concurs that poor patients receive lower quality of care (Mamdani and Bangser 2004). Having four or more children reduced the likelihood of reporting disrespect, potentially indicating quicker and easier deliveries and/or greater resistance to or normalization of abusive remarks or behaviour. Similarly, delivery by Caesarean section, in which the woman received anesthesia and thus has less pain during delivery reduced the odds of disrespect. Providers have greater control over timing and setting of Caesarean section births and may perceive these cases as more serious, therefore behaving more professionally with the patient. Further, in one of the study hospitals, women receiving Caesarean section were permitted a companion at their bedside and this may also have reduced the probability of poor treatment. Several other variables were significantly associated with disrespect and abuse in the exit survey. For example, women with first births and those who reported complications reported more disrespect and abuse. This may reflect anxiety about the birth experience as well as a greater need for care from providers who may have resented the demands and consequently were disrespectful. Coming directly to the facility was associated with lower disrespect because referrals and/or delayed arrivals may have created administrative and clinical challenges for providers. Negative attitude among medical staff towards unmarried pregnant women may explain why married women were less likely to have experienced disrespect than unmarried women. Finally, previous history of abuse or rape doubled the odds of reporting disrespect. These women may have been extremely sensitized to abusive behaviour or projected vulnerability to providers. This study had several limitations. First, our assessment relied on self-report, and thus does not provide an 'objective' measure of the frequency of poor and abusive care in facilities. This is particularly the case in settings such as this one where disrespectful care is to some degree normalized. However, given that the negative consequences of disrespect and abuse for women are mediated by their own view of what is abusive, a self-reported measure is appropriate. Second, our choice of 'any disrespect and abuse' to measure frequency limits our ability to compare severity of the abuse among women. Adding up the incidents of abuse, a potential alternative measure, was not possible as several of the items, such as shouting and negative comments, overlapped and may have represented a single incident. In any case, even a single episode signals a potentially abusive environment. Third, budget constraints prevented us from having a larger community sample, which would have provided greater precision of estimates and more power to discern associations. Fourth, our regression analysis of factors associated with abuse is cross-sectional and reverse causation is possible. However, this is unlikely for the majority of predictors clearly preceded the delivery in time (age, parity and wealth). One potential exception is low mood, which may have been influenced by abuse although it was asked for the 12 months preceding birth. Fifth, our analysis does not include provider or health system characteristics and thus does not address systemic drivers of disrespect. Provider level was not apparent to women and over 96% of providers were women, limiting variability. Other provider characteristics, including motivation were beyond the scope of this analysis. Future research should explore provider and facility level factors as contributors to disrespect and abuse. Finally, the results we found are specific to the health system and demographic and cultural context of northeastern Tanzania and cannot be generalized to other areas. Similarly, the majority of study participants delivered in hospitals limiting inference to lower-level centres. In summary, our finding that between 19% and 28% of women in a rural region of Tanzania experienced abuse or disrespect during facility delivery shows a health system in crisis. Abuse during childbirth is a fundamental abrogation of a woman's human rights and may have far reaching consequences for her mental health, future health care utilization and community trust in the health system (Gilson 2003). Further, given the generally poor quality of obstetric care and the attendant normalization of harsh or neglectful treatment in this setting, this may be an underestimate of the true prevalence of abusive treatment. Although our study reflects a particular context, other low-income countries face similar challenges with health system underfunding, worker shortages, low motivation and high burnout. Qualitative literature confirms that women encounter similar treatment elsewhere (d'Oliveira et al. 2002;Bowser and Hill 2010). One key implication of our findings is that efforts to increase facility delivery must address disrespect and abuse to ensure higher utilization by women and to safeguard women's fundamental rights during facility delivery. These results are a call to action. The ultimate aim of any reform is to stop abusive treatment by making abusive behaviour unacceptable to women, providers, health system managers and policymakers. Suggested interventions include strengthening accountability through legal redress, citizen participation on hospital management boards, client health care charters, improving the quality of the work environment for providers, training and introduction of care standards (Misago et al. 2001;Bowser and Hill 2010). Although we are assessing the feasibility of several of these approaches in this study, more research is urgently required to understand the deeper dynamics of power that drive disrespect and abuse and to learn how the care environment in low-resource settings can be fundamentally and lastingly changed. However, action should not await more research findings but be pursued in concert with research to ensure that best practices can be rapidly scaled. Until we do so, women will continue to be deterred from delivering in facilities and those who do will risk sacrificing their dignity in the process. --- Conflict of interest statement. None declared.

Although qualitative studies have raised attention to humiliating treatment of women during labour and delivery, there are no reliable estimates of the prevalence of disrespectful and abusive treatment in health facilities. We measured the frequency of reported abusive experiences during facility childbirth in eight health facilities in Tanzania and examined associated factors. The study was conducted in rural northeastern Tanzania. Using a structured questionnaire, we interviewed women who had delivered in health facilities upon discharge and re-interviewed a randomly selected subset 5-10 weeks later in the community. We calculated frequencies of 14 abusive experiences and the prevalence of any disrespect/abuse. We performed logistic regression to analyse associations between abusive treatment and individual and birth experience characteristics. A total of 1779 women participated in the exit survey (70.6% response rate) and 593 were re-interviewed at home (75.8% response rate). The frequency of any abusive or disrespectful treatment during childbirth was 343 (19.48%) in the exit sample and 167 (28.21%) in the follow-up sample; the difference may be due to courtesy bias in exit interviews. The most common events reported on follow-up were being ignored (N ¼ 84, 14.24%), being shouted at (N ¼ 78, 13.18%) and receiving negative or threatening comments (N ¼ 68, 11.54%). Thirty women (5.1%) were slapped or pinched and 31 women (5.31%) delivered alone. In the follow-up sample women with secondary education were more likely to report abusive treatment (odds ratio (OR) 1.48, confidence interval (CI): 1.10-1.98), as were poor women (OR 1.80, CI: 1.31-2.47) and women with self-reported depression in the previous year (OR 1.62,. Between 19% and 28% of women in eight facilities in northeastern Tanzania experienced disrespectful and/or abusive treatment from health providers during childbirth. This is a health system crisis that requires urgent solutions both to ensure women's right to dignity in health care and to improve effective utilization of facilities for childbirth in order to reduce maternal mortality.

Introduction More than one-third (35%) of women worldwide have experienced physical and/or sexual violence at some time in their lives, with intimate partner violence (IPV) being the most common form of violence, which indicates perpetrators are current or former intimate partners (World Health Organization, 2012, 2013). IPV against women has been globally recognised as a severe challenge to women's health, safety and equity, with a lifetime prevalence ranging from 23.2 to 37.7% (Garc<unk>a-Moreno et al., 2013). Specifically, the prevalence of IPV during the perinatal period ranges from 1 to 35% worldwide, and can result in several significant adverse physical, psychiatric and neurological health problems for women and newborns (Gazmararian et al., 2000;World Health Organization, 2002, 2013;Garc<unk>a-Moreno et al., 2005;Devries et al., 2010;Shah and Shah, 2010;Alhusen et al., 2015;Halim et al., 2017). Due to cultural barriers, scholars have overlooked IPV in China for decades. There are few studies reporting the prevalence of IPV against women during the perinatal period, with no national data available. The most recent meta-analysis included all 13 published studies in this area among Chinese population, and reported the overall prevalence of IPV during pregnancy was 7.7%; furthermore, none of these studies investigated the impact of IPV on the trajectory and the prognosis of perinatal depression (PND) (Wang et al., 2017). Among the health outcomes of IPV during the perinatal period, PND is one of the most common long-term chronic health outcomes and a growing public health concern. This is due to two reasons. Depression is the sixth largest contributor to the global burden of disease among females aged from 15 to 45 years old (Institute for Health Metrics and Evaluation, 2018). Also, PND is often underdiagnosed and can result in a series of adverse outcomes for women, children and families (Campbell, 2002;Bansil et al., 2010;Alhusen et al., 2015;Allbaugh et al., 2015;Halim et al., 2017). The prevalence of PND varies from 7 to 25% during the antepartum period and 10 to 20% during the postpartum period (Leung and Kaplan, 2009;Gelaye et al., 2016). Comparing with the general female population, the prevalence of PND was higher among IPV victims ranging from 15 to 79.2% (Leung et al., 2002;Cerulli et al., 2011;Islam et al., 2017). Many studies that have been conducted are cross-sectional and make it difficult to assess the causal relationships between IPV and PND. Further, both have similar adverse health outcomes, including miscarriage, preterm delivery, antepartum haemorrhage and low birth weight (Bansil et al., 2010;Beydoun et al., 2010;Alhusen et al., 2015;Doyle et al., 2015;Jackson et al., 2015;Finnbogadottir et al., 2016;Halim et al., 2017). Recent studies among PND patients have revealed that the trajectory of symptoms will alleviate over time (Ahmed et al., 2018;Drozd et al., 2018). Of note, the trajectory of PND refers to the longitudinal pattern of PND. However, it is not clear whether IPV victimisation will interfere with the natural prognosis of PND, which might be overlooked during treatments. Hence, we designed this study to test two hypotheses: (1) pregnant women who have experienced IPV will exhibit more severe PND symptoms than women without any IPV experiences; (2) IPV experience will impede the recovery prognosis of PND. We also explored the contribution of IPV to PND comparing with other risk factors. --- Methods Data for this study come from a larger cohort study intended to develop a prediction model for PND in Hunan Province, central south of China. --- Sample and sampling From September 2016 to February 2017, the parent study recruited pregnant women by convenient sampling from two maternal and child health care hospitals in Changsha City, the capital city of the province, and Yiyang City, a less economically developed area of Hunan (Hunan Bureau of Statistics, 2018). In the recruiting period, interviewers invited all pregnant women, who showed up at the obstetrical clinic of each hospital, to participate in the study. Once provided oral consent, interviewers would further screen for the eligibility, and the inclusion criteria were: (1) being 18 years old and above; (2) being within 13 weeks of gestation; (3) planning to take antenatal and postpartum examinations and care in the two hospitals; and 4) providing written consent and agreeing to participate in the follow-up interviews. All participants participated voluntarily without receiving any financial or treatment incentives. We excluded women who showed severe pregnancy complications or any severe mental/cognitive problems that would impede them finishing the survey, including schizophrenia, paranoia, autism, dementia and mental retardation. We also excluded participants who did not provide information on their IPV experiences for this analysis. --- Procedure According to the Code of National Basic Public Health Service of China, maternal and child health care hospitals are required to provide perinatal examinations for pregnant women seven times: any time before the gestational week 12, during the gestational week 16-20, 21-24, 28-36 and 37 to 40, any time in the postpartum week 1 and week 6 (National Health and Family Planning Commission of People's Republic of China, 2017). Therefore, the parent study used seven time points for data collection -T1 (baseline): when participants came to the hospitals for their first antenatal examinations (gestational week 4-12), T2 (gestational week 17-20), T3 (gestational week 21-24), T4 (gestational week 31-32), T5 (gestational week 35 till delivery), T6 (day 7 after delivery) and T7 (week 6 after delivery). Once the participants provided written consent, experienced and well-trained nurses would help participants complete the survey. When participants finished the survey, nurses would check if all required fields had been completed and remind participants to complete the missing items before participants left unless they refused. --- Assessments As the surveys were completed after medical examinations coupled with the length of questionnaires, the parent study collected different information, except PND, which was measured seven times, at different time points to save participants' time and reduce stress. The content of assessments at each time point is showed in Table 1. The self-reported questionnaires collected sociodemographic information including age, education, monthly income, family structure, first pregnancy, abortion history, smoking, drinking, the satisfaction of current relationship, and partners' age, education and monthly income at the T1. We adopted three items from the victimisation subscale of the Short Form of the Revised Conflict Tactics Scale (CTS2S, Chinese version, 2014) to investigate participants' IPV experience at T3, which shows good reliability and validity (Straus and Douglas, 2004;Zhang et al., 2014). Considering IPV is still seen as private conflicts which should be discussed within the family, and it may increase tension between participants and research staff, we first embedded the items in the Brief Resilience Scale (BRS), and then added positive relationship statements to increase comfort during the survey, for example: 'He accompanies me to do the gestational examination and shows great attention to my test results'. We used one item for physical violence ('my partner punched or kicked or beat-me-up'), one item for psychological violence ('my partner insulted or swore or shouted or yelled at me') and one item for sexual violence ('my partner used force to make me have sex, or my partner insisted on sex when I did not want to or insisted on sex without a condom'). Considering the CTS2S does not investigate a common form of psychological violence in China, known as the 'cold violence' or the coldshoulder from partners (Wu et al., 2005), we used the statement'my partner used to ignore me or pay no attention to me for a long time'. Participants who endorsed any of the four items were considered to be IPV victims. We used the Mandarin version of the Edinburgh Postnatal Depression Scale (EPDS), which has shown great reliability and validity in screening for depressive symptoms in the perinatal period, to explore participants' PND symptoms at each study time point (Cox et al., 1987;Murray and Cox, 1990;Evins and Theofrastous, 1997;Lee et al., 1998;Gibson et al., 2009;Lau et al., 2010;Shrestha et al., 2016). The total score ranges from 0 to 30, and a higher score indicates a higher severity of PND symptoms. The Cronbach's <unk>s were 0.77, 0.81, 0.81, 0.82, 0.83, 0.84 and 0.85, respectively. We used the BRS to explore participants' ability to recover from stress at T3, which consists of three positive statements and three negative statements (Smith et al., 2008). The total score ranges from 6 to 30, and a higher score indicates a better ability to recover from stress. The Cronbach's <unk> was 0.75. We employed the Simplified Coping Style Questionnaire (SCSQ) to explore participants' coping strategies for dealing with daily stress at T4, developed in China, measuring positive and negative coping (Xie, 1998). The mean score of each subscale indicates the tendency to use the coping strategy, a higher score indicating a higher tendency. The Cronbach's <unk> was 0.84. Participants answered the Social Support Rating Scale (SSRS) to explore their social support at T5, which was developed and widely used in China with great reliability and validity and was consisted of objective social support, subjective social support and the utilisation of social support subscales (Xiao, 1993;Liu et al., 2008;Su et al., 2009;Xie et al., 2009). The total score ranges from 12 to 66 with a higher score indicating a higher level of social support. The Cronbach's <unk> was 0.88. --- Statistical analysis In this study, we analysed data with R (version 3.5.1) and we set the statistical significance at 0.05 (R Core Team, 2013). --- Primary analysis The primary analysis compared the trajectory of PND symptoms between participants with and without IPV victimisation experience. Because the perinatal examination services were not mandatory, pregnant women might not attend examinations during the perinatal period or visit other service providers. As a result, there was some missing data. We conducted a pilot analysis to compare sociodemographic characteristics between participants with and without missing data in EPDS, and the results indicated there were no sociodemographic differences, including IPV experience, between the two groups of participants. Hence, if a participant's EPDS score was missing in the follow-ups, we would complete it with the LOCF (last observation carried forward) method (Overall et al., 2009). First, we conducted one-way ANOVA to compare the EPDS scores at each time point between IPV victims and non-victims; we also conducted mixed-model ANOVA to compare the differences between the two groups as a repeated measurement. To compare the trajectories between IPV victims and non-victims, we conducted Linear Mixed-effects Model analysis. We applied the R package 'psych', 'lm4' and 'lmerTest' to perform analysis (Bates et al., 2015;Kuznetsova et al., 2017;Revelle, 2017). --- Secondary analysis The secondary analysis explored the contribution of IPV to PND controlling for other associated factors. The dependent variable was repeated measured EPDS score; the independent variables were IPV experience, resilience, coping skills and social support. If there were any missing values of the BRS, the SCSQ and the SSRS, we would impute the missing score with the mean score of each scale. The covariates were participants' and their partners' ages and education levels ( junior high and below, high school, Bachelor's degree and master's degree and above). We also included both parties' monthly income (no income, $0.15-$298.36, $298.51-$745.90, $746.05-$1491.80 and <unk>$1491.95), family structure (nuclear family, stem family with parents-in-law, stem family with parents, living alone and others), first pregnancy, abortion history, smoking and drinking history, and the satisfaction of current relationship (satisfied, OK and not satisfied). We used the Generalised Estimating Equations (GEE) Model to explore the contributions of factors to the trajectory of PND by R package 'geepack' (Halekoh et al., 2006). We conducted univariate GEE analysis first, and then conducted multivariate GEE analysis with the factors of significance in the univariate analysis. We chose the Quasi-likelihood under Independence Model Criterion (QIC) as the goodness of fit to assess models, and a smaller value of QIC indicated a better model (Cui, 2007). We calculated the generalised variance inflation factor (GVIF), the GVIF<unk>(1/2*Df) value of 2 and above indicating the multicollinearity problem (Fox et al., 2007). Odds ratios (ORs) and 95% CIs were estimated to determine the associations between factors and the trajectory of PND symptoms. --- Descriptive analysis To compare the characteristics of IPV victims and non-victims, we conducted one-way ANOVA for continuous variables (age, social support, resilience and coping skills), <unk> 2 test for categorical variables (education, income, first pregnancy, abortion history, smoking, drinking, satisfaction of current relationship and family structure) and Fisher's exact test if needed. Descriptive analysis was conducted by R package 'psych' (Revelle, 2017). (No.CTXY-140002-2). During analysis, we utilised de-identified data. In this study, nurses would immediately calculate the EPDS score and check for IPV experience after the survey at each time point. At any time, if participants received a total score <unk>9 indicating a high risk for depression, we would explain the result and help them transfer to a local psychiatrist. Meanwhile, if participants showed any IPV experience, we would provide and explain printed materials, including a list of helpful resources and contact information, manuals of utilizing these resources and an introduction of IPV. --- Results The parent study recruited 1126 participants, with 813 participants (72.2%) eligible for this study. Participants aged from 20 to 46 years, with a mean of 30.78 <unk> 4.39 years. A total of 550 participants (67.65%) had received bachelor's degree and above; 395 participants (48.59%) had monthly income ranged from $298.51 to $745.90; 576 participants (70.85%) claimed this was not their first pregnancy; and among the 578 participants who had provided abortion history information, 407 of them (70.42%) had an abortion before. There were 31 (3.81%) and 66 (8.12%) participants who reported smoking and drinking, respectively. The score of BRS ranged from 6 to 29, with a mean of 18.59 <unk> 2.12. In the SCSQ, the score of positive coping ranged from 0 to 36, with a mean of 24.30 <unk> 5.56; and the score of negative coping ranged from 0 to 24, with a mean of 9.79 <unk> 3.86. The score of SSRS ranged from 13 to 60 with a mean of 43.50 <unk> 6.20. There were 660 participants (81.18%) that reported satisfaction with their current relationship and 326 participants (40.10%) were living in a nuclear family. The age of participants' partners ranged from 18 to 48 years, with a mean of 30.78 <unk> 5.01 years. Among participants' partners, 522 of them (64.12%) had received a bachelor's degree and above; 352 of them (43.42%) had monthly income ranged from $298.51 to $745.90. See Table 2 for details. --- Intimate partner violence experience Overall, 90 participants reported IPV experience in the past 12 months, with a prevalence of 11.07% (90/813). For physical, psychological and sexual violence, the prevalence was 4.55% (37/813), 9.23% (75/813) and 2.34% (19/813), respectively. Comparing with non-victims, we found victims were older (32.21 <unk> 4.39 v. 30.73 <unk> 4.37 years) and their partners were also older (31.68 <unk> 5.12 v. 30.67 <unk> 4.99 years). The prevalence of firsttime pregnancy was lower in victims (13.64 v. 29.28%). Victims had lower scores in the BRS (18.32 <unk> 2.42 v. 18.62 <unk> 2.08) and in the positive sub-scale of the SCSQ (22.82 <unk> 5.98 v. 24.49 <unk> 5.48). They also had higher scores in the negative sub-scale of the SCSQ (10.72 <unk> 4.49 v. 9.68 <unk> 3.76), indicating less resilience to stress and were more likely to adopt negative strategies. Victims had lower social support levels than non-victims (39.74 <unk> 8.10 v. 43.93 <unk> 6.74). See Table 2 for details. --- Perinatal depression symptoms and the trajectories Among all participants, the mean score of EPDS decreased from T1 to T6, and then slightly increased at T7. The mean scores of EPDS were 8. 60, 8.22, 7.99, 7.90, 7.87, 7.26 and 7.60, respectively. The mixed-model ANOVA analysis did show the victims had higher scores on the EPDS than non-victims at all time points (F = 28.11, p <unk> 0.01), indicating a higher level of depression symptoms through the whole perinatal period. See Table 3. For victims, the mean score of EPDS increased from 10.00 at T1 to 10.66 at T3, then decreased to 8.82 at T6, and eventually increased to 9.21 at T7. For non-victims, the mean score of EPDS showed a similar trajectory over time points that decreased from 8.43 at T1 to 7.07 at T6 and slightly increased to 7.41 at T7. We compared the trajectories of PND between victims and non-victim, and the result showed that the trajectories were significantly different between the two groups of pregnant women (t = 5.30, p <unk> 0.01). The decreasing slope for victims' PND trajectory was slower than non-victims' (t = 28.89, p <unk> 0.01) (Fig. 1). --- The trajectory of PND and associated factors In univariate analysis, participants' age, education, social support, coping skills, their partners' age and monthly income, and IPV experience were associated with the trajectory of PND with p <unk> 0.05 (Table 4). We included these factors in the multivariate analysis (Model 1). Results showed that participants' age and education, and their partners' age were not significant with a QIC of 5443. Hence, we excluded these covariates in Model 2, and the results showed the remaining factors were all significantly associated with PND and the QIC was 5423 (Table 5). The values of GVIF<unk>(1/2*Df) for IPV experience, social support, positive and negative coping skill, and partner's age and monthly income were 1.03, 1.01, 1.04, 1.16, 1.17 and 1.06, respectively, indicating a good model fitness. We found that if social support and the incline of using positive coping strategies increased 1 unit, pregnant women would have 0.93 (OR = 0.93; 95% CI 0.88-0.97) and 0.85 times (OR = 0.85; 95% CI 0.80-0.91) the risk to have PND symptoms, respectively. Comparing with pregnant women whose partners had no monthly income, when their partners had monthly income ($0.15-$298.36), they had 0.0075 times the risk to have PND symptoms (OR = 0.0075; 95% CI 0.00052-0.11). Contrarily, if the incline of using negative coping strategies increased 1 unit, pregnant women would have about 1.25 (OR = 1.25; 95% CI 1.14-1.37) times the risk to have PND symptoms; and if having any IPV experiences, pregnant women would have 3.78 times (OR = 3.78; 95% CI 1.39-10.26) the risk to have PND symptoms. --- Discussion To our knowledge, this is the first study in China to recruit a cohort of pregnant women to explore the impact of IPV on the trajectory and prognosis of PND symptoms. In this study, we reported the prevalence of IPV was 11.07% in the past 12 months, and the prevalence of physical, psychological and sexual violence was 4.55, 9.23 and 2.34%, respectively. We also reported that IPV experience was positively associated with the severity of PND symptoms; victims exhibited more severe PND symptoms and recovered more slowly from PND symptoms than non-victims. The reported overall prevalence of IPV was lower than most of the previous studies during the perinatal period which ranged from 16.8 to 22.6% in Tianjing, Liaoning, Henan and Shannxi Province, but it was higher than the reported prevalence of 6.4% in Guangdong (Fan et al., 2006;Wu et al., 2006). Currently, IPV during perinatal period is not well understood in China, given the limited number of studies and a wide range of reported prevalence. The prevalence rate variation can be explained by regional cultural beliefs that lead to different 4 Fengsu Hou et al. Epidemiology and Psychiatric Sciences understandings of IPV, inaccurate reporting, non-unified surveys that vary in sensitivity and reliability, and limited samples. Meanwhile, due to the lack of a standardised treatment protocol for IPV among health providers in China, IPV remains a very sensitive topic for both health providers and potential victims. There is a mutual hesitancy to discuss or disclose IPV. Hence, caution is warranted in interpreting these findings. We believed the elevated EPDS scores among victims illustrated the psychological impact of IPV (Campbell and Lewandowski, 1997;Campbell, 2002;Devries et al., 2013), and indicated the traumatic experience was a risk factor for PND symptoms. Consistent with previous studies, we found victims were nearly four times likely to have more severe PND symptoms (Bonomi et al., 2009;Ludermir et al., 2010;World Health Organization, 2011;Melo et al., 2012). In this study, the trajectory of PND symptoms decreased from being pregnant to delivery and then increase after delivery regardless of IPV experience, which was consistent with trajectory analyses of PND (Mora et al., 2008;Christensen et al., 2011;Ahmed et al., 2018). Meanwhile, victims showed more severe depressive symptoms and a slower prognosis of PND symptoms. Because the prognosis could only be observed through multi-metering at different times, evidence from cross-sectional studies would overlook the impact on the perinatal period; before, during and after the birth. Thus, this study provides valuable insights for clinicians that they should consider not only the possible bidirectional causal associations between IPV experience and PND but also the impact of IPV on the duration and outcomes of PND symptoms when victims' symptoms recover more slowly than non-victims. We noticed an increase of PND symptoms from T1 to T3 followed by a decline till T6 among victims. To explain this peak at T3 when we investigated IPV experience, we reviewed the survey procedure and confirmed participants completed the EPDS before IPV items, which excluded distress caused by the re-experience of victimisation. Combining these findings, we suspect an IPV experience would worsen pregnant women's PND symptoms. This suggests it is important to screen women with PND for victimisation during perinatal examinations, especially at T3, and then to provide interventions targeting IPV. This, in turn, may improve victims' mental health to the utmost. We found a higher level of social support was associated with less severity of PND symptoms. According to the Buffer Theory, social support plays a protective role in everyday life that buffers the stress or impact of adverse events (Cassel, 1976;Cochrane and Stopes-Roe, 1981;Schaefer et al., 1981). Our previous studies reported the perceived/subjective social support played a more important role in preventing depression over other dimensions of social support; and, overall, social support protected Chinese women from IPV, which could indirectly protect women from PND (Hou et al., 2015(Hou et al.,, 2018)). We believe that a specific cultural tradition that starts right after delivery and lasts for 1 month, known as 'zuo yue zi' or 'doing the month', increases women's social support. The tradition requires new mothers to be confined for 1 month for recovery. The new mother becomes the focus of the whole family and must avoid showering, catching a cold, eating cold food, doing housework (even taking care of the newborns except breast feeding), outdoor activities and should strictly stay in bed and take as much rest as possible. Women also follow the traditional Chinese medicine diet instructions (Holroyd et al., 1997;Raven et al., 2007). Hence, during this tradition, women could receive relief, satisfaction and joy that buffer depressive symptoms; meanwhile, the family's help in daily affairs and being the focal point would increase perceived and instrumental social support, which also buffers depressive symptoms. This may explain the lowest EPDS score during the first postpartum week. However, this tradition also isolates women from daily social interactions and reduces their activities, which could lead to the deterioration of social network and physical functions at the late stage of 'zuo yue zi'. When this tradition ends, new mothers would take care of the newborns and prepare to return to work, which may lead to the increased depressive symptoms at postpartum week 6. We did not explore the relationship between this tradition, IPV and PND in the current study. The relationship between 'zuo yue zi' and IPV has not been reported anywhere yet, and it is a common Chinese cultural tradition. We plan to explore our hypothesis of 'zuo yue zi' and PND in the future, and we encourage other researchers to explore this as well. We found victims were inclined to use negative coping skills that were positively associated with PND symptoms. Women with PND were inclined to use non-adaptive/negative coping strategies to deal with stress during perinatal period, including avoidance, distancing, denial, self-blame, substance use and behavioural disengagement. These strategies were associated with the health outcomes of IPV experience, especially PTSD, depression, substance use and re-victimisation in return (Kocot and Goodman, 2003;Faisal-Cury et al., 2004;Pakenham et al., 2007;Iverson et al., 2013;Flanagan et al., 2014;Gutiérrez-Zotes et al., 2016;Azale et al., 2018). Thus, we believe coping skills would not only interfere with IPV experience and its health outcomes, but also with stress and depressive symptoms. Pregnant women with partners who had no income in this study were more likely to develop higher levels of PND symptoms, similar to studies in the general population that showed lower household income was positively associated with depression (Kahn et al., 2000;Lorant et al., 2007;Pan et al., 2008). We interpret a partner with no income as unemployed or doing housework, and under this circumstance, pregnant women would perceive severe financial stress for household finances during the perinatal period and in the long term. Of note, the imbalance of income between couples and poverty was a risk factor of IPV (Jewkes, 2002;World Health Organization, 2010); thus, financial stress could indirectly lead to PND. Further, there were 16 pregnant women with partners who had no income, and 14 of them did not have income either. The 14 participants were younger (28.43 <unk> 3.82 v. 30.83 <unk> 4.38), less educated and had lower social support (38.86 <unk> 7.50 v. 43.57 <unk> 6.17) than the rest of the participants. Unfortunately, we believed the sample size of couples that had no income was too small to explore the impact on IPV and PND. We encourage future research to focus on this marginalised group of pregnant women regarding their mental health, IPV experiences as well as the relationship dynamics within the couple and its impact on both physical and mental health. --- Limitations We recognise that there are a few study limitations worth noting. First, during recruiting, the study did not record how many pregnant women we have approached and how many of them refused to participate in the screen for eligibility. Hence it was difficult to estimate the representativeness of the sample compared with the population that the two hospitals served. Second, over two-thirds of the participants and their partners received a bachelor's degree or higher, which were higher than the average education level in China. Higher education level is associated with a lower risk for IPV experience that, in return, may have an impact on the results. Third, the parent study designed the follow-up time length from pregnancy until 42 days postpartum. However, we could not observe IPV's impact on the peak time of postpartum depression which was 2-3 months after delivery (Stuart-Parrigon and Stuart, 2014). Fourth, because we collected IPV information at T3 (gestational week 21-24), we could not differentiate the impact of IPV that happened between T1 and T3 from that happened before pregnancy on the trajectory of PND. We could overlook both new and reoccurring victimisations from T3 to the postpartum period and underestimate the impact of IPV on PND symptoms. Thus, the results must be interpreted carefully. At last, we understand that participants can interpret follow-up surveys on depressive symptoms as caring about their feelings, which, in return, could serve as an intervention for PND, which might have an impact on the trajectories of PND for all participants. Thus, we encourage future longitudinal research to investigate the latent trajectories of PND among women who experience IPV before or during the perinatal period, to explore the relationship between victimisation and the peak of PND symptoms, and to understand the mechanism between IPV and PND eventually. Meanwhile, developing and applying a standardised universal screening tool for IPV through the whole perinatal period would benefit understanding the status in quo of IPV among pregnant women in China, which could lay the foundation for developing and implementing effective interventions. --- Epidemiology and Psychiatric Sciences --- Conclusion The findings suggest the reported prevalence of IPV is lower in Hunan than most of the previous studies during perinatal period in other provinces of China, and IPV victimisation is associated with increased severity and slowed prognosis of PND symptoms. Future studies that screen for victimisation and establish its explicit mechanism to the poorer prognosis of PND symptoms would benefit the prevention and treatment of PND. --- Data The data that this manuscript is based are not available to the public. The data from this study are under certain restrictions according to the National Natural Science Foundation Committee of China and always under the supervision of the principal investigator of the study. Thus, there are access restrictions to the data. However, at any time, researchers can contact the principal investigator (Wenjie Gong, [email protected]) for data sharing. --- Ethics The protocol including the written consent was reviewed and approved by the Ethics Committee of Central South University --- Epidemiology and Psychiatric Sciences Author contributions. FH conceived the idea of this paper, developed the plan for analysis, performed the statistical analysis and wrote the first draft. XZ provided expert knowledge on the statistical analysis and performed analysis. CC contributed to the conception of the analyses and provided expert knowledge on intimate partner violence. WH contributed to data clean and database management. YM implemented data collection and cleaned the data. WG initiated the project, designed and lead this study, monitored data collection and provided expert knowledge on perinatal depression. All authors contributed to the interpretation of data, revised the manuscript and approved the final version. Financial support. This project is funded by the National Natural Science Foundation Committee of China (Grant No.81402690 and 81773446). --- Conflict of interest. None. Ethical standards. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Aims. Intimate partner violence (IPV) is an important risk factor for perinatal depression (PND). But IPV's impact on the natural prognosis of PND symptoms is not well understood. We tested two hypotheses: (1) pregnant women with IPV experiences will exhibit more severe PND symptoms than women without IPV experience; (2) IPV experience will impede the recovery prognosis of PND. We also explored the contribution of IPV to PND comparing with other risk factors. Method. The sample is comprised of 813 pregnant women followed through perinatal period in Hunan, China. We assessed IPV experience using items from the Short Form of the Revised Conflict Tactics Scale (CTS2S), and PND symptoms via the Edinburgh Postnatal Depression Scale (EPSD). We conducted Linear Mixed-effects Model to compare the trajectories of PND symptoms between victims and non-victims and a multistage Generalised Estimating Equations Model to explore salient factors on the trajectory of PND symptoms. Results. There were 90 participants (11.07%) who reported IPV experience in the past 12 months. With respect to physical, psychological and sexual violence, the prevalence was 4.55% (37/813), 9.23% (75/813) and 2.34% (19/813). Victims reported more severe PND symptoms (t = 5.30, p < 0.01) and slower decreasing slope of trajectories (t = 28.89, p < 0.01). The PND trajectory was associated with IPV experience (OR = 3.78; 95% CI 1.39-10.26), social support (OR = 0.93; 95% CI 0.88-0.97), positive coping strategies (OR = 0.85; 95% CI 0.80-0.91), negative coping strategies (OR = 1.25; 95% CI 1.14-1.37) and monthly income of $0.15-$298.36 (compared to no income, OR = 0.0075; 95% CI 0.00052-0.11). Conclusions. The findings suggest the reported prevalence of IPV is lower in Hunan than most of the previous studies during perinatal period in other provinces of China, and IPV victimisation is associated with increased severity and slowed prognosis of PND symptoms. Future studies that screen for victimisation and establish its explicit mechanism to the poorer prognosis of PND symptoms would benefit the prevention and treatment of PND.

INTRODUCTION In the State of the Global Islamic Economy Index 2020/2021, Indonesia is recor ded in the 4th position as the world's producer of halal products with 91.2 points. Indonesia is not far adrift from other countries, namely Malaysia (290.2), Saudi Arabia (155.1), and the United Arab Emirates (133). Based on the 2020/2021 Global Islamic Economic Conditions Report, it presents data that Indonesia continues to develop in having a strong ecosystem to enable participation in the multi-trillion global Islamic economic market opportunity. Dr. H. Sapta Nirwandar as Chairman of the Indonesia Halal Lifestyle Center stated that this progress rests on the global Islamic economy in various sectors such as finance, food and beverages, pharmaceuticals, cosmetics, fashion, tourism and of course recreational media. In the midst --- 2 MABSYA: Jurnal Manajemen Bisnis Syariah, Vol 5 No 1 Tahun 2023 of a pandemic, of course, there are sectors that are getting tougher challenges, such as the tourism sector, some are relatively lightly affected, such as the food sector and even tend to be stable. Likewise, the technology and pharmaceutical sectors have increased quite rapidly. In this report, it is projected that most of the Islamic economic sectors will start growing again at the end of 2021 and even earlier. Therefore, Indonesia has a great opportunity to accelerate halal products and services, not only for domestic needs but als o has the opportunity to be able to go export. Halal in Arabic means "permissible", basically halal is a way of life and is not solely limited to the types of food that a Muslim is allowed to consume, although food is an important component needed to live a meaningful life. The point is that halal food is not only about the form of the food itself but also includes how to prepare it. The Law of the Republic of Indonesia Number 33 of 2014 concerning Halal Product Guarantee emphasizes that the halal concept includes food safety, cleanliness and integrity. Consideration of the place and process of the animals being slaughtered and most importantly, the condition of these animals will not endanger health becomes the main focus of what is Halal. As a Muslim, it is obligatory to eat halal and thoyib food, as mentioned in the Qur'an Surah An -Nahl ( 16) verse 114 which means: "So eat what is lawful and good from the sustenance that Allah has given you; and be grateful for the favor of Allah, if you worship only Him." The principle of halal is not only a religious obligation or observance, but is considered the standard of choice for Muslims as well as non-Muslims around the world. Empirically, it is found that non-Muslim communities have begun to pay great attention to the halal concept, even though the halal concept has not become the main element among non -Muslim consumers in Islamic countries. Golnaz, R et. al 2010 conducted a survey in the Klang Valley with 400 non-Muslim respondents interviewed through a structured questionnaire to gather information about their awareness and attitudes towards Halal food products in the Malaysian food market. The results of the study show that non-Muslim consumers are aware of the existence of halal food, halal principles and the advantages of halal animal slaughter. This can be proven by their significant awareness. Halal awareness is the initial key for a community group to realize the importance of the halal industry, so an analysis of the level of halal awareness is important to do. Pramintasari and Fatmawati (2017) conducted a sample study of 100 respondents with the conclusion that religious beliefs have a significant influence on halal awareness, the role of halal certification has a significant influence on halal awareness. Setyaningsih and Marwansyah (2019) conducted a study with the results of the analysis showing that halal certification and halal awareness have a positive effect on consumer decisions. Various studies have been developed to analyze variables or factors that affect halal awareness. Research on Halal awareness to buy food among non-Muslim consumers was also conducted by Bashir (2019) in an exploratory study with reference in Cape Town, South Africa. The study found that non -MABSYA: Jurnal Manajemen Bisnis Syariah, Vol 5 No 1 Tahun 2023 3 Muslim consumers in Cape Town have positive awareness about halal food, including its benefits and the production processes involved in producing it. The study also concluded that halal is not just a commercial name used as a trademark in the global market. However, halal has several dimensions; especially, for non-Muslim consumers, it is a sign of health and hygiene. By paying attention to the psychological aspect, halal is considered a sign of trust, comfort and safety. This makes consumers feel calm when they consume food products that are labeled halal. According to Kotler & Keller (2016) several factors that influence consumer behavior are cultural factors (culture), sub-culture (sub-culture), social class (social class) and social factors (social factors). ) small reference group (small reference group), family (family), roles & status (roles & statuses). The sociocultural perspective empirically contributes a lot in shaping the level of awareness of a community group on a concept, including in this case halal awareness which is currently starting to develop not only limited to Muslim community groups. The sociocultural group of Penginyongan people in western Central Java which includes the former Banyumas Residency, namely Banyumas, Cilacap, Banjarnegara, Kebumen, and Purbalingga. In addition to the former Banyumas Residency, this Penginyongan community group also appears in other areas that share the same culture, such as the Brebes, Tegal, Pemalang, Wonosobo, and Pekalongan areas. Ramadhan and Masykur (2018). The researcher considers the use of the term Penginyongan to be more appropriate to describe the sub-cultures that exist in the western part of Central Java. This is considered more representative of the people who come from the area so that it can provide a different perspective regarding the picture of the level of halal awareness there universally outside the context of the community in terms of religion. Hadiati (2014) in a study entitled Redefining Cablaka "Banyumasan Way of Speaking" states clearly that one of the differences between Penginyongan culture and other Javanese cultures lies in the way of speaking and speaking the language of the Penginyongan people themselves. It is also explained that all the characters that live in Penginyongan people can be seen in the way they speak and the language they use. Another characteristic of Penginyongan people is that they tend to be what they are. The Penginyongan community has a characteristic that is what it is, frankly, what it should be, without further ado, this refers to being forthright which is often referred to as the nature of cablaka. According to Priyadi (2007) cablaka is a character that is conveyed spontaneously by the Penginyongan human group to the phenomena that are in front of their eyes, without being covered up. The above sociocultural characteristics of penginyongan further add to the urgency of this research, where the cablaka penginyongan community is a factor for further research on the halal awareness side. On the other hand, the level of halal awareness is very m uch determined from the literacy level of the current community, so it is very important to conduct an analysis to compile a halal literacy index. Pratama and Hartati (2020) conducted a study with the results showing that partially and simultaneously halal literacy and religiosity --- 4 MABSYA: Jurnal Manajemen Bisnis Syariah, Vol 5 No 1 Tahun 2023 had a significant effect on the consumption of halal products for students of MKS UIN Sunan Gunung Djati Bandung. Halal literacy has been proven to have a significant role in influencing the behavior of compliance with Islamic law, especially halal orders (Salehudin, 2013). Therefore, it is important to conduct research on the level of halal awareness and halal literacy index in the sociocultural perspective of the Penginyongan community. Based on these problems, the level of consumer awareness of halal products is influenced by several factors, especially the sociocultural group of the Penginyongan community, the researcher focuses on conducting research related to the analysis of the level of halal awareness in the sociocultural group of the Penginyongan community from various perspectives of determinant factors in the form of religiosity (religious belief), awareness of healthy lifestyles (health consciousness), halal certification logos (halal certification), media exposure, and halal literacy (halal knowledge), where this research takes the title "Halal awareness and the Community Halal Literacy Index: Determinant Studies in the Sociocultural Context of Penginyongan.". --- LITERATURE REVIEW --- Previous Studies (Literature Review) Ambali and Bakar conducted a study on halal products or food in April and May 2012 with a sample of 210 Muslims in the city of Shah Alam, Selangor, Malaysia. The age of 18 years was selected using the convenience sampling method. The results of the study conclude that the important role of awareness about halal products in the lives of Muslims and their obligation to comply with Sharia, is a determinant of halal awareness. By using "Partial Least Square-SEM," the results of the study state that religious beliefs, media exposure of halal goods, halal logos, are determinants of Muslim awareness about the use and consumption of halal goods. Aziz and Chok (2013) conducted a study entitled The Role of Halal awareness, Halal Certification, and Marketing Components in Determining Halal Purchase Intention Among Non-Muslims in Malaysia: A Structural Equation Modeling Approach, concluding that halal awareness, halal certification, promotional marketing, and brand is positively related to purchase intention, while food quality is negatively associated. --- Relevant Theories a. Theory of Planned Behavior (TPB) as a Halal Awareness Formulation This study uses the theory of planned behavior (TPB; Ajzen, 1991) as the underlying theory to support the relationship between halal awareness and determinant factors in the form of religiosity (religious belief), awareness of a healthy lifestyle (health consciousness), halal certificate logo (halal certification), media exposure, and halal literacy (halal knowledge). TPB has been widely recognized and applied in food-related studies (Sparks & Shepherd, 1992;Verbeke & Vackier, 2004) and halal food studies (Bonne & Verbekem, 2008). According to TPB, there are three main components that influence human attitudes to behave. Its components are attitudes, subjective norms, and behavioral control. The TPB provides guidelines for predicting human social behavior. The most relevant component of TPB is attitude toward behavior. Furthermore, attitudes towards behavior, which stem from the belief in the collective behavior of the Penginyongan community such as the belief that the product is halal can lead to favorable attitudes such as having halal awareness which leads to the intention to buy halal food products. Subjective norms are, another function of beliefs, perceived as social pressures to engage or not engage in that particular behavior. --- b. Religiosity Religiosity Religion is a system of beliefs and practices in which a group of people interpret and respond to what they feel is supernatural and sacred (Johnstone, 1975). Most religions regulate or prohibit certain behaviors including consumption. Schiffman and Kanuk (1997) assert that members of religious groups differ in their decisions to eat, drink or use products influenced by their religious identity, orientation, knowledge and beliefs. --- c. Healthy Lifestyle Religious motives not only determine consumer awareness of halal products, but also health reasons related to religious identity, and the level of acculturation in whatever we consume daily (Bonne et al, 2007). Rice (1993) in Ambali & Bakar (2014) asserts that many diseases are caused by poor nutrition and unhealthy conditions from what is consumed every day. --- d. Halal Certificate Logo The application of halal certification and labeling is an effective means to facilitate consumers in determining the type of halal food. According to LPPOM, 2019b the MUI Halal Certificate is a written fatwa of the Indonesian Ulema Council which states the halalness of a product in accordance with Islamic law. This MUI Halal Certificate is a requirement to obtain a permit for the inclusion of a halal label on product packaging from the authorized government agency. Products that have been proven to have passed the halal test by MUI have gone through a series of processes and tests that have been proven not to be unclean and are allowed to be consumed. For companies that want to obtain LPPOM MUI halal certificates, both processing industries (food, medicine, cosmetics), Slaughterhouses (RPH), and restaurants/catering/kitchens, must register for halal certification and meet the requirements for halal certification. --- e. Exposure Media The development of communication technology has expanded human interaction. Most teenagers use applications and many types of social media to communicate and interact with the public. Social media has also been used to select and buy food. According to Anderson et al (1994), consumers will depend on the seller in making purchases and put their trust in the source of information and information received. In Indonesia, product and service advertising is found in magazines, newspapers, radio, television, internet, etc. Consumers also receive product information from friends, family, sellers and strangers. Peter & Olshon (2014) stated that exposure to information is a process of consumers being exposed to information in their environment such as marketing strategies, mainly through their own behavior. It is important for a consumer to get exposure to information for the interpretation process. Therefore, exposure to information can serve as a source of awareness about halal related to what Muslims consume. --- f. Halal Literacy of Community The level of halal awareness is very much determined from the level of community literacy that currently exists, so it is very important to conduct an analysis in order to compile a halal literacy index. Pratama and Hartati (2020) conducted a study with the results showing that partially and simultaneously halal literacy and religiosity had a significant effect on the consumption of halal products for students of MKS UIN Sunan Gunung Djati Bandung. Halal literacy has been proven to have a significant role in influencing the behavior of compliance with Islamic law, especially halal orders (Salehudin, 2013). Therefore, it is important to conduct research on the level of halal awareness and halal literacy index in the sociocultural perspective of the Penginyongan community. --- RESEARCH METHOD --- Research Approach The approach in this study uses a quantitative approach. According to Sugiyono (2013) that the quantitative approach is research based on the philosophy of positivism to examine a particular population or sample and take random samples with data collection using instruments, the data analysis is statistical. --- Population and Population Sample In this study the population and the population sample are using purposive sampling with the following criteria: 2016) providing a reference in taking the number of samples, namely: 1. A sample size of more than 30 and less than 500 is appropriate for most studies 2. In multivariate research (including multiple regression analysis), the sample size should be 10 times or more than the number of variables in the study. So that the number of samples used in the study were 200 respondents because the sample was more than 30 and less than 500. The sampling technique in this study was a non-probability sampling technique with purposive sampling. Sugiyono (2016: 120) explains that non-propability sampling is a sampling technique that does not provide equal opportunities or opportunities for each element or member of the population to be selected as a sample. --- Data Collection and Types The type of data in this study is primary data. Primary data is a source of data obtained directly to data collectors, (Sugiyono, 2013). Collecting data through questionnaires, the questionnaire used is a questionnaire with a five-point Likert scale to test hypotheses 1-4, while hypothesis 5 uses a dichotomous scale (False True Index) to obtain data from each construct in the research model. Based on insights gained from previous studies on consumer awareness and consumer perceptions of halal brands, labels, logos, products, science and technology (Leclerc, Schmitt, & Dubé, 1994;Mariam, 2006;Mazis & Raymond, 1997), the questionnaire was adapted to collect information. --- Instrument Quality Testing The questionnaire was subjected to validity and reliability tests. Construct validity is used to test how well the developed instrument measures a particular construct (Sekaran & Bougie, 2010), while reliability is used to test how consistently the measuring instrument measures the construct. The measure of validity in this study consisted of three types: construct, convergent and discriminant; they are used to check how well the used questionnaire can utilize the constructs as theorized in the model. Please note that the type of scale used to be tested on respondents is divided in to 2, namely: MABSYA: Jurnal Manajemen Bisnis Syariah, Vol 5 No 1 Tahun 2023 a. Likert scale 1-5 (to test the independent variable items halal awareness, religiosity, lifestyle awareness, halal certificate, and media exposure and the dependent variable is halal awareness). b. Dichotomy scale (to test the independent variable of halal literacy, where the correct answer will be given a score of 1, and the wrong answer will be given a score of 0). To test the validity and reliability of calculations carried out with the help of the IBM SPSS 20 program, it can be described in the following --- Classical Assumption Test To get accurate results in multiple regression analysis, the researchers tested the classical assumptions so that the results obtained were consistent regression equations, had unbiased properties and had timeliness. The classical assumption test is carried out with 5 tests as follows: a. Normality Test According to Ghozali (2013: 160) the normality test aims to test whether in the regression model the confounding or residual variables have a normal distribution. As it is known that the t and F tests assume that the residual value follows a normal distribution. Detection of normality statistically is by using the Kolmogorov -Smirnov test with the Asymp criteria. Sig (2-tailed) is greater than 0.05 then the data is said to be normal. --- b. Linearity Test Model Ghozali (2016:159) states that the linearity test is used to see whether the specifications of the model used are correct or not. The linearity test in this study uses the Lagrange Multiple (LM-Test) method by looking at the X2 count smaller than the table X2 value, it can be concluded that the regression model is linear. --- c. Multicollinearity Test The multicollinearity test aims to test whether there is a correlation between the independent variables in the regression model. A good regression model should not have a correlation between independent variables. If the independent variables are correlated with each other, then these variables are not orthogonal. Orthogonal variables are independent variables whose correlation values between independent variables are equal to zero (Ghozali, 2013: 105). Multicollinearity was tested using (1) tolerance value and its opposite (2) variance inflation factor (VIF). The value that is commonly used to indicate the presence of multicollinearity is the tolerance value 0.10 or the same as the VIF value 10. --- d. Heteroscedasticity Test This test is carried out to test whether there is an inequality of residual variance from one observation to another. Heteroscedasticity tests the occurrence of the residual variance inequality from one observation period to another observation period. A good regression model is Homoscedasticity or Heteroscedasticity does not occur (Ghozali, 2013:139). This heteroscedasticity test uses the glejser test method. --- e. Autocorrelation Test Autocorrelation test is a test where the dependent variable is not correlated with the value of the variable itself, both the value of the previous period and the value of the period after. Autocorrelation is a condition where in the regression model there is a correlation between residuals in a certain period t with residuals in the previous period (t-1), a good regression model is one in which there is no autocorrelation problem stated by Duwi Priyatno (2012:172). The test method uses the Durbin-Watson test (DW-test). --- RESULTS AND DISCUSSION --- Result a. Sampling Methods and Results Determination of the sample is done by non-probability purposive sampling method, namely the sample is selected on the basis of the suitability of the sample characteristics with predetermined criteria. Based on predetermined criteria, 200 respondents were obtained to meet the primary data needs in this study. This study was conducted to see the partial and simultaneous influence of religious beliefs, awareness of healthy lifestyles, halal certificate logos, and halal literacy on halal awareness of halal food products in the sociocultural group of the Penginyongan community. The data used in this study is primary data with specific respondent criteria. Researchers did not use the distribution of questionnaires through online but directly distributed/distributed to respondents. This is based on the consideration that the measurement of the sociocultural aspect of the Penginyongan community is seen from the main requirement, namely actively using the Penginyongan language in their daily lives. --- c. Results of Data Analysis 1) Results of Quantitative Data Analysis of Instrument Quality Testing a) Validity test The method used to test the validity in this study is divided into 2, namely: (1) The Likert scale 1-5 uses the Product Moment Pearson Correlation method (to test the independent variable items halal awareness (Y), religiosity (X1), lifestyle awareness (X2), halal (2) The dichotomy scale uses the Point Biserial Correlation method (to test the independent variable of halal literacy (X5), where the correct answer will be given a score of 1, and the wrong answer will be given a score of 0). In this validity test, the method used is point biserial because the dichotomous scale is categorized as a testing scale for data that is given a score of 1 if it is true and 0 if it is false. In this test the validity criteria are obtained by comparing the value of r count > r table at the output. b) Reliability Test Reliability test is a tool used to measure the consistency of the questionnaire which is an indicator of a variable or construct. A questionnaire is said to be reliable or reliable if a person's answer to a question is consistent or stable over time (Ghozali, 2006). Based on the reliability test above, it can be seen that the Cronbach's Alpha value in each variable is greater than 0.60, so it can be stated that all the variables used in the study meet the reliability requirements. --- 2) Results of Quantitative Data Analysis of Classical Assumption Test a) Normality test Detection of normality in this study using the Kolmogorov-Smirnov test with Asymp criteria. Sig (2-tailed) is greater than 0.05 then the data is said to be normal. After being analyzed using IBM SPSS 20, the Asymp results were obtained. Sig (2-tailed) is 0.843 > 0.05, so it can be concluded that the data distribution is normally distributed. --- b) Model Linearity Test The linearity test in this study uses the Lagrange Multiple (LM-Test) method by seeing that X2 count is smaller than the table X2 value, it can be concluded that the regression model is linear. Based on the output above, the coefficient of determination (R2) of the regression equation is 0.003 so that X2 is 200 x 0.003 = 0.6 while the value of X2 Multicollinearity was tested using (1) tolerance value and its opposite (2) variance inflation factor (VIF). The value that is commonly used to indicate the presence of multicollinearity is the tolerance value 0.10 or the same as the VIF value 10. The VIF values of all successive variables are 1.162, 1.153, 1.083, 1.022 which are smaller than 10 and all tolerance values are also greater than 0.10, so it can be concluded that there is no multicollinearity. --- d) Heteroscedasticity Test This heteroscedasticity test uses the glejser method by comparing sig. value > 0.05. All sig.value> 0.05, it can be concluded that there is no heteroscedasticity. From these conclusions, the regression model is declared valid as a testing tool because it is free from heteroscedasticity. --- e) Autocorrelation Test Test method using Durbin-Watson (DW-test). then it can be seen that N=200, k= 4, dL=1,728 (table) dU=1,800 (table) 4-dU= 4,000-1,800=2,200 4dL=2,272. The Durbin Watson value is between dU and 4-dU, so there is no autocorrelation. --- d. Hypothesis Testing 1) Multiple Linear Regression Analysis Hypothesis testing is done to test the hypothesis proposed in the study. The hypothesis proposed in this study is related to halal certification, halal awareness and food composition on buying interest. Multiple regression analysis was chosen to analyze in this study. The following are the results of multiple linear regression analysis performed using IBM SPSS 20. From the results of the regression analysis, it can be seen that the multiple regression equation is as follows: <unk> = 21.237-0.085X + 1.003X2 -0.51X3-1.53X4+ 0.123X5 Information: <unk>: Prediction of buying interest (Y) 21,237 : The constant of 21,237 means that if each independent variable (X1, X2, X3, X4, X5) is considered zero, then the Y prediction is 21,237. -0.085X1 : the magnitude of the coefficient of religiosity variable (X1) which mean s that for every 1% increase in the religiosity variable (X1), then halal awareness (Y) decreases by -0.085 assuming other variables (healthy lifestyle, halal certification logo, media exposure and halal literacy) constant 1.003X2 : the magnitude of the coefficient of the healthy lifestyle variable (X2) which means that for every 1% increase in the healthy lifestyle variable (X2), then halal awareness (Y) increases by 1,003 assuming other variables (religiosity, hala certification logo, media exposure and halal literacy) constant -0.51X3 : the coefficient of the halal certificate logo variable (X3) which means that every 1% increase in the halal certificate logo variable (X3), then halal awareness (Y) decreases by -0.51 assuming other variables (religiosity, healthy lifestyle, media) exposure and halal literacy) constant -1.53X4 : the coefficient of the media exposure variable (X4) which means that for every 1% increase in the exposure media variable (X4), halal awareness (Y) decreases by -1.53 assuming other variables (religiosity, healthy lifestyle, halal certificate logo and halal literacy) constant. 0.123X5 : the coefficient of the halal literacy variable (X5) which means that for every 1% increase in the halal literacy variable (X5), then halal awareness (Y) increases by 0.123 assuming other variables (religiosity, healthy lifestyle, halal certificate logo and media). exposure) constant. --- 2) Hypothesis 1-5 (H1-H5) The t-test criteria (partial) are: a) If the significance value (Sig.) <unk> probability 0.05 and the value of t count > t table, then there is an influence of the independent variable (X) on the dependent variable (Y) or Ha is accepted and H0 is rejected b) If the value of significance (Sig.) > probability 0.05 and the value of t count <unk> t table, then there is no effect of the independent variable (X) on the dependent variable (Y) or Ha is rejected and H0 is accepted. MABSYA: Jurnal Manajemen Bisnis Syariah, Vol 5 No 1 Tahun 2023 13 (1) The t-test between the religiosity variable (X1) and halal awareness (Y) shows that religiosity has no significant effect on halal awareness. This can be seen by comparing the t-count value of -0.643 <unk> ttable 1.97227 or Sig t 0.521 > 0.05 level of significant so that Ha is rejected and H0 is accepted. (2) The t-test between healthy lifestyle variables (X2) and halal awareness (Y) shows that a healthy lifestyle has a significant effect on halal awareness. This can be seen by comparing the value of t count of 7.160 > t table of 1.97227 or Sig t of 0.000 <unk>0.05 level of significant so that Ha is accepted and H0 is rejected. (3) The t-test between the halal certificate logo variable (X3) and halal awareness (Y) shows that the halal certificate logo has a significant effect on halal awareness. This can be seen by comparing the calculated t value of -3.105 (in this case -(minus/negative) is absolute and -is used to measure the direction of the relationship, which is negative) > ttable 1.97227 or Sig t 0.02 <unk>0.05 level of significant so that Ha accepted and H0 rejected. (4) The t-test between the exposure media variables (X4) and halal awareness (Y) shows that religiosity has no significant effect on halal awareness. This can be seen by comparing the t-count value of -0.674 <unk> t table 1.97227 or Sig t 0.501 > 0.05 level of significant so that Ha is rejected and H0 is accepted. (5) The t-test between the variables of halal literacy (X5) and halal awareness (Y) shows that halal literacy has no significant effect on halal awareness. This can be seen by comparing the calculated t value of 1.304 <unk> t table 1.97227 or Sig t 0.194 > 0.05 level of significant so that Ha is rejected and H0 is accepted. 3) Hypothesis 6 (H6) The F test was conducted to determine whether the independent variables together could affect the dependent variable. The decision-making method for this simultaneous test is first, Fcount is compared with Ftable at a significance level of 5%. If Fcount is greater than Ftable, then there is a significant effect between the independent variables on the dependent variable together. Second, if the significance value is smaller at the level of significant (sig. <unk> ) it means that there is a significant effect between the independent variables on the dependent variable together. Significance here means that Ha is accepted and H0 is rejected. From the test results obtained a significance value of 0.000 which is smaller than 0.05 and Fcount is obtained at 11,487 > Ftable, it can be concluded that the independent variables (religiosity, healthy lifestyle, halal certificate logo, media exposure and halal literacy) together or simultaneously has a significant effect on the dependent variable, namely halal awareness (Y) or in other words Ha is accepted and H0 is rejected. --- 4) Testing the Coefficient of Determination (R2) The coefficient of determination is used to test how much influence the independent variables have on the dependent variable. Analysis of the Model Summary: a) The R value of 0.478 in this case it can be concluded that the multiple correlation between the independent variables (religiosity, healthy lifestyle, halal certificate logo, media exposure and halal literacy) on the dependent variable of halal awareness is 0.487. b) R square or coefficient of determination obtained is 0.228 which means that variations in halal awareness are explained by variations in religiosity, healthy lifestyle, halal certificate logo, exposure media and halal literacy by 22.8% or variable religiosity, healthy lifestyle, halal certificate logo, media exposure and literacy halal is able to affect halal awareness by 22.8%. c) Adjusted R square is a coefficient of determination that has been corrected by the number of variables and sample size so that it can reduce the element of bias if there are additional variables or additional sample sizes. Adjusted R square of 0.209 means that variations in halal awareness can be explained by variations in religiosity, healthy lifestyle, halal certificate logo, media exposure and halal literacy by 20.9%. --- Discussion a. The Effect of Religiosity on the Level of Halal Awareness of Halal Food Products in the Sociocultural Group of the Penginyongan Community The first hypothesis shows Sig 0.521 > 0.05, this indicates that there is no significant influence between religiosity on the level of halal awareness of halal food products in the sociocultural group of the Penginyongan community. This finding contradicts the results of the Ambali and Bakar study with research on halal products or food in April and May 2012 with a sample consisting of 210 Muslims in the city of Shah Alam, Selangor, Malaysia where religiosity is a determinant of Muslim awareness about the use and consumption of halal goods. But on the other hand, Ishaq and Prayoga corroborate the findings in this research hypothesis where religiosity does not significantly affect halal awareness in a study of 120 Muslim communities in the city of Bogor who bought cakes during July-December 2016. The researcher found the fact that the Penginyongan sociocultural community did not make religiosity a consideration for buying halal food products. This is indicated by the existence of social factors, namely stereotypes about halal products that are sourced from the understanding or habits of the community in general, in other words, the sociocultural community buys products that are not necessarily halal. --- b. The Effect of a Healthy Lifestyle on the Level of Halal Awareness of Halal Food Products in the Sociocultural Group of the Penginyongan Community The second hypothesis shows Sig 0.000 <unk> 0.05 and the t value is 7.160 > t table 1.97227, this indicates that there is a significant positive effect between a healthy lifestyle on the level of halal awareness of halal food products in the sociocultural group of the Penginyongan community. This shows a unidirectional or positive relationship where if a healthy lifestyle increases, the level of halal awareness of halal food products in the sociocultural group of the Penginyongan community also increases. The findings of the second hypothesis are in line with the statement by Bonne et al

This study aims to determine the partial and simultaneous effect of religiosity, awareness of healthy lifestyles, halal certificate logos, exposure media and halal literacy on the level of halal awareness of halal food products in the sociocultural group of the Penginyongan community. The study used 200 respondents with a non-probability method through purposive sampling. Where the respondents in this study have a special characteristic, namely using Penginyongan language actively in their daily lives. Data through questionnaires in this study were processed using multiple linear regression analysis. The results showed that religiosity, media exposure and halal literacy had no partial effect on the level of halal awareness of halal food products in the sociocultural group of the Penginyongan community. There are only 2 variables that have a significant partial effect, namely a healthy lifestyle and the halal certificate logo. Simultaneous testing resulted in the conclusion that all independent variables simultaneously had a significant effect on the dependent variable, that is halal awareness. In the sociocultural group of Penginyongan community was also found to still use a social perspective/perception about the halalness of a product, not looking at the special characteristics of halal listed on the label/packaging of food products..

yongan sociocultural community did not make religiosity a consideration for buying halal food products. This is indicated by the existence of social factors, namely stereotypes about halal products that are sourced from the understanding or habits of the community in general, in other words, the sociocultural community buys products that are not necessarily halal. --- b. The Effect of a Healthy Lifestyle on the Level of Halal Awareness of Halal Food Products in the Sociocultural Group of the Penginyongan Community The second hypothesis shows Sig 0.000 <unk> 0.05 and the t value is 7.160 > t table 1.97227, this indicates that there is a significant positive effect between a healthy lifestyle on the level of halal awareness of halal food products in the sociocultural group of the Penginyongan community. This shows a unidirectional or positive relationship where if a healthy lifestyle increases, the level of halal awareness of halal food products in the sociocultural group of the Penginyongan community also increases. The findings of the second hypothesis are in line with the statement by Bonne et al (2007) The third hypothesis shows Sig 0.002 <unk> 0.05 and the t value is -3.105 (absolute) > t table 1.97227 this indicates that there is a significant influence between the halal certificate logo on the level of halal awareness of halal food products in the sociocultural group of the Penginyongan community but is negative. As Osman (2002) in Ambali & Bakar (2014) suggests in his research that one needs to know the status of food 'either by the logo or by the halal or non-halal label before buying or consuming the product. The researcher found a significant negative effect where in point 2 of the survey item variable the halal certificate logo, respondents quite a lot expressed their disagreement in terms of ensuring halal certification before choosing halal products and on the other hand expressed their approval to consume halal food by looking at the MUI certificate/logo while considering food that enters the body is halal. In this point, the researcher sees that respondents still have limitations in terms of ensuring halal certification of a product which might be influenced by the respondent's educational background with the majority graduating from high school by 58.5%. Through these findings, the researcher sees that educational background can be a fairly dominant variable to measure halal literacy in purchasing halal food products. --- d. The Effect of Media Exposure on the Level of Halal Awareness of Halal Food Products in the Sociocultural Group of the Penginyongan Community The fourth hypothesis shows Sig 0.501 > 0.05, this indicates that there is no significant influence between media exposure on the level of halal awareness of halal food products in the sociocultural group of the Penginyongan community. This finding is in line with the results of Pramintasari and Fatmawati's research on 100 responde nts in Kota Gede, Yogyakarta in 2017 where the same results were obtained, namely media MABSYA: Jurnal Manajemen Bisnis Syariah, Vol 5 No 1 Tahun 2023 exposure or information exposure through the media did not significantly affect halal awareness. Pramintasari and Fatmawati argue that this can happen due to the lack of advertisements from related products and also the lack of information from sellers and producers regarding the halalness of the product so that respondents do not get complete information, especially in terms of halalness. Most of the respondents feel th at they have received less exposure to information from advertisements or sellers or producers of related products. From the results of this study, it can be used as input for related companies that information exposure is needed to increase or influence the level of halal awareness when choosing or consuming products. Researchers found the fact that the Penginyongan sociocultural community did not take information from the media into consideration for buying halal food products. This is indicated by the existence of social factors, namely stereotypes about halal products that are sourced from the understanding or habits of the general public. Respondents also have limitations in absorbing new information related to incoming halal food products, in other words, the sociocultural community returns to buying products that are not necessarily halal. --- e. The Effect of Halal Literacy on the Level of Halal Awareness of Halal Food Products in the Sociocultural Group of the Penginyongan Community The fifth hypothesis shows Sig 0.194 > 0.05, this indicates that there is no significant effect between halal literacy on the level of halal awareness of halal food products in the sociocultural group of the penginyongan community. Based on the calculation of the use of the dichotomous scale, it is known that there are respondents who answered all of the 9 items incorrectly (given a score of 0) which leads to halal literacy, on the other hand the answer mode that appears is that respondents answer questions with correct answers as many as 6 items or there are 66.67% who contributed correct answers to 6 item questions. Researchers look at the educational background and the respondent's environment which causes halal literacy to be insignificant to halal awareness. This indicates that the level of halal literacy in the Penginyongan sociocultural community is quite high, which includes the understanding that the state guarantees religious adherents to worship according to religious teachings and provides protection and guarantees fo r the halalness of the products consumed. f. The Effect of Simultaneous Religiosity, Healthy Lifestyle, Halal Certificate Logo, Exposure Media and Halal Literacy on Halal Awareness Levels of Halal Food Products in the Sociocultural Group of Penginyongan Society From the test results obtained a significance value of 0.000 which is smaller than 0.05 and Fcount is obtained at 11,487 > Ftable, it can be concluded that the independent variables (religiosity, healthy lifestyle, halal certificate logo, media expos ure and halal literacy) together or simultaneously has a significant effect on the dependent variable, namely the level of halal awareness of halal food products in the sociocultural group of the Penginyongan community. These results are certainly different in the way of interpretation if they are related to the findings of the results of the H1, H3 and H4 hypotheses which do not have a partial effect on halal awareness. Simultaneous effect in the sixth hypothesis is by looking at the joint influence/contribution of each independent variable on the level of halal awareness of halal food products in the sociocultural group of the Penginyongan community. Religiosity is a system of beliefs and practices in which a group of people interpret and respond to what they feel is supernatural and sacred. This study shows that religiosity has no effect on halal awareness. The implication in the future is to add an in-depth interview method to the respondents' answers on the social and cultural side. --- CONCLUSIONS AND IMPLICATIONS b. Religious motives not only determine consumer awareness of halal products, but also health reasons related to religious identity, and the level of acculturation in whatever we consume daily. This study shows that a healthy lifestyle has an effect on halal awareness. The implication in the future is that the government and community leaders can socialize a healthy lifestyle with halal food products to the public. MABSYA: Jurnal Manajemen Bisnis Syariah, Vol 5 No 1 Tahun 2023 c. MUI Halal Certificate is a written fatwa of the Indonesian Ulema Council which states the halalness of a product in accordance with Islamic law. This MUI Halal Certificate is a requirement to obtain a permit for the inclusion of a halal label on product packaging from the authorized government agency. This study shows that the halal certification logo has an effect on halal awareness. The imp lication in the future is that consumers will have a better understanding of the application of halal labels that have been approved by the authorized institution. so that they can choose halal food products. --- d. Exposure to information is a process by which consumers are exposed to information in their environment such as marketing strategies, primarily through their own behavior. This research shows that media exposure has no effect on halal awareness. The implication in the future is that people will unde rstand and apply the information provided regarding halal food products. e. Halal literacy is proven to have a significant role in influencing the behavior of compliance with Islamic law. This study shows that halal literacy has no effect on halal awareness. The implication is to add an in-depth interview method in measuring halal literacy variables for depth of information.

This study aims to determine the partial and simultaneous effect of religiosity, awareness of healthy lifestyles, halal certificate logos, exposure media and halal literacy on the level of halal awareness of halal food products in the sociocultural group of the Penginyongan community. The study used 200 respondents with a non-probability method through purposive sampling. Where the respondents in this study have a special characteristic, namely using Penginyongan language actively in their daily lives. Data through questionnaires in this study were processed using multiple linear regression analysis. The results showed that religiosity, media exposure and halal literacy had no partial effect on the level of halal awareness of halal food products in the sociocultural group of the Penginyongan community. There are only 2 variables that have a significant partial effect, namely a healthy lifestyle and the halal certificate logo. Simultaneous testing resulted in the conclusion that all independent variables simultaneously had a significant effect on the dependent variable, that is halal awareness. In the sociocultural group of Penginyongan community was also found to still use a social perspective/perception about the halalness of a product, not looking at the special characteristics of halal listed on the label/packaging of food products..

Introduction Location-based games (LBGs) are multimodal mobile applications that enable, and often encourage, users to move around physically; they have been particularly praised for activating physically inactive individuals and providing a fun social outdoor activity [1,2]. While under normal circumstances these definitely are positive things, during the COVID-19 pandemic in 2020, people were advised to do the exact opposite: stay at home and keep social meetings to the minimum [3][4][5][6]. The entertainment industry reacted at large to the pandemic by offering various kinds of free services to consumers, increasing their motivation to stay home and avoid contracting and spreading the disease. In this context, it is particularly interesting to study the measures taken by LBG developers, and how their players reacted and responded to the situation. LBGs have recently gained a lot of popularity. From the perspective of multimodal technologies, they differ from traditional video games in that they use the player's physical location as a form of input that impacts the game world. The currently most popular LBG, Pokémon GO, was installed into roughly 55 million devices in 2019 [7]. The company who created the app advertises that their LBG apps have been cumulatively downloaded more than a billion times and that as many as 73% of Pokémon GO players change their regular walking routes weekly because of the game [8]. These figures give an estimate on the impact that LBGs have on human movement. The finding that LBG players change their movement patterns due to the game has also been demonstrated in academic studies [9][10][11]. Playing the games has been linked to increased time spent outside walking [12,13] and outdoor activity has been found to be one of the main reasons players play them [14,15]. As a study context in this work, we observe the reactions of LBG developers and players during the COVID-19 pandemic. Governments globally reacted to the pandemic in the first trimester of 2020 by issuing restrictions on citizens' movement, public gatherings and meetings [16]. In addition, individuals were encouraged to adopt personal health measures such as voluntary self-isolation and washing hands [4]. As LBGs are a genre of games that are typically played socially outdoors, and people were advised or even ordered to instead stay home, a natural conflict arose. This novel situation is unclear and unexplored in scientific literature. To address this research problem, we adapt the netnography research methodology collecting data from three sources. Consequently, we divide our methodology into three parts. First, we look at measures taken by LBG developers and changes done to the games to counter the spread of the pandemic. Second, we study player responses on social media focusing on Pokémon GO (the most popular LBG) specifically, by investigating top voted posts and reading their comments in 20 posts across three separate subreddits. Finally, we look at the impact of the COVID-19 pandemic on social play in Pokémon GO by employing data from a raid group (1 February-12 May 2020) in a Finnish municipality. The rest of this study is structured as follows. First, in the background, we discuss how LBGs influence player behaviour by reviewing the extant literature and represent the study context and related theories. We then present our research design, which is followed by the results in three sections, one for each research question. In the Discussion section, we highlight our key findings, raise discussion on the implications of our findings and present the limitations and future work for this study. We end our work with conclusions. --- Background --- How Location-Based Games Influence Behaviour Upon looking at the extant literature on behavioural consequences of playing LBGs, a few trends can be identified. First, LBGs typically increase physical activity [2,12,13] and reduce sedentary behaviour [17], based on some studies even permanently outside the gaming context [18]. Second, LBGs have implications on social well-being [1,19], increasing players' altruistic behaviour and we-intentions [20,21]. Third, playing LBGs impacts real-world movement patterns and propensity [10]. Finally, despite some reports suggesting that playing LBGs might cause players to adopt unwanted behaviours [22,23], empirical studies on the matter have shown these reports to not stand on firm ground [24]. While Riar et al. [21] found a correlation between engaging with cooperative game features and altruism, this finding can also be explained by the fact that, in Ingress, players face a strong opposing force, other human players, making cooperation necessary for individual and the team's success [25]. Furthermore, LBG teams have been shown to impact players' language adaption [25], proving the impact of social influence on player behaviour. In fact, Ewell et al. argue that the main benefit of LBGs is social-well being rather than physical exercise [1], unlike some early studies on Pokémon GO suggested [13]. Based on these findings, it is evident that social identity [26] plays a role in determining players' actions in addition to individual goals, and understanding the impact of social influence [27] will result in a more complete understanding of how players react to global pandemics. The extant literature on behavioural consequences of LBGs is summarized in Table 1. While information systems journal publications favor including defined theoretical frameworks, many of the studies are published in other journals, for example medical journals, which do not emphasize theory to an equal degree. Another noticeable phenomenon is the over-representation of Pokémon GO among the observed games. While this can hurt the generalizability of the results to cover all LBGs, it does make comparing studies together easier as the studied game-context is the same in nearly all cases. Finally, while the behavioural consequences of LBGs have been studied as such, behavioural changes due to unprecedented online or offline events is yet to be explored. The COVID-19 pandemic offers us an opportunity to study this and gain insight into understanding human behaviour in this context. --- Colley Pokémon GO 375 No overarching Pokémon GO reinforces existing geographical et al. [10] theory biases and influences player movement patterns. The game can cause players to permanently change commute routes. Harris [18] Beat the Street 1567 No overarching Gamification-based health behaviour interventions theory can have lasting effects with a significant portion of participants maintaining physically active lifestyle even two years after the intervention period is over. --- Laato Pokemon GO 178 Social identity Pokémon GO and Ingress impact player's attitudes et al. [25] Ingress theory towards game slang and can cause polarized attitudes towards players on opposing teams. --- Riar Ingress 206 We-intention Gameplay with cooperative features can encourage et al. [21] Altruism altruistic behaviour and we-intentions. --- Zach Pokémon GO 405 No overarching Playing Pokémon GO increases visiting places, et al. [19] theory improves well-being and increases physical activity. These were linked to enjoyment which was further linked to increased intention to spend money on the game. LBGs can have both positive and negative impacts on players during pandemics. during COVID-19, in countries where moving outside was allowed, LBGs could still motivate exercise and provide players with a healthy and fun outdoor activity that had the potential to alleviate some of the potential psychological and physical issues, such as cyberchondria [4] or obesity [28], which may arise from spending too much time stationary and in isolation at home. On the other hand, as LBGs such as Pokémon GO motivate people to gather physically together [29], and increase pedestrian traffic in large cities, there exists the danger that the games increase social contact, and thus, unintentionally contribute to the spread of the pandemic disease. A recent study on human behaviour during COVID-19 found perceived severity of the situation and self-efficacy were found to predict adopting personal health measures, while response costs had a negative effect [4]. This further emphasises the significance of LBGs' potential to increase perceived barriers to adopt recommended health measures. However, while LBGs may be a major part of some people's lives, they remain only one factor among many that impact human behaviour. In such a complex landscape, a wide perspective is needed to understand the situation. --- Human Behaviour during Pandemics Human behaviour during pandemics is affected by both internal and external factors. The internal factors refer to those constituting personal protection motivation [30], while external factors in this context refer to government enforced measures such as quarantines and other environmental effects [31]. The external and internal factors are linked, as humans better accept governmental restrictions in case they understand and agree with them [32]. In order to keep citizens aware of the situation during pandemics, and allow them the benefit of information-based decision-making and rational action, information regarding the pandemic needs to be communicated clearly [33][34][35]. Reducing uncertainty this way is paramount in motivating effective individual health behaviour whilst avoiding public panic [34]. Protection-motivation theory (PMT) is perhaps the most widely used theory in explaining human behaviour during pandemics (e.g., [36][37][38]). The theory decomposes individual level protection motivation into consisting of threat appraisal and coping appraisal constructs [39]. Threat appraisal can be further divided into perceived severity, perceived vulnerability and anxiety, while coping appraisal is the sum of self-efficacy, response efficacy and response costs [37,39]. Studies using PMT have shown perceived severity to be one of the key factors influencing behaviour change during pandemics, while response cost can alleviate this impact [4,36]. In the current context of LBGs, the motivation that the games provide to break quarantine can be conceptualized to belong under coping appraisal, more precisely, in response costs. As players enjoy playing LBGs, they will inevitably feel they lose something in case they are forced to quit playing due to pandemic restrictions. Following this line of thought, the main concern about LBGs during pandemics according to PMT is that they increase players' perceived response costs to adapt individual health measures, and thus reduce their protection motivation and encourage them to go out and play instead. Besides PMT, another similar framework often used for explaining human behaviour in situations with a looming health threat is the health belief model (HBM) [36]. While PMT is concerned about protection motivation and postulates it to be the result of threat and coping appraisal, HBM seeks to understand how health beliefs lead to action [40]. Both models typically share the construct of perceived severity and susceptibility, but instead of seeing these as antecedents to protection motivation, HBM postulates them to be at the same level with health motivation [41]. Perceived barriers, which can be seen to be closely linked to response costs in PMT, have been shown to be the most powerful dimension of HBM to explain human behaviour [40]. In this study, we select PMT as a theoretical lens which we use to analyze the collected data and understand our findings over HBM primarily because of its recent popularity [36] and because the coping appraisal constructs offer a well structured theoretical viewpoint. --- Study Context: The COVID-19 Pandemic The SARS-CoV-2 virus, causing the COVID-19 disease, was first detected in December 2019 in the Huabei region in China, particularly the city of Wuhan [42]. The virus has been classified as highly infectious, with some estimates of its reproduction number being as high as 3.58 if no preventative measures are taken [43]. With quarantines and travel bans, China was able to slow down the epidemic trajectory of the virus [44], but during March 2020, the virus had already spread uncontrollably outside China, which lead to the World Health Organization declaring it a global pandemic on 11 March 2020 [6]. In this study, we collect three datasets, one of them from Finnish Pokémon GO players. To this end, a brief explanation of the context of Finland during COVID-19 is needed. Finland is a northern European country that offered a suitable study case as at the start of the data collection period, February 2020, the country had still only a few confirmed cases of COVID-19 and zero confirmed deaths caused by the illness. After mid-March, when the pandemic situation escalated globally and the virus started spreading in Europe, the Finnish government issued the following restrictions to take place starting from 18 March onwards: --- • Face-to-face meetings of more than 10 people are forbidden. --- • People over the age of 70 or belonging to a risk group should self-isolate and stay at home. --- • School buildings are closed and schools must move to distance education. Libraries, hobby facilities, gyms and universities are closed as well, and most public events are cancelled. --- • Everyone arriving from abroad will need to immediately self-quarantine for two weeks. --- • Using public transportation is heavily discouraged. Besides these restrictions, other more minor ones were issued as well. On 27 March, the Finnish government temporarily closed Uusimaa, the area surrounding its capital city Helsinki, due to a COVID-19 outbreak until 15 April. Furthermore, on 29 March, the Finnish government ordered all restaurants to close their doors with the exception of allowing them to serve take-away food. These restrictions were in place throughout April 2020 and, except for the reopening of Uusimaa, were all still in place on 12 May 2020 when the data collection period for social LBG playing in Finland ended. --- Research Design --- Research Questions and Overall Research Methodology We employ the netnography research methodology [45] and collect three types of data: (1) the measures taken by LBG developers during March 2020 when the COVID-19 pandemic was declared; (2) how the Pokémon GO community responded to these measures by observing social media; and (3) how the COVID-19 pandemic influenced social play frequency. The netnography research method is a specific method of ethnography that focuses on observing human behaviour through online channels such as social media [45]. As an ethnographic method, netnography is at its core participant-observation research [46]. Netnography has recently grown in popularity due to it offering practical tools for qualitative data collection and analysis, and insight for several types of research problems [47]. The method can be used for, for example, validating prior perceptions of status quo in various industry sectors [48], for understanding new emerging internet platforms and their users [49], for gaining insight on player behaviour in online games [50] and for, as in our case, understanding player community responses to in-game updates and the global pandemic situation. Table 2 summarises the data collection sources. The three part methodology is summarized in Figure 1. Accordingly, we formulate three research questions, one for each part of our method. 1. What in-game changes did LBG developers make during the COVID-19 pandemic? 2. How did LBG players respond to these changes and the pandemic in social media? 3. Did the pandemic, governmental measures and in-game changes in Pokémon GO have an impact on the frequency of social play? --- Observation of In-Game Changes In order to answer the research question "what in-game changes did LBG developers make during the COVID-19 pandemic?" we observed social media accounts, official websites as well as in-game notifications of seven popular LBGs during March 2020 to identify whether the game developers took measures to change gameplay in order to combat the COVID-19 pandemic. The following games were selected for analysis (1) Pokémon GO; (2) Orna; (3) Ingress Prime; (4) The Walking Dead: Our World; (5) Minecraft Earth; (6) Harry Potter: Wizards Unite; and (7) Jurassic World Alive due to them being among the most popular LBGs [7,51]. Because of their popularity, the games were estimated to be among those having the largest influence on players' actions at a global scale. Each game was played for at least 20 hours by the authors in order to get an understanding of the game mechanics, what kinds of opportunities game designers have to influence player behavior through the games and do the games encourage behavior that should be avoided during a global pandemic, such as socializing in real world or travelling to new places. The main source of information regarding the updates was the games' official websites and in-game news. However, social media was also followed in case we missed some news or one of the games did not have a clear website with updates. These channels were read during March 2020 regularly by the authors, with the purpose of identifying unique news and updates specifically related to COVID-19. In the popular case that news of the same update was posted on an official website, as in-game news as well as on several social media channels, the official website was preferred as a source. This was done for consistency as well as because in most cases, the social media updates linked back to the official website. --- Social Media Reactions In order to answer the research question: "how did LBG players respond to these changes and the pandemic in social media?", we observed social media reactions of Pokémon GO players to the in-game changes made to that game. To this end, the netnography observation and analysis method was used. When applying netnography on a specific context, the online channels that is selected for analysis needs to be (1) relevant; (2) active; (3) interactive; (4) substantial; (5) heterogeneous; and (6) data-rich [52,53]. In our case, Reddit was chosen as the platform, due to it filling the above-mentioned criteria, providing the ability to search monthly top voted posts, seeing the number of comments on each post and being able to classify them based on popularity and it being one of the most used social media platforms for structured discussion [54]. Three of the most popular LBG subreddits were chosen for the analysis. These were all Pokémon GO specific: (1) /r/TheSilphRoad (The largest Pokémon GO fan subreddit); (2) /r/pokemongo (Pokémon GO main subreddit); and (3) /r/pokemongospoofing (a subreddit about cheating in Pokémon GO via falsifying GPS-location). The three subreddits were varied in scope, content, rules and approach and thus diverse and suitable picks for the current study. Furthermore, as they all concerned the same game, this allowed a more in-depth view of a single game and more comparable findings across the three-part research method. A search was done on the three subreddits on 3 April 2020, sorting by the top-voted posts from the past month. This covered all posts back to 4 March 2020, a week before WHO declared COVID-19 a global pandemic. Among the top voted posts was structured discussion regarding the updates made to Pokémon GO due to COVID-19, which allowed us to investigate the players' opinions, attitudes and viewpoints on these changes. The five posts related to COVID-19 with most upvotes and related comments were selected for analysis, with the exception of the largest subreddit, /r/pokemongo, where we observed the 10 most top-voted posts because it was the largest subreddit and had the most diverse discussion on the COVID-19 topic. Following the netnography methods [45], we read the discussion beneath the posts and made notes of points and key themes that emerged. Then, guided by the Gioia method [55], and using the theoretical lens of PMT [39], the comments were classified into 1st degree concepts in all three subreddits. After obtaining the first order concepts, these were grouped together to form 2nd order themes as guided by Gioia et al. [55]. Three constructs from PMT involved with the coping appraisal were used as aggregate dimensions through which the qualitative analysis was viewed: (1) response costs, (2) response-efficacy and (3) self-efficacy. --- Change in Frequency of Social Play As Pokémon GO was released in 2016 and raids were added to the game in summer 2017 [29], in February-May 2020, the raiding propensity in the game could be considered already quite stable. Raids are special location-based social events where a group of players meet at a specific physical location called a gym, which typically represent landmarks or other places of significance [11]. Once they arrived at the gym, the players join forces in battling a powerful raid boss pokémon. Should the boss be defeated by the players attending the raid, they are rewarded with items as well as with the opportunity to capture the raid boss pokémon they just defeated. The raid boss pokémon are typically rare or otherwise difficult to acquire, thus making raids highly appealing events for keen pokémon hunters. Under regular circumstances raids can be considered the main social aspect in Pokémon GO [29]. For observing whether players were playing LBGs socially during the COVID-19 pandemic, Pokémon GO was selected as it features legendary raids that typically require a team of at least five players or more to beat the boss. The data set was collected from the largest collaborative raid chat of 1200+ members in a major city in Finland. Participants in the chat were mostly from the particular city. The frequency of legendary raids in the case city were recorded starting on Saturday, 1 February 2020, and ending on Tuesday, 12 May 2020. This period was selected as it marks the time roughly 50 days before the Finnish government's interventions on movement took place (18 March 2020) and roughly 50 days after it. Recording the raids was accomplished by observing the largest raid chat in a selected Finnish municipality. Each unique raid reported by a player was included, and the number of players who had enrolled to participate in the given raid was also recorded. If this number exceeded 10, it was marked as a raid with 10+ people. Furthermore, for each given day, the number of unique players using the raid channel to communicate raids was recorded. It is possible that many participants joined the raids without signing up, and that several players signed up for a raid without actually joining the raid in person. Considering these limitations, the data could be used as a rough estimate depicting changes in raiding activity that happened during the course of the data collection period. Finally, to further bring meaning to this data, we invoked mobile location data from Google [56] and Apple [57] regarding the changes in population-level movement during COVID-19 compared to baseline, and used this data to understand and interpret our findings. --- Results of Measures Taken by LBG Developers Before presenting the measures taken by LBG developers to adjust their games to counter the COVID-19 pandemic, it is important to understand the affordances (as defined by Norman [58]) that these games have for influencing player movement and social interaction in the real world. As we played the selected LBGs and analyzed their gameplay, we identified substantial opportunities for the developers to influence player movement and social meetings via game mechanics. These are summarized in Table 3. All observed games revealed new content when the player moved to new locations in the real world. Furthermore, several games rewarded the player for walking, either by unlocking new things (e.g., Harry Potter: Wizards Unite, Pokémon GO, Jurassic World: Alive) or by increasing a number in a medal (Ingress Prime). Moving outside was further directed, for example, in Orna, where capturing territories and defending them is a big part of the game. As the territories are at fixed real-world geographical locations, travelling there is necessary for regaining control of the area. Pokémon GO, Ingress and Harry Potter: Wizards Unite have been found to further influence player movement by strategically located points of interest [11,59]. Finally, with regards to social play, some of the games never encouraged face-to-face meetings (e.g., The Walking Dead: Our World and Jurassic World: Alive) while others did it daily through several game mechanics (e.g., Pokémon GO). In summary, all of the analysed LBGs have some game mechanics motivating players to go outside, which can be seen as an opposing force to the COVID-19-related recommendations of the World Health Organization as well as many local governments around the world. There were some mixed signals from Niantic during the COVID-19 pandemic. On 12 March, we saw the first cancellation of a social event, the monthly community day event where players get together, typically with family and friends, for three hours to capture as many of a highlighted pokémon as they can. On the same day, Niantic announced that gifts would be easier to acquire from pokestops, making it less necessary to visit pokestops (and consequently, move outside); however, at the same time, the duration of a social raid event was extended. Then, again on 19 March, Niantic announced a new social raid event, but on 23 March Niantic issued further bonuses on solo-play and cancelled a few in-game social events. In addition to the above-mentioned changes, Niantic offered special bundles of poké balls in their in game shop at a radically reduced cost of one coin (in-game currency). On 31 March, Niantic announced that the interaction range for gyms is doubled, allowing players to play from home or while keeping distance to other players at raids. In their communication, Niantic never mentioned the pandemic by name, but stated instead, for example that they are making efforts to allow playing from home and allow playing while maintaining social distance, as displayed in the message in Figure 2. --- Other Location-Based Games In addition to Pokémon GO, we looked at measures taken by the developers of the six other LBGs. These all shared similarities to the measures taken by the developer of Pokémon GO. Changes made to the rest of the games are detailed below. --- Orna Orna announced an event called It's dangerous out there scheduled to last until 30 March where players are advised to stay safe and are offered bonuses to an in-game activity (gauntlets) which do not require moving around but can be played from home. --- Ingress Prime On 16 March, Ingress Prime announced they have cancelled four social events: (1) First, Saturday events on 4 April are all cancelled globally; (2) All 15 Lexicon Hexathlon scheduled on 25 April are postponed; (3) Requiem Anomaly on 9 May has been postponed; and (4) NL1331X event from 9 May to 3 July has been postponed [61]. Then, three days later, on 19 March, Ingress Prime announced four changes to the game Ingress itself, encouraging solo-play and providing better opportunities for remote and stationary play. All changes were announced to be live until further notice, clearly indicating that the changes were made to mitigate the spread of COVID-19 [62]. This earned praise from the Ingress community on social media with comments such as Well done!, This is actually a pretty good update and Will there be a I survived the coronavirus medal? appearing on Twitter, Facebook and Telegram. --- The Walking Dead: Our World On 14 March, the first news on in-game changes to allow gameplay for players in lock-down due to the pandemic was introduced. On 17 March, the game announced more changes that aimed to boost the feasibility of stationary play. On 23 March, the changes supporting stationary play were reinforced and some new changes were introduced on Reddit as well as the in-game news of the Walking Dead: Our World app. The changes included: (1) A free daily Terminus Map, which supports stationary play; (2) every Friday a free additional pack that supports stationary play; (3) reduced prices on items that support stationary play and online social cooperation; (4) increased duration on items that support stationary play and online social cooperation; (5) more playing content for players that do not move; (6) better opportunities to maintain in-game structures, requiring less travelling and less playing. The developers further announced they will be closely monitoring the COVID-19 pandemic and stated that another update will follow in one week on 30 March. On this date, a new bullseye event was introduced, while keeping all the above-mentioned measures in place. --- Minecraft Earth Minecraft Earth was the last game of the seven analysed games to react to COVID-19. On 25 March, the game developers announced that they are making in-game changes due to the pandemic to "Flatten the curve", referring to reducing the exponential spread of the COVID-19 virus. Accordingly, adjustments were made to to allow playing from home by increasing Toppable spawn rates and allowing the creation of adventures anywhere. The amount of Gifts that can be opened each day will be increased from 10 to 20 Moreover, on 17 March, the developers announced that Spell Energy Gifts will include increased amounts of Spell Energy. All these changes contribute to making stationary play more fun. On 26 March, the developers announced a new event, stressing in their post that the event has been reworked to support playing from home. Finally, it is noteworthy that Harry Potter: Wizards Unite contains a social play element: fortress battles. These are similar to Pokémon GO raids, where players get together to the same physical location and challenge fortresses filled with monsters. While the fortress-battles are social, they are not time-dependent the same way raids in Pokémon GO are, and can be played whenever the players choose. Perhaps because of these reasons, no adjustments were found to be made to fortress battles. --- Jurassic World: Alive On 21 March Ludia, the creator and maintainer of Jurassic World: Alive announced that they take the COVID-19 pandemic seriously but will keep all their games operational and continue to monitor the situation [63]. Simultaneously, they announced three changes to Jurassic World: Alive: (1) Adding the Giga Scent which provides three hours of stationary gameplay daily; (2) A new in-game purchase offer for Pile of Darts, which also is a step towards providing stationary play; and (3) Drone, ESD and Strike Tower range increased, making stationary playing easier. The update post regarding these changes was later updated with further information on changes made to the game to enable safer play during the pandemic. The changes were announced to be valid until May 1st. --- Summary of How LBG Developers Reacted Out of the seven analyzed games, all made changes to their games to reduce the spreading of the pandemic by reducing the incentives of their players to break quarantine or self-isolation. This shows that the gaming companies are quick to react to global news and are doing their part in motivating players to stay home. Despite the changes, however, many of the LBG still encourage going out to a certain degree. While playing from home was made easier and more fun, none of the games completely removed the location-based aspect of their games. Thus, a small incentive to go out and play still remained in the observed LBGs. --- Results on Social Media Reactions In addition to the in-game changes, we wanted to understand players' reactions to COVID-19 and to changes made by the LBG developers. To this end, we looked at social media responses, in particular, from three unique LBG-themed subreddits. --- /R/Pokemongo The /r/pokemongo subreddit was by far the largest LBG subreddit out there at the time of data collection with 2.4 million subscribers. While the overwhelming majority of posts and content on the subreddit are related to Pokémon GO, there is a large variance in the type of content. The subreddit typically consists of original art works, shared news, shared stories, discussion, as well as a considerable amount of Pokémon GO-related memes. The ten most upvoted COVID-related posts (4 March-3 April 2020) are displayed in Table 4. Various memes and original art were upvoted to raise awareness of the pandemic among the Pokémon community, showing how memes and art can be used to contextualize acute real-world problems to players. The comments related to the meme posts were typically more humorous or sarcastic, for example, Reddit user "ShannieD" sarcastically wrote "Sometimes, in a global pandemic, sacrifices have to be made." (POST #3) when commenting on a new Pokémon GO feature that was introduced to address the COVID-19 situation but which, as a trade-off, contained a hilarious bug. The comments on artworks typically showed appreciation, however, there were also clever remarks, for example, Reddit user "quickhakker" commented: "30% of Americans won't catch that" (POST #5) undoubtedly referencing the Pokémon slogan gotta catch 'em all as well as the then estimated level of people that will not get the COVID-19 disease in any case because of the effects of herd immunity. One of the central concepts that was seen at the level of the posts was that LBGs are not a suitable genre of games for the COVID-19 situation where self-isolation was advised (e.g., POST #6). Reddit user "dontcareaboutreposts" summarized the following: "The truth is that this game [Pokémon GO] is fundamentally based on walking to achieve goals." and continued "I'm not saying we should all stop playing, I'm still planning on catching some good boys when I go out for groceries and stuff. However, just keep in mind that this game isn't designed for your lifestyle if you're stuck at home. In order to fix that, Niantic would have to change the game entirely, and we probably wouldn't like it all that much." (POST #6). The number of upvotes (8400+) on the post indicated that several players shared these sentiments. This theme was present throughout discussion in almost all posts. Responses such as "DO NOT BREAK YOUR QUARANTINE PEOPLE! Stay inside, help everybody" (POST #1) as written by Reddit user "andion82" were commonplace. --- LBG Developers Should Be Given Time to Make In-Game Changes and Adjust to the COVID-19 Situation The comments on new features introduced to help the COVID-19 situation were understanding, even though there were some who criticized the slow speed in which these changes were implemented. Reddit user "macljack" was among the many who defended Niantic for at least attempting to change their game to address the COVID-19 situation: "Good lord people. This is a game which from the ground up is designed to be played outside and the developer has been working very hard to help us adjust to our current reality. If you aren't happy too bad they can't fix everything and they certainly can't make all the changes needed so fast." (POST #2). Other comments focused on admitting that the features Niantic introduced were not perfect but were hopeful for the future. As an example, Reddit user "liluncookednoodle" stated: "I think they just messed up when extending the gym radius, probably be fixed with a later update" (POST #3). --- Do LBG Developers Have a Moral Responsibility to Avoid Encouraging Unwanted Behaviour during COVID-19? Some heated discussion was held on the moral responsibility of LBG developers. Reddit user "linkkd" stated: "Now answer me: is it ok for a company to keep encouraging people to play their game that involves going out during a pandemic? While not giving people all the resources so they can keep playing from home?" (POST #6) to which Reddit user "Mal-De-Terre" replied: "You could... you know... not play..." (POST #6). Outside these arguments, the player community seemed highly conscious about the temptation to go out that Pokémon GO provides even in situations where it was forbidden by law, as displayed in the most top voted post about a man being fined for breaking quarantine to play Pokémon GO (POST #1), which was condemned by the player community as being irresponsible, especially considering the player's old age making him belong to a high-risk category. For example, Reddit user "KeesApenvlees" commented on the situation: "Imagine going out to play a game in one of the most infected areas of the world when you're 77 years old" (POST #1). There

In early 2020, as a countermeasure to mitigate the spread of the COVID-19 pandemic, governments issued limitations on the movements of their citizens, cancelling social events and advising people to stay home. As location-based games (LBGs) have been found to influence human movement, their role during COVID-19 deserves closer inspection. Under regular circumstances, the very aim of these games is to motivate people to go out, explore and meet other people. However, during COVID-19, people were advised to do the exact opposite. To study how LBG developers and players reacted to the situation, we used the netnography research method utilizing three types of data: (1) COVID-19 related in-game changes made by seven popular LBG developers during March 2020; (2) social media reactions on 20 posts across three popular Pokémon GO subreddits; and (3) the raiding activity (collaborative play) in Pokémon GO in a Finnish municipality during February-May 2020. All observed LBGs made in-game changes due to COVID-19. The social media reactions showed overwhelming appreciation towards these changes, and two central second order themes arose: (1) LBGs have the ability to influence human movement during pandemics; and (2) people should be able to self-regulate their behaviour during COVID-19 independent of LBG influence. Surprisingly, recorded Pokémon GO player activity in Finland was more influenced by offered in-game rewards than the COVID-19 pandemic. Our findings have implications on how games and gamification can be used to direct human movement in situations such as COVID-19 where population-level interventions are needed.

BG developers. Reddit user "linkkd" stated: "Now answer me: is it ok for a company to keep encouraging people to play their game that involves going out during a pandemic? While not giving people all the resources so they can keep playing from home?" (POST #6) to which Reddit user "Mal-De-Terre" replied: "You could... you know... not play..." (POST #6). Outside these arguments, the player community seemed highly conscious about the temptation to go out that Pokémon GO provides even in situations where it was forbidden by law, as displayed in the most top voted post about a man being fined for breaking quarantine to play Pokémon GO (POST #1), which was condemned by the player community as being irresponsible, especially considering the player's old age making him belong to a high-risk category. For example, Reddit user "KeesApenvlees" commented on the situation: "Imagine going out to play a game in one of the most infected areas of the world when you're 77 years old" (POST #1). There did not seem to be a clear consensus on whether LBGs should reduce incentives to go out and play, whether people should be able to self-regulate no matter what some games encourage and whether in fact both of these should take place. --- /R/Thesilphroad TheSilphRoad is a fan-driven subreddit that differs from /r/pokemongo in that it does not allow the posting of memes or artwork. It can also be characterized for the meeting place of the more serious and hardcore players. The five most upvoted COVID-19 related posts (4 March-3 April) are displayed in Table 5. Compared to /r/pokemongo, TheSilphRoad subreddit had considerably fewer top voted posts related to COVID-19 and much more posts strictly relating to in-game content. This can be seen to be a consequence of the subreddit rules as well as of the players that gravitate towards the subreddit in the first place. --- Pokémon Go Has Done a Good Job Minimizing Incentives It Provides Players to Break Quarantine In all posts, commentators seemed widely accepting and even grateful to Niantic for the changes made. Comments were often informative and serious, many of them strictly game-related. As an example, comments such as "Remote Battle Requirements also lowered to Good Friends" (POST #1) by the Reddit user "LeeDuck" were often upvoted. In addition to these informative comments, comments praising Niantic were also often upvoted. Comments such as Reddit user "transfat97's": "Niantic has honestly handled this whole situation wonderfully. I'm genuinely impressed." (POST #1) were commonplace and were supported further by, for example, Reddit user "exatron" who wrote: "Yeah, as much flak as we give them, they're doing just about everything they can here." (POST #1). --- Playing Should Not Be a Reason to Break Quarantine or Avoid Self-Isolation Redditors also engaged in discussion whether COVID-19 had increased or decreased playing in their area. A now deleted Reddit user posted the following "I'm actually playing more but my city is also at the beginning stages of Covid." (POST #2). Comments were also made about the option to play during COVID-19 safely using a vehicle. For example, Reddit user "SadieSnadieSnakeyLady" wrote: "Mine has no confirmed cases but my state has started stage 1 shut downs. My partner and I just play on the way to places we have to go to. We've always been lazy car players!" (POST #2). Some players commented saying they are in quarantine, and that they are unable to play Pokémon GO, but none showed signs of going out because of the game. For example, Reddit user "HaklePrime" wrote "Literally in quarantine right now awaiting labs, down to 8 Ultra Balls, no more poke coins, no more gifts, and in an extremely rural area. This feels like the time to quit, but I don't want to." (POST #4). --- The Pokémon Go Developer Could Have Done More Some commentators such as Reddit user "valdhir" raised concerns about the motivation LBGs provide to break quarantine or avoid recommended health measures by stating: "I find it odd that they still advertise giratina and timburr in raids while they are aware of the situation." (POST #1) which was upvoted a lot and echoed by users such as "PeterCosmos" who wrote "At least I'm not the only one finding it weird that they postpone a few things but still advertise raid hours" (POST #1). This discussion concerning the contradictory nature of Niantic's actions was slightly polarizing among Reddit users, as, when sorting the comments by "controversial", several of these comments appeared. Two themes arose with regard to actions that Niantic could take to combat the pandemic situation. The one that was more popular among Reddit voters was the removal or reduction of social features, which was supported by several commentators and posts. As an example, Reddit user "GimmeCatScratchFever" argued for completely removing the in-game social features by posting: "I think they should scale everything down to solo able." (POST #1). Another way that players suggested combatting the pandemic was to allow playing of all Pokémon GO's features while being stationary. For example, Reddit user "MarsNeedsFreedomToo" wrote: "Extending the range of gyms and pokestops that are within viewing distance would help with the current situation and make it easier to get and do field research/gift/raid from home." (POST#3). However, these suggestions also received critique. For example, Reddit user "smilesbuckett" wrote: "You basically want them to just enable spoofing for everyone? How do you imagine your idea realistically playing out?" (POST #1). --- /R/Pokemongospoofing The third and final subreddit we analyzed (4 March-3 April) was the third largest LBG subreddit that focused exclusively on one form of cheating in Pokémon GO, spoofing. Spoofing refers to location-spoofing, that is, falsifying the geographical location of the phone with software. The subreddit is peculiar as it consists mostly of individuals justifying their chosen form of cheating and sharing advice and experiences with others on how to avoid getting caught. The five top voted posts concerning COVID-19 during the indicated time period are shown in Table 6. --- Rejoicing of LBG Developers Loss of Revenue Due to COVID-19 Compared to the previous two subreddits, the commentators on this subreddit seemed to have a hostile attitude towards the developer Niantic, perceiving them as their enemy. Top-voted posts and comments more often than not made fun of the game developer and rejoiced in the possibility of them losing revenue due to the pandemic. Comments such as "Hilarious. They're handing out free incense to keep us home but won't unlock suspended accounts and will probably double down on spoofers. Oh the irony!" (POST #1) by Reddit user "skiermama" appeared often. Some users seemed more neutral, for example, Reddit user "Dyllamo" wrote "it really sucks bro. i don't think niantic will change their minds on people spoofing but at least they gave us lure modules and increased wild spawn rates. i miss spoofing tho" (POST #1). As indicated by the two quotes above, most of the content in this subreddit was about spoofing in Pokémon GO. Hence, the hostile attitude towards the game developer might be caused by the frequent bans players seem to be getting. This was exemplified by the Reddit user "AngeloPika" who wrote: "Niantic made a mistake chasing down spoofers like they did. However that's not my problem anymore. I stopped playing 1 month ago after my 4 accounts got 7 and/or 30 days ban. Believe me their are lots of other games and much much cheaper. Take care everyone" (POST #1). --- The COVID-19 Situation Disturbs Playing Users of this subreddit were exclusively stationary/remote players to begin with, as evidenced by the topic of the subreddit being "spoofing", meaning the movement restrictions of COVID-19 likely had minimal impact on their playing. Surprisingly, however, some comments indicated that even spoofers were influenced by the COVID-19 situation. Primarily, they could not complete legendary raids requiring the attendance of five or more players because people seemed to have stopped going to these social mini-events. For example, Reddit user "kiymon" wrote "However, not even so it's fun to play legit. Not a single 5 star raid I've done because no ones there to play. It's so boring that I have decided to quit playing. Well I think for me it's over. No spoofing, no playing." (POST #1) 5.3.3. Playing Should Not Be a Reason to Break Quarantine or Avoid Self-Isolation Despite the hostility towards Niantic, the subreddit contained several comments encouraging people to stay safe, stressing that health and safety were more important than any game. For example, the Reddit user "joinedthedarkside" commented "I just would like to say one thing and it doesn't matter if you're a spoofer like me, or a legit as I once was. Be careful with Covid 19. It's much more than a flu. Stay safe, wear a mask, always wash your hands, don't shake hands, avoid at any cost crowds and don't be that jerk that goes to the supermarket and buys all the food and toillet paper. We are all in this together despite our diferences." (POST #3). In addition, humor was present, as some commentators including "Mr_MustachioWhat" joked: "Coronavirus was launched by spoofers for getting their accounts suspended" (POST #5). These kinds of comments were received lightheartedly by other Reddit users and upvoted frequently. --- LBG Developers Have a Responsibility to Minimize the Impacts Their Game Has on Unwanted Pandemic Behavior The posts also contained interesting discussion regarding cheating (spoofing) being the ethical choice not only during the pandemic, but also outside it, as several Pokémon GO players were claimed to be driving around with their cars causing CO 2 emissions and accelerating climate change. Spoofing was defended also specifically in the COVID-19 context. For example, the Reddit user "Anyab8383" wrote "I enjoy playing legit when I can leave, but this is a literal public health crisis." (POST #4) and the Reddit user "jigu1996" wrote "Thats why we spoof. Prevention is better than cure" (POST #2). Niantic was bashed for banning several spoofing accounts just on the verge of the pandemic, with some posts claiming that they are actively encouraging people to not play remotely and go outside by banning spoofers. Ultimately while approaching the problem from a different angle, these comments shared the sentiments of the many players who commented in the other subreddits that LBG developers have a responsibility at some level (moral or ethical) to discourage unwanted behaviour during COVID-19 if possible. --- Identified Themes and Aggregate Dimensions Bringing together the results of conducted analysis across all three subreddits, we grouped central themes found in comments together to form 2nd order themes (see Figure 3). We have excluded from this analysis some of the themes related to spoofing, as we decided they did not concern LBGs' influence on human movement, as the comments, due to cheating, viewed Pokémon GO as a non-location-based game. Overall, based on the social media reactions, LBG developers can help with the COVID-19 situation with the measures they have taken. The two main ways they could have an impact were: (1) reduced incentives to socialize; and (2) more options for stationary playing. Looking at our results through the lens of PMT, they are connected to the often used coping appraisal constructs response efficacy and response costs [39]. The motivation LBGs provide players to go out during pandemics increases response costs, which lowers protection motivation. On the other hand, commentators were convinced that self-isolation was the responsible thing to do, which created tensions between LBGs influence and recommended health measures. Commentators had a strong response efficacy with regard to self-isolation, while they experienced also strong response costs for not being able to play. This tension leads to two 2nd order themes, which describe as solutions that players suggested to the situation: (1) LBG developers should make changes to their games to reduce response costs of players adopting recommended health measures to combat COVID-19; and (2) Players should be able to self-regulate their behaviour regardless of the LBG influence. In Figure 3, we have outlined how the 1st order concepts and 2nd order themes fit in the larger viewpoint of PMT. LBG developers have the possibility to reduce response costs of players, which the LBG developers did as evidenced by the observed in-game changes done due to COVID-19. On the other hand, the other commentators stressed individual responsibility and the role of self-efficacy in the following recommended health behaviour regardless of LBG influence. To summarize, LBGs are concerned with the coping appraisal aspect of PMT and the three constructs of self-efficacy, response-efficacy and response costs are needed to understand their influence. --- Results on Observation of Social-Play during the COVID-19 Pandemic We have now presented the results of our exploration on the measures taken by LBG developers as well as social media responses of Pokémon GO players. To investigate whether the pandemic and the measures taken by developers had an impact on social play frequency, we observed Pokémon GO players' participation in legendary raids in a Finnish municipality during 1 February-12 May 2020. When looking at Figure 4, we see two major peaks which both correlate with in-game rewards, mainly the availability of the legendary pokémon Darkrai in raids and its shiny form (available 6-8 March and again 28 April-5 May). The COVID-19 pandemic does not seem to have a significant effect on the raiding activity, even though it might be possible that as spring arrived in the observed municipality, the better outdoor weather had an opposing impact to the self-isolation recommendation related to COVID-19, and increased players' motivation to play. As we are concerned in particular with how government-issued restrictions impacted raiding activity, we focus on the time period of five days before (12)(13)(14)(15)(16) the Finnish government's intervention and five days afterwards (18)(19)(20)(21)(22). In the time period, five days before the limitations were issued there were 79 raids with seven containing more than 10 people, and in the time period five days after we recorded 70 raids with eight containing more than 10 people. Both of these numbers include a weekend; however, things such as weather and the changing in-game rewards might have still impacted these numbers. Still, we conclude based on this data that the government's call to limit social meetings and banning meetings of over 10 people had no impact on raiding culture in the case of a municipality in Finland. Finally, when observing the geographical location of the raids, no significant change towards an increased number of rural area raids was recorded and a majority of the raids throughout the observed time period took place near the city center. To better understand our findings in light of the effects of COVID-19 on human mobility, we look at the Google [56] and Apple [57] COVID-19 mobility reports. The Google data shows the current trend between 26 March-7 May compared to baseline and the Apple data show movement data from 13 January until 12 May. Both reports showed a roughly 50% decrease in the use of public transport in Finland due to COVID-19 in late March. The Apple data also show a 24% decrease in outdoor walking in this time period. These changes persisted up until May where the data collection period ended, however with a slightly increasing trend towards the baseline. Surprisingly, the Google data show that the use of parks and recreational grounds has gone up by roughly 90% from baseline due to COVID-19 while visiting retail stores has gone down roughly 30%. This implies that people moved in general away from busy areas into parks and possibly sub-urban areas where they live. When comparing the population-level movement data from Google and Apple to our data, there does not seem to be any connection. A similar change in mobility that was demonstrated in the population level could not be seen among LBG players. This indicates that LBG play could be obsessive or seriously habituated behaviour that persists over real world changes, despite the games being played under the laws and regulations of the real world. Accordingly, it shows that LBG developers have major influence over players' actions, and simple things such as in-game digital rewards can be used to move players around in the real world. --- Discussion --- Key Findings We summarize our findings for each research question as follows: --- • What in-game changes did LBG developers make due to the COVID-19 pandemic? Out of the seven observed games, all introduced in-game changes to support stationary play and to reduce the temptation the game causes to go out, explore and socialize. --- • How did LBG players respond to these changes and the pandemic in social media? The social media thematic analysis revealed two main 2nd order themes: (1) LBG developers can help with the on-going pandemic situation; and (2) People should self-regulate their behaviour and it is not the LBG designers and developers responsibility to intervene. These themes were connected to the coping appraisal construct of PMT, mainly response costs and self-efficacy, respectively. Players also demonstrated a high response efficacy with regard to self-isolation and were thankful that LBG developers took measures to reduce players' response costs of adopting the recommended health measures amidst the COVID-19 pandemic. --- • Did the pandemic, governmental measures and in-game changes in Pokémon GO have an impact on the frequency of social play? Contrary to what was expected based on the rest of the analysis, the observed raid chat indicated that during 1 February-12 May 2020 in Finland, players' behaviour was overwhelmingly more impacted by the LBGs rewards than COVID-19. A focused observation of player behaviour five days before and after the Finnish government issued restrictions on meetings showed no difference in social play activity. These findings, while limited by the sample, indicate that LBG developers have significant influence over their player population's movement, which they can manipulate with available digital raid rewards. The individual findings of our three-part methodology can be connected together using PMT [39]. Assuming LBGs do not influence their players' threat appraisal, we only focus on the coping appraisal. As mentioned, coping appraisal can be divided into self-efficacy, response efficacy and response costs [37]. The finding that players did not raid less even after government issued limitations on social meetings can be understood by looking at the tension between the coping appraisal constructs. In the case of response-and self-efficacy, players may feel they are generally able to socially distance themselves from others at raids while playing, and being able to comply with the recommended one metre distancing rule suggested by the World Health Organization [64]. As the data for social play came from a raid log, we did not record how players positioned themselves during actual raids. It is also possible that players valued the response costs of having to quit playing too high for them to avoid recommended health measures, mainly self-isolation. In fact, a recent study on why people self-isolate during COVID-19 found response costs to negatively influence self-isolation intention [4]. LBG developers managed to reduce the response costs for their players of adopting recommended health measures via the in-game changes they made. Besides coping appraisal, the other part of PMT, threat appraisal, also deserves to be looked at in our context. Even if LBGs do not influence their players' perceived severity or susceptibility, during COVID-19, these still played a role in players' actions. It is possible that the players did not yet perceive COVID-19 to be an accurate threat to them during the data collection period. However, the population-level mobility trends of Google [56] and Apple [57] showed clear changes in human movement; this was not shown in the data we collected. On the other hand, while the Finnish government had issued a recommendation to avoid extra social contact, no reinforcement of this rule was yet in place, meaning it was not illegal to go out and play. during the observed time period, the number of active COVID-19 cases in Finland remained constantly below a thousand, contributing to people perhaps not perceiving it as an immediate threat to them. --- Implications of the Findings Our results highlight LBG developers' ability to influence player movement also during pandemic situations. This has practical implications on gamification literature [65] and serious game literature [2,66]. The social media analysis showed LBG players to experience response costs for not being able to play, and suggested two solutions to the situation: (1) game developers could alleviate the perceived response costs by making in-game changes; and (2) players should better self-regulate their behaviour. With these findings, we contribute to the literature of LBGs' ability to influence players and specifically their movement [10,59,67]. Our findings also demonstrate how game developers seem to be increasingly monitoring the global situation and are quick to react and adjust their gameplay to take into account new situations. This highlights a trend where games today are updated regularly and consequently changing and evolving constantly. One of the questions that remains unanswered is why LBG developers were so quick to react to COVID-19 with in-game changes. We give three possible reasons: (1) Governments issued quarantines forbidding players to move outside, forcing LBG developers to react quickly in order to not lose these players as customers; (2) LBG developers were genuinely concerned about people's health and safety; and (3) as LBGs are marketed as games for health, the developers did not want to end up in news articles for motivating people to break quarantine (even though this still happened, as indicated by them most upvoted post on observed subreddits). It is possible that all three reasons were simultaneously at play, influencing different LBG developers to varying degrees. The first point might at least have a lot of weight, as demonstrated by the on-going competition of game developers to motivate people to stay home. In fact, several other developers and publishers of multiplayer and single player games provided special events, prizes and offers to players during the pandemic with the goal of encouraging people to stay indoors. For example, the Belarusian-based company Wargaming offered 14 days of premium membership to all its players in their games World of Tanks, World of Warships and World of Warplanes, which gives players more rewards from playing and consequently makes playing feel more worthwhile [68]. As another example, Ubisoft provided a number of games for free, such as Child of Light, Assassin's Creed Odyssey, Rayman Legends, during a limited period to encourage people to stay at home and play [69]. Additionally, 18 game industry leaders launched the #PlayApartTogether campaign which aimed to promote the World Health Organization's important messages and guidelines with regard to COVID-19, thus slowing down the spread of the virus [70]. Among these industry leaders were the companies Unity Technologies, Activision, Blizzard, Zynga, YouTube, Riot Games and Twitch, who together have access to a significant number of players worldwide. The changes made to the LBGs seemed to primarily focus on the two aspects also present in the social media analysis: (1) stationary play and (2) reduced social play. For example, Niantic wrote in one of their updates "As we develop ways to team up in Raid Battles from home..." [60] combining both these goals, allowing players to play from home while in quarantine but also participate in the social activities (raids) while maintaining self-isolation. This raises the question regarding the emergence of new gameplay norms and how COVID-19 might have permanently impacted LBG design and gameplay. In fact, some of the changes that were made to take COVID-19 into account are likely to remain in the LBGs even after the pandemic situation is over. Taking Pokémon GO as an example, remote raid passes were added to the game which are a permanent game mechanic. Another aspect is how the COVID-19 situation might have permanently impacted player propensity. As players can adopt new ways to play because of COVID-19, returning to the old ways might take time or not happen at all. Studies have already begun investigating what are the possible long-term effects of COVID-19 on, for example, small businesses [71] and trading [72]. However, we believe the impacts on LBGs will not be as substantial, as evident by our findings that COVID-19 had minimal impact on players' social play in the observed municipality in Finland. --- On Moral Responsibility of the Gaming Industry According to Statista, the number of active gamers worldwide is estimated to be 2.6 billion in 2020 [73]. Upon global threats, such as the COVID-19 pandemic, the actors in the gaming industry thus have a significant power, as well as arguably a moral responsibility, to convey important information and use games to influence this massive group of individuals. In the case of COVID-19, this means, for example, to cancel public events (e.g., fairs and e-sports tournaments) and to convince players to stay indoors by offering them various incentives. The moral responsibility of LBG developers is even greater, as their players' actions can directly influence the development of the pandemic. It is therefore important to discuss to what extent the developers of popular LBGs have accepted their moral responsibility and provided sufficient measures to combat the pandemic. Our findings suggest that a majority of the LBG developers employed various means to facilitate a change in player behaviour towards staying indoors, but ultimately leaving a lot of responsibility to the players. LBGs are played within the limits of government enforced laws and players should not under any circumstances raise above them, nor should LBGs motivate breaking the law. Before the COVID-19 pandemic, the laws and rules on how to play LBGs were fairly uniform globally, but the pandemic introduced a situation where some parts of the world went into lockdown forbidding unnecessary outdoor activity while other areas remained open. This new challenging situation and the rapid phase with which it was introduced to the LBG developers left little room to design careful solutions to the problem. The social media analysis showed that LBGs can support and help individuals adopt recommended health measures and decrease the incentives they provide to avoid self-isolation, but also that it ultimately remains the individuals' responsibility to abide by the law and adopt recommended health measures. However, the question remains whether LBGs encouraged illegal or irresponsible behaviour during COVID-19. Our findings show this was the case to a minor degree as demonstrated by the social media analysis. --- Limitations and Future Work Our work has methodological limitations in all three parts. First, in retrieving information on in-game changes, we used official websites when available but also social media channels. It is possible that we still missed some updates as the search was not systematic across all games due to varying communication methods by the different companies. Second, with regard to the social media analysis, we used netnography [45] and the authors perceptions and knowledge of the games and the community to evaluate the public response. As such, the analysis and understanding of the situation was to a degree dependent on the authors' viewpoints and experiences. The social media search was also limited by the chosen platform, which in our case was Reddit, and, more specifically, three Pokémon GO subreddits. Other social media channels, for example, less polarizing ones or those open to more critique, may have given other kinds of results. Third, the social playing activity observation had also its limitations. We looked at the most popular raid chat in a single municipality during a time when there were no restrictions on moving outside in place. The findings might suffer from geographical and cultural limitations, and it remains unclear whether they are representative on a global sale. The used raid chat measured intentions to participate in raids, but not for all players. Thus, the data are missing a proportion of players who did not use the raid chat as well as it does not confirm whether the reported raids took place in the end or not. While our findings demonstrated that LBGs influence player behaviour during pandemics, it remains unclear whether the players still playing would be going out without the motivation provided by the LBGs. Further research is encouraged on this topic. More specifically, future work could measure PMT constructs such as perceived severity [74], perceived vulnerability [75] as well as game addiction [76] and deficient self-regulation [77], and look how these relate to the intention to self-isolate during pandemics [4]. The findings of the current study could also be supplemented by studies on human behaviour during pandemics generally, relating player behaviour to what is considered normal and measuring whether there exists statistical differences in likelihood of breaking quarantine for LBG players compared to others. The findings of such study could be used by governments to understand and control human actions during pandemics. Studies could look into how the motivations and gratifications of LBG players changed during COVID-19. One other avenue for future work is looking at the playing locations during pandemics, which LBGs have specifically been shown to be able to impact [10,11,59]. Despite us not finding differences in the geographical locations of raids in the observed chat, there might exist variance in geographical location of other kind of playing such as egg hatching. Finally, it could be explored how LBGs could gamify social isolation, rewarding players for spending time in exclusive isolated environments. --- Conclusions Our findings demonstrate that LBG developers were quick to react to the COVID-19 pandemic. Furthermore, the empirical data on raid attendance collected among Pokémon GO players in Finland showed that players' gameplay was impacted more by offered in-game rewards in LBGs than the COVID-19 pandemic. While the game companies received mostly praise for the made in-game changes in social media, there were suggestions and calls for further action. This raises ethical concerns regarding the duty of LBG developers to minimize health risks, and whether government and health officials should even take LBGs into account or use them to their advantage when designing health interventions. The idea that LBGs acted to a small degree as catalysts of COVID-19 propagation is rather paradoxical given their underlying motive of improving the health of their players. Time will show how the pandemic will advance and future studies may reveal more information on the involvement of LBGs in the complex equation of containment, or spreading, of the virus. --- Conflicts of Interest: The authors declare no conflict of interest. --- Abbreviations The following abbreviations are used in this manuscript:

In early 2020, as a countermeasure to mitigate the spread of the COVID-19 pandemic, governments issued limitations on the movements of their citizens, cancelling social events and advising people to stay home. As location-based games (LBGs) have been found to influence human movement, their role during COVID-19 deserves closer inspection. Under regular circumstances, the very aim of these games is to motivate people to go out, explore and meet other people. However, during COVID-19, people were advised to do the exact opposite. To study how LBG developers and players reacted to the situation, we used the netnography research method utilizing three types of data: (1) COVID-19 related in-game changes made by seven popular LBG developers during March 2020; (2) social media reactions on 20 posts across three popular Pokémon GO subreddits; and (3) the raiding activity (collaborative play) in Pokémon GO in a Finnish municipality during February-May 2020. All observed LBGs made in-game changes due to COVID-19. The social media reactions showed overwhelming appreciation towards these changes, and two central second order themes arose: (1) LBGs have the ability to influence human movement during pandemics; and (2) people should be able to self-regulate their behaviour during COVID-19 independent of LBG influence. Surprisingly, recorded Pokémon GO player activity in Finland was more influenced by offered in-game rewards than the COVID-19 pandemic. Our findings have implications on how games and gamification can be used to direct human movement in situations such as COVID-19 where population-level interventions are needed.

Introduction In recent years, much has been made in the welfare state literature of the presence of new social risks in postindustrial political economies (Esping--Andersen 1999, Hemerijck 2002, Taylor--Gooby 2004, Armingeon and Bonoli 2006, Emmenegger et al. 2012, Morel et al. 2012). In fact, the term "new social risks" arguably signifies one of the defining areas of contemporary research on welfare state adaptations in advanced affluent democracies. The welfare state has long been the subject of study for its mechanisms of combating social risk and decommodifying the typical male industrial worker (Esping--Andersen 1990, Korpi 1980). However, in the context of postindustrialization and an evolving global economy, scholars and policymakers alike have turned to analyzing how the modern economy can avoid new social risks in times of technological change and globalization, with states still providing a modicum of social wellbeing for their citizens, especially those deemed to be most vulnerable. A range of policy tools remains in effect under postindustrialism, having originated in divergent models of welfare provision that today are commonly known as <unk>worlds of welfare capitalism" (Esping--Andersen 1990). How these various worlds of welfare provision-specifically, policy tools-interact with the well--being of new social risk groups forms the basis of this paper. This paper considers groups who are most likely to be vulnerable to new social risks and tests the effects of social policies on their poverty levels, filling an important lacuna in the literature. Specifically, I conduct multi--level regression analyses across 18 OECD countries around the year 2004, analyzing the effects of social policies on the likelihood of being poor of low--skilled young women and men aged 18--30, and of those at risk of possessing obsolete skills, namely low-skilled men aged 55--64. 1 These particular social risk groups are chosen for two main reasons: 1) they are well suited to empirical analyses of the sort conducted here because of the quality of data available, and 2) they are the "common denominator" of new social risk groups that figure prominently in the literature. Being low skilled and either young or nearing retirement (with the added age penalty of possessing obsolete skills) puts one at a distinct risk in the labor market. Additional social risk features like gender are captured in one of the social risk groups considered here (young low--skilled females), whereas other potential risk groups prove to be less well suited to empirical analyses because of a lack of data (as in the case of immigrants and LIS data), and a compounding factor of household composition. Since those who may fall into a new social risk category may also share a household with someone who does not fall into the risk category (who is either more economically secure or falls into an "old social risk" category), identifying other risk markers (besides skill level, age, and gender) becomes a more complex endeavor. Ultimately, the dependent variable in the paper's analyses, poverty, is a household phenomenon. The analyses are conducted by combining both macro--level policy data and household--and person--level micro--data from the Luxembourg Income Study (LIS) cross--national database. This paper provides an innovative contribution to the literature on social policy, new social risks, and the contemporary welfare state of advanced industrialized economies, in one of the first multi--level analyses to specifically focus on welfare policies and vulnerable population groups. My central question is to ask which policies-active labor market policies (ALMP), passive labor market policies (PLMP), employment protection legislation (EPL), family policies, and government daycare spending-are effective at combating new social risks. In addition to analyzing social policies, I also include union density and representation of women in national parliaments in my models as two measures that depict agents who are most intent on combating old and new social risks, respectively. Because the time point at which I analyze the effects of social policies on individual--level poverty is centered around the year 2004, my analyses capture the new social risk structures that have arisen in the new welfare state of the early 2000s-i.e. the "Third Way" of the social welfare state that promotes activation rather than passive welfare uptake (Huo et al. 2008). The paper's findings suggest that policies remain geared toward older segments of society, while the younger population is not effectively prevented from financial and therefore social risk. These findings have important relevance today, as youth remain a particularly susceptible group at risk of falling below the poverty line. --- Theoretical Background New social risks tend to be concentrated within specific groups: youth, women, families with small children, and older workers with obsolete skills. Given the nature of these societal groups, there is difficulty in identifying one underlying cause or uniting interest. As Kitschelt and Rehm (2006) state, there is "diversity, if not conflict" among the new social risk groups, contingent upon age and gender, due to a lack of unifying interest. In this paper, I focus on social risk groups as defined by low skill level: 1) young, low--educated males, aged 18--30; 2) young, low--educated females, aged 18--30; 3) older, low--educated men, aged 55--64. Young people with low skill levels are exposed to a high risk of unemployment while having dwindling earning power. Young low--skilled females may have as a further constraint the concern of raising young children and/or caring for elderly parents. Older low--skilled males have the added risk of preparing for imminent retirement. Furthermore, they risk having antiquated skills that do not match the updated skill--level requirement of the current labor market. 2 2 I do not include older women as a new--risk group, under the logic that they have traditionally been sheltered against social risks via their status as spouses, Before I discuss specific social policies and their hypothesized effects on individual measures of well--being, I turn to a discussion of new social risks and how to conceptualize them. The vulnerabilities characterizing new social risks stem from three distinct features of the postindustrial economy. First, while gender appeared as an overlooked yet vital component of the welfare state research schema of the 1990s (Orloff 1993, Sainsbury 1996, Daly 1994), it has now become fully inserted into the understanding of social risks and how these relate to the political economy. Changing gender roles are one of the primary aspects of contemporary social risk profiles: women have entered the labor force in higher percentages than ever before, and their educational attainment matches, or in some countries exceeds, that of men. Countless academic and mainstream-media reports discuss the implications of women's increased entry into the labor market, including the heightened need for childcare outside the home and the ways in which these gender shifts are spawning social and domestic shifts (Esping--Andersen 1999, 2009). With evolving gender roles and changing family structures, we have seen a rise in lone--parent, especially single--mother, households, which risk being poor due to the particular challenges for them of combining work and parenthood (Taylor--Gooby 2004, Esping--Andersen 2009). As women have made massive advances in education and employment levels, thereby achieving more equal opportunities with men, the balance of unpaid labor of care responsibilities within the home has shifted: the postwar gendered division of home labor imposes strains on the family in today's modern era. Second, changes within the labor market include the de--standardization of employment and the weakening labor market position of the low--skilled. In today's post--industrial societies, economic growth rates are lower and less certain, and states face various measures of economic austerity. Technological advancements have altered the landscape of the industrial manufacturing sector, resulting in lower mass employment in this sector, as well as increased economic unpredictability for the semi--and low--skilled. Economic globalization and the inherent competition that accompanies it have produced greater flexibility within the labor market, albeit to varying degrees. Lastly, changes have occurred within the welfare state itself. As activation has become the buzzword especially in the employment--lagging continental European countries, the welfare state is being rebuilt around work, as with the Hartz IV reforms in Germany and similar measures across the OECD. Thus, the new phase of welfare politics can be described as the effort to make all citizens fit into the labor market as the new means to social inclusion, particularly for women, who were previously discouraged from work and from the employment-based model of social inclusion. However, youth are a vital part of society that is facing unprecedented levels of risk and threat from long--term unemployment. and have typically had less active life--cycle employment profiles than their male counterparts (with the exception of the Nordic countries). As these developments have taken place, new social risks have presented themselves as obstacles to social parity and societal well--being. Let us now turn to a definition of new social risks, based on the synthesis of several streams of recent scholarly work. As aptly summarized by Bonoli (2006), new social risks are seen as the insecure situations under which individuals experience welfare losses and which result from the socio--economic transformations of the past three to four decades, generally subsumed under the heading of "postindustrialization." Deindustrialization, the boom of employment in the tertiary sector (service sector), and the significant entry of women into the labor market, have increased the instability of family structures and at the same time, increased the destandardization of employment. More jobs now are classified as "atypical" jobs, which include part--time work, temporary contracts, and low--wage or "mini--jobs," which do not carry social benefits. Possessing low or obsolete skills signifies a significant new social risk. During the postwar years, the low skilled found economic salvation in the manufacturing sector, where wages could grow because of advances in technology and increases in productivity. Strongly mobilized unions' bargaining power has waned due to a relative decline in union density across the OECD (Bonoli 2006). Today, low--skilled people are either unemployed or are employed in the low--value added service sector, which entails retail, cleaning, catering, etc., and is known for providing little opportunity for productivity increases (Pierson 1998, Iversen andWren 1998). In the contemporary economy, having low or obsolete skills poses a major risk of welfare loss, since the sheltered manufacturing sector which had provided an economic safe haven now does so considerably less (Bonoli 2006). In sum, what distinguishes new social risk groups from their old social risk counterparts is the difficulty of securing and maintaining employmentemployment (not the state) being the new key means of social protection and insurance against poverty. The primary characteristic of new social risk groups is insufficient employability. The "old" welfare state was able to guard against social risks via its mechanisms of unemployment insurance (short--and long-term), sickness and disability pay, and pensions-all of which are systems put into place to protect the workforce. New social risks are "new" in that they confront groups who are not certain of penetrating the workforce in the first place. Thus, this paper's question of whether social policies which began as instruments aimed at old social risk prevention are effective today against new social risks is a highly relevant and expedient one. The following section presents hypotheses regarding social policies and their effects on the poverty level of the low skilled. --- Hypotheses The hypothesized effects of the macro--level independent variables on the dependent variable-poverty of the low--skilled by age and gender-are summarized in Table 1. In this study, the micro--level variables are entered primarily as control variables. --- <unk>Table 1 about here<unk> Active Labor Market Policies Active Labor Market Policies (ALMP) are one facet of social policy that directly target employment levels. Active labor market policies can be seen as having an impact on the "insider--outsider" roles in employment. Outsiders, including those who are disadvantaged in the labor market such as the unemployed, atypical workers, and excluded people (single mothers, immigrants, low--skilled) who have difficulty securing and maintaining jobs, benefit from the training, re--entry, and skills--acquisition emphasis of ALMP (Rueda 2007). We can expect that active labor market policies have a positive effect in lessening poverty of the new social risk groups-that is, the higher the ALMP value (measured as government spending on active labor market policies as a % of GDP, divided by the unemployed population), the lower the odds of poverty. While active labor market policies are an inherently complicated explanatory variable due to the diversity of components, it is generally expected that the more a government invests in active labor market measures, the better the employability of the targeted population will be. 3 --- Passive Labor Market Policies Labor market strategies that fall under the rubric of passive labor market policies (PLMP) provide income protection for those who are temporarily without market income, rather than directly promoting employability (Martin and Grubb 2001). Passive programs such as unemployment insurance and income support assist the unemployed by supplying some income stability in the face of loss of income. However, because these policies are passive in nature, and do not actively retrain or reintegrate workers into the workforce, their outcome is mixed: they do not aim to enhance the employability of labor market outsiders, such as single parents and youth, but they assist those who are temporarily out of employment. Thus, passive labor market policies can be seen 3 A more nuanced analysis of the effectiveness of different active labor market policies, their take--up rates, and short--vs. long--term costs and benefits is beyond the scope of this paper's analyses. For a useful overview, see Card, Kluve, and Weber 2010. as a tool to aid "insiders," or those who already have labor market attachment. It would be difficult to parse out the effects of PLMP on different segments of the population. In most cases, greater government spending on PLMP will be expected to be associated with less poverty. PLMP is operationalized (like ALMP) as government spending on passive labor market policies as a % of GDP, divided by the unemployed population. --- Employment Protection Legislation Employment protection legislation (EPL) is a passive income/job-protection policy tool that is generally seen as benefiting a core group of insiders, who maintain a solid connection to the labor market, at the expense of those on the exterior of the core labor market who would otherwise like to penetrate the market and become stably employed (Esping--Andersen 1999, Rueda 2007). In countries with strict job protection laws and various restrictions on temporary and part--time work, a dual labor market emerges in which "outsiders" (those without stable employment) face difficulty in obtaining the secure positions enjoyed by "insiders." The high--EPL model of privileging the core workforce yields this insider/outsider divide: the high wages and job security enjoyed by chiefly male insiders is predicated in effect on the exclusion of youth and women. It is generally agreed that stricter employment protection laws inhibit employment among youth and outsiders who are left out of protected labor schemes, and propagate the insider/outsider divide (Rueda 2005). Therefore, I hypothesize that the stronger the employment protection levels in a country, the greater the degree of outsiderness, and therefore the higher poverty. One caveat here would concern the Nordic countries, where the effect of EPL on poverty will be smaller than the reducing effect on poverty of these countries' generous active labor market policies and family policies. In other words, the outsider-barrier nature of EPL in the Nordic countries will be felt much less acutely, if at all, due to the strong emphasis there on labor market activation and integration that is lacking in many continental European countries. --- Family Policy Generosity and Childcare Availability As women and men on the lower end of the income spectrum face greater obstacles to keeping their families out of poverty, it is of particular importance that the earners in the family (whether single--parent or dual--parent) have access to childcare options in order to maintain a basic income through employment, and that benefits are structured in such a way as to promote gainful employment and not promote undue exit from employment. Exit from employment hinders parents' prospects of later return to the workforce, as well as carries an income penalty of lost wages or wages that remain stagnant. Family policy can either exacerbate or diminish the inegalitarian consequences of modern female roles, as a report by Ray, Gornick, andSchmitt outlines (2008, 2010). When the 'female revolution' does not entail enhanced labor force participation by the lower income groups, greater social inequalities-at the very least, in income levelwill ensue. If the bottom--end of the income spectrum could fully participate in new female roles, we would expect far less polarizing social consequences. I expect family policy generosity and higher government spending on daycare both to reduce poverty. --- Union Density The level of union density, defined as union membership as a proportion of wage and salary earners in employment, is included as a measure of agency of old social risk protection. This variable offers another way of capturing insider-outsider dynamics, related to levels of wage inequality. There are generally lower levels of inequality among union members than among nonmembers of unions (Oliver 2008, Wallerstein 1999). Unions tend to favor wage scales that prevent firms from paying wages below a certain level, thus potentially affecting those at the bottom of the income spectrum (youth and single parents). The lower the union density, the smaller the proportion of the population that is protected by wage bargaining, and the more economically vulnerable are low-skilled workers. 4 In other words, where unions are strong, wage dispersion is lower, thereby affecting poverty levels. However, unions can be viewed as agents who have traditionally protected those who are prone to the old social risks of unemployment in the large manufacturing sectors, disability, sickness, etc., while younger low--skilled women and men would be outside such union coverage. Thus, I hypothesize that higher union density will be associated with lowering the poverty of older low--skilled men, but not of youth, who occupy more non--unionized and atypical jobs. --- Percentage of Seats of Women in Parliament The proportion of seats held by women in national parliaments is used as a proxy for women's mobilization. This measure of gender equality represents agency of those who combat new social risks associated with women's modern roles in the workplace. The higher the percentage of seats held by women in national legislatures, the higher the expected overall degree of gender parity, both in terms of inputs (policies) and outputs (women's labor force participation, education levels, etc.). Thus, I expect higher levels of women's representation in government to be associated with lower levels of poverty, particularly among low--skilled women, which will have positive spillover effects for low--skilled men through beneficial societal externalities. This line of argumentation draws on previous research that has established the link between 4 In the regression models, I also used the variables "union bargaining coverage" and "wage dispersion" separately, in order to test other possible measures of the insider--outsider divide. These were, however, insignificant. women's political mobilization and an expansion of welfare policies (Moller et al. 2003). Under this line of reasoning, women's political representation is expected to be associated with a decrease in poverty both via the mechanism of increased welfare generosity and a policy orientation that reflects greater levels of redistribution, both of which bear directly on new social risk groups. Measurement of Data and Sources I conduct my analyses using micro--data from the Luxembourg Income Study (LIS) Wave VI, around the year 2004. The macro--data come from a variety of sources, including the Comparative Welfare States dataset (Huber et al. 1997(Huber et al., updated 2004 Brady and Burroway (2012), my dependent variable is poverty, defined as poor = 1 (non--poor = 0) if s/he resides in a household with less than 50% of the median household income. This definition of poverty is the standard definition that is commonly used in cross--national poverty analyses (Brady 2003, Brady et al. 2009, Smeeding 2006). Household income is calculated after taxes and transfers, using the standardized LIS variable "DPI" ("net disposable income"). To adjust for household size, DPI is divided by the square root of household members. I calculate the poverty threshold for each country at 50% of median household income, including all individuals. To run my logistic regression models on select segments of the population-by social risk group-I reduce the sample to include only these specific groups; however, this is done after calculating the overall population poverty threshold. I define the new social risk groups by age, gender, and skill level (measured by education level). Table 3 presents the mean values of the group composition by country and welfare state regime. I analyze the effects of social policies-ALMP, PLMP, EPL, family policy, and government spending on daycare-along with union density and the percentage of seats held by women in national parliaments, on individual--level poverty. <unk>Table 3 about here<unk> Micro--Level Variables My analyses include a set of individual--level control variables that capture demographic variance in poverty outcomes. To account for the "economies of scale" effect, which assumes that households with multiple members pool resources and expenses, I measure several individual elements at the household level (Brady and Burroway 2012). These include binary variables for "No one employed" and "Multiple earners" in the household (reference category = one earner). I use the LIS--standardized measures of education, coded as binary values of "Head high education" and "Head low education" (reference category = medium education). 5 The other control variables include "Age of the household head," "Children under age 5," "Number of other adults in the household," and "Children under age 18 in the household." Macro--Level Variables Data on employment protection legislation (EPL) are from the OECD (Organization for Economic Cooperation and Development) annual time series. The summary index summarizes a number of sub--indices measuring the difficulty of layoff (terms of notice, severance pay, etc.) and regulations restricting the use of temporary work (Bradley and Stephens 2007). This index is calculated along 18 basic items, which can be classified in three main areas: 1) employment protection of regular workers against individual dismissal; 2) specific requirements for collective dismissals; and 3) regulation of temporary forms of employment. The Active Labor Market Policy (ALMP) and Passive Labor Market Policy (PLMP) variables are operationalized as public expenditure on active and passive labor market measures, respectively, as a percentage of GDP, divided by the unemployed population. Both the EPL and ALMP/PLMP variables are standard OECD measures that are widely used in welfare state analyses. Data on daycare is defined as "Public expenditure on day care/home--help services as a % of GDP," and comes from the OECD Social Expenditure database ("SOCX"). 6 Data on family allowances are defined as "Total expenditure on family allowances in the form of cash benefits as a percentage of the countries' gross domestic product," and come from the OECD, as provided by Gauthier 5 The categories are: 1) less than secondary (low), 2) secondary or some tertiary (medium), and 3) completed tertiary or more (high). 6 www.oecd.org/els/social/expenditure. (2010). 7 The union density variable, defined as net union membership as a proportion of wage and salary earners in employment, comes from Jelle Visser's union membership dataset (Visser 2011). The data for the proportion of seats held by women in national parliaments (expressed as a percentage) comes from the World Bank's World Development Indicators. The models analyzing particular social policies control for overall welfare generosity, which is defined as "gross public social expenditures as a percentage of current GDP" (OECD). To control for the economic context within a country, I include the unemployment rate (OECD in Huber et al. 1997Huber et al., 2010)). 8 --- Analytical Technique The regression technique utilized in this paper is multi--level logistic regression using random--intercept models. 9 The models are composed variously of different micro--and macro--level independent variables (see Tables 4,5, and 6 for models and results). Due to the clustering of individuals within countries and the inclusion of country--level variables, the standard logistic regression model violates the assumption of independent errors. Mixed logit models predict whether an individual is poor based on a set of individual--and country--level variables. Based on Brady and Burroway (2012), the random intercept model can be expressed in two equations. First, the log odds of being poor for the ith individual in the jth country is represented by eta (<unk> ij ) and is a function of country intercepts (<unk> 0j ) and a set of fixed individual--level characteristics (<unk>X ij ): 7 OECD StatExtracts. Social and Welfare Statistics --Social Protection --Social Expenditure --Aggregated data.(On--line: http://stats.oecd.org/index.aspx; accessed March 2010). 8 To keep the models parsimonious at level two (the country level), only one macro--level variable is included per model per dependent--variable group (young low--educated male, female; older low--educated male) along with the macro--level control variable. The control variable is either welfare generosity in the case of the models that analyze the effects of particular social policies on poverty, or an economic context control (unemployment rate) for the models with union density and women's representation in parliament. 9 Estimated in Stata 11 using the xtlogit command. In these models, the intercepts are allowed to vary randomly in order to capture the country--specific nature of the data; the scores on the dependent variable for each individual observation are predicted by the intercept that varies across groups (Steenbergen and Jones 2002;Rabe--Hesketh and Skrondal 2008). Second, each country intercept (<unk> 0j ) is estimated as a function of an intercept (<unk> 0Cj ), a set of country--level variables (<unk>C j ), and an error term (u 0j ): Because the analyses are limited to 18 countries, it is necessary to keep the models parsimonious at level two, which is the country level 10. Additionally, due to multicollinearity between the macro--level policy variables, 11 I include only one macro--level variable in addition to one macro--level control variable per model. --- Results Table 3 shows the percentages of the new social risk groups within the population, the percentage within the age and gender groups that is low skilled, and the percentage within the group that is in poverty. Figures 1 and2 show the important variation in the poverty rates of the new risk groups, by country and by welfare state typology. Summarizing the effects of policies when looking at the composition of the population by group type (defined by gender/age/skill-level) provides insight into the efficacy of particular countries' policy mixes in combating new social risks. As a general note of caution, all results should be 10 For an explanation of the number of level--two (country--level) units that is appropriate for multi--level modeling, as well as the difficulty in estimating cross-level interactions, see Stegmueller 2013. 11 The correlations range from.6--.9. read with the understanding that direct causality cannot be claimed, but rather, this paper shows associations between policies and poverty of certain at--risk groups. While it can be said that the Nordic welfare regime as a whole provides better coverage against social risk, looking at individual country profiles gives a more accurate picture of government effort against risk. While the Nordic welfare regime clearly protects older low--skilled males against poverty to a much better degree than the Continental or Liberal welfare regimes, the picture for the younger population is less clear. It is true that the Nordic countries have lower percentages of youth in poverty than the other regimes, but it is young, low--skilled males in particular that complicate the story. Denmark, for example, appears as an anomaly; it shows an unexpectedly high percentage of young low-skilled men in poverty (15.1% compared to a mean of 11.4% in the Continental countries). This is particularly unusual given Denmark's higher than average spending on ALMP, but it also has higher than average spending on PLMP. The combination of active and passive labor market policies in this country does not seem to be adequately protecting its low--skilled youth from poverty, whereas the older population seems to be benefiting disproportionately. As expected, in all welfare state regimes, young low--skilled women are worse off than their male counterparts. However, this difference is most stark in the Liberal welfare regime. The Liberal Anglophone countries have the lowest percentages of seats of women in parliament compared to the other two welfare state regimes, and similarly the lowest amount of government spending on daycare facilities. Looking at the welfare regime groups as a whole, one would conclude that the Liberal countries offer the least protection against social risk for women. However, looking at individual countries again provides a refined assessment: Australia, for example, has higher than average daycare spending and family allowances, and its young low--skilled women are indeed much better off compared to their peers in the other Anglophone countries, with a group poverty rate of 11.5% compared to the regime mean of 25.7%. This is particularly striking when noting that young low--skilled females comprise the biggest share of the population (6.7%) in Australia out of all the countries under analysis. Older low--skilled males fare far better in countries where mechanisms of old social risk protection are strongly in place. Where union density is higher, older low--skilled males are better protected against the risk of poverty. Looking at the individual country profiles, we see for example that Spain has the highest percentage of older low--educated men in poverty (16.7%) out of both the Continental and Nordic welfare regimes, and by far the lowest union density (15.5%) out of all the countries in the sample, save for France (8%) and the United States (12%). Similarly, Spain's spending on PLMP (.14%)-shown in this paper's analyses to protect older males via its passive insider income-protection mechanism-is one of the lowest in Europe. Italy shares a similar country profile with Spain in this regard, providing evidence of a southern European welfare regime that is distinguishable from the other regimes. The results of the multi--level logistic regression models are presented in Tables 4,5, and 6. The analyses are conducted by grouping the sample into new social risk groups, analyzing the dependent variable of poverty among low--educated young males and females (age 18--30), and low--educated older males (age 55--64). <unk>Tables 4, 5, 6 about here.<unk> Throughout all the models, the individual--level control variables are significant and stable. Multiple earners, additional adults, and persons over age 65 in the household all reduce the likelihood of poverty for the three groups (young low-educated males and females, and older low--educated males). The presence of multiple earners in the household reduces the odds of poverty by as much as a factor of 7.4 for young, low--educated, males. 12 For the female group, having multiple earners in the household reduces the odds of poverty by 5.6, and for the older male group, the presence of multiple earners yields a reduction in poverty odds by 4.1. Conversely, having no one employed in the household, children 5 years old and under, and a greater number of children in the household all increase the odds of poverty of the three groups. If no one is employed in the household, the odds of poverty increase by a factor of 4.8 for young low--educated men, around 3.5 for young low--educated women, and 3.7 for older low--educated males. For young men, the number of children in the household increases the odds of poverty by a factor of 1.3, while the presence of children under 5 increases the odds of poverty by a factor of 1.5. Similarly, for young women, the number of children increases the odds of poverty by a factor of 1.1, and the presence of young children increases the odds of poverty by a factor of 1.3. The economic context control variable, unemployment, is correctly signed in all models (increasing poverty odds by a factor of 1) but remains insignificant in all models. Strikingly, the welfare generosity control variable is insignificant in all models on the young groups, but is highly significant and correctly signed (decreasing poverty odds by a factor of 1.5--1.9) in the older male group. The implications of this finding echo the theme of this paper: traditional welfare state measures more effectively assist those people facing old social risks-those already entrenched in the labor market, e.g. the 55--64--year--olds in this paper's analyses-than they do youth. Public social spending, on the whole, is not shown in these analyses to be significantly correlated with a reduction in poverty among low--skilled young women and men-a finding which is quite novel in the literature. That public social spending is shown to be significant in decreasing 12 Odds ratios are used to interpret the effects of binary independent variables (micro--level variables in this paper's models). Standardized odds ratios are used to interpret continuous or ordinal independent variables (macro--level variables here). Tables 4,5, and 6 show both regular and standardized odds ratios for the macro--level variables. To interpret odds ratios below 1.0, the inverse is taken. For example, an odds ratio of.5 is interpreted as --1/.5 = --2. poverty only in the older male group suggests that the welfare state may have important gaps in its aim to protect against social risk. The effects of employment protection legislation (EPL) on poverty odds differ according to the group under analysis. For both young low--skilled males and females, higher EPL is associated with an increase in the odds of poverty, but the results are not significant. For the older male group, however, EPL is associated with a decrease in poverty odds (by a factor of 1.1), but again the results remain insignificant. Thus, we can neither confirm nor disconfirm our expectation of an increase in poverty of low--educated groups as a result of increased employment protection levels. Across all models, active labor market policies (ALMP) are shown to be the most important and consistent predictor of a decrease in poverty levels among the low skilled. The odds of low--skilled young male and female poverty are reduced by a factor of 1.8 for a one standard deviation increase in active labor market policy spending. For older low--skilled men, the results show even more importance of active labor market policies for reducing poverty than for the younger population, both in terms of factor size (2.0) and significance level. This finding may indicate that ALMP are more effectively targeted at older people, or that this group is better at responding to the opportunities provided by ALMP. Further analysis of the components, provision, and take--up rates of active labor market policies is a necessary

This paper considers groups who are most likely to be vulnerable to new social risks and tests the effects of social policies on their poverty levels. Specifically, the paper conducts multi--level regression analyses across 18 OECD countries near the year 2004, analyzing the effects of social policies on the likelihood of being poor of low--skilled young women and men aged 18--30, and of those at risk of possessing obsolete skills, namely low--educated men aged 55--64. The analyses are conducted by combining both macro--level policy data and household--and person--level micro--data from the Luxembourg Income Study (LIS) cross--national database. The central question asks which policies-active labor market policies (ALMP), passive labor market policies (PLMP), employment protection legislation (EPL), family policies, and government daycare spending-are effective at combating new social risks. In addition to analyzing social policies, the paper also considers union density and representation of women in national parliaments as two measures that depict agents who are most intent on combating old and new social risks, respectively. The findings show that active labor market policies (ALMP) are the most important predictor of a decrease in poverty levels among the low skilled. The negative effect of passive labor market policies (PLMP) on poverty is only significant for the older male group. Family policies are related to a reduction in poverty for both low--skilled young women and men. Union density is significant in reducing the odds of poverty of the older male group, while it is insignificant for both younger males and females-thereby reflecting a measure of prevention against old, but not new, social risks. Additionally, the paper's findings support the hypothesis that the greater the representation of women in national parliaments, the greater the chances of having policies that are associated with a reduction in poverty across age levels. Lastly, gross public social spending as a measure of overall welfare generosity is found to be associated with a reduction in poverty only of the older male group, but not that of the younger groups. The paper's analyses suggest that some social policies remain geared toward older segments of society, leaving the younger population at greater financial and therefore social risk.

the odds of poverty, but the results are not significant. For the older male group, however, EPL is associated with a decrease in poverty odds (by a factor of 1.1), but again the results remain insignificant. Thus, we can neither confirm nor disconfirm our expectation of an increase in poverty of low--educated groups as a result of increased employment protection levels. Across all models, active labor market policies (ALMP) are shown to be the most important and consistent predictor of a decrease in poverty levels among the low skilled. The odds of low--skilled young male and female poverty are reduced by a factor of 1.8 for a one standard deviation increase in active labor market policy spending. For older low--skilled men, the results show even more importance of active labor market policies for reducing poverty than for the younger population, both in terms of factor size (2.0) and significance level. This finding may indicate that ALMP are more effectively targeted at older people, or that this group is better at responding to the opportunities provided by ALMP. Further analysis of the components, provision, and take--up rates of active labor market policies is a necessary next step. The effect of passive labor market policies (PLMP) on poverty is only significant for the older male group. For one standard deviation increase in the passive labor market policy variable, the odds of older male poverty are reduced by a factor of 1.7. These results suggest that passive labor market policies, such as unemployment insurance, are most effective for the financial well--being of older low--skilled males, while the younger groups do not register a benefit from these passive measures. Furthermore, we observe a stark contrast in reduction of poverty odds between active and passive labor market policies. Active labor market measures have by far the more powerful effect on the reduction of the odds of poverty across all three groups. The policies related to the family-which can be considered as work/family reconciliation policies for the younger groups-are, as expected, related to a reduction in poverty for both low--skilled young women and men. A one-standard--deviation increase in the family policy allowances indicator yields a reduction of the odds of poverty by a factor of 1.3 for both the young female and male groups. For the older males, this effect is insignificant though similarly signed. For young men, the effect of government daycare spending is not significant, but for young low--skilled women, the odds of poverty decline by a factor of 1.6 with a one--standard--deviation increase in government daycare spending. Union density is significant in reducing the odds of poverty of the older male group by a factor of 1.7, while it is insignificant for both younger males and females. This finding, which exactly mirrors that of passive labor market policies, is consistent with the expectation that union density captures agency of actors promoting policies that are aimed at old social risks, i.e. temporary unemployment spells, disability, sick leave, etc. of established workers. Conversely, the number of seats of women in national parliaments-a proxy for agents developing policies aimed at new social risks relating to gender equality and work--family balance, among others-has a significant effect in reducing the odds of poverty for young low--skilled women by a factor of 1.3. This measure has a similar effect on the reduction of poverty odds for the older male group, by a factor of 1.7. This finding offers support for the hypothesis that the greater the representation of women in national parliaments, the greater the chances of having policies that are associated with a reduction in poverty among women and also of old social risk groups (of at least 55 years of age) who may be at risk because of obsolete skills. In general, this paper's findings corroborate previous research that showed that women's mobilization is associated with lower levels of poverty overall (Moller et al. 2003). Analyzing welfare regimes grouped together as a whole, coupled with scrutiny of individual country profiles, yields nuanced evaluation of the policy effects found in this paper's analyses. This paper offers evidence for the argument that the three worlds of welfare capitalism famously brought to light by Esping--Andersen (1990) are in need of refined categorization as policies and populations continue to adapt to changing times. Future research will need to take this paper's analyses, based around the year 2004, and apply them to policies and societies that exist today under greater financial and economic strain. --- Conclusion In the political economies of Europe today, measures of "old risk" prevention such as unemployment insurance and sick pay exist alongside "new risk" profiles that center on skill level and opportunity for participation in the labor market. The capacity to adequately cope with these risks will be unevenly distributed among citizens based on levels of education, income, and policy formulation. The new risk target group, or group most affected by the structure of new social risks, does not possess a sufficient attachment to the labor market to deal with the financial imposition that these risks imply. New risks have mainly to do with entering the labor market and establishing an enduring position in it, and with care duties that arise principally at the early stage of family--formation. However, many scholars have recently drawn attention to the later risks posed to families of providing long--term care for frail, dependent, elderly (Saraceno 2010, Knijn andOstner 2002). Individuals who are able to successfully navigate the transition to solid, paid employment, as well as those who develop strategies of care--taking using independent means, will not experience the urgency of these new social risks. Thus we see how polarization comes into the picture: new social risks pose a problem mainly to certain subsets of the population: these include those with lower education and less access to training, and those who do not have available recourse to the family or the market for provision of family care services for children and/or the elderly. In this paper, I have analyzed the effects of common social policy instrumentsactive labor market policies, passive labor market policies, employment protection, family policies, daycare-along with union density and women's representation in parliament, on the poverty levels of low--skilled segments of national populations. While gross public social spending as a measure of overall welfare generosity is found to be associated with a reduction in poverty only of the older male group, and not that of the two younger groups, I find that specific social policies contribute to the reduction of poverty among all three groups. Specifically, active labor market policies-involving public employment services, training programs, and employment subsidies for the un--and under--employedsignificantly reduce poverty of all three groups under analysis: low--skilled young women and men, and low--skilled older men. Notably, passive labor market policies, which are most often in the form of unemployment insurance, are most helpful in alleviating the poverty of older low--skilled men. This finding is in line with the expectation that passive labor market policies are generally targeted at those who have already contributed to the workforce and who receive passive income assistance in exchange for such service-a mechanism against old social risk that does not help to relieve the poverty of low--skilled youth-at new social risk-who do not have such employment history. This expectation about the difference in mechanism, effectiveness, and aim between active vs. passive labor market policies is borne out in the analyses' findings. In the same vein, union density is found to be significant and positively related to lowering the poverty of older low--skilled men, but not of the younger groups. This finding may reflect the weakening capacity of unions to protect the income of jobs across a wide spectrum, as opposed to protection within privileged sectors in which mostly older men work. Family allowances are notable for being associated with a significant reduction in the odds of poverty of both younger men and women, but not with lowering poverty of older men. This finding offers evidence for the positive effects of generous family policy on the income of young low--skilled adults, who rely on child benefits to offset the financial hardship that comes from child--rearing. The analyses in this paper shed light on the different ways in which social policies are effective in combating poverty across low--skilled segments of the population. In one of the first multi--level statistical analyses combining micro-and macro--level data to address policy effectiveness, the paper contributes to contemporary studies of public policy and the welfare state. There are several directions for future research based on these findings. First, researchers will need to overcome the inherent limitations of the data, including differentiating between different types of active labor market policies, for example (i.e. employment services vs. training programs vs. employment subsidization), as well as studying the different components that comprise contemporary family-policy packages (child benefits in cash vs. the length and structure of paid parental leave). Furthermore, while this paper's study provides insight on policy and poverty interactions in a post--Third Way era, it is a static snapshot of one time point (roughly the year 2004) across multiple countries. Future research will benefit from providing analyses that extend across time in addition to across countries, to show the diverse policy trajectories that have differing impacts on the poverty of certain groups. Furthermore, as social risk profiles continue to develop, future studies will need to emphasize the interaction between gender, age, and skill level, and examine how vulnerabilities arise differently across different welfare regimes. The path to poverty reduction is likely not a one--size-fits--all approach, but rather one that will combine elements from diverse national approaches.

This paper considers groups who are most likely to be vulnerable to new social risks and tests the effects of social policies on their poverty levels. Specifically, the paper conducts multi--level regression analyses across 18 OECD countries near the year 2004, analyzing the effects of social policies on the likelihood of being poor of low--skilled young women and men aged 18--30, and of those at risk of possessing obsolete skills, namely low--educated men aged 55--64. The analyses are conducted by combining both macro--level policy data and household--and person--level micro--data from the Luxembourg Income Study (LIS) cross--national database. The central question asks which policies-active labor market policies (ALMP), passive labor market policies (PLMP), employment protection legislation (EPL), family policies, and government daycare spending-are effective at combating new social risks. In addition to analyzing social policies, the paper also considers union density and representation of women in national parliaments as two measures that depict agents who are most intent on combating old and new social risks, respectively. The findings show that active labor market policies (ALMP) are the most important predictor of a decrease in poverty levels among the low skilled. The negative effect of passive labor market policies (PLMP) on poverty is only significant for the older male group. Family policies are related to a reduction in poverty for both low--skilled young women and men. Union density is significant in reducing the odds of poverty of the older male group, while it is insignificant for both younger males and females-thereby reflecting a measure of prevention against old, but not new, social risks. Additionally, the paper's findings support the hypothesis that the greater the representation of women in national parliaments, the greater the chances of having policies that are associated with a reduction in poverty across age levels. Lastly, gross public social spending as a measure of overall welfare generosity is found to be associated with a reduction in poverty only of the older male group, but not that of the younger groups. The paper's analyses suggest that some social policies remain geared toward older segments of society, leaving the younger population at greater financial and therefore social risk.

Taking up and scaling up care in feminist STS, particularly in interdisciplinary efforts toward institutional change, requires confronting questions of race, gender, sexuality, and coloniality as historical, inductive analytics essential to understanding the multiple dimensions and far-reaching impacts of science and technology (Subramaniam et al. 2017). Feminist STS scholars frame emotions and embodiment as ways to think about care in domains beyond gender-coded sites such as nursing and childcare (Martin, Myers, and Viseu 2015;Patrick 2023). We also acknowledge and speak back to the colonial roots of Western science, whose traditional forms of data collection, classification, and representation too often serve an imperialist approach to knowledge and research (Smith 2021). In this collection, we are ethnographers who study emotions and embodied experiences in interdisciplinary collaborations and theorize about care by documenting the ignored, silenced, and neglected experiences of marginalized team members. Mar<unk>a Puig de la Bellacasa probes the "meanings of care for knowledge politics in STS," a politics she argues is predicated on "oppositional standpoints" (2011,85). Oppositional consciousness is foundational to feminist standpoint theory, a body of scholarship interrogating the politics of knowledge production and the specific situatedness of "competent" knowers within science (Dotson 2011(Dotson, 2014;;Fricker 2007;Settles, Buchanan, and Dotson 2018;Settles et al. 2020). A decolonizing approach to theorizing with care means that opposition is collective and actively resistant to systems of subjugation (Hobart and Kneese 2020;Sandoval 2000). Our contribution to this feminist, decolonial research tradition is to mobilize ethnography to illuminate and eliminate structural disadvantages in science and technology, especially those that pose barriers to interdisciplinary collaborations across social, technical, and life sciences. We aim to catalyze frameworks of shared understanding and collectively work toward egalitarianism in the production of knowledge. We are especially inspired by feminist scholarship that has created foundational approaches to relations of technoscience and care. 2021). We are specifically interested in STS ethnographers' perspectives. Thus, in concert with other feminist STS ethnographers, we aspire to use the politics of care to transform the unfair and "unhappy affects" of interdisciplinary collaborations (Smolka, Fisher, and Hausstein 2021, 2) into epistemological resources (Harding 1992) that generate scholarship beneficial to coalition building that asks with whom and for what purpose (Davis and Craven 2016)? This Special Section draws from feminist thought to bring situated knowledges to the forefront by examining experiences and emotions that emerge within collaborative projects as sites for theorizing intersectionality, reflexivity, and positionality, which are key methodological approaches of feminist ethnographic research. We propose that care is a foundational concept for thinking about interdisciplinary collaborations. Further, care as a mode of attention (Martin, Myers, and Viseu 2015) within these research projects advances new knowledge about how the intersecting dimensions of power produce relationships, careers, scholars, and research design, as well as human society and the more-thanhuman worlds. In addition to feminist STS theories on care, this Special Section features ethnographers' feminist interpretations of scientific practices and knowledge production. Ethnography is shaped by Black feminist thought (Chapman 2010;Collins 2000;Davis and Craven 2016;Fraser 1998;Hurston 1998). Social science research from Black feminist perspectives takes up new questions, valorizes lived experiences, and practices an ethics of caring centered on empathy, individual creativity, and emotional intelligence (Collins 2000). Therefore, ethnography guided by these principles is creatively attentive to distinctions between researcher and researched, scientist and subject. This method takes care to make sure that women of color and others who have been historically disenfranchised from official sites of scientific knowledge production have the opportunity to have an active presence in texts by and about them. In this issue, the reader will learn more about the political and practical challenges of this type of care work. Using feminist ethnography, with its commitment to addressing relations of power within the research process, to conduct social studies of science adds greater complexity to the questions of quality and significance, voice and representation in our work. For example, when our "subjects" are scientists and we gain access to field sites through collaborations funded by technocratic foundations such as the United States' National Science Foundation and National Institutes of Health, historical asymmetries of resources and regard between the physical and social sciences can erupt and erode collegiality between collaborators and challenge the rigor and quality of our science. Too often, social scientists are integrated into funded collaborations in a "consultative manner" (Boudart and Borra 2023) and qualitative methods are adopted but shorn from critical methodological and epistemological traditions foundational to social science fields (Lewis 2022;Viseu 2015). This subordination of social theory and its experts is dangerous. First, it limits what topics and evidence we as ethnographers can engage with, critique, and even access, particularly when combined with other forms of marginality from our identities and career stages. Second, the preferential treatment of quantitative, positivistic science and the denigration of qualitative science is part of a larger neoliberal project to defund and discredit critical scholarship and reallocate scientific resources to historically enfranchised members of US society (Carrigan and Bardini 2021). Coleen Carrigan and Michelle Bardini (2021) coined the term epistemic prejudice to refer to this phenomenon as it unfolds in sites of scientific and technical knowledge production. Epistemic prejudice is a subset of "epistemic injustice," a broader form of social violence that thwarts epistemic practices of the marginalized and normalizes this violence (Fricker 2007). The papers in this collection document this well-known but understudied problem in the contexts of interdisciplinary collaborations (Boudart and Borra 2023). For example, we found that epistemic prejudice stymies transformational changes, silences voices of highly marginalized members of technoscience through the violence of generalizability, and leaves exploitative dynamics in both the production of technoscience and its applications untroubled. It also makes it harder to negotiate the production of integrative knowledge and to reach consensus on what new discoveries we care to share with the world. This prejudice can thus lead to conflict and censure, making it harder to critique and transform gendered, racialized, and heteronormative practices, values, and behaviors in a team's culture and in scientific practices and institutions more generally. Third, ethnography's distinctive feature is participant observation (Barker 2012). Spending time and hanging out with our participants often deepens camaraderie, and friendships can develop. This rapport, however, can make it more difficult to recognize or challenge epistemic prejudice in our interdisciplinary collaborations, because we care to not hurt feelings and thus jeopardize personal and professional ties. Fourth, engaged ethnographers can be cast in the gendered role of caretaker on projects, there to "observe not disturb" and provide ethically coded services and products, certainly not to lead research practices and meaningfully contribute to new knowledge (Viseu 2015, 642). We worry that the knowledge we can produce when shunted into hospitality roles rather than leadership in collaborations is therefore less complete, less rich, and less useful to liberatory projects. Additionally, the power relations animating these role allocations are ones of domination. Like other forms of harassment, they cause harm to both social sciences faculty and our students. 1 Finally, epistemic prejudice in science against those of us with expertise in studying social forces weakens the scientific community's ability to fortify itself against far-right activism targeting secondary and post-secondary education (for examples of such activism, see Fucci and Catalano 2019;Giroux 2013;Krigel 2020;Riley 2018;Saul 2023). This vertical stratification in the academy leaves critical scholars on the frontlines of these coordinated attacks on academic freedom with little support and thwarts the ability of the research community to mount and fortify a collective response. Therefore, one significant assumption we want to destabilize in this Special Section is the gendered idea that care in STS research is motivated only by a sense of duty or "warm feelings of love, affection, or nurture. Care is just as often propelled by anxiety, injury, injustice, indignation, or frustration" (Martin, Myers, and Viseu 2015, 630). In these ways, care is a form of protest. This Special Section is our attempt to confront the challenge of doing research across epistemic borders with hard-won evidence from feminist ethnographers creating both embodied and empirical knowledge on negotiating our roles in integrative research. Like many who challenge dominant norms, practicing care in STS knowledge creation can also make one vulnerable to retaliatory punishments, such as constraining career advancement by withholding resources or being uncivil (Viseu 2015). But we also risk being disregarded as an unreliable source of knowledge due to epistemic prejudice. Pejoratives, like "fluffy" and "soft," are designed to discredit our capacities as scholars and the kinds of scholarship we do and why (Martin, Myers, and Viseu 2015). For the collaborative turn in STS to blossom fully, we must resist this hierarchy between social and technical knowledge and publicly debate how social scientists should navigate precarious status on interdisciplinary collaborative teams (Reardon 2022;Reardon et al. 2015). Are we supporters or critics, collaborators or consultants, "adversarial outsiders or co-opted insiders" (Smolka, Fisher, and Hausstein 2021, 1)? The papers in this Special Section address these questions empirically, based on the authors' experiences as social scientists in interdisciplinary STEM projects. Together, we analyze our own methodologies of collaborative knowledge production across disciplines in order to ask how research teams might care for each other and their shared work in ways that forefront equity, empathy, and celebration of diverse kinds of knowledge. --- Positionality This Special Section grew out of an open panel at the 2021 Society for the Social Studies of Science (4S) conference. Into this STS professional network, we cast a wide net for other ethnographers who also have experience in interdisciplinary collaborations with technoscientists and faced their share of challenges within them. Organizing that panel was inspired by our own experiences with interdisciplinary collaborations in which we did not feel cared for or our expertise appreciated. For example, scientists and engineers sometimes invite us to collaborate with them on projects by doing project evaluation, education, and/or public outreach, but do not see us as researchers. Instead, we are assumed to be operational support in service of our technoscientific peers in the integrative field sites of STS. In another example, technoscientists pushed qualitative social researchers off funded projects that the latter made possible because the technoscientists felt they had gotten what they needed from us and didn't understand how our expertise could possibly shape the technical application of our qualitatively generated data. By taking up feminist ethnography, the contributors to this Special Section protest these conditions and turn them into intellectual resources mobilized for transformational change in STS and, more broadly, in interdisciplinary collaborations. Accordingly, this Special Section contributes to a politics of care that catalyzes feminist STS scholars' vision of interdisciplinary collaboration, thanks to methodological foci on undervalued and invisible labor, situated knowledges, power dynamics, and the dual nature of care-which we understand as both a value (e.g., things we care about) and an action (e.g., things we care for or take care of). A practice of care within interdisciplinary collaborations depends upon a recognition of the politics of labor. STS scholars have recognized the importance of different kinds of labor to the success of scientific practice, such as managing people and equipment, as "articulation work" or even "lab care-taking" (Fujimura 1996;Knorr Cetina 1999). But this work is underrecognized in assessments of research careers, especially its affective and emotional aspects, such as its typical absence in assessments for hiring, promotion, and tenure (Davies and Horst 2016;Smolka, Fisher, and Hausstein 2021;Viseu 2015). One example of a research methodology that assumes but does not support or reward social scientists' "affective labor" is what T.Y. Branch and G.M. Duché (2022) call collaborative sociotechnical integration (CSTI) research. CSTI projects follow protocols of intervention in STEM research to promote scientists' self-awareness. In CSTI projects, social scientists guide scientists to think through how their social and professional values influence their research practices, such as their biases about race and gender, their assumptions about more junior researchers' productivity and abilities, and their own access to resources and privilege. This delicate methodology requires social scientists to control their own emotions and responses to be active and non-judgmental listeners. Branch and Duché call for these social scientists to take good care of themselves, to prevent their burnout from exploitative affective labor and to "heighten the potential of these interventions " (2022, 13). Preventing harm to social scientists providing emotional labor to their technoscientific peers-and holding social scientists alone responsible for their own well-being-is a weak form of care indeed. Ethically, it is unacceptable to ask social scientists to expose themselves to potential harm from affective labor, especially in technocratic domains that discredit their expertise. If scientists deserve care as they navigate a CSTI study, then so do social scientists. After all, emotion-sharing between scientists and social scientists (rather than unidirectional emotional expression from scientists alone) enriches the relationship within the collaboration, and improves the rigor and breadth of the research practices-and thus, the resulting knowledge (Carrigan et al. 2023). This is just one example of how an attention to care when analyzing interdisciplinary collaborations can address power asymmetries in collaborations between social science and STEM researchers, while offering possibilities for improving science and its workforce culture. The following papers investigate their authors' experiences as members of interdisciplinary teams through a feminist lens of care. Like other STS scholars, our experiences as embedded ethnographers are part of our data sets and give us unique insights (Hackett and Rhoten 2011;Lyle 2017;Viseu 2015). Our positionality affects with whom we can talk, how we are received in the field, and how and where we can share our findings. So, in this way, the politics of care in knowledge production will always be shifting and changing based on place, practitioners, and the particular dimensions of structures of power (e.g., race, gender, economics, and institutional affiliations) that we all navigate to create knowledge (Cook and Trundle 2020). The few other publications in which social scientists reflect on their own methodologies for collaboration with STEM scholars are insightful and offer some practical guidelines for other social scientists (e.g., Balmer et al. 2018;Boenig-Liptsin, Tanweer, and Edmundson 2022;Carrigan et al. 2023;Forsythe 2001;Lyle 2017;Rabinow and Bennett 2012;Smolka, Fisher, and Hausstein 2021;Viseu 2015). In general, they warn that teams set STEM as the standard for productivity levels, research questions, methods, and ways of working, such that STEM scholars may ignore, override, or even denigrate social scientists and their research practices. These STS authors share stories of emotional labor they have undertaken to appease their collaborators, such as swallowing critiques to avoid conflict, and the emotional toll of feeling misunderstood, superfluous, or unwelcome. They recommend the importance of having at least some intellectual input into project design, holding equal funding and status (e.g., a co-investigator title) as STEM collaborators, and choosing to work with people who value social science contributions and truly want to produce socially beneficial project outcomes. They point out common biases that shape team interactions, including the prioritization of STEM; assumptions about researchers' race, gender, and age; and risks of doing interdisciplinary collaborative research without job security, such as for students, scholars in precarious temporary positions, and faculty on the tenure track. These are wise observations and recommendations that resonate strongly with this issue's authors. We strive to build on these contributions by sharing our own experiences and interpretations to demonstrate what ethnographers bring to the table of interdisciplinary knowledge projects. Together, the papers demonstrate that feminist ethnography is especially critical to STS research that cares about equity and justice in scientific practices, relations, and impacts. Each paper asks how researchers enact care in decisions about research questions, methods, data, and conclusions as well as in everyday interactions with each other as collaborators. Ashley Lewis takes up autoethnography to interrogate power dynamics in a funded interdisciplinary collaboration to develop models that envision different ways of building sustainable urban environments. In her essay, "STS Researchers as Technology: Multiple Positionalities as Interpretations of Participant Expectations and Agendas," she positions herself and the team's interdisciplinary practices as "technologies" to analyze the purposes of the project and the roles her multiple identities played in relationships with her colleagues, who viewed her either as a spy, the interdisciplinary catalyst, or a caretaker. This self-reflexive approach that forefronts emotions makes visible the taxing work of ethnographers collaborating with technoscientists, the hierarchy of power relations on teams, and the costs to STS ethnographers when what we do and contribute to interdisciplinary research is misunderstood or maligned. Coleen Carrigan offers feminist principles on taking care when documenting the neglected experiences of highly underrepresented actors in technoscience using ethnography designed according to intersectionality theory. --- Conclusion The papers collected here inspire ideal visions for how we as ethnographers can best balance caring for the communities we study, the ones we serve, and the ones we identify with. To enact this vision, and to situate mutual learning and interpersonal support as cornerstones of integrative knowledge production, we must take care that knowledge making is political. Race, gender, class, and ability status of scholars intersect with the organizational, institutional, and cultural context in which we practice science to shape and be shaped by entrenched power relations. If we pay attention to these relations and their complex mutualities, we can begin to raise questions about how to translate knowledge across epistemic and social barriers, how to align values and priorities across disciplinary cultures and unequal power statuses, and how social scientists can best balance engagement in STEM with critique and advocacy. Furthermore, what labor becomes visible when attending ethnographically to politics of care in interdisciplinary collaborations? What equitable relations become possible? For example, how is work distributed in integrative research, and what roles do researchers' discipline, gender, race, ethnicity, and sexuality play both in its allocation and recognition? What can the STS community do collectively to make interdisciplinary collaboration a matter of care? How might we enact care for each other, for our collaborators, and for our shared knowledge making? These papers provide insights into these important questions for social scientists as well as for our STEM collaborators. We approached our editing responsibilities with care, such as by hosting an open and inclusive call for papers, making time for discussion during our 4S conference session, organizing a workshop at which authors commented on each other's drafts to help us all improve them before submission to Catalyst, and striving to be supportive and constructive editors as authors revised their papers in response to peer reviews. In our experience, this has been a warm, rewarding process of collective knowledge production for which we are grateful to our Special Section authors and the Catalyst editors. We wish this approach would be the norm for academic publishing and knowledge sharing more generally. We hope publishing these papers is one way of sharing experiential knowledge, informing each other's collaborative practices, and reducing epistemic prejudice. For example, we ask STS journals to publish more papers co-authored with scientists-and science journals to publish more papers co-authored with STS scholars-as a way to legitimize collaboration across our disciplines to produce integrated knowledge. We call for mentoring, networking, and the expansion of knowledge-sharing practices for feminist collaborative methodologies. We envision an ever-growing community of practice around the important work of making all researchers feel cared for. Ideally, we would collectively propose standards for caring collaboration that funders would adopt into their calls for and evaluations of proposals. Official guidance would help normalize caring relations as a foundational component of ethical and responsible research practices in interdisciplinary collaborations. --- Note 1 To learn more about how the preferential treatment of technoscience in the academy, a phenomenon that some students call "majorism," hurts undergraduate students, please see Carrigan and Bardini 2021. --- Author Bios Coleen Carrigan is Associate Professor of Science, Technology, and Society in the Department of Engineering and Society at the University of Virginia. She uses feminist ethnography to investigate the cultural dimensions of technology and the politics of knowledge and reproduction. Caitlin D. Wylie is Associate Professor of Science, Technology, and Society in the Department of Engineering and Society at the University of Virginia. She studies the ethical and epistemic contributions of overlooked collaborators on research teams, such as technicians, students, and volunteers.

Collaborative research between scholars of science and technology studies (STS) and scholars of science, technology, engineering, and math (STEM) is a growing trend. The papers assembled in this Special Section offer both embodied and empirical knowledge on how ethnographers negotiate our roles in integrative research when constrained by what our technoscientific collaborators value, what funders demand, what our home institutions expect, what we want to learn from the worlds we study, and the social transformations we envision in science and society. We grapple with how we as ethnographers can best balance caring for the communities we study, the ones we serve, and the ones we identify with. We take care that knowledge making is political. Race, gender, class, and ability status of scholars intersect with the organizational, institutional, and cultural contexts in which we practice science to shape and be shaped by entrenched power relations. Through a feminist politics of care, this collection transforms tensions in interdisciplinary collaborations into resources that enlarge our understandings of what these collaborations are like for STS ethnographers, make visible certain labors within them and, crucially, enrich our vision for what we want these collaborations to be.

Introduction: Beyond several interests and speculations on the relationship between formal and informal actors and their networks in support of vulnerable populations, most studies do not conclusively establish whether the two types of support are substitutes or complements. While informal care and formal care may be substitutes in general, they are complements among the vulnerable groups. Despite how some studies have described complementarity, further insights on the synergy between formal and informal actors and networks are needed to pinpoint how to maximize policy and interventions to alleviate the challenges facing vulnerable groups in informal settlements. --- Methods: We conducted an ethnography using governance diaries with participants in Korogocho and Viwandani informal settlements in Nairobi, Kenya. The governance diaries approach involved conducting bi-weekly governance in-depth interviews (IDIs) with study participants for months, complemented with observations, reflections, participant diaries and informal discussions. We used framework analysis approach. Findings: Informal actors identified include family, neighbors, friends, community groups and community members, and their direct networks. Formal actors on the other hand included government institutions, individuals and authorities that make policies and rules and their desired and possible networks. Both the formal and informal actors and their networks had complementary roles that were beneficial to the vulnerable populations living and working in informal settlements. The complementarities between formal and informal actors and networks in supporting vulnerable groups were portrayed in roles and responsibilities to the vulnerable groups; rules, regulations and governance in supporting vulnerable groups; knowledge, skills and dynamic workforces among formal and informal actors and their networks; information flow on health and wellbeing to the vulnerable populations; transition of actors in supporting vulnerable groups; availability, access and involvement of formal and informal actors and networks to support vulnerable groups. The complementarities allowed for maximum support of the vulnerable populations than otherwise. --- Introduction Although several authors have explored the relationship between formal and informal actors and their networks in support of vulnerable populations (1), most studies do not definitively establish whether the two types of support are substitutes or complements (2,3). While informal care and formal care may be substitutes in general, they are complements among vulnerable groups (4). Despite how some studies have described complementarity, further insights on the synergy between formal and informal actors and networks are needed (2,5,6). Formal actors are institutions, individuals and authorities that make policies and rules and their actions are embedded in formal institutions (7). Informal actors are individuals or groups who have no constitutional mandate and do not have formal rules but still have an influence on service provision (1). In the near absence of formal actors and networks, informal settlements are characterized as ungovernable spaces lacking formal services (7,8), but the urban poor in such settlements are resilient and often create their own systems to fill gaps in service delivery (9,10). The service gaps are mostly filled by informal actors (10,11), often seen with adversarial lens from the point of view of law and order (1,12). Yet they constitute part of the social fabric and provide complimentary or lacking services and influence, sometimes better than formal actors and networks within informal settlements (13). Complementary model of support takes into account support from both formal and informal actors and networks through compensation and/or supplementary functions by the actors (5,6). According to this model, formal actors and networks are accessed when crucial elements of the informal actors and networks are lacking or when there is great need (i.e., greater illness or disability) and the informal actors are unable to provide the required support (3,5). Most support for vulnerable groups is provided informally by family and friends at home (14). Yet, increasing changing family structures (i.e., single-parent households, decreasing family size and increasing women participation in labor force) means that a growing number of vulnerable groups require and will use formal support services (15,16). The two types of support can occur simultaneously or can precede or follow each other (3,17). Even when the two types of care occur simultaneously, informal care may not be a substitute for formal care but a complement for higher skilled tasks (18). A single actor and network may not be able or willing to provide care, suggesting that informal and formal care are not substitutes but compliments in many cases (19), thus the need for more insights on endogeneity inherent in formal and informal actors and networks so as to uncover the complementarity of formal and informal actors and networks (19,20). In spaces where only informal support is provided or where only formal support is provided, the vulnerable populations tend to have deteriorated support on health and wellbeing services (21,22). Where formal and informal service providers have specialization or overlap, evidence point to the vulnerable being better served (5,6). When there is an overlap, social support received by vulnerable groups seem to be key (23,24), irrespective of whether it comes from formal or informal sources (2). However, the synergy of formal and informal actors and their networks in support of vulnerable populations in informal settlements is often missed out in the policy discourse and inputs to interventions. Consequently, further insights on the synergy between formal and informal actors and actions are needed to pinpoint how to maximize policy and practice inputs to alleviate the challenges of vulnerable groups in informal settlements (6). Indeed, the linkages between informalformal actors and networks in informal settlements should be further uncovered for joint utilization of informal and formal actors and networks (25,26). In Nairobi's informal settlements, informal actors and their networks have engaged and collaborated with the state complementarily to support the vulnerable populations living and working in informal settlements (25,27). Strategic complementarity enhances a multiplier effect, benefits, expertise and knowledge in supporting vulnerable populations (27). Yet, it is unclear how formal and informal actors and their networks work together to impact the health and wellbeing of vulnerable populations in the informal settlements (28). In seeking to address these knowledge gaps, this study contributes to understanding the following two questions: first, what are the benefits of formal and informal actors? Second, how do formal and informal actors complement each other for the benefit of vulnerable groups? --- Literature review This section presents literature on informal settlements in Kenya; marginalized and vulnerable populations, formal and informal actors and networks, including complementarity of the actors. --- Informal settlements in Kenya Informal settlements are unplanned sites that are not compliant with authorized regulations (29). The widespread growth of informal settlements in urban centers in Kenya has become a central debate in urbanization during the last two decades (30). Yet, the lag by the Kenyan government to improve informal settlements and at least to provide the minimum support on basic requirements and services has led to unimaginable suffering among residents (31). This is coupled by the fact that the government has had the history of failing to recognize the growth and proliferation of informal settlements and thus excludes the urban poor from the rest of the city's development plan (31,32). While constitutional and attitudinal changes are observable, it is hoped that advocating for the urban poor, particularly marginalized and vulnerable groups would help change the course of events in informal settlements in Nairobi, Kenya. --- Vulnerable and marginalized population Vulnerability refers to the conditions determined by physical, social, economic and environmental factors or processes, which increase the susceptibility of an individual or community to the impact of hazards (33,34). A vulnerable group is therefore a population that has some specific characteristics that make it at higher risk of falling into poverty (33), those who by virtue of gender, ethnicity, age, physical or mental disability, economic disadvantage, or social status may be more adversely affected in the community than others and may be limited in their ability to claim or take advantage of assistance and related development benefits (33,35). Marginalization generally describes the overt actions or tendencies of human societies whereby those perceived as being without desirability or function are removed or excluded (i.e., are "marginalized") from the prevalent systems of protection and integration, so limiting their opportunities and means for survival (33). A vulnerable and marginalized individual/group is defined as a group that in a particular context because of its relatively small population or for any other reason, has been unable to fully access basic amenities and participate in the integrated social and economic life as a whole (33,36). Children including child-heads of households (CHHs) are more vulnerable to health and wellbeing challenges (36,37). Three elements of challenges for a CHHs are biological and physical challenges; strategic challenges (i.e., children's limited levels of autonomy and dependence on adults); and institutional invisibility due to a lack of voice in policy agendas (38). Older people face challenges including a lack of access to regular income, work and health care; declining physical and mental capacities; and dependency within the household (35). Without income or work, older people tend to depend on others for their survival and are usually vulnerable in informal settlements where their caregivers also have health and wellbeing challenges (11,39). Persons with disability (PWD) are often (sometimes incorrectly) assumed to be unable to work and hence increasing their vulnerabilities to health and wellbeing challenges (40). Evidence shows that PWD have higher rates of poverty, and face physical, communication and attitudinal barriers, and a lack of sensitivity or awareness about their circumstances and situations (41). With the clear understanding of different vulnerable and marginalized population, It is widely acknowledged that the populations have unique basic needs from the general population and are harder hit, both in the short and long term, when there is no action taken and thus there is a need for formal and informal actors to take action for their livability (10,38). --- Formal and informal actors and networks Formal actors are groups or individuals with defined and structured guidelines, whereas informal actors have undefined guidelines (42,43). Informal actors play a key role to persist and retain legitimacy in informal settlements (2). Informal actors are diverse and may include community members or customary local governance institutions. Often, they fulfill some of the functions expected of the state, yet they are understudied, particularly with regard to how they complement formal actors (6). Within the context of social relationships, complementarity mostly refers to the premise that people tend to seek out other individuals with characteristics that are different yet complementary from their own (a concept sometimes called negative assortative mating by organizational theorist) (6). Philosophers have argued that formal and informal support systems cannot exist in strong form in the same society (17,44). In this article, the authors argue and demonstrate that such perspectives fail to consider the complementarity of the two systems and the necessity of both for the completion of most tasks, including service provision for the marginalized and vulnerable populations. --- Methods The study is reported per a set of standardized criteria for reporting qualitative research (COREQ) (45). --- Study design This was a qualitative study using the governance diaries method. Governance diaries is an ethnographic approach using more than one method of data collection and where participants make regular records of their daily activities and experiences in relation to actors and who has power in their lives in the provision of social and economic services (46,47). For this study, governance diaries included in-depth interviews (IDIs), which were informed by participant diaries, informal discussions, participant observations and reflections. Governance diaries are typically used in contexts where there is a need to explore the depth of everyday life, as time allows researchers to spend longer periods in the field for exploration (46,48). --- Study setting The study was conducted in Korogocho and Viwandani informal settlements in Nairobi, in the areas covered by Nairobi Urban Health and Demographic Surveillance System (NUHDSS) initiated in 2002 by the African Population and Health Research Center (APHRC) (49). Korogocho has a stable and settled population and residents have lived in the area for many years (50), while Viwandani is located next to an industrial area with many highly mobile residents who work or seek jobs in the industrial area (50). A social mapping activity in both settlements identified the most vulnerable groups as persons with disability, older persons and child heads of households. Each of the informal settlements has eight villages, which acted as a guide during the selection of study participants (Figure 1). --- Target population The population of interest were people with disability, child headed households and older persons. --- Sampling and sample size We sampled 24 participants comprising four PWD, four CHHs, and four older persons in each of the study sites. We purposively selected the participants who were residents and benefited from health and wellbeing services from at least two villages. --- Data collection process Community Advisory Committees (CACs) (individuals selected by the community to represent and act as a liaison between the researchers and the community), co-researchers (community members recruited as research assistants because they have a better understanding of the context and with closer rapport with respondents), and the researchers worked together in the recruitment of study participants. We used governance diaries to collect data from January to April 2021 on questions related to the complementarity of formal and informal support actors and related networks for vulnerable populations. Diaries approach entailed IDIs, participant observation, participant diaries, reflection and informal discussions. IDIs were the dominant method and was informed by the other methods. Below is the description of data collection process: Informal discussions: An informal conversation was carried out between the participants and the researchers to find out key insights and to create rapport with the study participants before the IDIs. The discussions were incorporated in the IDIs. Reflexive discussions: Reflective discussions were held between pairs of co-researchers on a daily basis, among the whole group of co-researchers on a weekly basis, and between researchers and coresearchers every 2 weeks, to understand the outcome and determine emerging themes and gaps to be probed during subsequent IDIs and routine observations. Observations: These included observation by the co-researchers, which allowed for a holistic awareness of events as they unfold and as such, enabling more comprehensive understanding of what matters to respondents. We also observed the environment related to our study subjects including observing health and wellbeing services. These observations resulted in photos and insights on what to probe further in the IDIs. The observations were conducted before, during, and after the IDIs to complement the discussions recorded. Reflexive discussions informed the content and concepts for observations. Participant diaries: We provided the study participants with guidelines pasted on the front of a diary. Each participant would write about daily activities related to formal and informal support actors and related networks at their homes, without writing their names. Coresearchers would call participants and conduct impromptu visits to remind participants about diary writing activities. IDIs: We used guides with questions on formal and informal support actors, benefits and complementarity of services and service delivery, concerning the vulnerable populations. IDIs for subsequent visits on the same questions were adapted based on observations, reflections, informal discussion and participant diaries (Figure 2). In-depth discussions between the co-researchers and the study participants were administered in pairs of two co-researchers; one who was moderating the interviews and the second, acting as an observer, note taker and facilitator of the recording of the conversations. We reached saturation in the IDIs during the sixth visit when we approached the fourth month. The outputs from informal discussions, observations, participant diaries and reflexive discussions informed and enhanced robust probing during IDIs. For example, if the co-researchers observed some ambulance or water pipe burst, during IDIs, they would probe more on the pipe bursts and the ambulance. The multi-pronged ethnographic data collection processes are summarized in Figure 2. Co-researchers received training for 6 days on the aims of the study, data collection process, data collection tools, and research ethics. We piloted the study tools with one older person, PWD and child head of a household in each of the study sites, followed by a debriefing to assess if the study approach and study tools were well understood by both co-researchers and study participants. The pilot exercise enabled us to adjust the translated guides to concepts understood by the study participants and to estimate the time an interview could take. We excluded participants in the pilot from the main study. --- Data management Recorded audios from IDIs, reflections and informal discussions were translated and transcribed from Swahili to English and saved as individual Microsoft Word documents. Outputs (Figure 2) were assigned number codes to prepare for analysis and to ensure confidentiality. Outputs that could not be typed (photos from observations and participant diaries) were scanned and saved in a safe folder, as they were used as reference materials during data analysis. --- Data analysis Transcripts were imported into NVivo 12 software (QSR International, Australia) for coding and analysis. NVivo is a qualitative data management software that can be shared and worked on in groups and facilitate thinking, linking, writing, modeling and graphing in ways that go beyond a simple dependence on coding (51). We used a framework analysis (52). Framework analysis is adopted for research that has specific questions, a pre-designed sample and priory issues (52). The first step of framework analysis was listening to the recordings to familiarize the researchers with the information related to complementarity of formal and informal actors and networks. To ensure reliability, two researchers (an experienced qualitative researcher and an anthropologist) and five coresearchers, who collected the data participated in the development of a coding framework by reading the outputs imported in NVivo 12 software, participant diaries and photos independently to establish an inter-coder agreement. Once the initial coding framework was completed, the team met to discuss the themes generated and to reach an agreement on themes (Table 1). The two researchers proceeded with coding, charting, mapping and interpretation of transcripts. --- Ethical considerations The study was approved by the AMREF Health Africa's Ethics and Scientific Review Committee (ESRC), REF: AMREF-ESRC P747/2020. We also obtained approvals from National Commission for Science, Technology and Innovation (NACOSTI), REF: NACOSTI/P/20/7726. Approval was also obtained from the Liverpool School of Tropical Medicine (LSTM) and the African Population and Health Research Center (APHRC) internal ethical review committees. All participants provided informed written consent before participating in an interview including consent for using photos and videos if there were any. --- Results In addressing our two questions, we present two distinct results out of our study. First in addressing the question, what are the benefits of formal and informal actors, we present formal and informal actors with their diverse networks. In addressing the question of how do formal and informal actors complement each other for the benefit of vulnerable groups, we present findings on the complementarity of formal and informal actors. --- Theme : Formal and informal support actors and their networks There was a great deal of shared knowledge about the nature and scope of informal support actors. Participants described how the actors were essential for meeting the health and wellbeing needs of vulnerable populations. Participants described that to support the vulnerable populations, there needed to be functioning support networks, which comprised of direct, possible and desired networks. Informal support actors included family, neighbors, friends and community members and they had much direct role and direct networks. Formal actors included government ministries, community groups, institutions, non-governmental organization and implementers, and they had more of desired and possible networks (Figure 3). Informal actors who were providing support services for the vulnerable populations directly without using agencies were described to have a direct network, while the formal actors that had the potential of providing support services because they were offering the services in the community were described to have possible networks. There were formal actors who were known by study participants to be of great influence in providing support services but were not felt by the vulnerable groups and were described to have desired networks. Some actors had multiple networks. The network of actors identified by the study participants is summarized in Figure 3. "One can possibly have government services but your life cannot be complete unless you have family doing those normal things directly for you like washing clothes, doing the groceries and all those things in the house and everything like that" (Older person, Male). We explored further on the formal and informal actors. As such we asked the study participants questions on (a) what are benefits of informal support actors and networks? (b) What are the benefits of formal support actors and networks? This laid the basis for understanding complementarity of formal and informal actors and their networks. --- Informal support actors and networks have multiple benefits Study participants described how informal actors and related networks reduced exhaustion and stress, as they support the vulnerable populations in performing some chores that would be strenuous. In addition, participants believed that informal support actors and networks helped change attitudes on vulnerabilities and built personal skills for having to deal with anxiety and depression through experiential learning. "When you have a neighbor supporting you, it reduces stress. If there are family members doing some household chores for you, then that gives you relief and reduces being tired" (PWD, Male). "It is the normalizing of old age by neighbors and friends that reduces worries... You meet with other older persons who give you tips on how to adjust to life challenges, as they have also experienced at one point... At this age, we cannot survive without friends" (Older person, Female). Furthermore, study participants unanimously described how informal networks were defined as well organized and essential. The participants underscored how informal actors and related networks were accessible, available and dedicated to supporting the vulnerable people in the community. "The informal actors are very organized, dedicated and they are always available to support. I can say they work for 24 hours" (Child head of a household, Male). "I don't know them by names and they have the heart to help. I met that youth when I was depressed, she was going to board a bus but she stopped to help me" (PWD, Female). The benefits of informal actors and their networks were seen to be collective and additive, that is, the community grew and developed in its capacity to support vulnerable people. Study participants described how informal actors and networks were helpful in resolving issues that would have been resolved by the formal actors. "As years go by and you are not able to do some things, you get to learn about how to seek help from people around... I would say we are going through difficult circumstances but there are volunteer --- FIGURE --- Results of network of actors for vulnerable population. individuals who support us all through. If it were not for neighbors, family and youth groups around to do work that should have been done by government, maybe our situation would be worse" (Older person, Female). --- Formal support actors and networks have multiple benefits Participants did not comment much on the formal actors, as they were not accessible to many vulnerable groups in the informal settlements. However, some of the participants described how formal actors were trained and had expertise on tasks, including but not limited to coordinating support and service provision. "The formal actors are trained and know how to do their work more while supporting us" (Child head of a household, Male). Few participants who acknowledged the formal actors and networks, described how the actors and networks played a key role in providing informal actors and networks with information and assurance of support. The study participants consistently stated how the actors and networks performed their roles by sharing skills, knowledge, and stories of caring as well as educating informal actors on needs and expectations of vulnerable persons. "Formal actors support us directly but in many cases they offer support to our caregivers including training. Sometimes they offer skills and take them through the steps of managing emotions and supporting vulnerable groups like us" (Older person, Male). --- Theme : A complementary relationship between formal and informal actors and their networks Beyond the multiple benefits of formal and informal actors individually, we find complimentary benefits of their activities. We asked participants to describe how formal and informal actors and networks complement each other. We present the findings below with different complementarities portrayed on roles and responsibilities; rules, regulations and governance; knowledge, skills and family dynamics; information flow to the vulnerable populations; transition of actors; availability and access of actors and involvement. --- Complementarity on roles and responsibilities Formal actors and networks appear to currently play a minimal role in mobilizing and supporting vulnerable populations. As such religious institutions, neighbors and some social-specific informal groups and networks played a key role in supporting the vulnerable groups efficiently. Despite the minimal role, formal actors and networks were viewed to be important and powerful for the operations of informal actors. "Formal actors and networks play a small role. Quite often it's just friends or church or neighbors who support us on time. The role that formal actors play could be viewed as minimal but they are powerful in the work they do. For example, a policeman here may not be seen frequently, but make the work of informal actors conducive" (Child-head of a household, Female). --- Complementarity on rules, regulations, and governance There were complex rules and regulations that informal actors were operating within. These included privacy and confidentiality. For example, study participants described how informal actors could be aware that vulnerable people needed help, yet due to privacy, they were unable to mobilize the needed support. However, in such cases, formal actors were described to prioritize assistance at the expense of privacy in their attempt to support vulnerable populations. "Sometimes a friend, family or neighbor could see an old person in need of help but cannot call out for a better support because they do not like disclosing people's secret. However, the formal actors would forgo privacy and ensure someone get help" (Older person, Male). Corruption and misuse of public resources by formal actors was unanimously reported. For example, participants described how relief food and other support for the vulnerable groups, distributed by formal actors mostly benefited nonvulnerable groups. However, where formal actors collaborated with informal actors like the women groups, youth groups or religious leaders, the most vulnerable populations always benefited. "They will register You <unk>as individuals to receive aid) but your name will not reflect in the beneficial lists; they will cancel. When the women, youth and religious groups are involved such things related to injustice does not happen... Some formal leaders want to take all the aid that comes for themselves, and share with their family members because most of their relatives get relief food and us we do not get (Child-head of a household, Male). --- Complementarity on knowledge, skills, and family dynamics Some study participants described how informal support actors and networks were highly problematic due to their lack of skills and family dynamics, as many of the actors were not properly trained in handling vulnerable people. The formal actors on the other hand were skilled and trained on handling vulnerable populations and were described to come in handy when called upon by informal actors. Further, informal structures were described as knowledgeable on community and community activities, whereas the formal structures had expert knowledge. As such, more benefits were realized when both actors and networks worked together in complementarity. "There is no training that informal actors go through; they lack knowledge and skills but they offer us counseling here and are handling issues based on convenience and sometimes it can be life-threatening. Formal actors are usually trained and skilled and they are very useful when called upon by informal actors to offer additional support" (Child-head of a household, Female). "Formal actors just do their work. I think they are trained and skilled. However, without informal structures, the formal actors will not understand the community activities" (PWD, Male). --- Complementarity on information flow to the vulnerable populations Participants reported problems of lack of overall coordination and flow of information about what was available for vulnerable persons. As such, informal actors and networks did not always refer vulnerable persons for specialized services in cases where more specialization was needed. Vulnerable groups also lacked information on where to find support from the formal actors and networks and eventually ends up utilizing the informal actors and networks who are known at the community. By itself, some older child heads of households, older persons or PWD would continue suffering for a long period, while negotiating with informal actors and networks to offer space for formal actors and networks, who had clear communication channels and referrals and were dependable. "Our family members and neighbors who are helping us also struggle, they have so many questions without answers... what do I do? where do I send this person?, how do I refer?' Where's the nearest social worker? So they end up trying all they could to support us. (PWD, Female). "Formal actors have a communication channel and clear ways of referring someone. They are better than the informal actors and are reliable... Many people here do not know where to go when they need support, as such they resort to neighbor, family and anyone around" (Child-head of a household, Male). --- Complementarity on transition of actors The changing nature of communities and informal actors and networks was a barrier to supporting the vulnerable population. The changes in the community included family income, economic recession, retirement, thus losing social networks and migration. In addition, a belief that if people have strong networks throughout their life will also have strong networks of support in old age and vice versa, brought forth challenges to individuals who were isolated at the time of our study. The formal actors on the other hand were described to have a clear succession plan for takeover on supporting vulnerable populations. "There has been a lot of relocation, as such the individuals who already knew our challenges have left. This has affected us... If somebody has lived their life isolated... when it comes to old age that's how they will be isolated" (PWD, Female). "Those support actors who are working under government are better placed because they have a good handover when they retire from work" (Older person, Male). --- Complementarity on availability and access of actors Informal actors and networks were perceived to be easily accessible from the community and were described to be efficient. Whereas, formal actors and networks were not accessible hence not preferred by the vulnerable groups in the informal settlements. As such, informal actors and networks filled gaps in service provision enabling service provision to people who did not have an extensive formal support. "Some formal structures come here and initiate some project activities to support us and disappear completely. To be sincere the support activities are not running well. If it were the neighbors or the family members initiating them, they would be here every day following up on how the activities operate" (Older person, Female). "The informal support help us understand a belief that informal actors and networks will always exist to provide support where formal actors and networks do not exist (PWD, Male). Study participants described how hierarchies in accessing formal actors for support was highly reported. This is because formally and administratively, some community steps should not be bypassed. The chain in the hierarchies was described to affect efficient access to support services. On the other hand, in cases where efficient services were needed, informal actors and their networks were preferred. "We mostly go to the chairman first because you cannot bypass steps. You start from the ground going up to other higher hierarchies in the government. By the time you get the solution, maybe you have suffered much. If you go to neighbors, family member or the religious leaders, you do not have to think of hierarchies while in need of a solution" (PWD, Male). "Sometimes the chain of command is complicated since if you want to go to the chief they will send you to the chairlady, chairman's and so on and you cannot easily access them, and this is the reason why vulnerable people rarely get support" (Child-head of a household, Female). --- Complementarity on involvement Low involvement in the community was also reported to affect the success of formal actors' roles in the community. Support from informal actors on information of who needs support, where and when resulted in formal actors being effective in support for the vulnerable populations. "There is this NGO; they came here and stationed sanitation facilities without consulting. We ended up not using them. When youth groups are involved, they usually consult with us and our issues are featured" (PWD, Male). This led us to ask for an example of a "best practice" in social networks for formal actors and networks to involve and work with already-established community organizations, or the individuals who are already supporting the vulnerable populations. This is because there were few cases where participants described formal actors working directly with vulnerable populations. "All social networks available should be strengthened from all angles by everyone and formal actors and networks should aim at working with groups and individuals who have already started working with us" (PWD, Male). In conclusion, empowering the vulnerable groups with information on the support to obtain from formal actors will greatly enhance complementarity of support. Among informal actors, the interactions varied depending on the intimacy and behaviors of the recipients of support. Moreover, it is important to encourage informal actors to make their services complimentary by recording individual and family requirements (i.e. financial or humanitarian or medical support), which could lead to a collaborative process between formal and informal actors. --- Discussion We explored the complementarity of formal and informal actors and related networks in support of vulnerable groups in informal settlements using governance diaries approach, supported by a multipronged ethnographic data collection processes which included participant diaries, IDIs, informal discussions, observations and reflective sessions. The key findings highlight the need to critically question the assumptions and rationale that lie behind the existence of dichotomous formal and informal support actors in silos as it relates to vulnerable populations in informal settlements. This is because complementarity of actors in delivery of services best captures the current relationship between the formal and informal support actors (3). Study participants described how informal actors and networks provided support to vulnerable persons because the formal actors and networks were non-existent or near-absent in service delivery in informal settlements. Our results showed that informal actors and networks are essential as they provide both taskoriented and emotional support to vulnerable persons. The informal actors and networks were considered to be naturally forming, organized, and unique in supporting the needs of the vulnerable populations in many cases (6). Our findings described how formal actors provided professional and specialized support as they were trained and skilled and at times supported the informal actors to offer better support. Our results also showed how informal actors, though filling important service delivery gaps, were identified as highly problematic as they were not qualified and had difficulties working. These challenges underscore their inability to replace formal actors and call for at least the complementing roles of formal actors and related networks. This dimension is related to other studies describing the need to exercise caution to avoid assumptions that formal support does not matter since providing formal social support is essential in support of the vulnerable population (2,6). While this is what formal actors are statutorily tasked to do, this is an important finding in our study context, as formal actors are usually seen as oblivious or insensitive to the needs of the vulnerable populations in informal settlements (7,53). Notwithstanding, evidence on complementarity suggests that the public approach to the social support of the vulnerable population through informal structures is uncommon or yet to be embraced and utilized by the majority of formal structures (5,6). The implication is that while there may be tensions between formal and informal actors and networks, our results suggest that participants would welcome guidance and resources to enable them to operationalize social support for vulnerable populations through complementarity of functions of formal and informal actors and networks. This is supported by other studies, describing that social support is perceived to be helpful and individuals need guidance on operationalization (2,5). Participants were already positively disposed to the benefits of both formal and informal actors and networks and this included reaping both community knowledge and expert knowledge. This is a profound finding and presents itself as an opportunity for utilizing dual knowledge in supporting the vulnerable persons in the community. It counters the narrative which places services from formal actors as outside of the community, as somehow different and less trusted (54,55). In reality, some formal actors and networks are sometimes members of the community (2, 5, 6), lived, worked and available to play roles as informal actors and networks in support of vulnerable populations. Another implication is the clear scope we found for formal actors and networks to target and support informal actors and networks through already existing community groups such as schools, religious institutions, and social clubs thus developing partnerships, community capacity and consequent increased benefits to the vulnerable groups (37). This is because the formal actors and networks are usually called upon when the informal support have exhausted their capability and the situation of the vulnerable has deteriorated so much that the informal network requires assistance to cope or critical elements of the informal network are missing. Our findings are speaking to a wider emerging evidence of significant improvements in health outcomes among slum dwellers in Nairobi within relatively short periods, following interventions that promoted collaboration and cooperation of multiple actors, including formal and informal service delivery structures. While not primarily focusing on complementarity, an intervention research program on maternal and child health-the Partnership for Maternal, Newborn and Child Health (PAMANECH) in Korogocho and Viwandani slums-implemented between 2012 and 2016 increased the capacity of private health facilities in the slums to provide basic emergency obstetric care and significantly reduced home deliveries, by bringing together local health service providers and officials of Ministry of Health in a complimentary than adversarial relationship (56). Further, as part of the search for pathways to address the challenge of health ine

We conclude that informal social support is needed regardless of the availability of formal social support. Moreover, a combination of formal and informal actors and related networks are essential to support vulnerable persons. Formal actors should establish, support, or maintain the informal actors and related networks through goodwill and sundry incentives as a vital dimension of building with local Frontiers in Public Health frontiersin.org Chumo et al. . /fpubh. . community structures and enhancing inclusion, participation and ownership of policy and program interventions by marginalized and vulnerable groups.

schools, religious institutions, and social clubs thus developing partnerships, community capacity and consequent increased benefits to the vulnerable groups (37). This is because the formal actors and networks are usually called upon when the informal support have exhausted their capability and the situation of the vulnerable has deteriorated so much that the informal network requires assistance to cope or critical elements of the informal network are missing. Our findings are speaking to a wider emerging evidence of significant improvements in health outcomes among slum dwellers in Nairobi within relatively short periods, following interventions that promoted collaboration and cooperation of multiple actors, including formal and informal service delivery structures. While not primarily focusing on complementarity, an intervention research program on maternal and child health-the Partnership for Maternal, Newborn and Child Health (PAMANECH) in Korogocho and Viwandani slums-implemented between 2012 and 2016 increased the capacity of private health facilities in the slums to provide basic emergency obstetric care and significantly reduced home deliveries, by bringing together local health service providers and officials of Ministry of Health in a complimentary than adversarial relationship (56). Further, as part of the search for pathways to address the challenge of health inequity between slum and non-slum urban dwellers, another study highlights the complementary roles of mobile outreach services and implementation research studies in expanding healthcare access to hard-to-reach but vulnerable groups in informal settlements beyond public facilities and other traditional service delivery models (57,58). It suggests like our current study, the potential promise of nontraditional service delivery models that are convenient and adaptable to specific contexts in bridging service access and utilization deficits among disadvantaged populations. --- Conclusion In line with the present findings, we conclude that informal actors and networks for social support of vulnerable populations are needed regardless of the availability of formal actors and networks more so in the informal settlements. This is because there is a prevailing near absence of many critical formal support in informal settlements and so informal actors and networks have devised support network mechanisms. Our findings underscore the need for a consequential engagement with informal stakeholders and incorporation of their rich local intelligence, often ignored and generally not quantified, documented, harnessed, nor incorporated into policy and action. Nevertheless, mechanisms that entails a complementarity of formal and informal actors and related networks are essential to support vulnerable persons because informal structures are knowledgeable on community and community activities, whereas the formal structures have expert knowledge. Formal actors and related networks should establish, support, or maintain the informal actors and related networks through goodwill and broader scope. Shifting the focus of complementarity of formal and informal actors and networks from a point of control to autonomy and collaboration would be a significant step in empowering vulnerable groups to make decisions about where to seek support. Comprehensive education and skills development that enables vulnerable groups and their caregivers to determine where, how, when and why to seek support from both formal and informal support actors and networks, and that seeks to ensure informed decision-making-is the best antidote to advancing support to the vulnerable populations in informal settlements. Lack of support can only persist in the context of misinformation and darkness, which is why efforts to raise awareness are essential and need to go further. On the global agenda, our findings of complementarity speaks to calls for not only breaking down traditional silos but building more cross-sectoral decision-making and multi-stakeholder partnership approaches and links among sectors, an era ushered by the SDGs 2030. It is typified by joint actions by health and other government sectors, representatives from private, voluntary and non-profit groups, to improve the health of populations, with actions taking the forms of cooperative initiatives, alliances, coalitions or partnerships and co-creation of solutions. These lend impetus for the need to extend the tradition in seeking complementarity between formal and informal structures in addressing the challenges of vulnerability and marginality among the urban poor; a call consistent with incorporating rich local intelligence, adaptive capacity and survival instincts as integral part of the building blocks for policy and action in the region and beyond. review and editing: IC, CK, AS, EI, and BM. All authors approved the manuscript for submission. --- Data availability statement The data presented in this study is available on request from the corresponding author. Other data related to this study is not publicly available because it is included within upcoming articles and cannot be shared at this time. --- Ethics statement This study was conducted in accordance with the Declaration of Helsinki, and approved by the AMREF Health Africa's Ethics Scientific Review Committee (ESRC), REF: AMREF-ESRC P747/2020. A research permit from National Commission for Science, Technology and Innovation (NACOSTI), REF: NACOSTI/P/20/7726 was also obtained. Approval was also obtained from the Liverpool School of Tropical Medicine (LSTM) and the African Population and Health Research Centre (APHRC) internal ethical review committee. All participants provided informed written consent before participating in an interview including consent for using photos and videos if there were any. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements. --- Author contributions Conceptualization: IC, CK, and BM. Data curation, formal analysis, and writing-original draft: IC. Methodology and writing- --- 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.

We conclude that informal social support is needed regardless of the availability of formal social support. Moreover, a combination of formal and informal actors and related networks are essential to support vulnerable persons. Formal actors should establish, support, or maintain the informal actors and related networks through goodwill and sundry incentives as a vital dimension of building with local Frontiers in Public Health frontiersin.org Chumo et al. . /fpubh. . community structures and enhancing inclusion, participation and ownership of policy and program interventions by marginalized and vulnerable groups.

Introduction War and violence have since the 1980s led to a constant influx of Somali refugees in the Netherlands [1]. In 2022, more than 41,000 people of Somali origin were living in the Netherlands [2]. The traumatic events that many Somali refugees experienced [3] put them at increased risk of poor psychological health [4,5]. Earlier research has highlighted pronounced within-group mental health differences among Somali refugees in various Western countries, for instance by employment status [6] and by the extent to which they identified with Somalia and/or the destination country [7]. The current study focuses place in which they settle and the wider society around them" [11]. It is a multi-faceted concept [12], with key facets being proficiency in the language of the destination country and informal contacts with destination country natives without a migration background [13,14]. As argued by Dagevos [12], social integration can be seen as related to, yet distinct from, cultural integration, i.e., the extent to which immigrants ascribe to the host society's prevailing moral standards and values, and the extent to which they identify as members of the host society [14,15]. Although the central focus of the current study is not on cultural integration, we will take aspects of cultural integration -specifically ethnic identification -into account when assessing the associations between facets of social integration and refugees' mental health. We do so because social integration and cultural integration are closely intertwined, and because prior research suggests that the latter is associated with refugees' mental health [7]. Social integration may benefit mental health in multiple ways. When social networks are diverse and include members of the native population of the destination country in addition to co-ethnics, this may open ways to important resources, e.g., information, socially distant from the refugee that could benefit their life chances, and potentially their health, in the destination country [16,17]. In contrast, inadequate local social networks may constitute a barrier for refugees to explore services and opportunities potentially available to them [18]. Poor command of the language in the destination country hinders developing informal contacts and social relationships with destination country natives, and forms a direct barrier to access to community services [19][20][21]. Low language proficiency has also been linked to raised feelings of loneliness among Somali immigrants in Western countries [18,22], and loneliness is, in turn, a known risk factor for depressive symptoms [23]. Moreover, communication difficulties arising from low language proficiency may complicate the contact with a mental healthcare professional, which may result in suboptimal quality of the care received [24]. This may be stressful and could, depending on the individual's coping behavior, result in negative emotions, which, ultimately, is detrimental for mental health. Refugees may also refrain from seeking mental healthcare entirely due to fear that they cannot communicate adequately with healthcare professionals, or because they are embarrassed about their language abilities [25][26][27]. Low language proficiency may thus result in inadequate -or even absent -treatment of emerging mental health issues, which, in turn, can be expected to translate in suboptimal mental health [28]. --- Discrimination The premise of the current study is that perceived discrimination may partly shape the impact of social integration on mental health among Somali refugees. Somali refugees are a group with multiple minority statuses, and they may therefore be target of discrimination on multiple grounds (e.g., race/ethnicity or Islamic beliefs) [29]. The negative association between experiences of discrimination and mental health is well-established [30][31][32][33][34], also in Somali refugees [35][36][37][38]. Perceptions that society is discriminatory and everyday experiences of minor acts of unjust treatment because of one's social identity are chronic stressors. More apparent personal discriminatory acts are moreover acute stressors that are superimposed on this chronic stress, and the combined stress resulting from discrimination is detrimental for mental health [39]. Experiences of discrimination may either be a catalyst or a nullifier of potential beneficial mental health effects of social integration. Assimilation theory [40] would lead one to expect that discrimination plays the former role. Social integration can reduce the social distance between ethnic minority and native majority members [41]. Informal contact and familiarity with ethnic minority members who have proficiency in the language of the destination country and orientate towards the destination society may make ethnic majority group members more accepting towards minority members. As a consequence, attenuation of prejudice and discrimination may be expected [17,40,42]. Moreover, socially integrated ethnic minority members might feel more recognized and develop positive attitudes towards the native majority group. Assimilation theory would thus lead one to hypothesize that the beneficial mental health effects of destination country language proficiency and informal contacts with destination country natives can partly be attributed to reduced experiences of discrimination. In stark contrast with what assimilation theory would lead one to expect, a phenomenon coined the integration paradox has recently been noted by scholars focusing on the links between social integration and discrimination [43,44]. The integration paradox postulates a positive, rather than negative, association between migrants' aptitude to integrate and experiences of discrimination [43,44], and it posits that the greater exposure to discrimination among more strongly integrated migrants may result in disengagement in and resentment towards the destination society [45]. There are various explanations for a positive association between social integration and perceived discrimination. Integrated ethnic minority members are more exposed to contact with native majority members in the public context than their counterparts who mainly surround themselves with members from their own ethnic group. This may increase the sense of intergroup competition and increase the desire to strongly support in-group interests. Moreover, discrimination is more easily detected by those who speak the language of the destination country well [43]. Integrated ethnic minorities in the Netherlands are also to a larger extent confronted with the negative public view towards and political debates about ethnic minorities [46], which may increase feelings of discrimination [43]. Warfa et al. [29] noted frustration among many Somali refugees with professional skills and a very good command of the English language in the United Kingdom and the United States about the lack of recognition for their skills in the destination countries. This frustration, the authors argued, put the refugees at increased risk of resentment and psychological distress [29]. Following this reasoning, it may be hypothesized that potential beneficial mental health effects of destination country language proficiency and informal contacts with destination country natives are, in part, cancelled out by stronger experiences of discrimination among those with better destination country language proficiency and more informal contacts with natives. --- Data and methods --- Sample The current study draws on data from the controlled circulation file of the 2015 edition of the Survey Integration Minorities (SIM) (Dutch: Survey Intergratie Minderheden) [47,48]. SIM is a repeated cross-sectional survey commissioned by the Dutch Ministry of Social Affairs and Employment and conducted by the Netherlands Institute for Social Research. It focuses on the structural and socio-cultural position of migrants in the Netherlands. The third round of SIM (SIM2015), collected between January and June 2015, was the first to include a subsample of migrants of Somali origin. Other groups interviewed were people with Turkish, Moroccan, Surinamese, Antillean, Polish and native Dutch backgrounds. Andriessen and Kappelhof describe in detail how the Somali subsample was recruited [47]. Statistics Netherlands randomly selected 1747 individuals of Somali origin (i.e., born in Somalia or at least one parent born in Somalia) from the Dutch population registers. Of these persons, 10 could not be contacted, either because they were deceased or because they no longer had a valid address. The 1737 remaining persons were sent a survey invitation, and 626 of them participated in the survey (response rate: 36.0%). Of these respondents, 234 filled in the survey online and 392 participated in computerassisted personal interviews (CAPI). The questionnaires for the face-to-face interviews and the web survey were identical, and both were available in Dutch as well as in Somali. Face-to-face data collection was done by 15 interviewers with a Somali background. Respondents were informed about the goals of the research, and it was emphasized that information would be anonymized and that participation in the survey and consent were voluntary. In the controlled circulation file of the dataset, selected information (e.g., age) was recategorized in broader categories in order to render identification of individual respondents impossible. The Research Ethics Review Committee of the Erasmus School of Health Policy & Management at Erasmus University Rotterdam assessed and approved the secondary analysis of the controlled circulation file of the SIM2015 dataset on which we report here (Reference: 21-033). Given our focus on refugees, we excluded second-generation migrants (n = 51) and migrants who migrated for other reasons than war, political reasons or religious persecution (n = 158). Given that information on formal refugee status was not available, we had to rely on self-reported migration reasons as a proxy measure. The exclusion procedure described here resulted in a reduction of the analytical sample to 417 respondents. Supplied analytical weights were used to account for selective non-participation in the survey. --- Measures Mental health was measured with an alternative version of the Mental Component Summary of the 12-item Short Format Health Survey (SF-12) [49]. Respondents were asked how often in the last four weeks they "had a lot of energy", "had difficulty to meet family or friends or plan other social activities due to physical health or emotional problems", "felt calm and peaceful", "felt downhearted and blue", "participated less in activities or accomplished less than you would like as a result of any emotional problems", and "were unable to do work or other regular daily activities as carefully as usual due to any emotional problems". Response categories differed somewhat from the original SF-12: the four first-mentioned questions had four response categories ranging from (1) "all the time" to (4) "never", and the final two questions had two response categories: (1) "yes" and (2) "no". Where necessary, answers were recoded, so that higher values corresponded with better mental health. Following the procedure described by Schellingerhout [50], a summary scale ranging from 0 to 100 was subsequently derived. Two facets of social integration were considered: Dutch language proficiency and the frequency of informal contact with Dutch natives. Three questions assessed whether the respondents experienced difficulties when having a conversation in Dutch, when writing in Dutch, and when reading Dutch newspapers, letters or brochures. The response categories for each of the three questions were (1) "often", (2) "sometimes" and (3) "never". For the first question, "not able to speak Dutch" (4) was presented as an additional response category. Responses were summed into a consistent scale (Cronbach's <unk> =.80) ranging from 3 to 10, with higher scores indicating better Dutch language proficiency. With regard to informal contact with Dutch natives, respondents were asked how often native Dutch friends or neighbors visited them, how often they spent leisure time with Dutch natives, and how often they had contact with native Dutch friends or acquaintances. For the first two questions, response categories ranged from (0) "never" to (2) "often". Response categories for the third question ranged from (0) "Once per month or less" to (2) "daily". Summing the answers on the three questions to resulted in an internally consistent scale (Cronbach's <unk> =.73) ranging from 0 to 6, with higher scores indicating more informal contact with Dutch natives. Perceived personal discrimination was captured with the question: "Have you ever been discriminated by the Dutch population? If so, how often did this happen?". Response categories ranged from "never" (1) to "very often" (5). In the multivariate analyses we controlled for gender, age, partner status, parenthood, educational attainment, employment status, religiosity and identification with Somalia and the Netherlands. These variables were considered potential confounders, because they may be expected to be associated with social integration as well as with mental health [6,7,32,37,44,[51][52][53][54]. Four age categories were distinguished: 15-24 years old, 25-34 years old, 35-44 years old, and 45 years and older. With regard to educational attainment, we distinguished three categories: (1) primary education or less, (2) lower secondary education, (3) higher secondary or tertiary education. Partner status was measured with a dichotomous variable distinguishing between respondents with a partner living in the Netherlands and their counterparts without a partner or with a partner living in a different country than the Netherlands. A dichotomous variable was included to distinguish respondents with at least one child from their childless counterparts. Another dichotomous variable indicated whether or not respondents were in paid employment. Length of stay was calculated by deducting the year in which the respondent first migrated to the Netherlands from the interview year. Given the positively skewed distribution of length of stay in years, log transformation was subsequently performed. Two dichotomous measures were included to capture respondents' identification with Somalia and the Netherlands. Both variables were coded as 1 for respondents who reported identifying themselves "strongly" or "very strongly" as Somali or Dutch, respectively, and as 0 if they reported identifying themselves as such only "somewhat", "not", or "not at all". A final dichotomous variable was included to capture religiosity. Note that respondents in our sample almost exclusively (96.4%) reported being Muslim. We distinguished between respondents who attended religious services at least weekly and their counterparts who attended religious services less often. Sample characteristics are presented in Table 1. --- Missing values Information on one or more variables of interest was missing for 88 respondents (22.1%) in the analytical sample. Information on mental health (n = 48) and informal contact with natives (n = 32) was missing most often. Multiple imputation using chained equations was used to deal with missing data [55]. The underlying assumption is that information was missing at random (MAR), i.e. that differences between the distributions of missing values and the distributions of observed values could be explained by variables included in the imputation model [56]. The findings from the substantive analyses on 20 imputed data sets were combined into a single set of results following Rubin's rules [57], which take the variability in results between the imputed datasets into account. An overview of the sample characteristics after multiple imputation and weighting is provided in Additional file 1: Appendix A. --- Analytical approach We estimated a set of ordinary least squares regression models to predict mental health. We first regressed mental health on Dutch language proficiency, informal contacts with natives, and the range of control variables described above. In a second model we added perceived discrimination as an explanatory variable. We performed formal mediation analyses to assess whether the effects of Dutch language proficiency and informal contacts with natives on mental health were mediated (or suppressed) by perceived discrimination. Following the procedure proposed by Preacher and Hayes [58], bootstrapping was used to estimate the indirect effects of Dutch language proficiency and informal contacts with natives on mental health via perceived discrimination. --- Results Results of the ordinary least squares regression models of mental health are shown in Table 2. Consistent with our expectations, the first model indicated that, after adjusting for the other variables in the model, Dutch language proficiency was positively associated with mental health. No significant association between informal contacts with natives and mental health was found. The model furthermore indicated that having a partner in the Netherlands, a strong identification with Somalia and frequent attendance of religious services were associated with better mental health. A key aim of the current study was to assess how the associations between facets of social integrations and mental health are shaped by perceived discrimination. Prior to adding perceived discrimination to our regression model of mental health, we regressed perceived discrimination on Dutch language proficiency, informal contacts with natives and the aforementioned range of control variables. The results of this analysis are presented in Additional file 1: Appendix B. After adjusting for the other variables in the model, a better command of Dutch was associated with higher perceived discrimination. This is consistent with the notion of the integration paradox, which posits that migrants with a stronger aptitude to integrate report more, rather than less, discrimination. No significant effect of informal contacts with natives on perceived discrimination was found. The second mental health model, in which we included perceived discrimination as an additional explanatory variable, showed that stronger perceived discrimination was associated with worse mental health. After the addition of perceived discrimination to the model, the coefficient estimate of Dutch language proficiency became notably larger. Results of the formal mediation analysis with bootstrapped standard errors are presented in Table 3. The partial suppression of the beneficial health effect of Dutch language proficiency by perceived discrimination was borderline significant (p <unk>.1). The coefficient estimate of informal contacts with Dutch natives did not change substantially after the addition of perceived discrimination to the model. We thus found no evidence of suppression of a mental health effect of informal contacts with Dutch via perceived exposure to discrimination. --- Discussion Drawing on Survey Integration Minorities data of 417 Somali refugees in the Netherlands we assessed whether social integration -operationalized as Dutch language proficiency and informal contacts with Dutch nativeswas associated with mental health among Somali refugees in the Netherlands, and how this association was shaped by perceived discrimination. Our results suggest that, overall, greater Dutch language proficiency is beneficial for Somali refugees' mental health. We did not find statistically significant evidence that informal contacts with Dutch natives impacted the mental health of Somali refugees. Results of the mediation analyses provided tentative evidence for the hypothesis derived from the notion of the integration paradox that the beneficial mental health effects of Dutch language proficiency are partly cancelled out by stronger experiences of discrimination among Somali refugees with a better command of Dutch. Our finding that Dutch language proficiency was positively associated with refugees' mental health is consistent with our expectations derived from prior work referred to in the introduction section. Taken together, this work suggested that poor command of the language in the destination country may give rise to feelings of loneliness and to inadequate or even absent treatment of emerging mental health issues. It is important to emphasize, however, that we could not test whether these potential mechanisms effectively underlay the positive association reported here between Dutch language proficiency and mental health. The fact that we did not find any evidence of a positive association between informal contacts with Dutch natives and refugees' mental health may be related to the way informal contacts with Dutch natives were operationalized. The emphasis in our measurement was on frequency of various types of contacts. However, quality of the contacts, e.g., the extent to which one can discuss intimate and personal matters, may be more important [59]. Research suggests that the quality of contact with neighbors tends to be lower in ethnically diverse neighborhoods [60], such as those where many Somali refugees live. People of Somali origin also tend to relocate relatively often [1]. As a consequence, the quality of the informal social contacts with Dutch natives of Somali refugees may often not be sufficient to meaningfully contribute to better mental health. In addition to the beneficial effect of Dutch language proficiency, our results also highlight that refugees who strongly identified as Somali and refugees who attended religious services at least weekly had better mental health than their counterparts who did not identify strongly as Somali and who attended religious services less often. The desire to be part of a group is a likely driver of frequent attendance of religious services among Somali refugees in the Netherlands [1]. Recent research suggests that friendships with immigrant peers may be beneficial for immigrants' mental health and psychosocial wellbeing [61,62]. The positive mental health effects of social integration as well as of self-identification as Somali and frequent attendance of religious services reported in the current study may be attributed to the preference among immigrants noted by Phinney et al. [63] for retaining ties with the culture of origin while also forging ties to the society of settlement. Persistent ties with the culture of origin should not be perceived as a barrier to social integration [14,64], and it is important that policymakers and practitioners recognize the importance, and possibly the complementarity, of both for refugees' wellbeing. In the current study, we perceived social integration and cultural integration as related yet separate concepts. This choice was arguably somewhat arbitrary, as these two types of integration have also been considered together as aspects of socio-cultural integration [14]. A broader focus on socio-cultural integration, rather than merely on social integration, would imply more elaboration on the mental health impact of values and identification with the destination country. Although we did not theorize about potential links between cultural integration and refugees' mental health, we did include a key aspect of cultural integration in our models, namely self-identification with the Netherlands. We did not find evidence that self-identification with the Netherlands was associated with better mental health among Somali refugees. Several limitations of the current study should be considered. Due to the cross-sectional design, causality cannot be inferred from the findings reported here. In pursuit of stronger evidence for causal links, future studies can adopt a longitudinal design and investigate, for example, the extent to which acquisition of greater Dutch language proficiency yields changes in perceived discrimination and/or mental health. Secondly, the mental health measure included in the SIM dataset was based on the validated SF-12 Mental Component Summary [49], but, as described in the measures section, it had some notable differences, for instance with regard to the number of response categories on several items. Although used in various studies by the Netherlands Institute for Social Research [1,50,65], the alternative measure has thus far not been validated. The average mental health score reported here was rather high. Possibly, mental health problems were underreported due to the stigma on mental health issues that has been noted among Somali refugees [66][67][68][69]. Given the relatively low response rate, the high mental health scores may also reflect sample bias. We used the supplied analytical weights to correct for selective non-response, but these weights only took gender, age category, household size and municipality size into account [47]. If after these corrections people with good mental health were still more likely than their counterparts with suboptimal mental health to participate in the survey, the average mental health score reported here may be higher than in the overall population of Somali refugees in the Netherlands. We would like to emphasize, however, that the main focus of the current study was not on absolute levels of mental health, but rather on the impact of facets of social integration and perceived discrimination on the mental health of Somali refugees in the Netherlands. In the light of the increasing diversity of Dutch society, it is crucial that mental wellbeing and inclusion of all its members is adequately promoted. Our results underscore the importance of understanding the challenges Somali refugees in the Netherlands are confronted with. There is a need for initiating and sustaining initiatives that encourage Somali refugees to learn the Dutch language and that provide them with tools to overcome language barriers to access services. In line with a recent police advice by the Netherlands Institute for Social Research [10], our results also suggest that such initiatives may particularly be successful in promoting the mental health of Somali refugees in the Netherlands when combined with actions that address discrimination. --- Availability of data and materials The dataset analyzed during the current study is available in the DANS repository of the Royal Dutch Academy of Sciences and Arts, https:// doi. org/ 10. 17026/ dans-xep-by9x. --- Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12889-022-14655-y. --- Additional file 1. --- Authors' contributions EK was responsible for study conception. EK and TvdB designed the study, performed the analyses and drafted the manuscript together. Both authors read and approved the final manuscript. --- Declarations Ethics approval and consent to participate This study was assessed and approved by the Research Ethics Review Committee of the Erasmus School of Health Policy & Management at Erasmus University Rotterdam (Reference: 21-033). Analysis is based on a publicly available secondary dataset. Consent was therefore not required for publication. All methods were performed in accordance with the relevant guidelines and regulations. --- 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: We assess whether social integration is associated with mental health among Somali refugees in the Netherlands, and how this association is shaped by perceived discrimination.We performed linear regression and formal mediation analyses on Survey Integration Minorities data (n = 417) to assess whether the effects of two facets of social integration -Dutch language proficiency and informal contacts with natives -on mental health were mediated or suppressed by perceived discrimination. Results: Dutch language proficiency was positively associated with mental health, but also with perceived discrimination. Informal contact with natives was not significantly associated with mental health or perceived discrimination. There was marginally significant evidence (p < .1) that perceived discrimination suppressed the positive association between Dutch language proficiency and mental health. Discussion: Greater Dutch language proficiency appears to be beneficial for Somali refugees' mental health, but this effect may partly be cancelled by the associated stronger experiences of discrimination.

Introduction --- Research background To understand the resurgence of rebellions in the east of the country, one must go back to the history of the genocide and the way refugees were managed. After the Cold War and he genocide in Rwanda in 1994, the International Community requested the then president of Zaire, Mobutu, to open the borders to Rwandan Hutu refugees who were fleeing the genocide in Rwanda. Among them were the Democratic Forces for the Liberation of Rwanda (French: Forces démocratiques de libération du Rwanda, FDLR) soldiers who entered the democratic republic of Congo (DRC) with arms and ammunition (Caillé, et al., 2019). This event is among the most frequently cited causes of insecurity in eastern DRC, specifically in the provinces of North and South Kivu. This misfortune of DRC is therefore attributed to be caused by her hospitality towards neighbouring countries according to observations by His Excellency Mr. Felix Antoine Tshilombo during the Holy Father, Pope Francis on his apostolic visit to the DRC on 31 st January 2023 and Cardinal Ambongo who underlined that the DRC is a welcoming country and that this hospitality brings it trouble. The same sentiments have been captured in the film entitled 'olukyo Lunene lwingirya nde' produced by North Kivu film artist, Amstrong in 2017. The film symbolically traces, in an eastern DRC context, how a visitor turns into the owner of the house and makes the whole family feel bad. --- Problem statement The war crisis in North and South Kivu, which is now leading to the genocide of the indigenous populations, has become a war of aggression waged by foreign peoples who have received the hospitality of the natives (Stearns, 2012). In 1999, Mgr Emmanuel Kataliko, former Archbishop of Bukavu in South Kivu, in a Christmas message, wrote that 'foreign powers, with the collaboration of the peoples we hosted during the Rwandan genocide, are organising wars with the resources of our country (Mbelu, 2009). The observation of the Assumptionist Father and former president of Kyaghanda Yira, Vicent Machozi, in 2013 is such that rebellion is an act of disobedience and internal violent resistance against legitimate authority with the aim of radically changing the mode of management or administration of a state or an army. This according to him does not exist in DRC who rightly speak of 'foreign rebels' who are in fact mercenaries, international terrorists, or terrorists without borders. Welcomed people have therefore turned into terrorists to attack the DRC. Is there a need to review the way we welcome neighbours as this may have the intention of taking over the homes of the host families? What is the responsibility you have in such a case? What do you do to get out of this misfortune? This article 'hospitality at the heart of misfortune' provides the socio-cultural analysis in the context of the DRC and proposes a sharing of responsibility between the visitor and the owner of the house in the misfortune that befalls the family. --- Study objectives The aim of this study is to examine how hospitality at the heart of a misfortune by socially and culturally analysing the film "Olukyo Lunene lwingirya nde" by filmmaker Armstrong. Specifically, the study aimed to: (i) introduce the film "Olukyo Lunene lwingirya nde" and its structure, (ii) analyze hospitality and its consequences as described in the film "Olukyo Lunene lwingirya nde", (iii) analyze hospitality and its consequences in the context of the war crisis in Eastern DRC, and (iv) create awareness-raising messages for the proper management of hospitality in the DRC. --- Literature review --- Theoretical literature review The study is underpinned by the Theory of Structural Functionalism. This theory defines social institutions to be a collective whole necessary to fulfill the various needs of individuals and centers on how these institutions meet their social needs. Structural functionalism says that for societies to survive they have to be stable and cohesive, and this comes from solidarity. Structural functionalism emphasizes more on social order. Structural functionalism believed that an individual is simply an occupant of his social role and are thus, not significant as only themselves but just because of their social roles and status. Structural functionalism believes that social inequality and oppression may be necessary for the stability, integration and functioning of a society. Structural functionalism says that discrimination fits perfectly in a society since it yields positive results (Fararo, 2001). Structural functionalism says that when a society becomes complex differentiation takes place and integration takes place among the new institutions. Thus, even though changes occur structures inside a society emerge to compensate for the change. These new integrated structures guarantee the smooth running of our society and thus, it argues that the members are responsible for its stability and order. Therefore, when we reach a point where further growth of society is not possible, crisis takes place, which transforms society. Consequently, change is a continuous process until it reaches crisis point where transformation takes place (Brinkerhoff, 1999). Structural functionalism intently focuses on equilibrium of a society and says that it consists of mutually dependent parts working together to maintain that equilibrium. It also tries to describe our social institutions mainly by its effects and thus, is unable to explain the reasons for the effects. Structural functionalism believes that society is inclined towards stability and equilibrium at the cost of social change (Hook, 2006). --- Empirical review Emizet and Ndikumana (2003)'s study analysed the causes of civil wars in the Congo since independence and investigates how the Congo case fits the model of civil war proposed by Collier and Hoeffler. Five conclusions arise from this case study. First, the level and growth rate of national income increased the risk of war by reducing the cost of organizing rebellions and the government's ability to counteract the rebellions. Second, while regional ethnic dominance served as a basis for mobilization of rebellions, ethnic antagonism was also an obstacle to the expansion of civil wars beyond the province of origin. Third, while natural resource dependence was a significant determinant of civil wars in the DRC, it is the geographic concentration of natural resources and their unequal distribution that made the Congo particularly prone to civil war. Fourth, the government's ability to counteract rebellions depended more on external support than on the government's military and economic capacity. Fifth, discriminatory nationality laws, disruptions in the ethnic balance of the eastern region caused by the influx of Rwandan Hutu refugees in 1994, and shared ethnicity between rebels and neighboring regimes variables which are not included in the Collier-Hoeffler model were significant determinants of the outbreak of civil wars in the 1990s. Karbo and Mutisi (2012)'s study on ethnic conflict in DRC identified several factors as contributing to the negative sentiments between ethnic groups in the DRC, including early political decisions regarding eligibility for citizenship of specific regions. The authors acknowledge the early existence of a shared culture between two of the groups involved in conflict and present perspectives that a mythology of ethnic difference has been created and perpetuated by colonizers, political powers, foreign interests, rebel groups and media. Alusala (2019) conducted a study on border fragility and the causes of war and conflict in the DRC. The study noted that the occurrence of civil wars in Africa has often involved cross-border characteristics, whether as causes or effects and therefore cannot practically delink the causes of territorial (inter-state) wars from those of intra-state (internal/civil) wars, as even civil wars have the potential of degenerating into inter-state wars. The study proposes that causes of conflict can be viewed in two dimensions. Firstly, as underlying (or core/root) causes and secondly as proximate causes. It explains how external (spatial) proximate events in one country can merge with internal (core) factors of instability in another country to trigger a conflict irrespective of barriers such as physical borders. The study uses the occurrence of the civil war that took place in Zaire (now DRC), to illustrate this thought. It analyses how pre-existing internal structural weaknesses (or root causes), the effects of the Rwandan civil war served as proximate causes (or triggers) to the war in the DRC and transformed it into a regional one. Seybolt (2000)'s study on the war in the Democratic Republic of Congo. Observed that since 1998 the armed forces of nine states and at least nine rebel groups have fought in the DRC for control of the DRC Government; control of the governments in Angola, Burundi, Rwanda, and Uganda; exploitation of the DRC's mineral wealth; and because of ethnic hatred. The study pointed out that a critical antecedent to the civil war was the presence of hundreds of thousands of Rwandans in the eastern DRC after the 1994 genocide and civil war in Rwanda. The intertwined involvement of governments, insurgents, and refugees from countries in the African Great Lakes region and to the west and south also makes the war in the DRC one of the world's most troubling. Mamili (2015) carried out study on the Great Lakes Region Conflict Case Study of Democratic Republic of Congo. The study observed that Rwandan-backed M23 armed group continues to perpetrate widespread war crimes, including summary executions, rapes, and forced recruitment of children into their forces. Numerous other armed groups have carried out horrific attacks on civilians in eastern Congo, including in North and South Kivu, Katanga, and Orientale provinces. Fighters from the Nduma Defense of Congo militia group, led by Ntabo Ntaberi Sheka, killed, raped, and mutilated scores of civilians in North Kivu. They include the Raia Mutomboki, the Nyatura, the Mai Mai Kifuafua, and the Democratic Forces for the Liberation of Rwanda (FDLR), a largely Rwandan Hutu armed group, some of whose members participated in the Rwandan genocide in 1994. The conflict revolve around minerals and poor governance. This research paper looks objectively on the causes of conflict, conflict management approaches and the social economic impact of conflict in DRC and the entire Great Lakes region. Greed grievance theory is employed to guide data collection and analysis. --- Methods and materials This study used descriptive search models. The designs in this study have different applications and characteristics. Cooper and Schindler (2006) show that the key difference between descriptive studies is their objectives. If the research aims to find out who, what, where, when, then the study is descriptive. Descriptive studies are those that aim to describe the phenomena associated with a given population or to estimate the proportions of that population with certain characteristics. The research has applied qualitative method in its approach to literature review. This study collected primary data from a structured interview guide with respondents and a focus group with a group of 6 people who experienced the war crisis in Eastern DRC and viewed the film. From the film they expressed opinions about the relationship between foreign hospitality and the war crisis in the DRC. This study used secondary data from the analysis of the film. The data was triangulated with the primary data in this paper to achieve the above-mentioned objectives. The target population of this study included the director of the film 'Olukyo Lunene Lwingirya nde' and people who were well informed on the effects of hospitality in the DRC, notably the president of the Civil Society of North Kivu, the journalist Kénédy, an independent political analyst, Mavughu Jurist and Magistrate, Kavotha traditional chief, Amstrong (the author of the film), and 6 people (in a discussion group) who have lived through the war crisis in Eastern DRC and have viewed the film that is the subject of this article. After analyzing the consequences of hospitality in the DRC in the light of the film "olukyo lunene...", this study proposed recommendations that could help the DRC to emerge from its colonial state. --- Results and discussion --- Presentation and structure of the film "Olukyo lunene lwingirya nde" Sindani Amstrong born in 1979, is a filmmaker who works in the Grand Nord-Kivu in the East of the Democratic Republic of Congo, more precisely in the town of Butembo. He produces films on education and the resolution of family and land conflicts. He has more than 13 years in this profession. He is originally from Luveve-Masereka where he shot most of his films (interview with Amstrong). He has a film experience without sponsorship. The films he has produced include: Kitaka Kyaluire; Obwera Bwerighula; Okwavya Kwetu Kwavere Kwavene; Olukyo Lunene Lwingirya Ndee I And II (2016); Ovuhanya Sivuliya Eyo; Parton Musenzi; Oyukakuronda Koluvanza Syaliluvulaa; Olulimi Ni Mbundu; Bonde Katwa Kokighuma Ngalabha; and Wema Ni Kumanyoko. The film "Olukyo lunene lwingirya nde: Akanyama kabalya Mundu kakasa ngalubundu" tells the story of a family that has great possessions, including a sheepfold. In this sheepfold there are cows, goats, sheep, and other livestock. One day this family needed a shepherd who could faithfully guard the animals for the whole family. The man and woman went in search of a shepherd. They met two young boys who spent their time playing a game of checkers. They recruit one of them who confirms that he is an experienced shepherd. It should be noted here that this recruitment is motivated by the woman who is already attracted to the future shepherd. The recruited shepherd is called Armstrong (the main actor of the film). He is adopted into the family of his boss and very quickly the woman falls in love with him. The woman and Armstrong, the new shepherd, plot how to make the boss disappear to inherit all his wealth. The woman begins to show more attachment to the young shepherd than to her husband. She gives the larger share of food (fire-roasted potatoes) to the shepherd and the smaller share to her husband. Despite the husband's complaints that his wife is denigrating him, she manages to get her husband to promise all his wealth to Armstrong if he fulfils his duty well. Urged on by his wife, the man eventually told Armstrong that he would become the heir to his wealth, even after his death (Amstrong, 2016). Armstrong seeks out a group of young people to help him herd the animals. They spend time with them playing traditional music and dancing. The boss caught Armstrong several times dancing instead of herding cattle. He tried to dismiss him from the job, but his wife pleaded for Armstrong, who was always her favourite and model shepherd. One day, the opportunity arose to make the boss disappear. He fell ill and Armstrong became his career. Instead of treating him, he injected him with a poison that caused his immediate death. Armstrong and Nyamudundo (the boss's wife) decided to leave the boss's lifeless body in the hut and enjoy the inherited (Amstrong, 2016). A village pastor, on a pastoral walk, discovered the lifeless body in one of the huts of the owner's house. He alerted the neighbours to see the tragedy but also to bury the body because the wife was not present. In the meantime, Armstrong and the boss's wife (Nyamudundo) are happy about the boss's death because they will finally inherit all the property. Some of Armstrong's friends try to sympathise with Armstrong, but Armstrong asks them not to cry because he will finally inherit the property of the boss and his wife. The boss's two sons had also gone into other businesses. Their father dies and is buried in their absence. They come to share the inheritance. They are told that there is nothing for them and that everything belongs to the shepherd. They try to convince their mother, but she points out that the boss had already said that all the property would belong to Armstrong including herself. One fact triggers Armstrong's arrest. Since he was already a reputed sorcerer in the village, Armstrong took the liberty of burning down the houses of the people living on the land he had inherited. This criminal offence attracts the rigour of the state, represented here by the police. The police arrests him and put him in prison, despite some attempts to bribe the police by Armstrong. The plot ends when Armstrong is put in prison. The film has seven parts: The search for the Shepherd, directing him to the sheepfold and promising him to be the heir as long as he fulfilled his duties (00:39-9:14); The shepherd keeps the flock, some moments of dancing with his co-shepherds, he receives (9:15 -10:18); Armstrong is given an exceptional place in the home and conflict arises in the home because of the shepherd (10:19-19:25); The jealousy of Armstrong's former friend (19:26 -19:51); from the boss's short illness to his funeral and death (19:20 -36:48); Armstrong takes possession of the boss's property, the boss's sons claim it, those living on the inherited land are evicted and their houses are burnt (36:49 -58:53); Arrest and imprisonment of Armstrong for the criminal offence of burning the houses (58:54 -1, 12:30). Hospitality is the main theme of this film. This theme is presented in its negative dimension and has negative consequences. The other themes in the film are as follows: animal husbandry; idleness and leisure; family conflicts; delinquency; jealousy; and prudence. --- The theme of the film The author of the film chose two proverbs from the Yira culture to express his filmic ideas. These are 'Olukyo lunene lwingirya nde' and 'Akanyama kabalya Mundu kakasa ngalubundu'. This choice is motivated by the war situation he himself experienced. He says he lived through the first wave of Rwandan refugees who entered the DRC in 1994. At the time he was 15 years old and lived in Kipese in Lubero territory (Amstrong, 2016) "These refugees came as vulnerable people and we even bought their goods: a goat for only $7 and a cow for $20. We had the impression that they were docile, simple people who needed help and protection. It was two years later that we were surprised to see them in the ranks of the military that liberated Congo with Kabila the father," says Armstrong in an interview. After taking refuge in Masereka, during the time of the Mayi Mayi Kaganga, between 1996 and 1997, he escaped several killings organised by the Mayimayi. All these experiences led him to find a way to raise awareness of the war crisis through films. For Armstrong, the population must rid itself of war by remaining attentive and vigilant in the practice of its hospitality (Amstrong, 2016). In the first proverb, Amstong (2016) states that 'nde' (cow) also has a negative connotation in Yira culture. It has an evil spirit called 'akalisha' and village sorcerers can use it when they move to harm people. In some traditional Yira villages, one can listen to the cries of a night while everyone is in bed (focus Group Discussion with some leaders of Yira culture in Butembo) Thus, for him, 'olukyo lunene lwingirya nde' (the big door brings in the cow), he simply means that man's imprudence is a door for misfortune. Also, for the author, when a cow is brought into a house, it is difficult to bring it out walking backwards. This is understood in the context of village houses which are generally less spacious. In such a context, to get the cow out, one is obliged to destroy it to get it out (Amstrong, 2016). In the second proverb, 'akanyama kavalya mundu kakasa nga lubundu', Armstrong attests that 'olubundu' (the cat) is a docile animal that guards even other small household livestock in the village. However, it has sharp claws and teeth. It can, from one moment to the next, turn against the livestock it is guarding. Here, the author's experience of the war crisis means that the Rwandan refugees welcomed in 1994 behaved like docile people. However, when the time came, they showed their claws by massacring the indigenous population. Armstrong uses both expressions in the context of war conflicts but also in the context of land conflicts that prevail in his locality of Masereka. For him, the frequency of land conflict cases started in 1992 and has already torn many families apart (Amstrong, 2016). The author therefore wants to give through his film a lesson on hospitality and land management and the awareness of the situation of war conflicts to refine solutions to get rid of them. It reminds us through the film of the responsibility of everyone. The state for example, in the film, has the responsibility to punish the thugs to maintain order in the country. That's why he ends his film with the main actor going to prison. In this study, olukyo lunene luinginrya nde refers to a gateway for good and evil and capable of passing everything through is a great risk because it fails to filter; censor; analyse. In other words, an exaggerated hospitality makes the Enemy enter with all its consequences. Ex: without going further, the people who were welcomed in Rutsuru before 1960 want to dethrone the landowners. This proverb is an appeal to open one's eyes so as not to pay after the negative effects of one's hospitality. Other similar proverbs are Omusoki syangalenga okomukama (the vassal does not overtake his king), 'erikokya omugheni simusesera' (welcoming a visitor is not synonymous with leaving him the bridal room). "Kakasa ngalubundu": that comes like a cat, or a fox refers to the fox which is characterized by its cunning and opportunistic behaviour. His approach is not too loud. It can also refer to the fact that an issue or problem that could escalate starts as a joke or an adventure. A person who will cause you harm enters your home quietly like a cat on a velvet paw; by the time he or she gets his or her claws out to hurt you, it will be too late, knowing already your inadequacies. Hospitality and its unfortunate consequences as depicted in the film "olukyo Lunene lwingirya nde". In the film, we can speak of a hospitality search. The Boss's couple decides to look for a shepherd who will be able to look after their rapidly multiplying animals. The intention is initially good. However, the choice is not a good one, because he will find a destroyer of his home and a plunderer of his property. The idea of giving a person a job is great because it combats the idleness and unemployment that already characterises the DRC. The image of the young people who spend time playing for fun illustrates the life of unemployment that can be seen in many young people in the DRC and even in those who have finished their studies. The film shows that the choice is already oriented and premeditated. Among the two young people playing the lady's game, the boss's wife directs the choice towards Armstrong without giving enough time to discern the skills of the two young people. The lady herself does not have time to interview the candidate to find out if he has the ability to do the job. This behaviour of the woman is already an indication that she is attracted to young Armstrong. The rest of the plot is based on this particular relationship between Armstrong and the Boss's wife (Amstrong, 2016). --- Hospitality management The contexts of hospitality in the Yira culture are multiple. Sometimes a person is adopted into a family out of compassion for him or her, depending on the circumstances. If it is a child who has been adopted, he or she grows up in the house and becomes the child of the house. In the ancient Yira culture, this type of adoption is very common (Amstrong, 2016). The problem only arises when this adopted child starts to show predatory behaviour. When predators started to multiply in families, the proverb was born as an advice to people to be careful when welcoming a stranger (focus Group Discussion with some leaders of Yira culture in Butembo) On the other hand, in the Yira culture, the question of caution, especially in matters of hospitality, was of low intensity. Strangers had a special place in traditional Yira villages. Indeed, in the centre of the village, there was a veranda where the men of the village met every evening to discuss current affairs and to solve their problems. The visitor had a place in these discussions. Some Yira proverbs even explain that during the palaver, a stranger or a passer-by can settle the matter. E.g.: 'vikatwa valabi' (matters are decided by passers-by). This is why, even in the libation rite, the passer-by's share is always reserved. The passer-by or visitor is also the one who gives the information from where he comes. In this way he helps the villagers to prepare themselves against eventualities. The Yira, who had such high regard abroad, would reserve ripe bananas or other food in the veranda so that a passer-by would find food in that village even if everyone else was absent from the village for one activity or another. In the course of history, other people have abused this hospitality and started to do wrong to the people of the village. The contact of Yira themselves with other cultures started to develop complicity against their brothers. This is why the call for caution was imposed and gave rise to the proverb 'olukyo lunene lwingira nzoghu'. This hospitality was often at the root of problems in the culture and strategies to solve them were often late in coming. Proverbs such as 'kakivukiraw'amenge kaghulukya' (it is after the misfortune that one knows the strategy to take), eribulir'amakala w'eluhutsa' (to realise when it is already late) and 'o'mundu syalibhan'e'nzoka awithy'oko muthi' (The day someone forgets to take a stick with him, that is when he will find a poisonous snake), are very telling. Indeed, by the time you look for a stick to save yourself, the snake will have already defended itself by biting you and running away. The last expression has already been developed by Waswandi (2019). For him, this Yira proverb laments that there are not many happy circumstances in life. When the day of misfortune comes, it surprises you alone. That is why you must never lose your vigilance; it is essential to organise yourself accordingly. In other words, when someone is overwhelmed by misfortune, friends are often absent. Life is a continuous struggle; everyone must try to be forward-looking by relying first on themselves and not on others alone, otherwise you will be caught off guard. This is also what the Belgians like to say to the Congolese: "Friends are umbrellas, you can never find them when you need them". Friends are not bad, they are not of bad will. If they were present, moved by your need, they would come to your aid. But the unfortunate thing is that nature arranges things differently. So you need vigilance in self-defence. What is important in these three expressions is that at least the strategy is taken even if it is late. We must therefore be careful and above all vigilant to prevent such a situation from happening. It is in this context that the expressions 'olukyo lunene lwingirya nde' and 'akantama kavalya mundu kakasa nga ludu' call for awareness and vigilance to ensure that such a situation does not repeat itself, as in the proverb 'Ekikalya wambene kyo kikanalya wambuli' (the harm that happens to your neighbour can happen to you) (focus Group Discussion with some leaders of Yira culture in Butembo). For his part, the author of the film states that in the Yira culture, people are very welcoming. For him, if you are looking for a wife, you have to choose a good family for fear of making a pact with a predatory family. For this reason, the child who is still in the direction of his mother was married because of the trust that exists between the two families. Despite this restriction, hospitality has always created problems. 'Olukyo lunene lwingirya nzoghu' (A big door brings in an elephant). The proverb in its original meaning calls for caution. Indeed, if your house has a large door, and is always wide open, it should be guarded against predators. In the Nande culture, this proverb is used in circumstances where a bad person has already entered the house and there is no way of getting rid of him. This ill-intentioned person has already taken the family hostage to the point of suffocating all those who can claim their right. In most cases, it is in the context of family inheritance that such people appear. The current context of war makes this proverb rebound because it is possible that hospitality has been mismanaged by bringing criminals into the culture. The crisis of interminable conflicts in the Great North Kivu knows the participation of foreign predators, which means that the door has already been widely opened for them and internal predators that we call here "accomplices". These accomplices further complicate these crises because they work against the backdrop of the aggressor or predator. These predators, who have received the hospitality of the Congolese, have multiple intentions. For some authors, they are aggressors (De Villers, 2005), for others, they are land occupiers, for still others they come for economic interests, etc. If the artists return to this proverb by sensitising the population to be cautious, it is because it is a reality that insecurity also prevails because of poorly organised and managed hospitality. In a group discussion after viewing this film, participants were unanimous that there are two ways of managing hospitality. On the one hand, you can welcome a foreign visitor with the goodwill to help. On the other hand, the latter may turn his back on you and become an enemy soon after. The latter can be quickly brought under control by the community, which puts things in order. On the other hand, a person may welcome a bandit into his house and use him against his neighbours. This is hospitality of complicity. In either case, the call for vigilance is the responsibility of everyone in the DRC. Akanyama kabalya Mundu kakasa ngalubundu proverb shows that in the Yira culture, people were always confronted with threats. Vice President Edgar cites Kanyarwanda, and other types of war that the Yira culture went through. To guard the door against predators, the elders asked young boys not to marry a woman from an unknown culture for fear of exposing a whole family. Even at the time of the rites, only the initiated participate. Those who violated these precepts were at the root of proverbs such as 'valyana nzighu' (he who eats with the enemy), or'sekera vithi' (he who laughs or has fun with the killers). This Yira proverb means 'the animal that will hurt you comes to you in a docile way'. In other words, it is not the one that comes to you that necessarily has good intentions towards you. This proverb warns against the hypocrisy hidden in docility. There is a paradox between evil and docility. A person can be apparently docile but still carries evil. This is the real lack of honesty. When a person is completely honest, he has peace of mind, and he maintains self-respect. Honesty is about respect, integrity, and self-awareness. It is the basis of trust and social relationships. It gives us hope, confidence, compassion and improves our decision making (Descarpentries, 2019). The proverb brings us face to face with a person with a character that hides their true personality and affects, most often out of self-interest, opinions, feelings, or qualities that they do not possess. Generally, hypocrites respect others out of self-interest. Hypocrisy always goes with lying (Pharo, 2006). To have a hypocritical attitude is to behave in a cowardly and dishonest way. The proverb 'Akanyama kabalya Mundu kakasa ngalubundu' is an expression of a hypocrite and his attitude. In the Yira culture, this proverb is often used for people who have been taken in by families, grown up in them, even been exemplary children and in the end they eliminate the rightful owners to get the inheritance. In most cases, the context of land inheritance is the most characteristic of this proverb. "Olukyo lunene lwingirya nde' and 'Akanyama kabalya Mundu kakasa ngalubundu' are two closely related proverbs. They teach caution against hypocrites and predators. Other proverbs from the same culture support this virtue of prudence in the context of hospitality. These include 'Omuthim'avisa' (the heart hides many things). Waswandi (2019) states that in Yira anthropology, man is a being endowed with consciousness and reason who thinks about what he is and what he will share as knowledge with another human being; in this sense of communication, man is a speaking being. In the intellectual psychological sense, it represents the consciousness which is a knowledge, an intuition or a feeling (more or less clear, more or less distinct) that a human being has of himself, of his acts, of his states, of his characters; in the moral sense, the omuthima heart designates the consciousness understood as a capacity to make or formulate moral appreciations, ethical judgements on good and evil: it is then synonymous with the mind and the soul. Before what the omuthima heart says becomes knowledge shared with another human being in sincerity, its content exceeds what the mouth of this subject can say or communicate: it is this passage to

The war crisis in North and South Kivu has become a war of aggression waged by foreign peoples who have received the hospitality of the natives. The resurgence of rebellions in the east of the country goes back to the history of the genocide and the way refugees were managed. The aim of this paper was to examine how hospitality at the heart of a misfortune by socially and culturally analysing the film "Olukyo Lunene lwingirya nde" by filmmaker Armstrong. Specifically, the paper introduce the film "Olukyo Lunene lwingirya nde" and its structure, analyze hospitality and its consequences as described in the film "Olukyo Lunene lwingirya nde", hospitality and its consequences in the context of the war crisis in Eastern DRC and create awareness-raising messages for the proper management of hospitality in the DRC. This paper used descriptive search models and collected primary data from a structured interview guide with respondents and a focus group with a group of 6 people who experienced the war crisis in Eastern DRC and viewed the film. This study used secondary data from the analysis of the film. The data was triangulated with the primary data in this paper to achieve the above-mentioned objectives and the recommendations.

against hypocrites and predators. Other proverbs from the same culture support this virtue of prudence in the context of hospitality. These include 'Omuthim'avisa' (the heart hides many things). Waswandi (2019) states that in Yira anthropology, man is a being endowed with consciousness and reason who thinks about what he is and what he will share as knowledge with another human being; in this sense of communication, man is a speaking being. In the intellectual psychological sense, it represents the consciousness which is a knowledge, an intuition or a feeling (more or less clear, more or less distinct) that a human being has of himself, of his acts, of his states, of his characters; in the moral sense, the omuthima heart designates the consciousness understood as a capacity to make or formulate moral appreciations, ethical judgements on good and evil: it is then synonymous with the mind and the soul. Before what the omuthima heart says becomes knowledge shared with another human being in sincerity, its content exceeds what the mouth of this subject can say or communicate: it is this passage to the act of saying or doing what the heart has said and done, which constitutes one of the great mysteries of man. It is here that we see how man is capable of hypocrisy. His intentions being an enigma to others, man is capable of living the opposite of what he really is. The two preceding proverbs are in line with this perzaqspective, so they invite us not to have blind trust. A spirit of discernment is needed in the context of hospitality. For if everything a human being does were to be made known to the public, judges would never do their job: thieves would already be caught by the time they had their heart set on robbing. The bandits, the criminals who make diabolical plans unannounced, would be ashamed once their plans were known. --- The consequences of hospitality in the context of the war crisis in Eastern DRC The Honourable Jules, president of the Yira Kyaghanda cultural association, reaffirms that the DRC is a victim of its hospitality. He explains that the war crisis in the DRC has its origins in the migration of Rwandan populations. These migrations were always assisted and supported by the international community. In 1959, the international community obliged the DRC to accept Rwandan refugees. They occupied South Kivu and in the course of history they sometimes turned into armed groups demanding to be recognised as Congolese citizens. This led to a collective nationality that made them Congolese. For Jules, they took the name of Banyamulenge because they occupied the hill of 'Mulenge' in South Kivu. Edgar Mateso, vice-president of the civil society of North Kivu, adds that in 1986, when Yoeri Kaguta Museveni took power in Uganda, he chased away the national army for the liberation of Uganda (NALU) and the ADF. They fled into the Semuliki forests in eastern DRC. Out of hospitality, the DRC welcomed them and let them, and their weapons go free. Today, the phenomenon is costing the DRC more than 10 million people their lives (Onana, 2023). In 1994, during the Rwandan genocide, the international community forced the DRC government to take in Rwandan refugees fleeing the genocide. They entered with arms and ammunition to provide Rwanda with a pretext to come to Congo to fight the FDLR. All the insecurity and war crisis that the DRC is experiencing comes from the fact that it obeyed the international community, while it thought it was respecting international law, which required it to welcome the Rwandan refugees," says Jules. This is what the Deputy Prime Minister, Minister of Foreign Affairs, Christophe Lutundula, had already argued that the DRC is paying a heavy price for its hospitality since the genocide perpetrated in Rwanda in 1994, during his intervention in May 2022 at the summit of heads of state and government of the African Union held in Malabo, Equatorial Guinea (Onana, 2023). In 1996, the Congolese, in their blind hospitality, accepted the liberation of their country by foreigners, the Rwandans and Ugandans. These foreigners entered the DRC and, with the blessing of the people, took power, occupied strategic government posts and decided to kneel the DRC for more than three decades for the benefit of foreigners: neighbouring countries and the international community, says Egar Mateso. According to the head of Congolese diplomacy, this heavy toll is characterised in particular by massive human rights violations; the rape of women; the systematic plundering of natural resources; the destruction of the ecological fabric and infrastructure, but also the repeated massacres of the populations of the East of the country by national and foreign armed groups, allied to international terrorism. "All these economic crimes and crimes against humanity, and all these atrocities have been plunging our country into mourning for the past 28 years", the Deputy Prime Minister deplored, before adding: "We are aware of the suffering of refugees and displaced persons, and above all the financial and economic cost of human crimes on our continent". "In the DRC, we have the experience and an acute awareness of this, which is why the Congolese delegation to the meeting tabled six amendments to the draft declaration of this humanitarian summit. These amendments relate to humanitarian challenges in Africa, including terrorism, reconstruction and post-conflict development," concluded Christophe Lutundula. The deputy prime minister said that at present, the DRC is experiencing a worrying increase in the number of displaced persons as a result of deadly attacks by armed groups, including the March 23 Movement (M23), a movement defeated in 2013 by the MONUSCO intervention brigade, and resurrected more than 10 years later by neighbouring countries that support it with heavy armaments and men against the positions of the Armed Forces of the DRC (FARDC) in the province of North Kivu, in the east of the country. --- The context of responsabilities Responsibility for the crisis of war conflicts arising from hospitality is shared between the DRC, the international community, and neighbouring countries. The Honourable Jules, in our interview with him, argues that the great responsibility for the conflict crisis lies with the Congolese government, which is characterised by disorganisation, corruption, absence of national sovereignty, lethargy and laissez faire. These characteristics are the wide-open door that lets in any kind of beast. The Congolese state has welcomed refugees without thinking about the mechanisms for monitoring them. For Jules, there are no measures to regulate the movement of foreigners in the DRC. In his opinion, this is the best way to run a government that works on behalf of foreigners. We should not expect more than that from him. However, during the Mobutu era, Zaire, which was a sovereign state, was not obliged to welcome foreigners on its soil, especially as they were armed in all the cases we have mentioned. Magistrate Mavughu (interview), in the same vein, states that in international law, the sovereignty of the country is respected. Egar Mateso attests that Zaire at the time had to disarm the allied democratic forces (ADF) in 1986 and the AFDLR in 1994 and control them to limit the dangers associated with them. These indications show that the government of the time was also irresponsible. Its preoccupation was elsewhere instead of looking after its people. No country in the world can one accept to receive armed foreigners, one first disarms and controls them (Hugon, 2006). Now that foreigners have been welcomed with their weapons, they will demand the same rights as nationals. During the enrolment, for example, they enrolled as Congolese citizens while they are used by neighbouring countries. This behaviour has created enemies within the country. These enemies have gained access to strategic positions in national institutions, in the security services and in intelligence. This is what has allowed the international community together with neighbouring countries to bring the DRC to its knees until today (focus Group Discussion with some leaders of Yira culture in Butembo). In other words, until recently, when people talked about the Congolese government and its responsibility, they seemed to ignore the fact that it was foreigners who occupied strategic positions. They, instead of serving the DRC, have refined strategies to infiltrate the DRC even in its intimacy so that if the DRC would like to recover and rebuild itself, it has a difficult job to do. This explains the endless insecurity in eastern DRC (Kavota, interview). Magistrate Mavughu goes so far as to give an example of Article 217 of the DRC constitution, which, composed in favour of the predators, stipulates the following: "The Democratic Republic of Congo may conclude treaties or agreements of association or community involving a partial surrender of sovereignty with a view to promoting African unity. In other words, the DRC can concede or abandon part of its territory for the causes of African unity. Hon. Jules explains how the DRC has concluded many agreements and unnatural alliances in favour of foreigners. It is these agreements that complicate the peace process in the DRC to this day. The real Congolese were in distraction and selfishness state. The Congolese who were manipulated were preoccupied with personal interests and others did not understand the Machiavellian plan of the international community which uses the neighbouring countries (Focus Group Discussion). The other responsibility, the most recent one, is intermingled with naivety. For Mr Edgar, the solution to the DRC's problem will never come from outside the country. The DRC government itself has called on foreigners to make life difficult for it. Or at least if it is not the DRC that calls them, then it falls into the trap of its enemy. MONUSCO in the DRC is the work of the Congolese government. The renewal of its contract with MONUSCO without evaluation of its mission is the work of the Congolese government. In the discussion (focus Group Discussion with some leaders of youth in Butembo) it emerged that Monusco's mandate has never been peacekeeping and the protection of civilians. Moreover, many of them report cases where massacres are carried out under their eyes, near their camps. They are even caught in situations where they give weapons and food to the enemy. This is complicity rather than a mission of peace (Focus Group Discussion). The pooling of forces in the hunt for the ADF is the work of the government. The same applies to the regional force. The DRC, which always has good intentions of wanting to end the war in collaboration with its neighbours, always falls into the trap of forgetting that the causes of the DRC's insecurity are at the same time the desire of its neighbours to have its minerals (focus Group Discussion with some students in Butembo). Honorable Jules explains this by the Burundian president's recent adage of two children fighting over a maize and itching for someone else to come and decide who fights. Since he himself needs it, he will do anything to get it back (interview). While for Jules, the Congolese state is weak at all levels, it is incapable of fulfilling its duties towards its people; it should be pointed out that this is mainly because those who assume great responsibilities work for the international Machiavellian plan in collaboration with neighbouring countries. It is therefore not possible for them to concentrate on the major problems of their country. On the contrary, the state facilitates everything that is organised against the republic. For example, the soldiers who give war plans to foreigners in order to have localities taken by the M23 rebels are still in their command posts from the brewing. They cannot be revealed. This is an indication that the state favours what is against itself. It is a fragile state (focus Group Discussion with some leaders of Yira culture in Butembo). Wema Kenedy, in the same perspective, maintains that the Congolese government, in order to justify its incapacities, tells the Congolese public that it is the neighbouring countries that are responsible for the misfortune of his country without saying why they do not protect themselves against their neighbours, since they know their enemies (interview). The few patriotic leaders who are concerned about the security of the people are quickly blocked by the infiltration of those who work for foreigners. (focus Group Discussion with some leaders of Yira culture in Butembo). The other responsibility identified in the discussion group is that of population which is primarily responsible for the crisis of war conflicts in the DRC. In all the main cases, there is the conscious or unconscious participation and complicity of the population. In 1996, for Edgar, it was the population that supported the war of liberation in great ignorance of selling its fate. The population welcomed with joy and commitment the foreigners who were fighting to dethrone the Mobutu regime. The first responsibility of the population in the misfortune of the DRC thus lies in its naivety (focus Group Discussion with some leaders of Yira culture in Butembo) The film we have analysed returns to the theme of the boss's naivety in blindly accepting that a stranger should keep the family property. He thus ended up having his life snatched away. The Congolese people behave exactly like this scenario. The second responsibility of the population lies in its complicity with the enemy. By getting used to the insecurity in the East of the DRC, some people find the moment to seek benefits at the expense of the community. The armed groups, used as crutches of the enemies, have their origin in the population itself. But they choose, because of the financial benefits, to make the population suffer (Interview with a KAVOTA traditional chief). In the same perspective, Salu (an old wise man in the town of Butembo and catechist) maintains that the complicity of the people is starting to become a culture for the population. The sense of patriotism and of the common good is disappearing, and the population can accept to collaborate with the enemies bringing them material goods such as food, clothes to facilitate the carnage of the population in Beni town and territory. Also, the population is, by complicity, unable to denounce the traitors who are by them. In Beni, the military spokesperson of the Sokola operation one said that the war against the ADF was asymmetric because the enemy is in the forest and in the town living among the population at the same time. Through its hypocrisy, the international community participates indirectly in the destabilisation of African countries. In 1994, for Edgar, it was the international community that forced the Congolese government, which is a member of the UN, to take in Rwandan FDLR refugees with arms and ammunition. This hypocrisy can be seen when foreign states appear to be sympathetic while they are pacting with the enemy of peace in the DRC. They come under the guise of supporting human rights and peace, but their hidden agenda is to bring the DRC to its knees. The non-government organisations (NGOs) are also part of the same perspective (focus Group Discussion with some leaders of Yira culture in Butembo). --- Approaches to shared responsability The irresponsibility of the Congolese government is the big door that lets the beast in. According to Jules, it is even better to talk about 'kisoro' (leopard) than 'nde' (cow). We would say 'Olukyo lunene lwingirya kisoro'. Hospitable generosity is one good intention at the outset, respecting international law to welcome those who suffer by protecting them is another. However, due to internal disorganisation, this hospitality has brought evil into the country so that it demands to leave. It is the cunning that characterises them, says magistrate Mavughu. For Edgar, the fundamental cases of major migrations in the DRC, notably in 1954 with the Banyamulenge, in 1986 with the ADF and NALU, in 1994 with the FDLR and in 1996 with the war of liberation, the DRC has shown itself to be the big door through which anyone can enter without being checked. The consequences suffered from these entries into the DRC are the result of leaving the gate wide open without a protective mechanism. The big door is also identified by what is inside the house. It is not the door that attracts, if not all large doors would attract strangers. It is rather the potential or wealth that is inside the house. Today we see aggression almost on some of the borders of the DRC. In the East with the Rwandans (M23) and the Ugandans (ADF), in the North with the Mbororo (CAR), etc. The DRC remains the big door because it allows foreigners to enter its soil. Edgar argues that the expression 'Akanyama Kavalya Mundu Kakasa ngalubundu' can be applied to all predators who pretend to be positive people in the DRC, while they serve the misfortune of the Congolese. As an illustration, Edgar recalls that in 1996, foreigners presented themselves in the DRC as liberators, yet there is nothing liberating about them. On the contrary, they came to subjugate the DRC. They are the prototype of the apparently docile but predatory animal against the inhabitants of the house. The liberators will be welcomed and integrated into the institutions, the army, the security of the DRC to the point of even taking over the country (focus Group Discussion with some leaders of Yira culture in Butembo). The same people who liberated, in 1996, when they realise that those who work for them are tired and ask to be replaced, they organise a rebellion to seek easy and docile integration into the institutions by mixing and/or mingling. For Edgar, one only has to look at the frequency of rebellions (1996-1998; 2007; 2013, etc.) to see that it corresponds to the moment when the previous entries are tired and can be replaced. Honorable Jules believes that this expression is to be situated at the international and regional level. Indeed, UNMISCO, on behalf of the international community, has been in the DRC for more than 22 years to maintain peace in the country. For 22 years, the DRC has never been at peace. On the contrary, several reports show the complicity of this MONUSCO with armed groups and rebels to destabilise the region, while it was expected to accomplish its mission. It embodies the expression 'Akanyama Kavalya Mundu Kakasa ngalubundu', which means 'the animal that will bite you comes obediently'. It is here, for Jules, that Monusco shows its hypocrisy when it no longer knows how to justify the reasons for which it is in the DRC. The second animal is the Ugandan force that has joined forces with the FRDC in the far north against the ADF. The massacres of the population by the ADF continue while this mutualisation is in operation. The regional force, for Jules, is another animal that is failing in its official mission. All these forces are initially considered as rescue forces that come to save the Congolese people. The Congolese government has ignored the intentions of those who come to its aid. In bilateral relations, this expression can be extended to countries that claim to be friends of the DRC, when in reality they are sympathetic to the enemy. Kenya, for example, during the time of President Uhuru, was friendly to the DRC. It witnessed several agreements and even facilitated dialogue between the armed groups. It opened up opportunities for them to open banks in the DRC for business. But his behaviour in the regional forces, that of being an observer and not a defender with the FARDC, shows that the DRC has made the wrong friend. In opinion, they are sympathetic, but in reality they favour the enemy. For Jules, all these countries are hypocrites and the DRC should understand that in the current state of affairs it does not have its true friend. --- Conclusions and recommendations In a context where the leaders are foreigners and others work on behalf of foreigners, it is difficult to establish a plan to get out of this grip. In any case, the population is the only victim of this plot. It is all very well to ask the leaders to play their role in protecting their people, ensuring their development and thinking of a better future. These leaders rather protect their co-foreigners, the neighbouring countries, ensuring their development by means of (sometimes secret) agreements. To the population, the paper recommends that they come out of their distraction. The population must be vigilant. In the film, the pastor's appeal is appealing. He stresses that we must be cautious and vigilant and above all know how to listen to the advice of others. This means finding out about the person you are hosting. The pastor says he warned the boss that Armstrong was not worthy of keeping his property. The people must understand that they have put their destiny into the hands of predators and that they must get it back. They must stop whining, looking for scapegoats for their misfortune, but become aware of this misfortune and make a popular revolution. This popular revolution requires honest and truthful people. But it could be that the population is complicit in its own misfortune by refraining from denouncing the traitors. It is in the population that the traitors are most likely to be found and in the leaders. The population is a platform for people who know each other. You know your neighbours and what they do. You can know that they are collaborating with the enemy, and you cannot denounce them for the common cause. The population must deprave fear and develop determination to impose peace and security. From all the above, the people must understand that security is not the property of corrupt and foreign leaders because they do not care about the people. From the perspective of hospitality, in order to avoid infiltration into the population, which makes the war more complicated and asymmetric, the system of 10 houses that is already working well elsewhere is urgently needed in eastern DRC. It consists of decentralising the security system to 10 houses. The head of the 10 families or houses knows his subjects and visitors who arrive are presented to him for registration. The exit of his visitors is also declared. The population has to wake up from its sleep to think of a new patriotic political class. It must discover the honest patriotic leaders who really fight for the general cause and those who indulge in buying votes with ephemeral small gifts. The population must develop a vision of the future. The intellectual cream of the DRC, who look on helplessly at a country that is engulfed, is called upon to educate the population in all areas of life. The director of the film that inspired this article said that he does not have the capacity to physically go to war. His only way to raise awareness for peace is to produce films. For Edgar Mateso, education is needed for a population that has been crouched in misery for over 22 years. It must start with awareness of its own history, its issues, and finally show strategies to get out of it. The population must be educated about everything we said in the previous point. Education, Edgar Mateso adds, has the role of giving future generations confidence and awareness of their history. It is awareness that will help us to take precautions to develop mechanisms so that mistakes are not repeated. The state must organise itself as a matter of urgency. This is what can provide the solution to all the DRC's problems. The army, the intelligence service and the civil services must be well organised. This organisation implies honesty and patriotism. As long as the Congolese state does not take back its power in hand, there will be no peace in the DRC. This therefore require de-infiltration of the institutions; electing legitimate and patriotic leaders; the institutions supporting democracy (Independent Electoral Commission of DRC), courts and tribunals must be impartial and independent; the potential in human resources, materials, to carry weight at the international level. The DRC always negotiates from a position of weakness, which is why we manage to get back on our feet; review the constitution; do not accept everything that comes from outside, or know how to say no to the international community, only ratify what is in the country's interest; and like in the film, punish the thugs. Contributions: Conceptualization, P.K.J-P.; methodology, P.K.J-P. and K.M.J-B.; validation, P.K.J-P.; investigation, P.K.J-P.; resources, P.K.J-P.; data processing, P.K.J-P.; manuscript writing, P.K.J-P. and K.M.J-B.; visualization, P.K.J-P.; supervision, P.K.J-P.; manuscript proofreading, P.K.J-P. and K.M.J-B. The authors have read and approved the published version of this manuscript. --- Conflicts of interest: The authors declare no conflict of interest.

The war crisis in North and South Kivu has become a war of aggression waged by foreign peoples who have received the hospitality of the natives. The resurgence of rebellions in the east of the country goes back to the history of the genocide and the way refugees were managed. The aim of this paper was to examine how hospitality at the heart of a misfortune by socially and culturally analysing the film "Olukyo Lunene lwingirya nde" by filmmaker Armstrong. Specifically, the paper introduce the film "Olukyo Lunene lwingirya nde" and its structure, analyze hospitality and its consequences as described in the film "Olukyo Lunene lwingirya nde", hospitality and its consequences in the context of the war crisis in Eastern DRC and create awareness-raising messages for the proper management of hospitality in the DRC. This paper used descriptive search models and collected primary data from a structured interview guide with respondents and a focus group with a group of 6 people who experienced the war crisis in Eastern DRC and viewed the film. This study used secondary data from the analysis of the film. The data was triangulated with the primary data in this paper to achieve the above-mentioned objectives and the recommendations.

Introduction Urogenital Chlamydia trachomatis infection, or chlamydia, is the most prevalent bacterial sexually transmitted infection (STI) worldwide [1]. Left untreated, chlamydia can lead to complications like pelvic inflammatory disease, ectopic pregnancy, and infertility. To reduce complications and transmission of chlamydia, active case finding and early treatment are critical strategies [2,3]. Suriname is on the South American continent, but as a consequence of a shared colonial past it is more socio-culturally connected to the Caribbean region. The prevalence of chlamydia in the general population in many countries of the Caribbean is unknown because testing facilities are lacking and routine screening is not available. A study in Guadeloupe among patients who were referred for a genital infection, showed a prevalence of 17% among men and 10% among women [4]. A study in Barbados among the general population showed a prevalence of 11% [5] and a study in Trinidad and Tobago among pregnant women showed a prevalence of 21% [6]. We previously found a prevalence of 21% among high-risk women and 9% among lowrisk women in Suriname [7]. The variety of ethnicities is distinctive for Surinamese society. The Surinamese population consists of Creoles and Maroons (both descendants of African diaspora due to the slave trade), Hindustani, Javanese, and Chinese (all descendants of labor immigrants from the former British Indies, Dutch Indies, and China, respectively), Caucasians (descendants of European colonialists), indigenous Amerindians, and people of mixed race. The five major groups are Hindustani (27.4%), Creole (17.7%), Maroon (14.7%), Javanese (14.6%), and mixed race (12.5%). These groups cannot be considered a'minority' since they are comparable in size and integrated parts of the total population [8]. Previous Surinamese studies on sexuality, however, have mainly focused on the Creoles, and rarely on other ethnicities [9,10]. The structure of sexual networks is important for STI transmission, but elucidating these transmission networks based on epidemiological and behavioral data alone is challenging. Combining epidemiological and behavioral data with molecular microbial genotyping techniques can provide more insight into the transmission patterns of C. trachomatis. Molecular typing can reveal the relatedness of bacterial strains that circulate among the population and may identify transmission networks at the pathogen level. Because of the low genetic variability of C. trachomatis, a typing tool with a high discriminatory resolution between strains is necessary to reveal network associations of C. trachomatis. Whereas suitable molecular techniques for Neisseria gonorrhoeae have been available for some time [11], high-resolution typing methods for C. trachomatis, such as multilocus sequence typing (MLST), have only been developed recently [12,13]. Studies using high-resolution typing of C. trachomatis strains have examined the relation between clinical symptoms [14], geographic location [15], and sexual risk group [16,17]. The relation between ethno-demographic characteristics and C. trachomatis strains in sexual transmission networks of heterosexual populations has not yet been analyzed using high-resolution molecular pathogen typing. Earlier we reported a high chlamydia prevalence among both low-and high-risk women [7]. Here we report on the chlamydia prevalence among women as well as men. The aim of our study among men and women at two clinics in Paramaribo, Suriname was to elucidate determinants for chlamydia, notably the role of ethnicity and ethnic sexual mixing, and to identify transmission patterns and sexual networks using molecular epidemiological network analyses. --- Methods --- Ethics Statement The study was approved by the ethics committee of the Ministry of Health of the Republic of Suriname (VG010-2007) and the ethics committee of the Academic Medical Center, University of Amsterdam, the Netherlands (MEC07/127). Patients participated anonymously and gave written informed consent. --- Recruitment Sites and Population Participants were recruited at two sites in Paramaribo, Suriname: 1) The Dermatological Service, an integrated outpatient STI clinic, frequented by men and women, that offers free-ofcharge examination and treatment of STIs and infectious skin diseases such as leprosy and leishmaniasis,. All individuals who visited for an STI check-up were invited to participate in the study. These participants were considered to be a 'highrisk' population for chlamydia. 2) The Lobi Foundation, a family planning (FP) clinic frequented by women only. All consecutive women visiting the clinic were invited to participate in the study. As women do not primarily visit this clinic to be checked for STIs, these participants were considered to be a 'low-risk' population for chlamydia. Recruitment took place between March 2008 and July 2010. Exclusion criteria were: age younger than 18 years and previous participation in the study. A nurse interviewed participants about demographic characteristics (including self-reported ethnicity) and sexual behavior. --- Specimen Collection and Testing Procedures Urine samples from males and nurse-collected vaginal swabs from females were obtained for nucleic acid amplification test (NAAT) testing with the monospecific Aptima Chlamydia assay for the detection of C. trachomatis rRNA (Hologic Gen-Probe Inc., San Diego, USA). Nurses were trained to collect the swabs before routine speculum examination was performed, as described before [7]. The samples were collected according to the manufacturer's instructions, stored in a fridge (at temperature between 2u and 7uC) and packed according to IATA rules for transport by plane to the Public Health Laboratory in Amsterdam for NAAT testing. Technicians performing NAAT did not receive any information about the participant. NAAT test results were forwarded to the two clinics in Suriname, where the chlamydia positive participants were treated within 1 to 8 weeks after the clinic visit with doxycycline (100 mg bid for 7 days at the FP clinic and 100 mg bid for 10 days at the STI clinic) or, in case of (probable) pregnancy, with a single 1000 mg oral dose of azithromycin. Participants who tested positive for urogenital chlamydia also received treatment to be used by their partner(s). --- MLST Multilocus sequence typing (MLST) was used to genotype C. trachomatis. Details of this method were described previously [13]. In brief, DNA was extracted at the Public Health Laboratory Amsterdam from transport medium in which the swab or urine had been put, using isopropanol precipitation. All DNA isolates were tested for the presence of chlamydial DNA with the in-house pmpH qPCR as described previously [18,19]. The DNA isolates were amplified by a nested PCR and sequenced for the regions ompA, CT046 (hctB), CT058, CT144, CT172 and CT682 (pbpB). The sequences were checked against an in-house library and against the Chlamydia trachomatis MLST database (mlst.bmc.uu.se), and were given an allele number for each region. Only samples of which all alleles were successfully amplified, sequenced and identified, and therefore had obtained a full MLST profile (sequence type, ST), were included in the analyses. As ompA is part of the MLST scheme, genovars could be assigned for all included samples. A minimum spanning tree was generated using MLST profiles. Cluster analysis was performed allowing single locus variance using BioNumerics 7 (Applied Maths, Sint-Martens-Latem, Belgium). A cluster was defined as a group of STs differing by not more than one locus from another ST within that group, and had to include at least 10% of the total number of samples (i.e. at least 17 samples). Typing data of the study population are also reported in a paper comparing the distributions of C. trachomatis strains among residents of Paramaribo and residents of Amsterdam (Bom et al., submitted). --- Statistical Analysis The study population consisted of high-risk men and women recruited at the STI clinic and low-risk women recruited at the FP clinic. To examine whether epidemiological characteristics differed between these three study groups the x 2 -test for independence was used. Prevalence was calculated as the number of positive tests in the study period divided by the total number of individuals tested in the study period [20]. To assess determinants of chlamydia, we performed univariable logistic regression analysis and examined the effect of the following variables: age, education, ethnicity, different ethnic group of sexual partners (i.e. ethnic sexual mixing), study group (including sex and recruitment site), condom use, number of partners in the preceding month, number of partners in the preceding 12 months, having had sex in exchange for money or goods, and (for men) having had sex with men (MSM). Age was divided into four categories. Because of small numbers we grouped Caucasian, Chinese, and Indigenous Amerindian ethnicities together in univariable and multivariable analyses. Ethnic sexual mixing was defined as having had sex with at least one partner of another ethnicity in the preceding 12 months. Variables that were associated with chlamydia at P#0.1 in the univariable analysis were entered into a multivariable model. Higher chlamydia prevalence at younger age and, with a higher number of sexual partners has been established by various other studies [21] and therefore these determinants were forced into the multivariable model. Ethnicity and ethnic group of the partner(s) were variables of specific interest and were also forced into the model. To avoid multicollinearity, we only included the variable 'number of partners in the preceding 12 months' in the model and not the variable 'number of partners in the preceding month'. We considered P,0.05 as statistically significant. We checked for interactions between study group and all other variables in the final model and also checked for interactions between the number of partners in the preceding 12 months and ethnic sexual mixing. To examine whether ethnic group was a determinant for ethnic sexual mixing, we performed a multivariable logistic regression analysis. Variables that were associated with ethnic sexual mixing at P#0.1 in univariable analysis were entered into a multivariable model. The final model included number of partners in the preceding 12 months, sex in exchange for money or goods, and study group. We compared the observed frequency of people who had sexual partners from their own ethnicity with the expected frequency (if partner selection from the population would have occurred at random with respect to ethnic background) by using the x 2 goodness-of-fit test [22]. The expected number of people with sexual partners from their own ethnicity was calculated by multiplying the total number of reported partners of an ethnicity by the proportion of individuals from each ethnicity in the study. In order to identify transmission patterns and sexual networks, a minimum spanning tree was made with different colors for different ethnicities and C. trachomatis clusters were compared in terms of ethnic composition using x 2 -tests for independence. Analyses were performed with SPSS package version 19.0 (SPSS Inc., Chicago, IL). --- Results --- Study Population A total of, 415 men and 1093 women were included in the study. The response rate among men was 78.3%, among women visiting the STI clinic 83.0% and among women visiting the FP clinic 99.8%. The included and excluded men did not differ by age (P = 0.303) and ethnicity (P = 0.329). The included and excluded women visiting the STI clinic had a comparable age (P = 0.238) but ethnicity did differ (P = 0.020). Demographics and sexual behavior of study participants are shown in Table 1. All epidemiological characteristics differed significantly between the three study groups. The overall median age was 29 years (IQR 25-37) and the majority had a low (40.5%) or medium (42.9%) level of education. In total, 444 (29.4%) were of Creole ethnicity, 289 (19.2%) of Hindustani ethnicity, 177 (11.7%) of Javanese ethnicity, 277 (18.4%) were mixed race, and 258 (17.1%) were of Maroon ethnicity. Women visiting the STI clinic were younger compared with men from the same site and women visiting the FP clinic (P,0.001). Women visiting the STI clinic reported higher risk behavior, such as.2 partners in the previous year (23.0%), and more frequently reported sex in exchange for money or goods (16.7%), compared with women visiting the FP clinic (6.1% and 0.7%, respectively). --- Prevalence and Determinants of Chlamydia The prevalence of chlamydia was 18.6% (95% CI, 14.3-23.6%) among women visiting the STI clinic, 9.5% (95% CI, 7.7-11.7%) among women visiting the FP clinic [7] and 22.9% (95% CI, 19.0-27.1%) among male STI clinic visitors. The highest prevalence of chlamydia was found among Creole men visiting the STI clinic (30.1%) but this was not significantly higher than the prevalence among men from other ethnic groups which ranged between 15.2% and 21.4% (P = 0.123). Hindustani women had a slightly lower prevalence (6.3%) compared with women from other ethnic groups, which ranged between 10.9% and 15.3% (P = 0.054). Univariable associations between epidemiological characteristics and chlamydia are shown in Table 2. Age, ethnic group, ethnic sexual mixing, study group and number of partners in the preceding 12 months were significantly associated with chlamydia in univariable analysis. In multivariable analysis, chlamydia was significantly associated with ethnic group (OR, 1.76; 95% CI, 1.03-3.00 for Creoles, OR, 2.05; 95% CI, 1.09-3.84 for Javanese, both compared with Hindustani); age (OR, 3.01; 95% CI, 1.93-4.71 for those aged,25 years, compared with those aged $35); and study group (OR, 2.30; 95% CI, 1.52-3.49 for men visiting the STI clinic and OR, 1.91; 95% CI 1.24-2.94 for women visiting the STI clinic, both compared with women visiting the FP clinic), but not with ethnic sexual mixing (OR, 1.33; 95% CI, 0.96-1.85) and number of partners in the preceding 12 months (OR, 1.39; 95% CI, 0.92-2.11 for having.2 partners compared with having #1 partner) (Table 2). The interactions between study group and all other variables in the final model and the interaction between the number of partners in the preceding 12 months and ethnic sexual mixing were not significant. --- Sexual Mixing among Ethnic Groups A total of 643 participants (43.6%) reported sexual mixing with other ethnic groups, and 790 (52.4%) did not report any sexual mixing. Ethnic sexual mixing differed between ethnic groups. Of the Hindustani 65 (23.5%) reported sexual mixing. This was higher for individuals with Creole (n = 191; 44.3%), Javanese (n = 85; 49.4%), Maroon (n = 95; 38.6%), or mixed race (n = 170; Table 3 shows the ethnic groups of the participants included in the study and the observed and expected ethnic background of their partners. Of the Creole, Hindustani, Javanese and Maroon participants between 60.5% and 77.9% reported to have had sex with a partner of their own ethnicity; for mixed race individuals this was 44.4%. Maroon individuals were more likely to have a partner with a Creole ethnicity (29.8%) compared with a partner with a Hindustani (3.1%) or Javanese ethnicity (3.9%). Likewise, only 1% of the Hindustani and Javanese individuals reported sex with a Maroon partner. The observed frequencies of only having sexual partners from participants' own ethnicity were significantly higher than expected frequencies if partners had been selected from the population at random with respect to ethnicity (P,0.001 for all 5 major ethnic groups). --- Genovar Typing and MLST We were able to type 170 samples of the 224 C. trachomatis positive samples (75.9%). The strains belonged to nine ompA genovars, predominantly E (32.4%), F (19.4%), D (18.2%) and I (12.9%). Furthermore, J (5.9%), G (5.3%), K (2.9%), B (1.8%), and H (1.2%) were found. Among the 170 fully typed samples, we identified 65 different MLST profiles of which 32 (49%) were novel when checked against the MLST database on January 8, 2013. These novel MLST profiles were found in 52 (31%) of 170 samples. A minimum spanning tree was generated using MLST profiles (Figure 1) in which three large distinct clusters of C. trachomatis strains could be identified. Cluster 1 consisted of 27 samples (genovars I (81.5%) and J (18.5%)), cluster 2 consisted of 34 samples (all genovar E) and cluster 3 consisted of 36 samples (genovars D (23.5%) and F (76.5%)). There were 13 smaller clusters (containing 2-10 samples) and 20 singletons. Although all five major ethnic groups were represented in all three clusters, the proportion from various ethnic groups differed significantly between the three clusters (P = 0.003). Figure 2 shows the distribution of individuals in each cluster for each ethnic group. Individuals with Javanese ethnicity were mainly found in cluster 2 (53.8%). Of the Hindustani, 35.1% belonged to cluster 1. Of the Creole and mixed race individuals 45.9% and 55.9%, respectively, were found outside the three main clusters of C. trachomatis strains. --- Discussion --- Prevalence of Chlamydia in Suriname This is the first report on epidemiology of chlamydia in Suriname in both a high-risk and a low-risk population. Previously, we described the high prevalence of 9% and 21% respectively among low-risk and high-risk Surinamese women [7]; here we report a very high prevalence of 23% among high-risk Surinamese men. The high prevalence found in Suriname in our study can partly be attributed to the current lack of screening facilities in Suriname. The prevalence among women visiting the FP clinic was comparable to that reported by a recent study in the Caribbean region among women in the general population [5]. Another study in the region among women who were referred for a genital infection, presumably a high-risk group for chlamydia, reported a prevalence of 11% [4], and among pregnant women a prevalence of 21% was found [6]. Studies among STI clinic visitors in the Caribbean region are scarce, but a study in Jamaica from 1999, in which chlamydia was tested by direct fluorescence assay and culture (which are now considered obsolete diagnostics), reported a prevalence of 55% [23]. The high prevalence found in low-or middle-income countries indicates the urgent need for reliable and affordable diagnostics, preferably a point-of-care test. The prevalence found among the STI clinic visitors is likely to be higher than the prevalence in the Surinamese general population. Furthermore, despite the high response rate, the included and excluded women visiting the STI clinic differed by ethnicity and the reported prevalence should be interpreted as the prevalence among those who were tested and might not reflect the 'true' prevalence. The response rate among the population attending the FP clinic was very high and the prevalence may be a reasonable reflection of the sexually active Surinamese population. The higher prevalence indicates that preventive measures focused on the sexually active population in general are urgently necessary. Our study showed that the younger age group was disproportionately affected by chlamydia, so targeting prevention at this group seems most cost-effective, especially since safe sex messages probably will be more effective at sexual debut [9]. --- Prevalence of Chlamydia among Ethnic Groups The Creole and Javanese groups seemed more affected by chlamydia compared with the Hindustani. A study from Trinidad and Tobago performed in 2004 compared three ethnic groups (African, East Indian and mixed race) using univariable analysis and found that individuals of East Indian descent were less likely to be infected with chlamydia compared with those of African descent [6]. Compared with Trinidad and Tobago, a society characterized by two dominant ethnic groups, Surinamese society is much more ethnically diverse. Since the prevalence in all but one ethnic group was above 12%, testing and treatment of all groups is required. The distribution of ethnic groups included in our study was approximating a correct representation of the actual Surinamese population according to the 2004 population census [8], although our study included more Creole and mixed race individuals and less people with Hindustani ethnicity. --- Chlamydia and Sexual Mixing among Ethnic Groups Previously it was found that sexual mixing patterns could be important for dynamics of the spread of STI [24]. Here we show that the frequency of having only sexual partners from participants' own ethnicity was higher than expected if partners would have been selected regardless of ethnicity (i.e. assortative mixing). On the other hand, almost half of the study population reported ethnic sexual mixing, which showed that bridges between the Colors indicate cluster: Blue -cluster 1; Green -cluster 2; Yellow -cluster 3; Pink -residual group. doi:10.1371/journal.pone.0068698.g002 ethnic groups do exist. Ethnic sexual mixing differed per ethnic group and was highest for mixed race individuals followed by Javanese and Creoles. Nevertheless, this sexual mixing was not associated with chlamydia, which is in line with a study among immigrants in the Netherlands where ethnic sexual mixing was not associated with self-reported STI [25]. One study on ethnic mixing of Surinamese immigrants in the Netherlands showed that Hindu-Surinamese individuals were more likely to mix than Afro-Surinamese individuals [26], which is in contrast to our data derived from Suriname. In the Dutch study among Surinamese migrants, eight times more Afro-Surinamese individuals were included than Hindu-Surinamese individuals [26]. Population size and the size of the ethnic group are of importance for the likelihood of ethnic sexual mixing and might explain the difference between the studies. Hindu-Surinamese migrants in the Netherlands might be more likely to meet individuals from different ethnicities, and therefore more likely engage in ethnic sexual mixing. Besides the epidemiological characterization of ethnic sexual mixing, we used MLST typing to identify pathogen-associated networks among participants with chlamydia. Previously ompA genovar typing has been used [27] but MLST was found to be more discriminative and provides more solid proof of independent circulation [17]. Furthermore MLST is less affected by intragenic recombination of C. trachomatis, than typing based on only the ompA gene is [28]. MLST revealed that all major ethnic groups were represented in all three clusters of C. trachomatis strains, which suggests that these strains circulate endemically among all ethnic groups. Although the distribution of clusters within each group varied, clear separate networks for C. trachomatis transmission by ethnicity could not be identified which can be explained by ethnic sexual mixing between the groups. The typing results were in agreement with the epidemiological data. In contrast, studies comparing non-mixing populations (heterosexuals and MSM) showed hardly any overlap in chlamydial strains [16,17]. In our study we could not distinguish separate networks between MSM and heterosexuals as only 7 MSM were included of whom only one had chlamydia and the provided sample could not be typed by MLST. By checking the MLST profiles in the international C. trachomatis database, 32 (49%) novel strains were found. This database has existed since 2007 and comprises 459 profiles to date. It is most likely that many novel strains will be found. The database will expand and include an increasingly wide variety of C. trachomatis strains from different parts of the world. Combining the molecular data with epidemiological characteristics will provide more insight into global C. trachomatis transmission networks. Several potential limitations should be mentioned. In our study differences in prevalence of chlamydia between ethnic groups were found, but we were not able to elucidate why these differences exist between ethnic groups. Therefore, additional risk behavior data are necessary. For example, concurrency is an important factor in the spread of HIV/STI [29] and is not uncommon among Surinamese individuals [26,30,31]. Also, we did not have information on other partner characteristics besides ethnic group such as age, type of partner (regular or casual), or condom use with different partners. Mathematical transmission models could be of added value to better identify sexual networks. Participants were interviewed face to face by a research nurse. Therefore, they may have given socially desirable answers and response bias may have occurred. Such bias might have occurred for variables such as condom use and number of sexual partners and would probably have resulted in an underestimation of risk behavior. Furthermore, ethnicity of the partner was self-reported and misclassification cannot be excluded. In conclusion, the prevalence of chlamydia in Suriname is very high, with 10% in a low-risk population and up to 23% in a highrisk population. This prevalence is high overall in all ethnic groups (.7%), but higher in the Creole and Javanese groups compared with the Hindustani population. Although a high degree of sexual mixing occurs between the ethnic groups, having sex with a partner of the same ethnic group was more common than would be expected if partner selection occurred regardless of ethnic group. Nevertheless, based on the MLST typing analysis there is no sound evidence for separate ethnic sexual transmission networks and differences in prevalence of chlamydia between ethnic groups could not be explained by ethnic sexual mixing patterns. Prevention activities must rather be targeted at the whole community at risk, with a focus on the younger age groups. Adequate testing facilities and subsequent treatment are needed to reduce the disease burden of chlamydia in Suriname. --- Author Contributions Conceived and designed the experiments: JvdH LS SB HdV. Performed the experiments: JvdH RB AG LS. Analyzed the data: JvdH RB MSvdL SB HdV. Contributed reagents/materials/analysis tools: LS AG SB HdV. Wrote the paper: JvdH RB AG LS SB MSvdL HdV.

Little is known about the epidemiology of urogenital Chlamydia trachomatis infection (chlamydia) in Suriname. Suriname is a society composed of many ethnic groups, such as Creoles, Maroons, Hindustani, Javanese, Chinese, Caucasians, and indigenous Amerindians. We estimated determinants for chlamydia, including the role of ethnicity, and identified transmission patterns and ethnic sexual networks among clients of two clinics in Paramaribo, Suriname.Participants were recruited at two sites a sexually transmitted infections (STI) clinic and a family planning (FP) clinic in Paramaribo. Urine samples from men and nurse-collected vaginal swabs were obtained for nucleic acid amplification testing. Logistic regression analysis was used to identify determinants of chlamydia. Multilocus sequence typing (MLST) was performed to genotype C. trachomatis. To identify transmission patterns and sexual networks, a minimum spanning tree was created, using full MLST profiles. Clusters in the minimum spanning tree were compared for ethnic composition. Results: Between March 2008 and July 2010, 415 men and 274 women were included at the STI clinic and 819 women at the FP clinic. Overall chlamydia prevalence was 15% (224/1508). Age, ethnicity, and recruitment site were significantly associated with chlamydia in multivariable analysis. Participants of Creole and Javanese ethnicity were more frequently infected with urogenital chlamydia. Although sexual mixing with other ethnic groups did differ significantly per ethnicity, this mixing was not independently significantly associated with chlamydia. We typed 170 C. trachomatis-positive samples (76%) and identified three large C. trachomatis clusters. Although the proportion from various ethnic groups differed significantly between the clusters (P = 0.003), all five major ethnic groups were represented in all three clusters.Chlamydia prevalence in Suriname is high and targeted prevention measures are required. Although ethnic sexual mixing differed between ethnic groups, differences in prevalence between ethnic groups could not be explained by sexual mixing.

Introduction An abundance of information has been circulating online since the beginning of the COVID-19 Pandemic in December 2020. Information regarding the etiology of the disease, the mode of transmission, protective measures, and vaccination have been prevalent online since the time when COVID-19 was declared a pandemic. 1 There is however a concern that not all information provided online are valid, true, reliable, or safe. It is generally considered that official agencies are a more reliable source of information than those circulating online. For example, it is better to source information from the World Health Organisation (WHO), or the Center for Disease Control and Prevention (CDC), as well as government public health departments of various countries. 2 Unfortunately, different agencies, both health and nonhealth related have become a source of information that is not backed up by scientific evidence, which have resulted in unnecessary stress, anxiety and uncertainty among the general population. 3 However, it has been observed in early literature that when people are faced with the threat of misinformation, there is a possibility that the general population would seek out the truth from trusted and reliable sources for persuasive knowledge with the desire to influence a change in behavior for the better. 4 People intend to recirculate information from a feeling of uncertainty, lack of scientific background, and the lack of intention to check the factual evidence behind a shared piece. 5 The rapid disseminating nature of social media has threated misinformation to become prevalent in nature. With already an overabundance of information, prevalence of misinformation can feed into the cyberchondria and mental stress for the users with a possible negative impact on their cognitive, logical, and decision-making abilities. 1,6 During the peak of the COVID-19 disease, online searches were the only method for many people to get information on how to protect themselves and their loved ones from this disease. 7 Information found online were quickly shared without confirming their accuracy or truthfulness. The psychological explanation behind the drive to unknowingly spreading potential misinformation is an underlying sense of threat, triggering the self-defense mechanism, causing people to grasp at the earliest, easiest, and most achievable remedy for a concern. 8 This was observed for the use of natural remedies as a means of protection against COVID-19. There is a significant body of literature regarding COVID-19. Notable studies were conducted where it was found that COVID-19 misinformation spread was prevalent in the UK and USA, especially in their social media platforms. [9][10][11] A study conducted in China, 12 and a global metal analysis of existing studies 13 both concluded that misinformation spreading via social media is a large concern. The social media platforms most commonly found to have recirculating misinformation are WhatsApp, Twitter and Facebook. 14,15 A large body of literature support that the general population are willing to share information on social media sans evidence. 10,[16][17][18][19][20][21] Previous studies investigate the effect of the recirculation of misinformation during COVID-19 which for example, the abuse and misuse of chlorine to wrongfully prevent against COVID-19. 3 Among natural remedies, herbal remedies was one of the rumors which was highly recirculated on social media and on different platforms, as well as having published research articles, from the idea that natural remedies would be harmless and its use would be without side effects [22][23][24].While herbal remedies and herbal products are not discouraged to be taken, they should not be considered a sole cure for COVID-19, as the management of COVID-19 does not exist, except for reducing the chances of transmission through vaccination. The concern is that if more people believed in unverified claims of natural remedies, 25 and did not proactively stop the recirculation of the information regarding the use of natural remedies to protect against COVID-19, then actual actionable steps would go unprioritized. 26,27 This was significantly observed in Saudi Arabia. Ever since the beginning of the pandemic, the number of internet users increased to 95.7%, including in Saudi Arabia, and social media become an environment for rumors and misinformation during this critical period. 28 Despite the recommendation of the Ministry of Health (MOH) for the general population to reach COVID 19 information from official sources a noticeable increase in rumors were still persistent. 29,30 It is important to understand this phenomenon, the cultural behavior and perception of receiving or distributing health information as the first step towards COVID-19 long-term management. This research aims to estimate the prevalence of recirculating information regarding natural remedies uses as protective measures among non-health care workers (NHCWs) in comparison to health care workers (HCW) and to associate the finding with all the demographic variables including age, gender, education level and health care specialty. In addition, the present study is aimed to understand the participants' perception regarding the recirculation of the information about using natural remedies as protective measures against the COVID-19 infection with others. --- Methodology --- Study Design and Population May 8, 2020 among HCWs and NHCWs in Saudi Arabia. The required sample size for the study was calculated using OpenEpi version 3.0. 31 Considering The NHCW population size of Saudi Arabia which is around 34 million 32 and the HCW population size which around 500,000, 33 for the HCW study group, a minimum of 385 participants per group is required to achieve a 95% confidence interval and a 5% margin of. To minimize errors and obtain higher external validity, the sample size for this study was targeted to be as high as possible. The study was made available to the general population, and HCWs of Saudi Arabia. Anyone under the age of 18 were not allowed to participate in the study. --- Measurement Tool A 10-item questionnaire, developed by A. Alotiby, was used as a measurement tool to estimate the prevalence and perception of recirculating information among HCWs and NHCWs regarding the use of natural remedies as protective measures against the COVID-19 infection. To evaluate the appropriateness, relevancy, clarity, and adequacy of the questions, the questionnaire was reviewed by a panel of experts consisting of three assistant professors; one of family medicine, one of public health and protective medicine, and one of clinical nutrition. The questionnaire was designed in English and translated into Arabic, which is the native language of the participants. To evaluate the appropriateness, relevancy, clarity, and adequacy of the Arabic questionnaire, it was tested by four experts, each of whom were native Arabic speakers, and 10 volunteers from the general population. Necessary modifications to the Arabic questionnaire were made based on the feedback of the experts and the volunteers. The nine questions were divided into two sections. The first section consisted of 6 questions about the participants' general information; their gender, age, education level, region of residence in Saudi Arabia, whether they were HCWs or NHCWs, and if they were HCWs, what was their specialty. The second section included three questions which were used to estimate the prevalence of circulating information about natural remedies' uses as protective measures, the preferred social media platforms used to circulate the information, and the participants' perception regarding sharing and circulating the information with others. Some possible answers to the perceptionrelated question about recirculation of information pertaining to natural remedies used as protective measures during the COVID-19 pandemic were inspired by previous studies. 24,34,35 In addition, all the possible answers to the perception-related question were reviewed by four individuals expert in medical immunology, family medicine, preventive medicine, and clinical nutrition so as to evaluate their appropriateness and adequacy. The reliability of the questions was tested using Cronbach's test. The questionnaire items were observed to be reliable with a minimum reliability score of 0.68 for (nominate a question) and the highest of 0.82 for (nominate another question). Due to restricted movement and social distancing requirements, data collection for the survey was conducted online via a Google Survey URL. The survey included an online informed consent form on the first page. The URL to the questionnaire was posted online on social media platforms and were emailed by the Saudi Commission for Health Specialties (SCFHS) to all registered HCWs on the SCFHS database. --- Statistical Analysis At the end of the data collection period, a.csv format file was downloaded using Google Survey's data management tool. The data were extracted from the.csv file using IBM SPPS version 22 (SPSS, Inc. Chicago, IL), revised, processed, and managed. This stage required data manipulation and reconfiguration to be made useful for applying to the IBM SPSS version 22 statistics software. The descriptive statistics of the data were extracted using SPSS software. These included the frequency distribution of all participants' demographic data, and the circulation of the information. Comparisons between HCWs and NHCWs regarding prevalence and perception of circulating the information and the preferred social media platforms used was performed based on crosstabulation using Pearson chi-square test for significance. Crosstabulation was used to test for association between participants' personal characteristics and the prevalence of circulating the information. Statistical significance was considered for P values less than 0.05. --- Results --- Social and Demographic Characteristics of the Participants The total number of survey participants after data revision was N=1249 of whom 275 (22.0%) were HCWs and 974 (78.0%) were NHCWs. Of the HCWs, 100 participants were physicians, 78 were laboratory technologists, 23 were pharmacists, 21 were nurses, and 16 were clinical nutritionists, Table 1 for more details. Among the participants, 560 (44.8%) of were from the Western region, which was the region with the highest number of responses, and 403 (32.3%) were from the Central region. Additional demographic information of the participants is that 1192 were Saudi nationals (95.4%), 961 were females (76.9%), about 66% of the participants were young adults and only 2.7% were old adults, around 57.1% of the participants had a bachelor's degree while 26.1% were at a post-graduate level. The HCWs column with n=275 shows the following modal values. Among HCWs, the majority were from the Western region (51.3%), were female (64.4%), were young adults (70.2%), and held at least a bachelor's degree (51.6%). The NHCWs column with n=974 shows the following modal values. Among NHCWs, the majority were from the Western region (43.0%), were female (80.5%), were young adults (64.8%), and held at least a bachelor's degree (58.6%). The full details of the demographic information are provided in Table 1. This study tested the prevalence of information in social media platforms. Table 2 demonstrates distribution of circulating information regarding natural remedies uses as protective measures against the COVID-19 infection based on the responses of the study participants. According to the survey, approximately of the study participants recirculated the information about using natural remedies as protective measures during COVID-19 pandemic with others. The prevalence of recirculation the information was significantly higher among NHCWs than among HCWs (61.9% vs 52.0%, respectively). The responses of Table 2 are statistically significant at P = 0.049. Regarding the preferred social media platforms that were used to recirculate the information, the survey response shows that WhatsApp was the most popular choice of social media platform used by both groups, HCWs and NHCWs. Table 3 shows the distribution of the responses. Among the participants, 52.4% of HCWs and 51.3% of NHCWs used WhatsApp to share and recirculate the information. According to the survey response, Twitter was the second most popular choice with 32.0% of HCWs vs 26.4% of NHCWs taking the platform to recirculate information. The third significant social media platform, according to the survey response, was Snapchat, with --- Participants' Perception Regarding the Recirculation of the Information Related to Natural Remedies Uses as Protective Measures During the COVID-19 Pandemic Regarding the participants' perception of recirculating the information about the use of natural remedies as protective measures against the COVID-19 infection, the survey response shows that participants believed they did not share medical information until they were sure that it was correct (23.6%). Among HCWs, the distribution of this particular perception was at 25.1% while for NHCWs, the distribution was at 23.2%. The survey response also suggests that 10.2% of people who share information think that sharing the information without evidence is harmless and may be beneficial. This observation was seen for 7.3% of the HCW respondents and 11.1% of NHCW respondents. Regarding the belief that the information is correct based on participants' experience, this was mentioned by 10.2% of respondents of whom, 8.7% were HCWs and 10.6% were NHCWs). More details are presented in Table 4. All the values in Table 4 are statistically significant at P = 0.10. --- Association Between Socio-Demographics and the Prevalence of Sharing the Information Related to Natural Remedies Uses as Protective Measures --- 5132 the association between demographic details and the circulation of information are shown in Table 5. --- Discussion The results of the survey suggest that the Saudi Arabian population, both HCWs and NHCWs, may be wary of the correct medical information regarding COVID-19, or at least, are aware that there is a prevalence of medical misinformation circulating online, and on social media platforms. For instance, the majority portion of survey respondents did not participate in recirculating the information related to the use of natural remedies as protective measures against COVID-19. Compared to the findings of similar studies conducted in other countries, Saudi Arabia differs from the US and UK where social media platforms were commonly used for, and were often the sources of COVID-19 related information for several of the general population. [9][10][11] Early studies of social media activities in China also indicate the role of social media platforms in spreading and circulating both information and misinformation, 12 which was also confirmed to be the overall global case through a large-scale study of 87 countries. 13 The study results showed that 59.7% of participants shared information on social media, with 22.5% doing it at all times, 8.2% sharing it usually, 5.7% sharing it often, and 23.3% doing it sometimes. About 40.3% of the population never shared information. The overall statistic of 59.7% was less than the worldwide prevalence, which was 87.0%. 27 Thus, this study's findings might indicate that the general population of Saudi Arabia has been more vigilant about sharing information on social media, which corresponds to previous findings made during the COVID-19 pandemic. 36 --- 5133 The data of this study shows that the Saudi Arabian general population's preferred social media platform is WhatsApp. Therefore, there is a higher likelihood that COVID-19 related information would be circulating most on this platform. According to the data from the survey of this study, the three most common social media platforms in Saudi Arabia are WhatsApp, Twitter, and Snapchat. Globally, WhatsApp, Twitter and Facebook are three of the more common social media platforms where COVID-19 related information and misinformation are circulating. 14,15 Based on the current study's findings, the prevalence showed lesser recirculation of social media compared to worldwide data (59.7% vs 87.0%). 27 This might indicate that social media has not been heavily abused in Saudi Arabia by the general population when it comes to circulation of COVID-19 related information. The apparently docile nature of COVID-19 related information recirculation in Saudi Arabian social media platforms is a positive indicator that the general population are aware of the necessary sources, such as the Ministry of Health in Saudi Arabia for getting their information. 36,37 However, consistent with the findings of other studies regarding judging the validity of information on social media platforms, the Saudi Arabian general population are more likely to judge the validity of information based on their own experience, and deem it beneficial for the public to share COVID-19 related information sans evidence. 10,[16][17][18][19][20][21] Thus, it can be posited that Saudi Arabian general population's perception of COVID-19 related information circulating on social media platforms is of a neutral disposition. While the Saudi Arabian general are less likely to contribute and share medical information with others, and are less likely to share the information without first confirming that it is correct, there are still a small portion of Saudi Arabians who deem it okay to share any COVID-19 related information on social media platforms. Observing the demographic distribution of the Saudi Arabian general population, it can be observed that at least half of the participants from each region have participated in recirculating the information related to natural remedies uses as protective measures during the COVID-19 pandemic. However, this is not consistent with the findings of previous studies conducted for the Saudi Arabian population, where the Northern Region was seen to be most susceptible. 36 This inconsistency might be not taken into consideration as the number of Northern Region participants in the previously mentioned study is about 1.5% of the total number of participants from other regions; this is the main limitation and weakness of Alnasser et al's 2020 study 36 and it might affect the reliability of the study regarding participants' regional distribution. The current study is suggestive that regardless of the location, there is at least a 1 in 2 chances that the resident might have recirculated information on social media platforms. The possibility of someone in Saudi Arabia having shared the information related to use of natural remedies as protective measures during the COVID-19 pandemic with others is higher if they held at least a Bachelor's degree. While having a bachelor's degree is not necessarily an indicator of susceptibility to information or misinformation online, the probability of someone sharing misinformation decreases with increasing education levels. 38 Thus, the Saudi Arabian general population displays an unconventional trend, where people with a higher education level are more likely to recirculate information. This observation is significantly different than those made for the general population of Ireland, Mexico, Spain, UK and USA. 38 It is important to consider why Saudi Arabians might have recirculated information. A possible explanation is due to an effect termed "cyberchondria", where people with the lack of knowledge, skills and time to conduct extensive research, but are obsessed with looking for evidence are susceptible to sharing as much information as possible for validity 1,30 cyberchondria means the obsessive looking for online health information. The overabundance of information, and the lack of guidance to know which information to look for is also a significant perpetrator for the spread of misinformation. The correct information is usually not able to be filtered out by the layperson, and therefore, it is more than likely that someone would believe the information found online to be valid. 39 Anxiety and panic can also induce the recirculation of misinformation online, especially regarding preventive measures against COVID-19, which includes natural remedies. 39 It is possible that some information on natural remedies were presented as medical information and were wrongly perceived as actual information. The general public might have considered that performing these suggestions would not yield a negative result, and would not be detrimental. On the contrary, whatever small percentage of a chance existed by undertaking natural remedies as precautions against COVID-19 would be worth the action. 1 An abundance of exposure to misinformation also potentially affects the cognitive ability of a layperson to continue to question their validity, and could serve as an inhibiting https://doi.org/10.2147/IJGM.S326767 --- DovePress International Journal of General Medicine 2021:14 agent for actually seeking out the correct information from the proper source. 3 The difference between NHCWs and HCWs in recirculating information, and looking for evidential information was not significant in the current study, but this could be accounted for due to differing cultural and education background which could serve as another potential factor that affects the recirculation of misinformation, especially the lack of evidential information. 3 --- Conclusion Despite the harmful effect of social media in the recirculation and perseverance of COVID-19 related medical misinformation pertaining to natural remedies, there is a need and necessity for the efficient use of social media as a mass-outreach platform that can be audited by health agencies. This would be beneficial to battle misinformation as well as disseminate proper health information. 6 Given how much the number of internet users have increased in Saudi Arabia since the COVID-19 pandemic, social media can serve as an important platform to reach out to all age groups, people of education levels, regions, professions, background and culture. This study has shown that Saudi Arabia has a volatile nature regarding COVID-19 related misinformation. While the majority of the population have responded that they have never participated in sharing information related to natural remedies as preventive measures against COVID-19, there still exists the belief that sharing any information online without evidence is not actually harmful but could in fact be beneficial. Nevertheless, this can be harmful because repeated spread of misinformation can change community attitude toward any behavior, such as the misinformation about vaccines. Fortunately, Saudi Arabia's attitude towards COVID-19 related misinformation differs vastly from the rest of the world. Compared to the global general population, Saudi Arabia has comparatively higher awareness, and higher reluctance to share medical information related to COVID-19 online. While some possible explanations were provided behind this observation, this study still has some limitations, fulfilling which would present a wider and clearer picture. These are discussed in the next section. --- Limitations and Future Studies This study has focused on the recirculation of information related to natural remedies as protective measures against COVID-19, with a specific aim to compare HCWs and NHCWs. While the total number of participants have met the participant size requirement, individual groups of HCWs and NHCWs fall short in the HCW category. Thus, a larger sample size would be beneficial for conducting deeper data analysis. Additionally, a qualitative approach with a semistructured interview would significantly contribute to verifying the underlying reasons behind information sharing on social media platforms related to COVID-19. The generalization of the current study is also affected by the relatively smaller HCW sample size. Thus, for future studies, it is recommended that a larger sample size, with a mixed research methodology, and specific focus on the underlying reasons behind COVID-19 information sharing tendencies be conducted. --- Data Sharing Statement The original contributions presented in the study are included in the article; further inquiries can be directed to the corresponding author. --- Ethics Approval and Informed Consent Ethical approval of the current study was authorized by the Biomedical Ethics Committee of the Faculty of Medicine at Umm Al Qura University and the Saudi Commission for Health Specialties (SCFHS). The study is in accordance with the ethical considerations as stated in the Declaration of Helsinki. The data were collected via an online Google survey, which included an online informed consent form on the first page, and participation in this study was voluntary. Once the participants choose to participate in the study after reading the informed consent on the survey's front page, they are processed to complete the questionnaires. --- Author Contributions All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work. --- Funding The author declares that no funds were received to conduct this research. --- Disclosure The authors report no conflicts of interest in this work. --- International Journal of General Medicine --- Dovepress --- Publish your work in this journal The International Journal of General Medicine is an international, peer-reviewed open-access journal that focuses on general and internal medicine, pathogenesis, epidemiology, diagnosis, monitoring and treatment protocols. The journal is characterized by the rapid reporting of reviews, original research and clinical studies across all disease areas. The manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. Visit http://www.dovepress.com/ testimonials.php to read real quotes from published authors. Submit your manuscript here: https://www.dovepress.com/international-journal-of-general-medicine-journal International Journal of General Medicine 2021:14 DovePress

Introduction: Ever since COVID-19 was declared as a global pandemic, there has been a prevalence of misinformation circulating online on social media platforms. In order to better tackle COVID-19 it is important to determine how the general population perceive the sharing of medical information on social media platforms. Based on this, the aim of the study is to analyse the perception of Saudi Arabian Health Care Workers' (HCWs) and Non-Health Care Workers' (NHCWs) regarding the sharing and resharing of medical information, whether true or false, on social media platforms regarding COVID-19. Methods: To achieve the aim of this study, the general objective is to identify the most commonly used Social Media Platforms, determine the proportion of the Saudi Arabian population who have participated in recirculating information in those social media platforms, and to analyse their perception of medical information sharing in social media platforms. This study was conducted using a quantitative research methodology. The measurement tool used for this study was an online survey conducted using Google Survey. A 10-item questionnaire was adopted and translated to Arabic to conduct the survey. Results: The total number of responses for the study were N=1249. The findings of the study indicate that Saudi Arabian general population understand the prevalence of unverified information, but are accepting of the practice of sharing information without evidence on social media platforms, with the belief that such information does not cause actual harm to the general public, but instead would be beneficial. WhatsApp was the most preferred social media platform for receiving and sharing information among participants, followed by Twitter and Snapchat.The findings of this study indicate that the Saudi Arabian population are more wary than the global general population regarding misinformation online on social media platforms regarding COVID-19.

INTRODUCTION Human Immunodeficiency Virus (HIV) is a type of virus that infects white blood cells and causes a decrease in human immunity (Crux & Elahi, 2017). Acquired Immune Deficiency Syndrome (AIDS) is a collection of symptoms that arise due to decreased immunity caused by infection with HIV (Putranti et al., 2018). HIV patients require treatment with antiretrovirals (ARV) to reduce the amount of HIV virus in the body so that it does not enter the AIDS stage, while AIDS sufferers need ARV treatment to prevent opportunistic infections with various complications (Ministry of Health of the Republic of Indonesia 2020). According to estimates by the WHO and the Joint United Nations Program on HIV and AIDS (UNAIDS), 36.7 million people were living with HIV worldwide at the end of 2016 (World Health Organization, 2017). HIV/AIDS in Indonesia is one of the fastest-growing epidemics in Asia. In 2007, the prevalence rate of HIV/AIDS in Indonesia was ranked 99th in the world, but due to the low understanding of the symptoms of the disease and the high social stigma that accompanies it, only 5-10% of people with HIV/AIDS are actually diagnosed and treated. (United Nations Program on HIV and AIDS, 2018). The Ministry of Health is committed to eliminating AIDS by 2030. This commitment is reflected in the 95/95/95 target, namely that the first 95% of people living with HIV know their HIV status, the second 95% of people living with HIV are receiving ARV drug therapy, and the third 95% of all people living with HIV who have received ARV drugs have decreased viral load (Bandar Lampung Health Office, 2020). A number of strategic steps have been prepared by the Ministry of Health together with relevant stakeholders, including issuing the NAP for the Elimination of HIV AIDS, expanding access to prevention, HIV diagnosis services, and treatment of ART and opportunistic infections, collaborating with relevant stakeholders, and innovating in the prevention and control of HIV AIDS and STIs. Studying treatment adherence factors based on the characteristics of HIV patients at the Sukabumi Bandar Lampung Health Center in 2021 will support the AIDS elimination program in 2030.. --- RESEARCH METHOD This is an observational, descriptive, and quantitative research project with a cross-sectional approach. The research will be conducted at the Sukabumi Health Center in Bandar Lampung in 2021. The population in this project is 103 HIV patients. The sampling technique used is total sampling. The criteria included in this trial were HIV patients currently undergoing treatment, provided they were responsive to medical treatment. In this project, there are HIV patients who died. The variable in this study was medication adherence in HIV patients. Data collection uses medical record data. Data analysis in this study included univariate analysis using percentages. The data above shows the total number of patients with PLHIV in the working area of the Sukabumi Health Center as 103, with age variations ranging from less than 20 years to more than 50 years of age. where there are more male patients, namely 69 people (67%) and as many female sufferers as 34 people (33%). The education level starts from junior high school to bachelor's level 1. And those who undergo treatment between 1-3 years are at most 30 patients, and only 9 patients undergo treatment for more than 9 years but less than 10 years. And all patients still adhere to treatment. --- DISCUSSION There are more PLHIV patients from urban areas than from rural areas. People living with HIV usually need ARV if the CD4 level is 350 mm3. The use of ARVs in Indonesia began in 1990 using patented drugs; only in November 2001 did it switch to generic drugs. Kimia Farma itself has only been able to produce generic ARVs since the end of 2003, so that ARV drugs can be given free of charge since 2004. Until now, the source of ARV drugs in Indonesia has come from APBN funds produced by Kimia Farma and from the Global Fund, with a 70:30 comparison of funds.ARV therapy (ART) is always used in combination; that's why it's called HAART (Highly Active Antiretroviral Therapy) (Granich et al., 2010). So far, there have been a first and a second. Adherence, or adherence according is the behavior of taking drugs, which is an agreement between the patient and the prescriber, where the patient is involved in making decisions about things that the patient wants based on decisions that have been made by doctors and are mutually agreed upon (Horne, 2006). Compliance in the use of drugs as a health behavior can also be viewed from a psychological perspective, especially in light of social cognition theories such as the Health Belief Model (HBM), Theory of Planned Behavior (TPB), and Informational-Motivational Behavioral Model (IMB) (Stonerock & Blumenthal, 2017). Has reviewed the three theories in relation to adherence to ARV use. Based on the HBM theory, an action behavior will be formed from a person's perception of the vulnerability and severity of the disease, as well as the perception of the benefits and obstacles faced. In general, people living with HIV who consider their illness to be severe and have experienced serious symptoms know the benefits of ARVs and are more obedient in taking medication, but one of the obstacles they face is stigma (Kagee, 2008). The Theory of Planned Behavior states that attitudes, normative support, and perceptions of behavior control are the determinants of intentions, while intentions are the main determinants of the occurrence of a behavior, a positive attitude in general will increase compliance (Warburton & Terry, 2018). On the other hand, negative attitudes towards antiretroviral drugs, such as concerns about side effects and the perception of not needing ARVs, are related to non-adherence (Iacob & Jugulete, 2017). However, there are no studies that explain adherence to ARVs holistically using TPB. Based on information in IMB theory, motivation and ability to behave are fundamental determinants of behavior. The results of Karl Peltzer's research in South Africa using the IMB theory showed that the level of adherence of people living with HIV had higher scores in information, behavioral abilities, and social support (Pretorius, 2019). Considering that ARV therapy is a lifelong therapy, the problem of adherence to therapy is a common problem from the five tables above, it can be seen that a total of 103 people with HIV/AIDS undergoing treatment at the Sukabumi Health Center, with various variations in age, occupation, gender, education, and origin of residence, adhere to treatment. Based on age, patients who are in the productive age range of 31-40 years are 41.7 % of the total number of patients in the above and below age groups. The same study on ARV medication adherence in Sorong Papua also shows that respondents' self-efficacy tends to be high, as does their adherence to medication behavior. This is considered in line with the results of the bivariate analysis, which showed a relationship between selfefficacy and adherence to taking antiretroviral (ARV) drugs in HIV-AIDS patients. Based on these results, it can be said that increasing self-efficacy can also increase patient compliance with treatment (Myer & Phillips, 2017). Various studies show things that hinder compliance, including fear of side effects, forgetfulness, an unhealthy lifestyle, poor health conditions, missing medicine boxes, a lack of personal awareness, experiencing opportunistic infections, daily activities, economic problems, namely, insufficient income for ARV treatment, impossible jobs, and fear of stigma. Supporters of adherence include those who have a regular schedule for taking medication, understand the importance of compliance, get good treatment results, and have confidence in the treatment process. In several other studies, the causes of non-compliance stated by people living with HIV include side effects of drugs such as nausea and dizziness, boredom, unfriendly health workers, the distance from which services are not accessible for some sufferers, and the fear that their status will be known by others. In addition, sometimes people living with HIV are late or miss taking ARVs because they forgot or fell asleep (Roy et al., 2017). So far, the characteristics of adherence to medication for people living with HIV at the Sukabumi Public Health Center have been good, although it has not been further investigated what the specific things are that are the biggest obstacles and supporters for people living with HIV. It is hoped that from this compliance, the efficacy of treatment in maintaining the patient's status in a healthy position and being able to carry out activities like other healthy people can be achieved. --- CONCLUSION The univariate variables of age group, occupation, education, gender, and origin of residence did not affect whether people living with HIV were nonadherent to treatment.

The government has set a target for accelerating the prevention of HIV/AIDS in Indonesia, namely zero new infections, zero people dying from HIV/AIDS, and zero stigma and discrimination. Stigma against people living with HIV has a major impact on HIV/AIDS prevention and control programs, including the quality of life for people living with HIV. Good knowledge will reduce the stigma that appears. Adherence to the use of ARV (antiretroviral) is one of the factors that can significantly extend the life expectancy of people living with HIV (people living with HIV AIDS). ARVs work against infection by slowing the reproduction of HIV in the body Purpose: To identify the factors that influence the adherence of people living with HIV to taking ARVs. Method: This is an observational, descriptive, and quantitative research project with a cross-sectional approach. The research will be conducted at the Sukabumi Health Center in Bandar Lampung in 2021. The population in this project is 103 HIV patients. The sampling technique used is total sampling. Results: Meanwhile, there are more PLHIV patients from urban areas than from rural areas. People living with HIV usually need ARV if the CD4 level is 350 mm3.The univariate variables of age group, occupation, education, gender, and origin of residence did not affect whether people living with HIV were non-adherent to treatment.

Background Socioeconomic status (SES) is an important component in studies that investigates health disparities for adolescents, as SES is associated with many health behaviors as well as health outcomes for adolescents [1][2][3][4][5]. The validity of the results from these studies depend on the accuracy of these SES measures. Previous studies that compare concordance between adolescent and parentreported SES however, have ignored whether such concordances are in fact affected by household financial stress [6][7][8][9]. Household income, parents' educational attainment and occupation class are most commonly used to measure SES for adolescents, and it has been argued that adolescents are unable to report these variables accurately. Wardle et al. [10] found in a sample of 1,824 adolescents that was comprised mainly of girls, approximately 16% of the subjects either did not or could not determine their parents' occupation, and approximately 25% of the subject could not answer whether their parents have a college degree. Similarly, Currie et al. [11] in a sample of 4,079 Scottish schoolchildren found that over 20% of 11-15 year olds were unable to provide a substantive response on father's occupation. However, for studies that compare adolescent's own report on parental SES and that reported by the parents, most found moderate to good agreement depending on the SES measure in question. A study [6] used a Spanish sample of adolescents (n = 91) and found that percentage of agreement for parental education and occupation ranged from 63.6 <unk>87.7% (kappa statistic ranged from 0.39 <unk>0.77). In another study of Norwegian sample (n = 924), agreement of reports for parental occupation was judged to be acceptable (kappa ranging from 0.65 <unk>0.86). Similar results were found by Vereecken and Vandegehuchte [7] (Flanders sample, n = 235). However, it should be noted that degree of concordance between adolescent and parent reports on the SES variables may be different for households experiencing different levels of financial stress. Financial stress has been defined by most of the previous studies has whether the household has enough money to pay for its expenses or have money left over during a period of time before the survey. Respondents are normally asked to choose from a Likert scale response (for example, from more than enough to very short, or from a lot of difficulties to no difficulties, or from a lot of money left over to shortage) [12][13][14][15]. Household financial stress is important to look at because it reflects material availability and if concordance varies by actual economic resource of the household, then using proxy measures on these SES variables could lead to biases depending on the level of financial stress the household experiences. Studies have shown that family financial stress plays important roles in adolescent's health and development [12,13]. Family financial stress has been shown to be associated with depressive symptoms, delinquency and drug use for adolescents [14,16]. A study indicated that family financial stress has adverse effect on adolescents' self-rated health [17]. In addition, family financial stress can lead to suicidal ideation for adolescents through its impact on parent's behavior (such as parental hostile behavior and physical abuse) [18]. It is unreasonable to assume that the degree of concordance for the SES measures is uniformly distributed by family financial stress, and if concordances of the SES measures vary by family financial stress, then estimates of SES disparities in adolescent health using traditional SES measures could be biased even in cases where high concordance between adolescent and parent's reports are found. Studies have shown that while education, occupation and income have been widely used to measure SES, these three variables may behave very differently from each other in determining health behaviors and health outcomes [19][20][21]. Specifically, these three variables represent different aspects of social class [8]. In this research, we use all three measures of family SES to determine whether the degree of concordance vary by family financial stress. --- Methods --- Data The Youth Project was a panel survey conducted by the Academia Sinica of Taiwan in 2000, which is a publicly released dataset. A multi-stage stratified sampling method was used for this study. The various criteria used for the sampling including urbanization degree, proportion of student population in each stratum, and mean student number of the class in each stratum. A total of 29 sub-regions were obtained. Classes were chosen at random within each stratum. Once a class is chosen, all students within the class as well as their parents were interviewed. Overall, 81 classes were chosen from 40 schools (16 from Taipei City, 15 from Taipei County and 9 from Yi-Lan County). The details of the survey design can be found elsewhere [22,23]. The survey consists of 2690 students who were in their first year of junior high school (mean age = 13 years). Of the 2,690 adolescents, 27 of them did not have a matching parent questionnaire. For the remaining 2,663 adolescents, eight had a parent questionnaire returned but it was indicated by the adolescents that the questionnaires had been filled out by themselves, and thus were classified as without a matching parent questionnaire. Of the remaining 2,655 subjects, eight parent questionnaires indicated that the respondent was a grandparent and 37 indicated that the respondent was in "another" relationship with the child and 17 had missing values for the relationship question. Since the student questionnaire only asked for the mother and father's educational attainment and occupation, in order to be conservative, these 45 subjects were not included in the analysis for adolescent-parent agreement. This means that a total of 2,593 adolescents with a matching parent questionnaire that was filled out by the parent (either father or mother) were available for this study. --- SES measures The adolescents were asked the question "What is your father's occupation?", and in a separate question "What is your mother's occupation?". Both of these questions are open-ended and were coded based on standards developed by the Youth Project. Eventually the occupations were classified into (1) Managerial; (2) Professional; (3) Highly skilled; (4) Semi-skilled; (5) Agricultural workers; (6) Low skilled; (7) Unskilled; (8) Military; (9) Unemployed/not in job, and (10) Unable to classify. Category (9) included those who were unemployed, housewives, students, and those with no-wage jobs. Class (10) includes answers that only indicated the type of industry and were without a job title. In the parent questionnaire, the questions "What is your occupation?" and "What is your spouse's occupation?" were asked. Both are open ended questions with a similar coding method to that mentioned above. The questionnaire also asked the responding parent to determine the relationship with the child, and the parent was able to choose from "Mother", "Father", "Grandparent" and "Other". The first two relationships (mother or father filling out the questionnaire) represented 97.3% of the entire sample. The adolescents were asked to report the monthly household income, and the answer used a 12-category scale ranging from "Below NT$30,000" (approximately US$1,000, based on the exchange rate NT$30 = US$1) to "Above NT$150,000" (approximately US$5,000). The parent was asked to report the monthly household income by an open ended question "The monthly household income of your family is approximately ___thousands of NT$". The answer from the parent's report on this question was then coded into the same interval as the one from the adolescent questionnaire described above. Finally, the adolescents were asked to report their father and mother's educational attainment using two separate questions, and the parents were asked to report their own as well as their spouse's educational attainment level. This variable consisted of six categories ranging from "primary school or below" to "graduate". --- Financial stress To see whether the degree of concordance vary by household financial stress, we included analyses using two parental perceived financial stress questions. The parents were asked the question "How has the financial status of your household been for the past year before the interview?" and the respondent can choose from "a lot surplus", "some surplus", "balanced" and "shortage". Asking for financial balances is a typical approach to measuring financial stress and has been used in many studies [15]. To measure relative financial stress, the parents were asked in a separate question "How is the current standard of living of your household compared with other households?" and the respondent can choose from "a lot better", "better", average", "worse" and "a lot worse". --- Statistical analysis Descriptive statistics were used to show distribution of the responses by adolescents and parents. We first compared the distribution of responses, including those with missing responses, for the three SES variables, namely mother and father's occupation, mother and father's educational attainment (Table 1) and household income (Table 2) for those with a matching parent questionnaire. The degree of agreement was analyzed using the weighted. Cohen's has been widely used to compare answers for similar questions by different respondents [24][25][26]. For ordinal variables, weighted should always be used so that partial credits are given to responses in the adjacent group but not in exact concordance [27]. Following Whiteman and Green [28], we weighted the statistic by the square of the deviation from exact agreement. Such weights were applied to parental education and household income, since these two measures of SES have a clear ordered rank. No weight was applied to parental occupation since it is a multinomial variable. Guidelines for assessing the degree of agreement have been proposed as follows [8]: 0.8 <unk> <unk> 1 (very good), 0.6 <unk> <unk> 0.8 (good), 0.4 <unk> <unk> 0.6 (moderate), 0.2 <unk> <unk> 0.4 (fair) and <unk> 0.2 (poor). The distributions of the parent-reported SES variables by levels of household financial stress are presented in Tables 3,4, 5. We then compare the degree of concordance between adolescents' report and the parents' reports relative to the two parent-rated household financial stress questions (Table 6). It should be note that if both parties (adolescent and parent) had non-response, such non-responses may also be considered "consistent" between the two parties. Previous studies usually ignore cases with missing responses in calculating Cohen's. However it should be noted that missing responses may not be at random, and it is most likely that those belong to the lower SES groups are actually the ones who are more likely to have missing responses. Thus as a sensitivity analysis, we tested whether results changed by treating pairs of respondent (adolescent and parents) as having consistent responses if both parties had nonresponses. To do so, we generated a separate group for the three SES measures for cases where both the parents and the adolescent had missing responses. For parental education and household income, this new group is ranked as the lowest (since it is reasonable to assume that it is more likely for the low SES households to have missing values for both parties) and weights still applied in calculating the statistic. For parental occupation, this new group is treated as an independent group in the multinomial variables for occupation. 95% confidence intervals (95%CI) were calculated using the bootstrapping method. A significant difference of is determined by non-overlapping 95% CI. --- Results The distributions of responses by adolescents and parents for parental education, parental occupation and household income are presented in Tables 1 and2. Adolescents have higher non-response rate for parental education compared with parent's responses. However, for parental occupation and family income, adolescents actually had lower non-response rate than their parents. For both adolescents and parents, the highest nonresponse rate was observed for family income, compared with other SES measures. The statistic showed good agreements between the reports by adolescents and by parents for both father and mother's educational attainment levels ( = 0.86, 95% CI = 0.85-0.88 and = 0.84, 95% CI = 0.82-0.86, respectively). The degree of concordance is lower for parental occupation ( = 0.39, 95% CI = 0.36-0.41 and = 0.47, 95% CI = 0.45-0.49, for father's and mother's occupation respectively). For household income, = 0.44 (95% CI = 0.39-0.49). The relationship between parent-reported SES and financial stress is shown in Table 3, 4, 5. The results showed that household financial stress is closely associated with the SES variables. For example, out of the parents who reported "surplus" for the financial stress question, 23.9% of them reported father's education equal or above university (Table 3). The corresponding figures for those parents who reported "average" and "shortage" were only 7.5% and 4.7% respectively. Similar patterns were observed for maternal education and household income. For parental occupation, a much higher percentage of the parents who reported "surplus" belong to the occupation categories of managerial, profession and skilled occupations. The degree of concordance for the three SES measures relative to financial stress and relative standard of living from the parent's perception is reported in Table 6. For parental education and occupation, the degree of concordance is the lowest for parents reported highest financial stress. For father's education for example, decreased from 0.87 (95% CI = 0.85-0.90) for families with surplus in the financial stress question to 0.78 (95% CI = 0.66-0.84) for those with worst financial balances. The non-overlapping 95% CI indicates that the decrease in is statistically significant. Similar pattern was observed for father's occupation (between those who reported surplus and balanced), and mother's occupation (between those who reported surplus and not enough). Such pattern of decreasing concordance was less significant for the relative standard of living question. As a sensitivity analysis, we also tested whether the results remain if treating concordance for missing values as a separate group (Tables not shown). The results from this analysis were similar to the ones without missing values. --- Discussions We found that the degree of concordance for the three SES measures between adolescent and parent reports decreases with higher family financial stress, and the results hold if treating both parties having missing values has concordant. The role financial stress plays in relation to the traditional SES variables should be discussed. Some suggested that financial stress reflects resources availability, which may not necessarily be captured by the tradition SES measures, as households with similar incomes can show a wide variation in financial stress [15] In addition, financial stress may act as an intermediate factor between the SES and health relationship [29]. However, our data indicated that financial stress is highly correlated with the SES variables in this research, where lower financial stresses were observed for parents with higher education, more skilled jobs and higher household income. This indicates that financial stress may reflect to a large extent the "true" SES of the households. The implication of our results thus is significant: the concordance between the parent and adolescent reported SES variables may be actually determined by the "true" underlying SES of the household. Thus the bias would be larger for higher financial stressed families when estimating the SES gradient for adolescent health. Such bias could arise regardless of whether the SES variables were reported by the parents or by the adolescents. There are some possible mechanisms for the results found. First, it is possible that adolescents from families with higher financial stress are less aware of the SES situations of the family. For example, it is possible that poor parent-adolescent communication is more prevalent among higher financially stressed families, and hence adolescents were not told about the situations associated with family SES. Second, it is also possible that parents or adolescents from higher financially stressed families are more reluctant to report correct SES data. Previous studies have reported that SES is closely related to self-esteem for adolescents [30], showing that adolescents may be sensitive to their family SES conditions and hence may be reluctant to report accurate SES data when SES is low (which could be reflected by higher family financial stress). These mechanisms can be tested by future studies. We also found that the phenomenon of decrease in concordance was not observed when using relative standard of living. This may indicate that the above proposed mechanisms work more when the household experience actual financial difficulties. This may also explained by the previous findings that people may use different reference group to rate their relative standings, and the ratings are sensitive to different reference groups used [31]. In other words, a parent may report better in the relative standard of living question while another parent with similar SES may report worse, causing the relative standard of living question being less associated with a household's SES situation. Our results show that concordance for household income is not affected by household financial stress. One obvious explanation is that these two variables are highly related. In other words, parents report their level of financial stress based on household income to a large extent, thus causing less variation of concordance for income when stratified by financial stress. There are several strengths and weaknesses of this research. In terms of strength, first, though household financial stress and relative standard living may be closely correlated with the three SES measures, the formal two suffer from much less non-responses. The nonresponse rates for the financial stress variables were only about 1% of the sample. Thus this allows us to test whether concordances of the SES variables are actually affected by a proxy of the "true" SES. Using financial stress has the additional advantage of incorporating factors that are normally not considered when measuring SES (such as whether family members include those with illness, which would reduce available household resources), and hence may be able to better reflect the actual SES condition of the household. The weakness of this research should also be noted. Like all self-assessed variables, there could be measurement error. For example, a parent may report the household has surplus of income when in fact it does not. For the SES measures, it should also be noted that it is possible that reports by adolescents and parents for the SES measures are both incorrect and hence even a high agreement does not indicate a valid answer. This however, is beyond the scope of this study. In addition, Lien et al. [8] inferred from another study that if both the parent and the children do not report accurately on a particular question, it is more like to be a problem in the response from the family rather than a problem of invalidity caused by the adolescent's lack of understanding of the family situation. Another limitation is that the data used in this study are not very recent. It is possible that individual or societal factors that may influence concordance changed over the past years. It should also be noted that the degree of agreement may not be stable across time, depending on factors such as employment status and feelings of economic security. A solution would be to conduct a test-retest analysis within a period of time. This however, is not available from our data. Finally, the sample used here is representative of Northern Taiwan, and not the entire country. However, Northern Taiwan is of higher SES compared with other parts of the island, and it is reasonable to hypothesize that concordance is higher for the higher SES families. Thus the degree of poor concordance may be underestimated (instead of overestimated). Several studies found moderate to good concordance between adolescents and parents reports on SES variables such as parental education, parental occupation and household income [6][7][8]32,33]. Other than the traditional SES measures, a study found good concordance between these two parties on receipt of public assistance [33]. However, whether such concordance influence by household financial stress should be considered. Our results also suggests that in the presence of different levels of financial stress, parental education may still be the most consistent measure of adolescent SES, since its concordance remained higher than other SES variables for all levels of financial stress. Due to the generally high number of missing values for traditional parental SES variables reported by adolescents, many studies have used the "family affluence scale" (FAS), which included car ownership, telephone ownership and the child having their own unshared bedroom [11,26]. The advantage of using such scale is a lower level of missing data. While a adolescent may not know their parent's educational attainment, they are very likely to know whether their family owns a car [10]. It has also been found that the FAS is highly correlated with a country's gross domestic product [26]. Limitations of the FAS have also been proposed. A study argued that results from FAS are generally non-comparable due to variations in cultures and differences in time [8]. For example, the possibility of owning a car may become much higher for now compares with a decade ago. Some also argued that complete measures of SES should cover both resource-based and prestige-based measures [34]. For these reasons, traditional measures of SES should not be replaced by wealth [35]. This research does not intend to discuss the validity of FAS and whether traditional SES measures should be replaced by FAS in measuring SES for adolescents. However, our results point to some new directions for future research in this area. Firstly, there is a need to consider whether consistency between the adolescent's and parent's report on FAS also decreases with financial stress, and whether the results vary by culture and time. Secondly, it is important to determine the mechanisms for the relationship found between the traditional SES measures and household financial stress and standard of living. By doing this, while it will still be difficult to know the true values for the missing data by either the adolescent or their parent, at least one can postulate a possible upward or downward bias in the estimated SES gradients for adolescents. --- Conclusions Though the agreement between adolescents' and parents' reports on parental education, parental occupation and household income is generally judged to be good by previous research, using adolescents reports for family SES may still be biased if analysis is not stratified by family financial stress, as the degree of concordance for the three SES measures between adolescent and parent reports decreases with higher family financial stress. --- Authors' contributions CP was responsible for data analysis and writing up the manuscript; NH designed the study and helped in drafting the manuscript. YC coordinated the research and finalized the manuscript. All authors read and approved the final manuscript. --- Competing interests The authors declare that they have no competing interests. --- Pre-publication history The pre-publication history for this paper can be accessed here:

Background: Many studies compared the degree of concordance between adolescents' and parents' reports on family socioeconomic status (SES). However, none of these studies analyzed whether the degree of concordance varies by different levels of household financial stress. This research examines whether the degree of concordance between adolescents' and parent reports for the three traditional SES measures (parental education, parental occupation and household income) varied with parent-reported household financial stress and relative standard of living. Methods: 2,593 adolescents with a mean age of 13 years, and one of their corresponding parents from the Taiwan Longitudinal Youth Project conducted in 2000 were analyzed. Consistency of adolescents' and parents' reports on parental educational attainment, parental occupation and household income were examined by parent-reported household financial stress and relative standard of living. Results: Parent-reported SES variables are closely associated with family financial stress. For all levels of household financial stress, the degree of concordance between adolescent's and parent's reports are highest for parental education ( ranging from 0.87 to 0.71) followed by parental occupation ( ranging from 0.50 to 0.34) and household income ( ranging from 0.43 to 0.31). Concordance for father's education and parental occupation decreases with higher parent-reported financial stress. This phenomenon was less significant for parent-reported relative standard of living. Conclusions: Though the agreement between adolescents' and parents' reports on the three SES measures is generally judged to be good in most cases, using adolescents reports for family SES may still be biased if analysis is not stratified by family financial stress.

Introduction Hokkaido University (HU) established Creative Research Initiative "Sousei" (CRIS) in 2002 as a University-wide organization to promote cutting-edge, worldclass research and to plan a mid-and long-term trans-departmental research system. After the incorporation of HU in 2004 and structural reforms, the Center for Advanced Science and Technology (CAST) was merged in FY2005 into CRIS, which then began to serve also as a base to materialize time-bound research schemes aimed at commercialization. In April 2009, CRIS was re-inaugurated as Creative Research Institution to serve also as a management organization with the mandate to coordinate 18 research-dedicated institutes, apart from giving continuity to the R&D activities through its Research Department, which then comprised 5 horizontal divisions: frontier, innovative, strategic priority, projectbased (with businesses), and endowed. During FY2003-7, CRIS executed the MEXT Super-COE HU Research & Business Park (HUR&BP) Project. Fostering interdisciplinary exchanges, CRIS has a mission to promote research in an innovative and cross-disciplinary (in the broad sense, encompassing multidisciplinary, interdisciplinary, and transdisciplinary; we refer to Wagner et al. (2011) for a summary of key terms) manner aiming at knowledge creation and utilization. In this paper, we present the first results of analyses on the research output of CRIS (publication volume, type, etc.) and outcome (e.g., citations and interdisciplinary contribution), partly to gauge the degree of reflection of the cross-disciplinary research output in the WoS database. Our aim was to assess the potential of bibliometry as an analytical tool for analysis and interpretation of the research performance of an institute having a complex mission at different levels of aggregation (e.g., institute, department, research groups). This was essential to take into account a dozen or more combinations representing a variety of styles, occasionally with misspelled variants for the Japanese name "SOUSEI" (meaning innovation or creation) and for the string "CREAT" for creative. The phrase CRIS BLDG had to be combined with logical NOT with (ii) in order to exclude references merely to the CRIS Building that also houses institutions other than CRIS. Because of the time-bound nature of the projects executed at CRIS and the very fact that CRIS used to be the secondary affiliation for many researchers, part of the research output resulting from research at CRIS might have been published with mere acknowledgement to CRIS, with another institute/department at HU as the only affiliation. Though the data retrieved may not be complete, we regard them to be fairly representative of the volume of research output from CAST and CRIS researchers. --- Publication data and methodology of analysis Retrieval from WoS using the above-mentioned search strings on 15 January 2012 has yielded 643 citable items (articles, proceedings papers, reviews, and letters) jointly contributed by CAST and CRIS as illustrated in Fig. 1. The detailed analysis presented hereafter, however, is restricted to a total of 611 items retrieved on July 1, 2011 from the same database. There were 506 and 107 items with affiliation to CRIS (mainly from 2003 onward) and CAST (from 1996), respectively, implying that just 2 out of 611 items belonged to both affiliations. --- Methods of analysis To assess the degree to which bibliometric analysis of publications recorded in the WoS database reflected the research activities at CRIS (including CAST), the following analyses were performed: (i) Counting the frequency of assignment of items, and also of publications citing them, for different time spans to each of the 222 ISI science categories (SCs) and 18 macro-disciplines, following the procedure of Leydesdorff & Rafols (2009). Both datasets were limited to records in WoS. Construction of a "Science Overly Map" using the SC counts following Rafols et al. (2010) aided by the Pajek 2.00 (1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010) program for visualization (ii) Semantic analysis of co-words in titles of citable items separately for CAST and CRIS. Co-occurring words in titles of items were processed by using Bibexcel (Persson 2009) to generate a co-occurrence matrix comprising stemmed words. The matrix was subjected to a network analysis for clusters and mapping aided by visualization with VOSviewer (Van Eck & Waltman 2010). (iii) Analysis for bibliographic coupling of items in terms of journals in cited references to generate a cosine matrix by using BibJourn.exe (2011) by Loet Leydesdorff (pers. comm.), and further visualization as a 2D network map by using Pajek. --- Results of the bibliometric analysis --- Degree of coverage of various scientific disciplines Figure 2 summarizes the citable items for 2002-2010, a time span representative for CRIS, in terms of the disciplinary coverage based on the assignment of each item to one of the macro-disciplines (equivalent to 18 clusters in the overlay base map) obtained by summing up frequencies of occurrence in several SCs by using the fractional counting method (for percentage data, see second column in Table 1). Three macro-disciplines represented by Biomedical Science (32.8%), Chemistry (19.2%), and Agriculture Sciences (12.0%) covered more than half (54%) of the items. Significant contributions varying from 8.7% to 4.1% from 5 other macro-disciplines (Ecological Science, Materials Science, Physics, Infectious Diseases, and Cognitive Science) comprised another 30%. Further aggregation at a higher level to 4 broad fields revealed the share of Biomedical Sciences, Physical Sciences and Environmental Science & Technology (see Fig. 2) to be 43.0%, 33.5%, and 23.3%, respectively, whereas the Social Sciences category or field was almost absent. Calculation of the share of macro-disciplines for the 2002-2010 dataset discussed previously was repeated for additional time spans, including 2005-2008 as the most representative period for output of the HUR&BP project and the most productive one for CRIS, after merging of CAST into CRIS (Table 1). The dataset was extended to include 3,106 items (also citable) citing the 2005-2008 output (329 items), to gain better insight into interdisciplinarity (Porter et al. 2007). Comparison of the datasets in 4 different columns in Table 1 reveals a remarkable similarity in the share of most macro-disciplines, with an exception of minor differences for Agricultural Science and Cognitive Science. --- Appraisal of cross-disciplinary coverage through a science map Based on the overall similarity in the disciplinary share discussed above, we feel any dataset used to create Table 1 to be suitable for construction of a Science Overlay Map to visualize the internal dynamics of the research output (publications) or outcome (citations). To gain overall insight for both CAST and CRIS, all 611 items were assigned to individual SCs without fractionation (i.e., if an item was assigned to 3 SCs, each of them received a score of 1 rather than 1/3) to draw a 2-dimensional map (Fig. 3). In the map, macro-disciplines and SCs with a predominant share (percent relative to 611 items) were identified as follows: a) Biomedical Science: Biochemistry & Molecular Biology (20.1%); Genetics & Heredity (8.7%); Biophysics (7.4%); Biotechnology & Applied Microbiology (7.0%). b) Materials Science: Polymer Science (9.3%); Material Science, Multidisciplinary (4.9%). c) Chemistry: Chemistry, Physical (6.1%); Chemistry, Multidisciplinary (5.2%). d) Agricultural Sciences: Plant Sciences (6.7%), Food Science & Technology (4.7%). The map is advantageous in its power to discriminate SCs with a minor contribution (e.g., Paleontology, with <unk>0.5% of the total output; top right in Fig. 3). Whole counting, however, variably enhanced the visibility of individual SCs and macro-disciplines in the map compared to the use of fractional counting used to generate data in Table 1. The score for "Multidisciplinary Science" comprising specific set of journals assigned only to this SC remains unaffected by the counting method. For other SCs contributing at least 1% of the 611 items using fractional counting, whole counting enhanced the share by a factor of 1.10 (for Zoology) to 3.37 (for Chemistry, Applied), with an average of 1.73. At the level of macro-discipline, Physics and Ecological Science exhibited the least enhancement (ca. 1.3), whereas a maximum value of ca. 2.1 characterized Chemistry and Clinical Medicine. --- Co-word analysis and visualization of clusters Datasets from CAST and CRIS were analyzed for co-words in titles separately to reveal distinctive peculiarities. Selected words and 2-D visualizations of their cooccurrence relations forming clusters are presented in Tables 2&3 andFig. 4. Vosviewer allowed zooming and viewing specific areas as color density maps, enhancing readability and interpretation. Research outcomes from activities initiated at CAST, and continued at CRIS for some time (mainly as former next-generation post-genome and genome dynamics research divisions, during FY2005-2008) were as follows: chromosome-based molecular cytogenetic/karyotypic studies of animals (clusters 1, 6 in dataset 1 and clusters 8, 10 in dataset 2), phylogeny of mammals through ancient and modern DNA analyses (cluster 3 in dataset 1), and taxonomic/phylogenetic characterization of red and green algal species (cluster 4 in dataset 1). Cluster 7, protein-structure analysis, was another prominent theme in both datasets. The following most productive fields (corresponding clusters in dataset 2, Fig. 4b) were clearly evident for CRIS: synthesis, and characterization of polymers/macromolecules/gels (cluster 1); photochemical fabrication of nanodevices using molecular crystals or organic materials (cluster 2); human cell culture using fish collagen and production of honeycomb film scaffold for transplantation (cluster 3); rhizospherethe plant root & soil environment and new cultivation system (cluster 4); zoonotic diseases including avian influenza (cluster 5); gastrointestinal tract/biosphere and functional enzymes/foods, etc. (cluster 6); and, genomic expression in sea squirts (clusters 9& 10) from the world"s oceans. --- Coupling pattern of journals as indicators of scientific specialties The complete dataset (N=611) was analyzed for bibliographic coupling in terms of journals in the cited references that serve as the knowledge base; this also provided information on scientific disciplines. Of the 20,834 total references cited, 11,253 belonged to 2,696 journals indexed in WoS. Visualization in a 2D map involved running bibJourn.exe at a threshold of 0.2% (only journals appearing in at least 22 cited references) to obtain a matrix of Salton cosines, and further processing with Pajek after partition. Figure 5 shows the mutual arrangement of 93 coupled journals (in cited references). Ten journals (each provided with corresponding frequency) that topped the list of the knowledge source consulted by (co-)researchers from CAST and CRIS were: Nature (255), Science (245), P Natl Acad Sci USA (204), J Biol Chem (147), J Am Chem Soc (96), Cell (82), Nucleic Acids Res (80), Phys Rev Lett (77), J Mol Biol (75), and Biochem Biophys Res Co (74). The first 3 journals belong to the "Multidisciplinary Sciences" according to the ESI 22-field division, but are included in the "Biomedical Science" macro-discipline (Fig. 3) in the 18cluster classification we have used (Fig. 3). The size of each node labeled on the map reflects the frequency of citations of journals. The mutual separation of nodes increases with decreasing coupling relationship, and the thickness of connecting lines indicates the strength of the joint relationship. In Fig. 5, three important groups of journals are enclosed by ovals. The area designated roughly as "biomedical and agricultural sciences" is very broad and surely exhibits an interdisciplinary nature. --- Discussion and conclusion The percentage share of the 2002-2010 research outcome from CRIS (partially also from CAST) in terms of 222-ISI SCs, 18-macro-disciplines, and further aggregation into 4 fields (Biomedical Sciences, Physical Sciences, Environmental Science & Technology, and Social Sciences) using the fractional counting method revealed that 3 fields in Science & Engineering comprise almost the whole dataset, with a fairly large share for each (varying between 23 and 45%); the Social Sciences field was virtually absent (Table 1). An overlay science map revealed the disciplinary structure at the level of SCs, again showing the clear dominance of Biomedical Science (including 6 items or only a 1% share of the Multidisciplinary Sciences category), Material Science, Chemistry, and Agricultural Sciences. Co-word analyses for titles separately for CAST and CRIS revealed clusters such that the word assemblies allowed recognition of research themes leading to the production of an appreciable number of publications in journals recognized and indexed in the WoS database. Themes marked by clusters simultaneously in the CAST and CRIS data (Tables 2&3; Fig. 4a,b) on genetic/genomic and protein structure analyses were indeed interdisciplinary, as evidenced by significant overlaps among the clusters. The genetic/genomic studies involved close collaboration among researchers from the Graduate Schools of Science, Advanced Life Science, and Agriculture as well as many researchers from institutes abroad, and the objects studied (e.g., animals, algal species) have global coverage (Hokkaido University 2011). The proteinstructure studies focused on trailblazing research on DNA-protein-sugar chain mechanisms, and the findings served as the basis for collaboration between HU and businesses (e.g., companies engaged in the medical care/pharmaceutical sector) for drug development/discovery R&D projects. Most of these studies are currently being continued at the Genome Dynamics Research Center (since 2008) and the Frontier Research Center for Post-Genome Science & Technology (mainly since 2007) affiliated with the Faculty of Science and the Faculty of Advanced Life Science, respectively (Hokkaido University 2011). Clusters identified from the CRIS data (Table 3; A bibliographic coupling analysis (Fig. 5) showed that almost all journals serving as the most representative knowledge base for our dataset belong to the Biomedical and Agricultural (including some related to environment) Sciences, Chemistry, and Materials Science, reinforcing the similarity with findings from disciplinary assignments and the co-word analyses. Other notable SCs (macrodisciplines) detected from a joint analysis of all previous data, although comparatively less productive, seem to be Physics (see Figs. 3,5), Neurosciences (Cognitive Science), and Geochemistry & Geophysics (Geosciences). These disciplines have been actively pursued by the frontier research team dealing with "molecular/structural simulations of superconductors", the 4 th innovative research project at CRIS, and the Isotope Imaging Laboratory in the Strategic Project Research Division, respectively. These themes are partly representative of the trans-disciplinary research carried out as innovative projects by young researchers and by other programs that engaged researchers transcending various departments and also businesses. Comparison of data for different time spans at the level of each macro-discipline (Table 1) reveals relatively lower values for Agricultural Science and Cognitive Science in the last column for items citing 329 publications for 2005-2008. Such low values may have resulted from the comparatively low annual volume of publications in these 2 macro-disciplines during the period concerned. Publications in Agricultural Science showed an already clearly increasing trend from 2005, whereas Cognitive Science showed a slight recovery after an almost lack of publications during 2007-2008. As these trends in the publication volume were dictated by several factors (e.g., completion of the HUR&BP Project in April 2008; continued funding to a few selected projects), these minor variations are not important. However, a longer period (e.g., at least 5-6 years) could be more representative if the aim were to judge the average productivity and impact at the level of an institute. An almost complete absence of items in Social Sciences in the WoS records was clear, even though CRIS had a few research programs engaged partly in this field, i.e., the Environmental Science & Technology Policy Program under HUR&BP and 2 research projects in the Innovative Research Division (Hokkaido University, 2011). Filling the information void in social sciences would require consulting non-WoS journals (including those written in Japanese) and other modes of publications (e.g., monographs). It remains to be seen to what extent such an approach would be necessary for a fuller appreciation of the research output in other science and engineering fields. The analyses and interpretations attempted so far, though largely descriptive, have demonstrated the usefulness of bibliometry as a tool for recognizing the comprehensive knowledge structure (output and outcome) at the level of an institute at Hokkaido University. Further analyses using other network tools that combine several different pieces of information (e.g., word-author-journal) and 2D visualization as time-series maps will surely give insight into shifting tendencies in research practice, emerging disciplines, etc., and thus provide data useful for strategic planning. CRIS is an institute with the mission of promoting/conducting cross-disciplinary research, and the body of knowledge already produced there indeed involved teamwork and collaboration. However, it is desirable to apply indicator-based methods, such as those suggested by Leydesdorff & Rafols (2011) and Wagner et al. (2011), to judge the extent of multidisciplinarity (simple integration), interdisciplinarity (a holistic approach with input from various disciplines leading to partial/complete fusions, novel syntheses, etc.), and transdisciplinarity (extending beyond or crossing the restricted boundaries of constituent disciplines, research participants, etc.) in quantitative/statistical terms. Finally, we emphasize that there is a clear need for applying bibliometric data objectively, with due consideration of the mission, structure, temporal characteristics, etc., of the research establishment in question. Matthew H Dick, Professor at the Graduate School of Science, for many comments to achieve clarity in interpretation and the linguistic improvements. We were encouraged very much by T. Ogawa, Deputy Director of CRIS, to perform this experimental analysis on the CAST and CRIS datasets. It is to emphasize, however, that we as authors are solely responsible for the approach, analyses, and interpretations presented in this paper. (Leydesdorff & Rafols, 2009). The Social Sciences category (not shown here) has a share of merely 0.2%. Number of items analyzed: 561 Table 2 Seven clusters, each being defined by 5 co-occurring terms (selected from the set of 10 most frequent stemmed words) that reflect the most productive research themes from CAST Dataset 1: 107 items (CAST) Cluster No. & stemmed words: Fig. 4(a) 1: chromosom, gene, mous, chicken, fish 2: sequenc, genet, mitochondri, divers, speci 3: popul, hokkaido, brown, bear, deer 4: japan, red, solieriacea, rhodophyta, gigartinal 5: rat, salmon, structur, cell, transgen 6: molecular, karyotyp, cytogenet, evolut, shrew 7: dna, pharaoni, bind, halorhodopsin, protein Table 3 Eleven clusters, each represented by 5 co-occurring terms (selected from the set of 10 most frequent stemmed words) that reflect the most productive research themes from CRIS Dataset 2: 506 items (CRIS) Cluster No. & stemmed words: Fig. 4(b) 1: synthesi, hydrogel, polym, surfac, network 2: molecular, structur, crystal, organ, cluster 3: cell, human, film, collagen, gel 4: rice, phosphoru, growth, metabol, tropic 5: mous, influenza, viru, h5n1, pathogen 6: gene, function, sequenc,isol,bacteri 7: protein,differenti,bind,neuron,signal 8: chromosom,sex,dna,induc,bird 9: carbon,microarrai,hybrid,ascidian,marker 10: intestinali,ciona,transcript,cycl,specif,11: dynam,calcium,hydrat,first,ion Fig.4 (a,b). Density label maps to visualize bibliometric mapping and the clustering of research output based on co-occurring words in titles of the citable items. Stemmed co-words were processed by Bibexcel (Persson 2009) to generate co-occurrence matrices that were clustered and mapped with VOSviewer. The size of each node (solid circle) and the size and contrast of the corresponding label are proportional to the assigned weight. Selected clusters are given theme labels. (a) 107 items from CAST (7 clusters, with slight overlap). Minimum word frequency = 3. (b) 506 items from CRIS (11 clusters, with significant overlap across several of them). Minimum word frequency = 4. For terms defining each cluster, refer to data in Tables 2 and3. --- Figures with Captions

This study describes the results of a preliminary bibliometric analysis of 611 research items, published between 1996 and 2011 by researchers affiliated with Creative Research Institution (CRIS) and the Center for Advanced Science and Technology (CAST), Hokkaido University (HU), retrieved from the Web of Science (WoS) database. CRIS has a primary mission to promote cutting-edge, world-class, trans-departmental research within HU, and it conducts fundamental, commercialization-related, cross-disciplinary research and nurtures young in-house/recruited researchers through targeted, innovative tenure-track programs in multiple disciplines. Its research output derives from 3-to 7-year-long time-bound projects funded strategically by HU, external grants (e.g., MEXT Super-COE HU Research & Business Park Project (FY2003-7)), industryuniversity collaboration with regional businesses, and endowments (e.g., Meiji Dairies). Analyses using co-words, bibliographic coupling, overlay map aided with visualization, etc., lead to the following inferences: (i) The published items comprise a dozen well-defined (inter-)disciplinary clusters, dominated by 3 macro-disciplines (biomedical science, 33%; chemistry, 21%; agricultural science, ca. 10%) that constitute 18 clusters used for mapping; (ii) research conducted by externally funded or endowed projects in the biomedical, physical and environmental science & technology fields (3 broad areas of aggregation derived from the Science Overlay Map) is interdisciplinary; and (iii) there is an apparently low visibility of publications from projects jointly executed with industries to an almost complete absence of output from CRIS in the fields of social sciences in the WoS database.

Introduction Following the shooting of Mark Duggan by police on the 4 th August 2011, there were riots in many large cities in England. The riots began in London on the 6 th of August following a protest over Mark Duggan's death. They then spread to a number of other English cities; lasting around six days before petering out. The riots generated both looting and arson, receiving blanket coverage in the UK media. As the rioting was widely perceived to be perpetrated by the urban poor, links were quickly made with Britain's welfare policies. An epetition was posted on a government website calling for rioters to 'loose [sic] all benefits'. It rapidly gained more than 250,000 signatures and received widespread media attention (Mains, 2011). On the 11 th of August, the government explicitly made the connection between the riots and welfare policy. Iain Duncan Smith, the Secretary of State for Work and Pensions, noted to the media that he was considering changes to an upcoming welfare reform bill, adding an amendment which would cut welfare benefits to convicted rioters (Porter and Kirkup, 11 Aug 2011). These events led to widespread media debate regarding class, welfare, and poverty, and brought the issue of the deservingness of welfare recipients to the fore. But what impact did the riots, and the subsequent media coverage, have on attitudes toward welfare recipients? Using this national media event, we analyse the impact of the media on attitudes towards the welfare state and also welfare recipients. There is substantial interest among social scientists in the role the media plays in shaping political attitudes and in democracies more broadly (Mccombs and Shaw, 1972, Brynin and Newton, 2003, Drew and Weaver, 2006). While it is commonly assumed that the media have some influence on political attitudes and preferences, there is ongoing debate as to the nature and extent of this effect (Bartels, 1993, Drew andWeaver, 2006). During the 1990s and early 2000s, numerous studies documented the persuasive power of the mass media (Bartels, 1993, Prior, 2013, Ladd and Lenz, 2009). However, fragmentation of media markets due to increasingly personalized media choices has led some to hypothesize that the media now has only'minimal effects' on attitudes (Bennett and Iyengar, 2008). In this paper, we examine these competing hypotheses and consider some of their implications by observing whether media coverage influenced attitude change in response to the 2011 English riots. --- Minimal effects? Persuasion and the media Much of the literature on the persuasive power of the media has focused on whether members of the public change their attitudes or voting preferences in response to some media message or campaign. One set of media-persuasion theories argues that the media can have a sizeable impact on political attitudes. Media coverage tends to increase awareness of political events among those exposed (Iyengar and Reeves, 1997). Newspaper endorsements of a particular party increase the likelihood of readers voting for that party (Ladd and Lenz, 2009) and economic expectations among the public are more positive if the media reports 'good' economic news (Gavin and Sanders, 2003). This research has mostly been observational in nature. However, there have been a number of experimental studies attempting to test whether media coverage can persuade people to adopt particular political ideas (Levendusky, 2013). Such studies show that party identification is more malleable than attitudes and values (Gerber et al., 2009). Similar results have been observed in quasi-experimental studies. One set of natural experiments tracked the differential roll-out of Fox News in U.S. towns. Exposure to Fox News, when it became available, increased the vote share of the Republican party by approximately 10% among viewers (DellaVigna and Kaplan, 2007). Experimental studies have a number of advantages in terms of isolating a causal effect of media representations but also have some limitations. Replicating the behaviour and decisionmaking processes found in the real world has proven difficult in the artificial setting of the laboratory (Prior, 2013). Field experiments (where participants are randomly assigned to read particular real-life newspapers) may not correspond to actual media use, or may not apply to readers who already subscribe to the 'intervention' newspapers (Prior, 2013). Additionally not all subjects will willingly read print media (Levendusky, 2013), and effects may also extend to non-readers, who may be exposed through diffusion via social networks. It is also likely that the media's effects vary considerably with individual receptivity, societal circumstances, and with the polarisation of the media context itself (Zaller, 1992). Taking these criticisms in account, another strand of empirical research has characterised the impact of the media on political attitudes as highly variable (Gentzkow and Shapiro, 2010) and "minimal at best" (Druckman, 2005). This marks a return to many of the classic studies in the field, which observed that the media exhibited "minimal effects" on attitudinal formation or conversion (Klapper 1960). Instead, media consumption is argued to simply reinforce pre-existing attitudes (Norris, 2006). What little power the media possessed to alter people's political attitudes may have been further eroded by changes in mass media consumption patterns (Bennett and Iyengar, 2008). Rising numbers of media outlets, for example news websites and digital television channels, have fragmented the market and may have led to an 'individualisation' of media consumption (Arceneaux et al., 2013). People tend to avoid information that conflicts with their preexisting values and beliefs (Prior, 2013). Increasing diversification of the media market allows people to avoid conflicting information more easilyto restrict their news consumption to only those sources which affirm their existing beliefs (Levendusky, 2013). Further, this fragmentation has led to the decline of the inadvertent audiencethose who would watch because they had no other choice. This group can now potentially avoid news media altogether (Prior, 2007). Yet there are reasons to be cautious about hypothesizing a minimal effect of the media on public attitudes in the UK, particularly in terms of newspapers. Much of the above cited empirical work has been conducted in the US. While daily circulation of the UK print media has declined by 4 million over the last 20 years, the UK print media market, unlike the US, continues to be dominated by a few national newspapers which remain a major source of political information (Brynin and Newton, 2003). Again, unlike the US, these UK newspapers are highly partisan, with the overwhelming majority leaning towards the political right. Only 15% of all newspaper circulation in 2010 supported the Labour party during the 2010 election (Wring and Deacon, 2010). Newspaper readers are therefore frequently exposed to right-leaning arguments and attitudes. Despite this decline in circulation, the greater degree of homogeneity in the UK context suggests media exposure may continue to influence political attitude formation and change. This minimal effects debate has also spurred other research documenting alternative mechanisms of media influence, including information, agenda-setting, and framing. While mass media communicate information most citizens remained relatively uninformed about particular topics. Rather than using the media as a source of developing detailed knowledge, most use the media as a heuristic through which to make decisions that emulate the behaviour of the relatively well-informed (e.g., journalists) (Lupia, 1994). Agenda-setting theorists argue that the media shapes the picture of the world in people's heads which, in turn, creates a sense of what the most important current issues are, e.g. immigration (Mccombs and Shaw, 1972). Media also affects framing, the process by which people develop a particular conception of a specific topic, which in turn influences attitudes (Chong and Druckman, 2007). For example, certain newspapers may frame the riots within the context individual moral failure or they may frame it as a response to material deprivation (Lightowlers, 2015). Selecting a particular frame for the riots may then influence whether people feel sympathy for the rioters. Whether or not the media is able to influence public opinion through these processes has implications for its role in a functioning democracy (Baker, 2007). The rise of the mass media has been coupled with concerns that a small number of actors influences public opinion through media content. However, if the media has only minimal effects on political attitudes then the influence of ownership on content becomes less important. By contrast, if the media is able to shape political attitudes through persuasion, agenda-setting and/or framing, and ownership influences content, then the role of ownership and the media in facilitating public debate in a democracy becomes a critical issue. These concerns formed part of the motivation for the recent Leveson inquiry into press standards in the UK, which drew substantial public attention by shining a light on the relationships between the media and political leaders. --- Media coverage of the 2011 riotsthe link to welfare recipients Although the print media in the UK remains highly partisan and right-leaning, is there evidence that this influenced reporting of the riots? Certainly, prominent political leaders on the right made an explicit link between welfare recipients and the riots. Prime Minister David Cameron suggested that if people in social housing "misbehave, [they could] be thrown out of [their] house" (11/8/11). As noted above, Secretary of State for Work and Pensions Iain Duncan Smith (supported by the Prime Minister) also called for extensions to the law allowing the government to remove state assistance from those convicted of rioting (15/8/11). This relationship between the riots and welfare benefits was also reflected in mainstream media coverage. However, there were strong differences between media outlets, both in the frequency with which the riots-welfare link was made, and in the tenor of this content. To investigate these differences, we examined coverage of the riots in two right and left-leaning newspapers (The Daily Mail/Mail on Sunday, and the Guardian/Observer), and on the BBC News website (the UK's most popular internet news source at this time, based on data from the British Social Attitudes Survey) (see Web Appendix 1 for more details on how we examined newspaper coverage). Searching the Lexis Nexis news database for the period August 6 th -Sep 10 th (the week of the riots and the month following) we found 893 articles across the four newspapers which directly addressed the riots. Within this group we then identified 109 articles which additionally included a reference to welfare benefits (12% of the total coverage of the riots in these newspapers). Examining the sources separately, we found that 9% of Guardian/Observer and 18% of Daily Mail/MoS articles on the riots made a connection to welfare. Searching the BBC News online archive using the same method we found that only 4% of BBC News articles on the riots made the link to welfare. We subsequently manually coded articles linking the riots to welfare into the following three categories: 1. Positive (articles supportive of welfare claimants, e.g., an article describing the proposal to remove benefits from convicted rioters as "fundamentally wrongheaded" (Comment is Free, 29/8/11); 2. Negative (articles critical of welfare claimants, e.g., an article citing "welfare handouts" as one of the factors leading to the behaviour of the "young thugs" (Shipman,11/8/11); and 3. Neutral (articles with a balanced view, e.g., an article discussing the proposal to dock benefits for convicted rioters without positive or negative commentary (Wintour,7/09/11). Using this coding scheme, we found that 59% of Guardian/Observer articles linking the riots to welfare were positive, 34% were neutral, and 6% were negative. In the Daily Mail/MoS 7% were positive, 13% were neutral, and 80% were negative. On the BBC News website 10% were positive, 90% were neutral, and none were negative. This largely neutral line taken by the BBC News website is also likely to have been reflected in its television coverage of the riots. Consumers of different sources of news media received diverging pictures of the riots. Newspaper readers, and particularly readers of the right-leaning Mail papers, were exposed to a substantial volume of coverage linking the riots with the welfare system and with welfare recipients; whereas readers relying primarily on the BBC News website were not so exposed. Readers of the Mail would also have been more frequently exposed to coverage which portrayed welfare benefit claimants in a negative light and argued that welfare dependency was a strong cause of the riots. Coverage of this type was also common in other right-leaning newspapers such as The Sun and The Daily Express. In contrast, non-readers (e.g., web or TV news consumers) may become more sympathetic to welfare recipients because the coverage in these alternative sources was more likely to explain the riots in terms of deprivation or other social explanations. People are obviously exposed to a variety of media sources and so readers of left-leaning papers or of BBC News were aware of the government's linking of welfare policy to the riots; but such claims would have been more consistently counterbalanced (or potentially overwhelmed, in the case of left-wing newspapers) by other viewpoints. --- Hypotheses The media coverage of the riots allowed us to test theories of media persuasion in the context of attitudes toward welfare recipients. The riots were a huge national event in the UK and received blanket media coverage. Readers of the print media were presented with very different messages about the rioters than were non-readers, specifically with respect to the link between the riots and welfare claimants. We would therefore expect attitudes toward welfare recipients to diverge between these groups after the riots had occurred. Specifically, we expected that after the riots the attitudes of newspaper readers would differ more strongly in a negative direction from those of non-readers. We predicted that this effect would be strongest between readers of right-wing newspapers, such as The Sun and The Daily Mail, and non-readers. Commentary linking welfare recipients to the riots focused most strongly on the concept of 'deservingness'. That is, the debate centred on whether rioters (the majority of whom were assumed to be claiming state benefits) were deserving of welfare. We therefore predicted that the effect of newspaper coverage of the riots would be strongest for attitudes relating to deservingness; for example, whether people believed that most people receiving welfare really deserved help. --- Data and method We used data from the 2011 wave of the British Social Attitudes (BSA) survey (N=3,311). The BSA is an annual cross-sectional survey that uses multi-stage stratified random sampling to obtain a nationally representative sample of the British adult population. The sample of addresses was drawn from the Postcode Address File and one adult (18+) was selected within each selected dwelling unit. Weighting is used to correct for the unequal selection probabilities arising from these procedures. More details of the survey are available from the UK Data Archive (Stafford, 2011). Data collection for the 2011 wave began in June 2011 and ended in November 2011. Respondents interviewed prior to the riots (i.e. prior to the 6 th of August) constituted the pre-treatment sample, and those interviewed in the month after the riots (10 th of August -10 th of September) constituted the post-treatment sample. In order to focus on the immediate aftermath of the riots, we excluded respondents interviewed while the riots were still ongoing, and those interviewed more than a month after they were over. The interview date variable is not publicly available in the 2011 version of the data set but is available from NatCen on request (subject to a small processing fee). One of the aims of the BSA survey is to assess attitudes towards the welfare state and toward recipients of welfare. Media coverage linking the riots to welfare policy focused strongly on whether welfare claimants were truly deserving of the help they received. Consequently we primarily examined the impact of the media's coverage of the riots on responses to three attitudinal items in the BSA (each of these items was put as a statement, with which respondents were required to indicate their agreement on a 1-5 scalewe re-scored these items such that 1 indicated strong disagreement and 5 strong agreement): 1. Many people who get social security don't really deserve any help 2. Around here, most unemployed people could find a job if they really wanted one 3. Most people on the dole are fiddling in one way or another We also examined changes in attitudes toward the welfare state in general using the BSA's welfarism scale. This is a cumulative measure derived from eight questions; including whether respondents believe the welfare state is Britain's greatest achievement and whether welfare stops people from standing on their own two feet. In the BSA dataset, this item is scored on a 1-5 scale, with lower scores indicating greater support for the welfare state. In our analysis we have inverted the scale to aid interpretation. As a check on our findings, we replicated our primary analyses in the 2005, 2007, and 2008 waves of the BSA. These are waves for which the exact interview date of each participant is publicly available, and in which no nationwide rioting occurred. --- Study design The occurrence of the riots in roughly the middle of the 2011 BSA data collection period create conditions approximating a natural experiment. Natural experiments commonly have three characteristics: 1) they are observational studies, 2) where some people are exposed to a particular intervention or event and others are not, and 3) the exposure to the intervention is not controlled by the researchers. One important component of natural experiments is that exposure to the intervention should approximate the conditions of an actual experiment. In other words, assignment to the intervention should be random or 'as-if' random. In this study we assume that BSA data collection was not causally related to the riots, and that the riots did not affect the data collection (i.e. who was sampled and when they were sampled). Proceeding from this assumption, we argue that the pre-riots data collection forms one nationally representative sample and the post-riots data collection forms another nationally representative sample. The only difference between these two groups should be their knowledge of the riots. If this is not the case then it is possible that our results may have been influenced by some confounding factor. For example, did the riots change 1) the number of people reading a newspaper, 2) the ideological slant of the newspapers that individuals read, or 3) support for particular political parties? We found that the riots were not associated with a shift in the ideology of newspaper readership (p = 0.16) or in the number of people who were reading a newspaper (p = 0.96). We also observed no change in party identification across this period (p = 0.14). We also tested whether there were differences in the socio-demographics of the sample before and after the riots but found no qualitative differences between these periods (Table 1). [Table 1 here] Further we examined whether there were regional differences in the data collection. Here we found that Welsh respondents (n = 135) were more common before the riots while Scottish respondents were more common after the riots (n = 167). As relatively small proportions of the entire sample, these variations are unlikely to influence our results (see Table 1). Both Wales and Scotland are left-leaning areas that might be more sympathetic to welfare recipients and so the influence of the data collection on the sample composition would be minimal (given that the Welsh sample is more common before the riots and the Scottish sample after). This is confirmed in Table 1 where support for the Conservative party does not vary over time. We also find no difference in whether people support both increasing taxation and spending more on welfare, education, and health across this same period (Difference between pre-and post-riots sample = 0.002, p = 0.95). To ensure these differences are not altering our results we adjust for region in our models as a robustness check. --- Statistical analysis To estimate the effect of the media on attitudes toward welfare recipients we used differencein-difference models (DiD). DiD models are a form of fixed-effects estimation which estimate differences in the mean value of an outcome of interest for two (or more) populations over a specific time period (Angrist and Pischke, 2009). This approach removes some of the bias created by consistent differences between these groups (Angrist and Pischke, 2009). The strength of this econometric technique is that it mimics an experimental research design using observational data by estimating the effect of an intervention on an outcome by comparing the average change in the intervention group with the average change in the nonintervention group. Ideally, repeated observations would be measured within the same individuals over time but this technique is widely used with repeated cross-sectional data (Angrist and Pischke, 2009). One of the innovative components of this research is combining this within sample contrast (which views the data as repeated cross-sections) with this DiD approach. This modelling framework estimates differences in attitudes toward welfare recipients before and after the riots for newspaper readers vs. non-readers. Eq. 1: Intervention effect = (W <unk> Post, read -W <unk> Pre, read ) -(W <unk> Post, non -W <unk> Pre, non ) W <unk> is a measure of the average level of support for welfare recipients among a particular group of people (readers versus non-readers) at a particular time (pre-and post-riots). W <unk> is a vector of three different attitude measures, as described above. The subscript Post refers to those people interviewed after the riots while the subscript Pre indicates those who were interviewed before the riots. The subscript read indicates those who self-reported reading a newspaper either before or after riots while the subscript non refers to those who self-reported that they did not read a newspaper before or after the riots. To clarify this estimation procedure, consider Jane, who was interviewed after the riots and reads a newspaper. Her answers to these attitudinal questions about welfare recipients (W Post, read ) will be included in the measure of the average level of support for welfare recipients among other individuals who were also interviewed after the riots and who read a newspaper (W <unk> Post, read ). However, because of this she cannot be a member of any of the other three averages (W <unk> Pre, read, W <unk> Post, non, W <unk> Pre, non ). The intervention effect is our coefficient of interest and is the difference between these two observed effects for readers and non-readers, yielding the main difference-in-differences estimator (Angrist and Pischke, 2009). To put this equation (eq. 1) into a linear regression framework we can write the difference-indifference estimator as: Eq 2: Welfare attitudes it = <unk> 1 Non -readers it + <unk> 2 Readers it + <unk> 3 Riots t + <unk> 4 Readers i <unk> Riots t + <unk> Where <unk> 1 estimates the average level of support for welfare recipients among those individuals interviewed before the crisis (this becomes the constant). <unk> 2 estimates the difference between readers and non-readers in the average level of support for welfare recipients. <unk> 3 estimates the difference in the average level of support for welfare recipients for non-readers before-and-after the riots. Changes in this latter group reflect what would have happened had the readers been non-readers and includes other background trends. <unk> 4 is the coefficient of interest and estimates the change in the difference in the average level of support for welfare recipients between readers and non-readers after the riots. <unk> is the error term. To test our hypotheses we set up four intervention-control pairs. First, we compared all newspaper readers with all non-readers. Second, we compared only readers of right-leaning newspapers with all non-readers. Third, we compared readers of all left-leaning newspapers with all non-readers. Fourth, we compared those who read online news (predominantly the BBC news website) with other non-newspaper readers. This final contrast was intended to investigate the attitudinal effect of the riots on readers of a non-partisan news source. We use the BBC News website primarily because it is the largest online source of news in our sample that we can identify. After the BBC (n = 758), the next largest online news outlets in the BSA sample are Sky News (n = 92) and the Daily Mail (n = 85). During the riots the BBC News website received huge attention, with 10.9 million unique UK users on 9 August 2011 alone (Wilson, 24/07/13). Theoretically, the BBC also represents a useful comparison due to its strong stated emphasis on objectivity and neutrality. Previous research indicates that both education and party identification influence newspaper readership and attitudes toward welfare. Consequently, in the main models reported below we adjust all our estimates for education and party identification. To test the robustness of our findings, we report the unadjusted findings (without controlling for education and party identification) and we report a fully adjusted model which controls for other key sociodemographic confounders, including age, gender, marital status, social class, whether respondents watch television news, whether respondents read the news online, and their geographical region of residence. Adjusting for the impact of these other news sources, such as television and online is particularly important because they may also influence attitudes. Unfortunately we do not have data on radio news and so this is not included in the analysis. All analyses are weighted using the BSA population and design weights. --- Results Table 2 shows that, before the riots, there were no significant differences between newspaper readers and non-readers in their attitudes towards welfare recipients on any of the three measures. However, after the riots, attitudes diverged. Newspaper readers became more likely than non-readers to believe that those on welfare did not really deserve help, that the unemployed could find a job if they wanted to, and that those on the dole were being dishonest in claiming benefits. Common among studies of social attitudes, the R 2 in these models is quite low, approximately <unk>0.05 (Cohen, 1977). Figure 1 shows that the source of this divergence is both an increase in negative attitudes among readers and a decrease in negative attitudes among non-readers. 1 1 There were no overall differences in welfare attitudes between the pre-and post-riots samples. Post-riots respondents were not more or less likely to believe welfare recipients deserved help (Difference in means = -0.026, p = 0.55, n = 2160), whether they could find a job (Difference in means = 0.025, p = 0.58, n = 2161) or whether they were fiddling the dole (Difference in means = -0.008, p = 0.85, n= 2159) (Web Appendix 2). However, the difference-in-difference models revealed a substantial divergence in attitudes between newspaper readers and non-readers pre-and post-riots. Our models show that the attitudes of newspaper readers and non-readers diverged by approximately 0.25 points following the riots (on a 5 point scale). Taking the whole scale into account, this is a fairly small effect. But, given that this divergence occurred over a relatively short period of time, it is surprisingly large. To put these effects into a more readily interpretable context we also re-estimated the models in table 2 using logistic regression models (1 = agree or strongly agree with statement; 0 = otherwise). Before the riots occurred, approximately 36% of readers and 36% of non-readers believed welfare recipients "don't really deserve help". After the riots, 41% of readers and 30% of non-readers believed the same statement. Similar results can be observed for the other two measures of support for welfare. [Table 2 here] [Figure 1 here] We also examined attitude differences for other groups of news consumers: those who only reported consuming print news, those who only reported consuming web news, those who reported consuming both web news and print news, and those who did not consume any of these forms of news. Only the print media readers diverged from the non-news consumers in terms of their attitudes towards welfare recipients over the riots (Web Appendix 3). Across this period web news consumers and non-consumers exhibited a non-significant decline in negative attitudes towards welfare recipients (Figure 2). Similar trends are observed for those who only consume TV news (Web Appendix 4). This suggests that the decrease in support for welfare recipients across this period among newspaper readers may be set against a background of generally increasing support in the rest of the population. [Figure 2 here] Having observed a significant divergence between all newspaper readers and non-readers, we subsequently examined the impact of the riots on readers of right and left wing papers separately. This distinction tests whether, as anticipated, the divergence between the print media and non-readers is concentrated among right-leaning newspapers rather than leftleaning newspapers. Similar to the results shown in Table 2 for newspaper readers in general, Table 3 shows that before the riots there were no differences in attitudes between readers of right-leaning papers and those who did not read newspapers. After the riots, readers of rightwing papers were more likely than non-newspaper readers to agree that welfare recipients didn't really deserve help and that they could find a job if they really wanted to. They were also somewhat more likely to agree that most people on the dole were 'fiddling', but this difference was not statistically significant at the <unk> = 0.05 level. Table 3 shows that the results for left-leaning newspaper readers were contrary to our expectations. The coefficients indicating the divergence of left-wing readers from nonnewspaper readers are in the same direction and are similar in size to those for right-wing readers. In fact, in the case of 'could find a job', the divergence for left-wing readers is actually somewhat larger (0.29 versus 0.26). This could constitute evidence against our preferred explanation for these results (an effect of media coverage focused on right-leaning newspapers). However, the sample of readers of left-leaning newspapers was extremely small, meaning that our estimates are highly uncertain. [Table 3 here] --- Impact of the riots on alternative indicators of welfare support and other social attitudes The BSA includes other indicators of attitudes toward the welfare state and welfare recipients (Web Appendix 5). These measures are less focused on deservingness, and we therefore expected them to be less influenced by media coverage of the riots. As predicted, we did not observe any clear patterns of divergence on these alternative attitudinal measures. However, using the BSA's welfarism scale, which is a cumulative measure incorporating all of the welfare attitude items, we observed that newspaper readers became less sympathetic towards welfare recipients than non-readers after the riots (Web Appendix 5). As a further check on our findings, we investigated the effect of the riots on attitudes towards non-welfare and non-riot related topics. If these attitudes also changed over the riots period, it would point towards an alternative explanation than an effect of the riots themselves. We replicated our primary analyses with four different attitudinal measures: 1) whether respondents agreed that big business primarily benefits the owners, 2) whether respondents agreed that there is one law for the rich and one law for the poor, 3) whether they agreed that censorship is necessary to uphold moral standards, and 4) whether they agreed that corporate management try to get the better of their employees (Web Appendix 6). Consistent with our predictions, there was no divergence in any of these variables before and after the riots in 2011. --- Counterfactual analysis In the above analyses we assumed that the division of the BSA 2011 sample into pre-and post-riots observations was 'as if random'. However, there may be systematic unmeasured differences between those who responded to the survey prior to August 6 th, and those who responded between August 10 th and September 10 th ; for example a seasonality effect. To check this possibility we therefore re-ran our analyses in three previous BSA waves for which the respondent interview date is publicly available; 2005, 2007, and 2008 (see Web Appendix Tables 789101112). In 2005 we found no evidence of a divergence in welfare attitudes between newspaper readers and non-readers across the 'riots' period. We also found qualitatively similar results for 2007 (Web Appendix Tables 9 and10) and 2008 (Web Appendix Tables 11 and12). Taken together, the divergence in support for welfare recipients observed in 2011 has not been observed in previous years. --- Sensitivity analyses We conducted a series of additional sensitivity tests to ensure our findings are consistent across different model specifications. We re-ran the analyses including all respondents interviewed after the 10 th of August in the post-riots sample. This did not qualitatively alter our results but the impact of the media on whether respondents believe welfare recipients are cheating the dole was attenuated slightly (p <unk>0.1) (Web Appendix 13). Variation in the proportion of refusals or don't knows across the study period could influence these findings but we find that this does not vary between the pre-and post-samples on any of the three primary welfare questions, e.g., those on benefits deserve help (p = 0.15). Many factors influence why people read particular newspapers and also their response to an event such as the riots. We therefore re-estimated our primary models, additionally adjusting for age, gender, marital status, social class, geographical region, whether respondents watch the news on TV, and whether respondents read the news online, finding that our results did not qualitatively change (Web Appendix 14). We also re-estimated our models removing all other covariates, i.e., without controlling for education or support for political party, and again found that our results did not change (Web Appendix 15). Given our unexpected findings for left-leaning newspaper readers (see Table 3 and accompanying text), we decided to directly test the divergence between this group and rightleaning newspaper readers using the same methods as previously.. Here, the models are inconclusive. The results are somewhat contrary to our expectation that readers of rightleaning newspapers would become less sympathetic to welfare recipients than readers of leftleaning papers. We find that the coefficients are in the expected direction in three case but one of these is almost negligible ('Dole cheating') whereas two of them (Don't really deserve help' and 'Support for the welfare state') are comparable with the coefficients observed in table 3, which compare right-leaning readers and non-readers. Our results also suggest that readers of left-leaning papers became slightly more likely to believe that unemployed people could find a job if they want to. However, none of these differences were statistically significant at the <unk> = 0.05 level, likely because this contrast is under-powered given the small number of left-leaning newspaper readers (see Web Appendix 16). The observed changes in welfare attitudes may be driven by an effect of the riots on respondents' perceptions of threat. The riots, as a threatening event, may have made newspaper readers more fearful and mistrustful of others, with changes in their welfare support being a symptom of this broader effect (Kaariainen and Lehtonen, 2006). To test this possibility we examine whether there are changes in the level of social trust over this period. We find that after the riots there is no significant difference in the level of social trust between newspaper readers and non-readers (Difference-in-differences <unk> = 0.07, p = 0.26). Finally, we considered the possibility that those with less interest in politics may be more uncertain in

Following the shooting of Mark Duggan by police on the 4 th August 2011, there were riots in many large cities in the UK. As the rioting was widely perceived to be perpetrated by the urban poor, links were quickly made with Britain's welfare policies. In this paper, we examine whether the riots, and the subsequent media coverage, influenced attitudes toward welfare recipients. Using the British Social Attitudes survey, we use multivariate differencein-differences regression models to compare attitudes toward welfare recipients among those interviewed before (pre-intervention: i.e. prior to the 6 th of August) and after (postintervention: 10 th of August -10 th of September) the riots occurred (N = 3,311). We use variation in exposure to the media coverage to test theories of media persuasion in the context of attitudes toward welfare recipients. Before the riots, there were no significant differences between newspaper readers and non-readers in their attitudes towards welfare recipients. However, after the riots, attitudes diverged. Newspaper readers became more likely than nonreaders to believe that those on welfare did not really deserve help, that the unemployed could find a job if they wanted to and that those on the dole were being dishonest in claiming benefits. Although the divergence was clearest between right-leaning newspaper and nonnewspaper readers, we do not a find statistically significant difference between right-and left-leaning newspapers. These results suggest that media coverage of the riots influenced attitudes towards welfare recipients; specifically, newspaper coverage of the riots increased the likelihood that readers of the print media expressed negative attitudes towards welfare recipients when compared with the rest of the population.

non-readers. Our results also suggest that readers of left-leaning papers became slightly more likely to believe that unemployed people could find a job if they want to. However, none of these differences were statistically significant at the <unk> = 0.05 level, likely because this contrast is under-powered given the small number of left-leaning newspaper readers (see Web Appendix 16). The observed changes in welfare attitudes may be driven by an effect of the riots on respondents' perceptions of threat. The riots, as a threatening event, may have made newspaper readers more fearful and mistrustful of others, with changes in their welfare support being a symptom of this broader effect (Kaariainen and Lehtonen, 2006). To test this possibility we examine whether there are changes in the level of social trust over this period. We find that after the riots there is no significant difference in the level of social trust between newspaper readers and non-readers (Difference-in-differences <unk> = 0.07, p = 0.26). Finally, we considered the possibility that those with less interest in politics may be more uncertain in their attitudes towards welfare recipients, and therefore that they may be more likely to change their views due to media reporting. First, we examined whether the politically interested and non-interested diverged in their attitudes toward welfare recipients across this period. We find no evidence of divergence on all three measures; deserve help (p = 0.91), find a job (p = 0.72), or 'fiddling' the dole (p = 0.47). --- Discussion The not-so-minimal effects of the media These findings contribute to a growing literature using design-based research (such as natural experiments) to estimate the effect of the media on political preferences and attitudes. Consistent with this literature on media effects, our results suggest that print media coverage of the riots increased negative attitudes toward welfare recipients. While growth in the number of outlets has fragmented the media market, this has not necessarily reduced the media's impact on political attitudes. Especially in the United Kingdom, where the print media remains a highly centralized and important source of information regarding current affairs and political debate, the media's persuasive power remains. Although the fragmentation of the mass media may undermine the impact of any particular news outlet, this diversification may also allow the media to increasingly mediate the way in which people perceive the social world. Mediatization refers to how the media actively shapes the political discourse (Mazzoleni andSchulz, 1999, Kepplinger, 2002). The media are not passive transmitters of information or facts. They frame, construct, and shape the information they receive (Stromback, 2008). Readers and viewers are then exposed to these messages andas our results indicatedevelop mediatized political attitudes based on this narrative. For example, this mediatized political narrative influences whether people believe those receiving unemployment benefit are able to find a job or not regardless of whether there are jobs available. Additionally, the Department for Work and Pensions' estimates of the extent of benefit fraud have been below 5% since 2004 and yet after the riots newspapers readers, compared with non-readers, became more likely to believe that'most people on the dole are fiddling one way or another'. These fluctuations do not reflect an objective reality but rather reflect the capacity of the news media to create a narrative through which the social realities of unemployment, social welfare, and the economy are understood. This sudden shift in attitudes toward welfare recipients in 2011 must be set against a backdrop of increased negativity in media coverage of welfare in the UK over the last 20 years. The extent of coverage has not radically increased but the tone became noticeably more negative around 2010 (Baumberg et al., 2012). Given this trend, could coverage of a single event influence attitudes? Certainly the riots were only one event, but they were a uniquely large and conspicuous event in recent UK history, receiving blanket and continuous coverage while dominating the national conversation for a substantial period. Our results suggest this did indeed have a measurable effect on welfare attitudes among newspaper readers while analysis of previous years showed no similar effects. The controversy regarding media effects has been difficult to resolve because capturing the influence of the mass media is challenging (Brynin andNewton, 2003, Ladd andLenz, 2009). Design-based research has been able to address some of these challenges while consistently providing evidence of the continued impact of the media on partisanship and political attitudes, suggesting the process of mediatization shapes perceptions of the social world. --- The persuasive power of the media What is less clear from these findings is the mechanism by which readers alter their perceptions of the social world. Two main possible mechanisms have been suggested in the literature. First, political attitudes may be derived from social group membership (Green et al., 2002). In making decisions about political attitudes, Green et al. argue that people consider the different social groups which they believe align (or not) with different attitudes. They then ask themselves whether they are a member of that group. The implication is that if a person views themselves as a Daily Mail reader, and the Daily Mail argues that rioters are predominantly benefit claimants who do not deserve help, then they will be more likely to support this position. Alternatively, persuasion may affect readers because beliefs change. By this view, Daily Mail readers (for example) are (semi-)rational actors who adopt new beliefs based on the evidence presented to them (DellaVigna and Gentzkow, 2010). Although decisions about beliefs often rest on imperfect memories, double-counting repeated information, and other forms of judgment errors, they still reflect changes in belief based on information that is communicated from a sender to a receiver. In this view, persuasion should be more effective when recipients are more uncertain about the truth and yet we do not find unqualified support for this mechanism. The apparent effect of print media coverage of the riots on attitudes toward welfare was clearest for readers of right-leaning papers. However, we were unable to statistically distinguish the between readers of left and right-wing papers in terms of these effects (see Table 3 and Web Appendix 16). In fact, in some cases the coefficients suggested a slightly larger negative media effect among left-wing readers. Broadly, there are two possible explanations for these results. First, our sample of left-wing newspaper readers was very small, and our estimates of the media effect for this group are consequently highly uncertain. It is possible that, given a sufficiently large sample of left-wing newspaper readers, we would observe that their attitudes were indeed less negatively affected by media coverage of the riots than were readers of right-wing papers. Alternatively, the results may reflect a genuine similarity in the effects for both left and right-wing print media consumers. This would be difficult to explain on the basis of the content of the media coverage, and would therefore likely point to an alternative explanation for our findings. In contrast to the right-leaning papers, non-readers became more sympathetic toward welfare recipients. This increase in sympathy is consistent with the non-print media coverage, e.g., BBC Online News (which, as noted above, is likely to also represent the tone of the coverage of BBC television news), suggesting that media coverage from these sources also influenced attitudes. If interest in politics does not explain these findings, are they driven by group identification? While Daily Mail readers might view themselves as part of a group of likeminded individuals, it might be surprising to find that BBC Online News readers would view themselves in the same way. In fact, television and radio news content may not evoke the same degree of group identity potentially associated with the print media. In short, while there are no clear theoretical reasons why partisan media of any ideology (or even neutral media) would not have similar effects on readers, more research is needed to understand the mechanisms through which newspapers and other forms of media, such as television and radio, may influence attitudes. --- Democracy and ideological diversity Although developing a detailed model of the role of the media in democracies is beyond the scope of this paper, these results do raise some questions about this relationship, particularly around the issue of media ownership. Faced with the rise of the mass media, many governments have implemented regulation to restrict the concentration of power in media markets. Two ideas underline why governments have regulated media ownership. First, media markets that are not regulated will tend to produce ideological homogeneity. Second, this homogeneity will influence citizens. Based on these two ideas, governments regulate media markets in an effort to create ideological diversity, which is assumed to enable citizens to make more informed political decisions (Baker, 2007). But are unregulated markets more likely foster ideological homogeneity? If newspapers reflect rather than create public opinion then ideological homogeneity may be driven by the public rather than owners of media outlets. For example, if the public is already ideologically homogenous then a newspaper may seek to maximize profits and secure a larger market share by bringing their ideology in line with that of the public. By this view, the impact of owners on shaping content is considered to be minimal (Gentzkow and Shapiro, 2010). Evidence supporting this process mostly comes from the US where the majority of newspapers serve relatively local markets. This is problematic because newspapers tend to be less partisan in more localized markets where they need to appeal to a larger proportion of the community (Dalton et al., 1998). Yet, even in the US, newspaper owners shape content to reflect their own preferences. Ownership influences the extent of election coverage around particular issues (Dunaway, 2008) as well as the slant of the coverage on those same issues (Gilens and Hertzman, 2000). The UK is no exception. Two of the largest national newspapers are owned by Rupert Murdoch, who is unabashed about the influence of his right-wing political views on the content of his newspapers. Regulation has often been used to minimise the ideological homogeneity created by ownership. In the UK, for example, radio and TV are legally bound to present balanced political news coverage and to limit political editorializing (Brynin and Newton, 2003). We found that consumers of these media sources (television news and the online news service provided by the BBCwhich is primarily a broadcast service) were not affected by the riots in the same way as were readers of the highly partisan print media. The partisan print media seems to affect consumers in ways that are distinct from the regulated broadcast media; suggesting that more diversity among the print media may influence political attitudes in the population. Recent trends in public policy have weakened safeguards intended to prevent the consolidation of media ownership, which may reduce diversity among the print media. Since the 1990s both the Conservative and the Labour party have issued policy statements which stress the importance of ideological pluralism and diversity for democracy (Department of National Heritage, 1995, Department of Media Culture and Sport (DMCS), 2001). Yet, these statements have been concurrent with policy changes which allow increased consolidation of media ownership. Of course, these issues not only apply to the relationship between welfare and social protection but also have implications for other policy domains, such as the environment. Gavin and colleagues have examined the mediatisation of climate change in the UK and beyond (Gavin and Marshall, 2011). They argue that the media's coverage of these issues is both agenda-setting and communicating important information but this coverage has, at times, been too heavily influenced by climate change sceptics (Gavin et al., 2011). As a result, people may have become more confused about climate change (Gavin and Marshall, 2011). Bringing these two research streams together has a number of implications. First, it raises questions regarding the role of the media in fostering (or hindering) public debate. For example, it may give the impression that there is a climate change debate when there is not or it may give the impression that welfare fraud is common when it is not. Second, it highlights the role of vested interests in these political debates. Here the issue of ownership is again highly salient but more research is required, inside and outside the US, regarding whether ownership influences content and on what specific issues. This cross-national approach is critical because there is likely to be variation across contexts in whether climate change scepticism is associated with political ideology and therefore whether it would influence content. Taken together, these examples highlight that the role of the media in democracies requires more sustained engagement across a range of topics, including welfare, climate change and others. Results from this study suggest media coverage can influence public attitudes towards vulnerable groups. Given this association, the implications of increasing consolidation of media ownership, and the consequent ideological homogeneity of media content, requires further debate. --- Limitations Our study has several important limitations. First, because we relied on a within-sample contrast between those interviewed for the BSA before the riots and those interviewed afterward, we were unable to estimate attitude change within individuals over time. A second concern is that the pre-and post-riots split in the sample was not 'as-if' random and that unobserved differences between the samples may remain, e.g., regional differences. While we cannot rule this out entirely, we do not find significant difference between these samples on a range of socio-demographic indicators, offering some support for this assumption. Third, people often select the news media they consume based on pre-existing preferences, which may reflect their increased susceptibility to arguments about the deservingness of welfare recipients. Not only did we fail to find significant differences between readers and nonreaders before the riots but our findings were not explained by party identificationa useful proxy for existing preferences. Fourth, it is impossible to disaggregate the effect of the riots themselves on attitudes, separate from the media effects. This is because media effects spillover and influence those who may not consume the mass media. In other words, there is no clear intervention and control group because those who'read a newspaper' are still friends with and talk to those who are not. A final limitation of this study is that we were not able to capture the long-term effects of the riots on attitudes towards welfare recipients. Nevertheless, we were able to show that an effect persisted some weeks and even months after the riots had ended. Although these effects may not reflect permanent attitudinal change, they are not necessarily short-lived. --- Conclusion The 2011 riots raised the profile of issues related to the deservingness of welfare recipients. Our findings suggest that media coverage of this event was able to significantly affect attitudes towards this group over the short-term. Specifically, those exposed to print media (but not those exposed to broadcast or web news) diverged significantly from the rest of the population in terms of their negative attitudes towards welfare recipients. These findings have implications for future policy debates. Attitude divergence in the shortterm was observed among those consuming the highly partisan print media (although, as noted above, we were unable to clearly differentiate between readers of right-and left-leaning newspapers). Highly partisan print media appears to influence consumer's beliefs about the social world in ways that are distinct from non-partisan consumers (such as the television news or the online news service provided by the BBC), suggesting that the regulatory requirement of ideological neutrality of the TV media and the BBC may have consequences for political attitudes in the UK. These results should prompt further debate concerning how media influences attitudes and whether media partisanship coupled with highly centralized ownership is a public concern. Figure 1: Attitudes towards welfare recipients before and after the riots, by newspaper readership Figure 2: Attitudes towards welfare recipients before and after the riots, by web news readership Table 1: As-if randomization tests for pre-and post-riots samples Table 2: Effect of newspaper readership on attitudes toward welfare recipients before and after the riots, from linear difference-in-difference models Table 3: Effect of partisan newspaper readership on attitudes toward welfare recipients before and after the riots, from linear difference-in-difference models Web Appendix 16: Effect (<unk> coefficients) of the ideology of newspaper readership on attitudes toward welfare recipients before and after the riots, from linear difference-indifference models --- Figures and Tables Web Appendix 1: Description of the method for analysing content of print and online media For the print media sources we searched the Lexis Nexis news database for the period August 6 th -Sep 10 th (the week of the riots and the month following) for any article published in the relevant sources which included "riots" as an index term, and which also included this term at the start of the article (using the Lexis Nexis option to exclude duplicates based on moderate similarity). We manually excluded articles in which the riots were not the primary topicfor example, celebrity interviews where the riots were mentioned. This left 893 articles across the four newspapers which directly addressed the riots. Within this group we then identified 109 articles which additionally included a reference to welfare benefits (12% of the total coverage of the riots in these newspapers). Examining the sources separately, we found that 9% of Guardian/Observer and 18% of Daily Mail/MoS articles on the riots made a connection to welfare. Articles published on the BBC News website are not systematically archived on the Lexis Nexis newspaper database. We therefore searched the BBC News online archive directly using the same terms and exclusion criteria (additionally excluding articles which were primarily advertisements for upcoming BBC broadcast programs, or invitations to participate in interactive activities like webchats. Only 4% of BBC News articles on the riots made the link to welfare. We subsequently manually coded articles linking the riots to welfare into the following three categories: 1. Positive -Articles were coded as positive if they primarily made arguments supportive of welfare benefit claimants or the welfare systemfor example, that welfare benefit claimants are genuinely in need of help. An example of a positive article from the Guardian described the proposal to remove benefits from convicted rioters as "fundamentally wrongheaded" (Comment is Free, 29/8/11). 2. Negative -Articles were coded as negative if they primary made arguments critical of welfare recipients or the welfare system; for example arguing that welfare recipients are undeserving, or that benefits dependency was one of the primary causes of the riots. An example of a negative article from The Daily Mail cited "welfare handouts" as one of the factors leading to the behaviour of the "young thugs" (Shipman, 11/8/11). 3. Neutral -Articles were coded as neutral if a balanced view of different sides of the debate was presented (for example, where equal space was given to quotes from supportive and critical organisations), or where an event such as a policy announcement was presented without commentary. An example of a neutral article from the Guardian described the government's proposal to dock benefits for convicted rioters without positive or negative commentary. (Wintour,7/ --- Web Appendix Web Appendix 1: Description of the method for analysing content of print and online media Web Appendix 2: Change in attitudes toward welfare recipients before-and-after the riots Web Appendix 3: Effect of media consumption on attitudes toward welfare recipients Web Appendix 4: Attitudes towards welfare recipients before and after the riots, by TV news consumption Web Appendix 5: Effect of newspaper readership on attitudes toward the welfare state before and after the riots, from difference-in-difference models Web Appendix 6: Effect of newspaper readership on other political attitudes before and after the riots, from difference-in-difference models Web Appendix 7: Effect of newspaper readership on attitudes toward welfare recipients before and after riots period in 2005, from difference-in-difference models Web Appendix 8: Adjusted effect of partisan newspaper readership on attitudes toward welfare recipients before and after the riots period in 2005, from difference-in-difference models Web Appendix 9: Effect of newspaper readership on attitudes toward welfare recipients before and after riots period in 2007, from difference-in-difference models Web Appendix 10: Adjusted effect of partisan newspaper readership on attitudes toward welfare recipients before and after the riots period in 2007, from difference-in-difference models Web Appendix 11: Effect of newspaper readership on attitudes toward welfare recipients before and after riots period in 2008, from difference-in-difference models Web Appendix 12: Adjusted effect of partisan newspaper readership on attitudes toward welfare recipients before and after the riots period in 2008, from difference-in-difference models Web Appendix 13: Effect of newspaper readership on attitudes toward welfare recipients including those interviewed after September 10 th 2011 Web Appendix 14: Effect of newspaper readership on attitudes toward welfare recipients before and after the riots, adjusted for socio-demographic variables Web Appendix 15: Effect (<unk> coefficients) of newspaper readership on attitudes toward welfare recipients before and after the riots without control variables, from linear differencein-difference models

Following the shooting of Mark Duggan by police on the 4 th August 2011, there were riots in many large cities in the UK. As the rioting was widely perceived to be perpetrated by the urban poor, links were quickly made with Britain's welfare policies. In this paper, we examine whether the riots, and the subsequent media coverage, influenced attitudes toward welfare recipients. Using the British Social Attitudes survey, we use multivariate differencein-differences regression models to compare attitudes toward welfare recipients among those interviewed before (pre-intervention: i.e. prior to the 6 th of August) and after (postintervention: 10 th of August -10 th of September) the riots occurred (N = 3,311). We use variation in exposure to the media coverage to test theories of media persuasion in the context of attitudes toward welfare recipients. Before the riots, there were no significant differences between newspaper readers and non-readers in their attitudes towards welfare recipients. However, after the riots, attitudes diverged. Newspaper readers became more likely than nonreaders to believe that those on welfare did not really deserve help, that the unemployed could find a job if they wanted to and that those on the dole were being dishonest in claiming benefits. Although the divergence was clearest between right-leaning newspaper and nonnewspaper readers, we do not a find statistically significant difference between right-and left-leaning newspapers. These results suggest that media coverage of the riots influenced attitudes towards welfare recipients; specifically, newspaper coverage of the riots increased the likelihood that readers of the print media expressed negative attitudes towards welfare recipients when compared with the rest of the population.

creation concerning women empowerment with in marriage and Further broad and longitudinal studies are needed to determine the predictors of the problem among female students at Hawassa and Ethiopia as a whole. --- Keywords Sexual violence, Night shift female students, Hawassa city --- Background One of the world's most dominant human rights violations is violence against women and girls it taking place every day, many times over, in every corner of the globe. Violence against women and girls is defined as any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women and girls, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life [1]. One form of interpersonal violence is sexual violence. According to the WHO definition, Sexual violence is any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, against a person's sexuality using coercion, by any person regardless of their relationship to the victim, in any setting [2]. Sexual violence can occur in different forms these include rape with-in marriage, rape by a stranger, sexual abuse of children, forced abortion, forced prostitution, sexual abuse of mentally or physically disabled peoples, forced sterilization, forced exposure to pornography, female genital mutilation, trafficking for purposes of forced prostitution but not limited to this [3]. It takes place within a variety of settings, including the home, workplace, schools, and the community [4]. Schools are an important institution or organization environment that may women's routinely exposed to sexual violence [5]. Among five college females, one of them are victims of acquaintance rape during their academic career and less than 5% of college women who are victims of sexual assault report their victimization globally [6]. A study done on undergraduate students from Columbia University and Barnard College in New York City, established that sexual assault victimization among college students in the United States was higher [7]. Sexual violence is common; it occurs in every culture, in all levels of society and in every country of the world. WHO multi-country study on violence against women in ten countries reported that the lifetime and previous 12 months prevalence of sexual violence against women ranges between 15-71% and 4-54%, respectively [8]. The study done in Chile college students experiences of rape, attempted rape, and other types of forced sexual contact since age 14 were reported by 12.3%, 10.8%, and 25.1% of subjects, respectively [9]. Sexual violence in developing countries is an acute problem because it is related to HIV infections, especially in countries where the infection rate is high. The magnitude of sexual coercion ranges from 5 to 33% among Ugandan university students [10]. The studies conducted in different parts of our country, Ethiopia on prevalence of sexual violence shows different result. A Study conducted among night time secondary and high school students in Hawassa city reported that lifetime prevalence of sexual violence was found out to be 86.4% [4]. The study done in Bahir Dar town showed that among private college female students, 37.3% of college females have experienced some form of unwanted sexual contact [11]. A study from Nekemte town revealed the lifetime prevalence of completed rape, attempted rape and sexual harassment was 20.8%, 23.1% and 41.3% respectively [12]. The consequences of sexual violence were absenteeism, grade repetition, dropout of school, negative and confused believes of self, exposure to sexually transmitted infections and unwanted pregnancy [13]. Behavioral, lifestyle, and relationship factors have all been identified as risk factors that increase a women's vulnerability to sexual violence victimization. However, factors like discussion about reproductive issues with family and family control were factors which decrease vulnerability to sexual violence [14]. The government has adopted legal and policy frameworks to address the problem of sexual violence in Ethiopia. Furthermore, institutional structures including specialized units dealing with the problem of sexual violence have been established at different levels of government. But, because the practice of sexual violence is long rooted in cultural, traditional practices, and religious beliefs, Moreover, Ethiopian Ministry of Health has developed a standard operating procedure for the response and prevention of sexual violence in Ethiopia in 2016,while the problem still is quite pervasive [15,16]. Besides, several studies were undertaken on sexual violence among students in general. Nevertheless, there is paucity of information about sexual violence among night shift students in particular; even if they are more vulnerable to sexual violence due to the nature of the class time. Additionally, the nature of a city; which is the place of many strangers make night shift students susceptible to sexual violence, due to these experts suggested conducting this study. Therefore, this study was aimed to assess the prevalence of sexual violence and its associated factors among night shift female college students in Hawassa city. --- Methods and materials --- Study setting, design and population Institution based cross sectional study was done in Hawassa city administration which is found in Sidama Region, Ethiopia. It is located 275 km away from Addis Ababa, the center of Ethiopia. The city is one of the fastest-growing cities of Ethiopia which is crossed by one main asphalted road from Addis Ababa to Moyle. There are four governmental and twenty-eight private colleges in the city. There are different departments in each college: accounting, management, marketing, secretarial science, surveying, industrial electrical machine, information technology etc. each provided be level 1-5, diploma, degree, and some of them up to masters level. There were 2961 night shift students in governmental colleges; from these 777 were females, and also females comprise 1606 out of 2751 private college nights' students. All night shift female students in Hawassa city private and governmental colleges were the target populations, in which second year and above were considered to draw samples. Selected night shift 2nd year and above female students at the time of the study were participants. All methods were performed in accordance with relevant guideline. --- Source population All night shift female students in Hawassa city private and governmental colleges. --- Study population All night shift 2nd year and above female students in selected private and governmental colleges. --- Study participants Selected night shift 2nd year and above female students who were willing and available during the study period. --- Sample size determination The Sample size was calculated using a single proportion formula. From the study done on female night school students in Hawassa city 26.6% experienced attempted rape in their lifetime [4] p = 0.266, at marginal error of 5% with 95% confidence level which is 1.96. For possible non-response during the data collection time, 15% added which gave a final sample size of 345. n = Z 2 p(1 -p) d 2 = 1.96 2 <unk> 0.266(1 -0.266) 0.05 2 = 300 --- Sampling procedures There are two governmental and twenty-two private colleges which have been providing night shift program. Among twenty-two private colleges, seven colleges were selected by using the lottery method and all government colleges were included. The total sample size was proportionally allocated to each of the colleges based on the number of night shift female students. From selected college students who are 2nd year and above was considered as the study population. Then finally, the study participants were selected by a systematic sampling technique using frame provided by the college registrar N (night shift female student in each college), n (proportionally allocated sample size to each college). K = N/n = 5.5 <unk> 5. --- Operational definition Sexual violence When a female student experienced at least one of the following: rape, attempted rape, and sexual harassment. --- Rape Is the act of forcing a female student through violent threats and deception to engage in sexual behaviors with penetration of the vagina [17]. --- Attempted rape Efforts to rape someone which does not result in penetration with penetration of the vagina [18]. --- Sexual harassment When a female student experienced one of the following: Is unwanted sexual behavior such as physical contacts or verbal comments, jokes, questions, kissing, hugging, and suggestions [18]. --- Substance use Use of at least one of the following substances; alcohol, chat, Shisha, Hashish or drugs that are assumed to affect the level of thinking and increase the risk of involving in sexual violence [12]. --- Early sexual debut When a female student experienced sexual activity at or before 18 years old. --- Data collection tools and procedure The questionnaire adapted from the WHO multi-country questionnaire on violence against women and another internationally developed questionnaire on sexuality was used [19]. The questionnaire was made to measure sociodemographic, socio-economic characteristics and factors associated with sexual violence. Data was collected by nine diploma registrar workers and one BSc holder supervisor was assigned to control the data collection and assist data collectors. Before data collection was started, important communications were made with relevant institutions by using a letter prepared by the Hawassa university department of midwifery with different college's heads. List of night shift female students were taken from the registrar of each college. The selected students were communicated and the purpose of the study was explained by the data facilitators. The questionnaire was distributed to every participant and collected on the same day to ensure confidentiality and prevent information contamination. The data was checked for the accuracy, completeness, and consistency of the information. --- Data analysis The data were entered with Epi data version 3.1statistical software and analyzed by SPSS V.22. Bi variant analysis was carried out to see the association of each independent variable on the dependent variables. Then, Variables with a p value less than 0.25 in bi-variable logistic regression were entered to multivariate logistic regression to adjust the effect of confounders on the outcome variables. Finally, multiple logistic regression analysis techniques were carried out the statistical association was evaluated using odds ratio at 95% confidence interval and a p value less than 0.05. The Hosmer and Lemeshow (HL) test was used to check model fitness in our study. The HL test indicated that our final model was fit (0.906). --- Data quality assurance The questionnaire prepared in English was translated into Amharic, and then back-translated into English to ensure consistency. The questionnaires were pretested on 5% [18] night shift students of the actual sample size in Golden star College in Hawassa city before the actual data collection period. Sensitive questions were tried to be placed later to minimize non-response rate and offensive reaction. The Training was given for both data collectors and supervisor. Data clean up and cross-checking was done before analysis. 1). --- Result --- Socio-demographic characteristics A --- Substance use of students About 89 (27%) of the participants stated that they have a history of alcohol drinking, of those who have a history of alcohol drinking, almost 80 (89.8%) drink occasionally. 56 (17%) of the students have a habit of chewing khat (Catha edulis). Only a few students, 16 (4.8%) reported having smoked cigarettes sometimes. 17 (5.2%) used substances like hashish 6 (1.8%) used cocaine at some point in their lifetime (Table 2). --- Sexual history From the total participants, 233 (70.6%) reported that they had sexual experience. 151 (64.8%) were started sexual intercourse at the age group of 15-18 years old. The mean age and SD for having the first sexual intercourse was found to be 12.5 <unk> 8.3 years. Among the study subjects, 83 (25.2%) of them had experienced two or more sexual partners in their lifetime. The major reasons to do sexual intercourse for the first time were 76 (32.6%) with in marriage (Table 3). --- The prevalence of sexual violence Out of the total study subjects, the prevalence of last 12 month sexual violence was 202 (61.2%) 95% CI (55.8, 66.4) which includes rape, attempted rape and sexual harassment. Last 12 months rape, attempted rape and sexual harassment was 46 (13.9%) 95% CI (10.6, 17.9), 23 (6.95) 95% CI (3.6, 10.9) and 163 (49.4%) respectively. The lifetime rape was 92 (27.9%) 95% CI (23.3, 32.7) and among the raped victims, 49 (53.3%) have reported having at least one incident of rape in their lifetime. The lifetime attempted rape was 122 (37%) 95% CI (32.1, 42.4).from those 44 (13.3%) of the respondents have escaped from attempted forced sex by getting help from other people. At least once form of sexual harassment was reported by 276 (83.6%) in their lifetime. Most of those who reported having been harassed at least ones reported to face unwanted kiss by 121 (43.8%) in their lifetime and 84 (50.6%) face verbal jokes using advanced words and comment on physical appearance concerning sexuality in the last 12 months (Table 4). --- Perpetrators of rape The victims were asked about their perpetuator and 22 (23.8%) of them reported that they were raped by boyfriends, followed by 18 (19.6%) by teachers. The mechanisms used to force the victims into sex differs were, 37 (40.2%) reported that it was after they were threatened of harm, following 26 (28.3%) by drinking a lot. The majority of the victims 37 (40.3%) reported that the age of perpetrators was > 35 years. Out of the total victims, 33 (35.9%) of them faced the rape in their home, following 25 (27.2%) of them in hotels (Table 5). --- Reporting about sexual violence Two hundred sixty five (80.3%) of the study subjects perceived that binge night shift female student was a risk for sexual violence. 61 (66.3%) of the raped study subjects reported that they had told no one about their victimization. Only 15 (16.3%) of the rape was reported to the legal body. The victims of rape were asked about why they did not report to any body and gave different reasons. 30 (39%) were didn't know what to do. 22 (23.9%) of them goes to the health facility and get medical care. Concerning the action taken against perpetrators, in the majority of the cases 72 (77.2%) no legal action was taken (Table 6). --- Factors associated with sexual violence On binary logistic regression analysis, father educational status, educational status of participants marital status, parent living condition, family income, work, being night shift, alcohol use, Impact of poor grade, and having sexual partners were associated with last 12 month sexual violence. But when adjusted only having father with no formal education (AOR = 2.39, 95% CI 1.04-5.33), drinking alcohol (AOR = 3.55, 95% CI 1.84-6.85), having sexual partners (AOR = 1.89, 95% CI 1.03, 3.5) and multiple sexual partners (AOR = 3.44, 95% CI 1.64, 7.2) were significantly associated with last 12 month sexual violence (Table 7). --- Discussion Among a sample of 330 female students who participated in the study, the majority (70.6%) were sexually active. Of those who initiated sexual activity, 28.3% started sexual activity forcefully or as a result of rape. In this study, the prevalence of sexual violence and its associated factors were identified. The findings from this study showed that more than half of students had experienced different forms of sexual violence for the last 12 months period. The prevalence of last 12 month sexual violence was 202 (61.2%) 95% CI (55.8, 66.4) which includes rape, attempted rape and sexual harassment. The result of this study was lower compared to study conducted among night shift secondary school and high school female students in Hawassa town indicated that prevalence of last 12 month sexual violence was 68.4% [4]. The difference might be due to that study used large sample size and study period. The current study showed that the last 12 month prevalence of sexual violence among night shift female students is higher than a study conducted in Germany (5.4%), chili (9%) and Nigeria (11.8%) [20][21][22]. This variation could be due to a difference in culture, life style, socio-economy, and interventions made across the countries. The finding also revealed that higher last 12 month prevalence of sexual violence than a country side study done in Ambo University (43.7%) [18], college female students in Nekemte town [12] and female high school students in Wolayta Sodo, (24.4%) [23]. This discrepancy might be due to the difference in the target population, study setting; student who lived in university is secured than a student who attends class from their home, operational definition of the problem. In this study, for example, any action against the women was considered as sexual violence and the nature of class time, because night time is more convenient for violent people, in this study. The odds of having sexual violence in the last 12 months were 2.36 times higher in students whose father were no formal education than students with higher level educated. This is congruent to the study from Ambo which indicate that educated father have had protective effect to sexual violence of daughters than uneducated fathers [12]. This might be also the fact that educated fathers better informed decisions in the sexual sphere with their daughter than uneducated ones. Finding of the study also depicts that students who ever experienced multiple sexual partners had 3.44 times more likely to have experienced sexual violence within the last 12 months compared to those students who haven't had sexual partner. This finding is supported by a study conducted among female private college students in Bahirdar city [11]. And the study was done among female high school students in Soddo town [24]. This might be explained by the number of partners increases the chance of being sexually violated might be increased. Also, it could be explained by engaging in health-risk behaviors increase women's vulnerability to forced sexual intercourse and the chance of getting abusive partners and peers among females with multiples sexual partners is by far higher than the referent groups. Compared to those who have had no partners, those have sexual partner were 1.89 times more likely to experience sexual violence in the last 12 months. This is in line with a study conducted among night junior secondary school and high school female students in Hawassa town [4,25]. This finding shows sexual violence is common among those who have an intimate relationship, which signifies less responsible sexual decision-making among partners. The study indicated that those students who have had history of alcohol consumption were 3.54 times higher risk for sexual violence than their counterparts. This finding is similar to a study conducted among female students of Wolayta Sodo University [26] and among college female students in Nekemte [12] This might be due to alcohol consumption may predispose female to sexual violence because alcohol use cause loss of judgment, selfrestrain in sexual intercourse and protective power of female from sexual violence. The finding of this study has great public health significance in the journey of reducing the burden of sexual violence on college students, so the result of this finding helps responsible bodies, researchers, and health professionals to emphasize significant variables associated with sexual violence among women during their lifetime and research area. --- Conclusion This study revealed that the last 12 month prevalence of sexual violence is high among night shift female college students in Hawassa city. The factors associated with sexual violence in this study were having illiterate father, drinking alcohol, Having sexual partner, and multiple sexual partners. As a result, interventions focusing on those identified factors by the concerned bodies could probably reduce the burden and consequences of induced asexual violence. Their fore, students should prevent themselves from health risky behaviors and Hawassa educational bureau should be work on awareness creation on women empowerment with in marriage and Further broad and longitudinal studies are needed to determine the predictors of the problem among female students at Hawassa and Ethiopia as a whole. • 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:? Choose BMC and benefit from: --- Availability of data and materials The raw data documents are available upon request from the corresponding author. --- Abbreviations --- Author contributions All authors made significant contribution to the work reported, weather that is the conception, study design, execution, acquisition of data, analysis and interpretation of data, or in all these areas; took part in drafting, revising or critically reviewing the article, gave final approval of the version to be published, have agreed on the journal to which the article has been submitted, and agreed to be accountable in all aspects of the work. All authors read and approved the final manuscript. --- Funding The study was conducted getting the fund from Hawassa University. We declare that the funding body had no role in the designing of the study, the collection, analysis and interpretation of the data, the writing of this manuscript and in the decision to submit it for publication. --- Declarations Ethics approval and consent to participate This study was reviewed and approved by the Institutional Ethical and Review Committee of Hawassa University with Ref. No: IRB/093/12. Official permission was also obtained from the Midwifery department and colleges as well. Participation in the study was completely voluntary and refusal to respond to some of the questions or interruption from the study was possible at any time and never causes any effect on the respondents. Students were informed that questions were anonymous and confidential. Written informed consent was obtained from all subjects and/or their legal guardian before data collection. Names of the students were not recorded anywhere on the questionnaire. Measures were also taken to ensure confidentiality of information both during and after data collection. --- Consent for publication Not applicable. --- Competing interests The authors declared that no competing interests exist. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background Sexual violence is any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, against a person's sexuality using coercion, by any person regardless of their relationship to the victim, in any setting. Several studies were undertaken on sexual violence among students in general. Nevertheless, there is paucity of information about sexual violence among night shift students in particular; even if they are more vulnerable to sexual violence due to the nature of the class time. The government has embraced legal and policy frameworks to discourse the problem of sexual violence in Ethiopia; nevertheless, the problem still is quite pervasive. Objective This study was aimed to assess the prevalence of sexual violence and risk factors among night shift female college students in Hawassa city. Methods Institution-based cross-sectional study design was employed. A structured questionnaire was used to collect the data from 345 study participants. Systematic random sampling technique was used to choice study participants. Epi data version 3.1statistical software and Statistical Package for Social Sciences version 22.0 were used to enter and analysis the data. Both bivariable and multivariable logistic regression analyses were performed to recognize risk factors. P values < 0.05 with 95% confidence level were used to state statistical significance. Results A total of 330 students were participated in the study making a response rate of 95.6% with a mean age of 24.9. The prevalence of last 12 month sexual violence was 202 (61.2%) 95% CI (55.8, 66.4) which includes rape, attempted rape and sexual harassment. The 12 month prevalence of each form of violence was 46 (13.9%) 95% CI (10.6, 17.9), 23 (6.9%) 95% CI (3.6, 10.9) and 163 (49.4%) 95% CI (46.2, 53.6) of rape, attempted rape and sexual harassment respectively. The independent predictors of sexual violence having a father with no formal education (AOR = 2.39, 95% CI 1.04, 5.33) presence of multiple sexual partners (AOR = 3.44, 95% CI 1.64, 7.2), having sexual partner (AOR = 1.89, 95% CI 1.03, 3.5), and consuming alcohol (3.55, 95% CI 1.84-6.85) by the victims.This study shown that the prevalence of sexual violence is high among night shift female college students in Hawassa city. Having a father with no formal education, drinking alcohol, having multiple sexual partners and having sexual partner were more likely to have sexual violence within the last 12 month. Thus, students should prevent themselves from health risky behaviors and Hawassa educational bureau should be work on awareness

Introduction Marital conflict is unavoidable. Occurring in virtually all relationships, conflict is an inevitable part of family life. As such, children living in families witness marital conflict. It is clear that interparental relationships are integral to children's psychosocial well-being [1,2]. Previous research has shown that the effects of marital conflict on children are likely to vary by gender, indicating that gender plays an important role in the relationship between marital conflict and child adjustment [3]. In other words, although both boys and girls are vulnerable to the effects of high marital conflict, gender appears to moderate potential outcomes [3]. For example, the threat associated with marital conflict may be more significant for boys, who tend to respond by externalizing problems. In contrast, girls evidence a tendency toward blaming themselves for parental conflict, thus developing internalizing problems. One study on adolescents found that parental hostility was associated with internalizing in both boys and girls, whereas externalizing was only significant in boys [4]. As such, gender may play a significant and complex role in the relationship between marital conflict and child adjustment. Thus, in order to understand how marital conflict impacts children, marital conflict tactics need to be explored with a focus on gender. Numerous tactics can be adopted in the face of marital conflict. Where some deal with conflict in a positive and constructive manner, other tactics are negative and destructive. Extant studies have divided marital conflict tactics into two categories: namely, constructive and destructive. Constructive marital conflict tactics involve more positive strategies for ameliorating tension, including the open discussion of problems, resolving conflict calmly, and showing of affection during or after the conflict [5][6][7]. The use of constructive tactics elicits positive emotional reactions from children, such as secure attachment, better problem-solving skills, and emotional stability [8]. Constructive marital conflict may benefit positive child outcomes by teaching them problem-solving skills and effective ways of communicating, ultimately fostering more positive social relations. Positive outcomes include lower levels of internalizing (e.g., anxiety, depression, and withdrawal) and externalizing symptoms (e.g., aggression, delinquency, and conduct disorders), and higher levels of social skills, prosocial behavior, and emotion regulation [9,10]. In contrast, destructive marital conflict involves more negative conflict resolution tactics, including aggressive and threatening behavior, arguing frequently, and leaving issues unresolved [5,6]. Such destructive tactics may make children more vulnerable to developing adjustment problems, eliciting negative emotional and behavioral reactions such as aggression, conduct disorders, anxiety, and depression [5][6][7]11]. Exposure to destructive conflict is associated with increased symptoms of psychological distress among children [12,13]. Involving an implied threat to the emotional security of children, destructive marital conflict is associated with negative child outcomes including higher levels of internalizing and externalizing symptoms, and lower levels of social skills, prosocial behavior, and emotion regulation [14][15][16][17]. Accordingly, the presence of marital conflict and the way in which conflict is approached influence the environment in which the children learn and grow. Children are also likely to experience the indirect effects of marital conflict because it impacts parenting behaviors-the effects "spilling over" from the marital subsystem to the parent-child subsystem [18][19][20]. The association between marital conflict and children's behavioral and emotional difficulties is well documented, with marital conflict found to be associated with a wide range of both externalizing and internalizing outcomes in children. Efforts to understand the association between marital conflict and child development have increasingly focused on how parents express and approach conflict in their relationship. In approaching marital conflict, scholars differentiate between the ways in which parents interact and handle interpersonal conflicts on the one hand, and the behaviors and words exchanged during disagreements on the other [21]. Scholars have measured destructive marital conflict by the frequency of minor and major conflicts, the severity or degree of conflict, and conflict tactics. Destructive marital conflict contains various elements of avoidance, involving the child or children in the conflict, stonewalling, verbal aggression, and physical aggression [22][23][24]. As noted, conflict tactics influence the psychological well-being and development of children: children who live in families characterized by high levels of specific forms of interparental conflict are more likely to develop adjustment problems. Although extant studies have focused on destructive marital conflict through combined scale (e.g., stonewalling, verbal aggression, and physical aggression), these studies do not estimate the impact of specific conflict tactics on child outcomes. As such, it is necessary to explore specific conflict tactics in order to understand how marital conflict impacts children. This is particularly necessary because despite the likelihood of the effects of marital conflict on children varying according to gender, few studies have examined the influence of gender on the association between specific conflict tactics and child adjustment. Thus, in order to understand how marital conflict impacts children, specific conflict tactics need to be explored with a focus on gender. Further research is necessary to clarify the link between specific conflict tactics and gender-a line of enquiry that will aid in the provision of preventative measures at an early stage. This study addresses this gap. Focusing on gender, this study investigates the link between specific interparental conflicts and children's mental health symptoms in families in which the parents live together. More specifically, this study hypothesizes that specific interparental conflict tactics-namely, cooperation, avoidance-capitulation, stonewalling, verbal aggression, physical aggression, and child involvement-are uniquely associated with children's internalizing and externalizing problems. Previous studies have not conclusively shown whether specific interparental conflicts impact girls and boys differently. Addressing this gap, this study investigates the moderating effect of gender on the relationship between specific interparental conflict and children's internalizing and externalizing problems. --- Methods --- Subjects This study forms part of a larger longitudinal study examining the effects of the child-rearing environment on the social development and adjustment of children. In 2014, we requested permission from all facilities in Nagoya city in Aichi prefecture, a major urban area in Japan, and conducted our survey at facilities where permission was obtained. As one of Japan's leading cities, Nagoya city provides a representative sample of Japan. Subjects were recruited from 52 kindergartens and 78 nursery schools. To recruit subjects, self-reported questionnaires were distributed to all parents of five-year-old preschool children enrolled in the kindergartens and nursery schools. The parents of children provided written informed consent and agreed to participate. We have conducted an annual survey as the children age, following their progress from preschool to junior high school. The baseline was created via the first wave in 2014, during which we obtained the address of subjects. Each year, we mailed questionnaires to the parents of children (second wave in 2015, third wave in 2016). This study uses the data from the third wave survey. The research for this study was conducted in 2016. Data were collected via self-administered questionnaires, which respondents completed manually using pen and paper. This study distributed one questionnaire per child, with the expectation that parents would answer jointly. Questionnaires were mailed to the parents of children, who completed the questionnaires and returned them to the researcher by mail. Self-report questionnaires were provided to subjects deemed eligible for the follow-up survey: the parents of seven-year-old children (N = 1,643) who were in the second grade of elementary school (child subjects were aged five during the first wave, and seven in the third wave). Of the 1,643 questionnaires disseminated, 935 completed questionnaires were returned. In order to accurately clarify the association between interparental relationships and child adjustment, this study excludes the following from its analysis: (1) children from single-parent families, (2) children diagnosed with developmental problems, and (3) children whose parents did not return complete questionnaires. To examine the impact of the specific interparental conflict tactics on children's internalizing and externalizing problems as closely as possible, we excluded children diagnosed with developmental problems. We defined parents as mothers and fathers; while they did not need to be biologically related to the target child, they did need to reside with the child. Of the 935 children whose parents completed the questionnaire, 799 (85.5%) met the inclusion criteria. A sample size for analysis was not set because this study forms part of a larger longitudinal study. Nonetheless, the obtained sample size (n = 799) was large enough to detect linear regressions to assess associations between the interparental relationship and child outcomes [25]. Subject characteristics are shown in Table 1. The average age of the subjects was 8.02 years (SD = 0.36). In regard to gender, 51.8% of the subjects were boys (n = 414) and 48.2% girls (n = 385). The median annual household income was between JPY 5,000,000 and 5,999,999. Regarding subject mothers, the median age was 39.77 (SD = 4.42). In terms of their level of education, 1.9% had compulsory education, 20.2% had an upper secondary school diploma, 39.9% had up to four years of college/university education, and 38% had at least four years at college/university or higher degrees. In regard to subject fathers, the median aged was 41.87 (SD = 5.46). In terms of their level of education, 4.3% had compulsory education, 23.4% held an upper secondary school diploma, 14% had up to four years of college/university education, and 58.3% had at least four years at college/university or higher degrees. In terms of socioeconomic status, subjects' socioeconomic status was similar to that typical of other Japanese individuals of a similar generation [26,27]. --- Ethical statement Children's parents were informed of the study's objectives and procedures and made aware that they were not obligated to participate in the baseline survey. Parents provided written informed consent on behalf of their children prior to participating in this research. Ethical approval for this study was obtained from the Kyoto University Ethics Committee (E2322). --- Measures Data were collected via questionnaires with several different scales covering a wide range of issues concerning the child-rearing environment and child developmental outcomes. However, this study only uses measures pertaining to interparental relationships and children's psychosocial difficulties. Interparental conflict. This study utilizes the Conflict and Problem-Solving Scale (CPS), a self-report questionnaire measuring the characteristics of the specific marital conflict strategies used by respondents [24]. The CPS is a 44-item questionnaire that uses a four-point Likert scale ranging from never (0) to often (3) to measure various aspects of marital conflict. The CPS comprises four conflict dimensions-frequency, severity, resolution, and efficacy-and six conflict strategy subscales: cooperation, avoidance-capitulation, stonewalling, verbal aggression, physical aggression, and child involvement. Cooperation involves the use of reasoning, problem-solving, and cooperation. Avoidance-capitulation involves attempts to ignore or escape arguments, while stonewalling refers to impasses in conflict characterized by unresolved hostility, distress, and disengagement. Verbal aggression pertains to the use of verbally hostile conflict tactics, while physical aggression involves the use of physical violence in interparental conflict. Finally, child involvement concerns the direct or indirect involvement of the child in the parents' conflict. These scales have adequate internal consistency [24]. To address cross-cultural translation issues in this study, we back translated the items and checked their reliability according to the methodology recommended by Acquadro et al. [28]. In the sample used in this study, internal consistency coefficients range from 0.76 to 0.88 (Table 2). Externalizing and internalizing problems in children. This study uses the Strengths and Difficulties Questionnaire (SDQ) to measure mental health problems in the child subjects, specifically externalizing and internalizing problems [29]. The SDQ is a 25-item questionnaire that uses a three-point Likert scale ranging from not true (0) to certainly true (2) to measure externalizing and internalizing behaviors. In the SDQ, the difficult behavior score is calculated as the sum of the scores obtained for the following subscale: emotional symptoms, conduct problems, hyperactivity, and peer problems. Following the recommendation of Goodman et al. [30], this study combined the conduct problems and hyperactivity-inattention subscales into an externalizing problem scale, and the peer problems and emotional problems subscales into an internalizing problems scale. These scales have adequate internal consistency [29][30][31]. Additionally, the SDQ was cross-culturally validated for the Japanese context [31]. In this study, internal consistency coefficients were 0.70 for the externalizing problems scale, and 0.74 for the internalizing problems scale (Table 2). Demographic covariates. Parents provided their demographic information, including their child's sex, annual household income, maternal education level, and paternal education level. Annual household income was reported in Japanese yen (JPY). Regarding parental education, both parents were asked to report their education in years, as well as the highest level of education completed. --- Data analysis First, the relationships between subject characteristics and children's behavioral problems were analyzed via one-way analysis of variance (ANOVA), as shown in Table 1. Second, associations between the interparental relationship and child outcomes were assessed using multiple linear regression with CPS scores (cooperation, avoidance-capitulation, stonewalling, verbal aggression, physical aggression, and child involvement) as predictors and SDQ scores (externalizing problems and internalizing problems) as outcomes. The regression analyses were stratified by sex. Regression analyses were organized as follows. In Model 1, each predictor was entered individually to assess its univariate association with each outcome (cooperation, avoidance-capitulation, stonewalling, verbal aggression, physical aggression, and child involvement). In Model 2, all predictors (cooperation, avoidance-capitulation, stonewalling, verbal aggression, physical aggression, and child involvement) were entered simultaneously. As several subject characteristics were significantly associated with behavioral problems in the analyses (see Table 1), we included the factors as covariates in each analysis (see Tables 3 and4). Multicollinearity was assessed using variance inflation factor (VIF), and multicollinearity was considered when the VIF value exceeded 2. The VIF value was <unk>2 indicating no multicollinearity among the predictors, and no problems with multicollinearity were found. All analyses were conducted using IBM SPSS Statistics 23.0. --- Results --- Subject characteristics and emotional/behavioral problems Subjects' demographic characteristics and the relationships between these characteristics and behavioral problems are shown in Table 1. In regard to boys, the externalizing and internalizing problem scores of boys in lower income households were significantly higher than those of boys in higher income households. In contrast, externalizing problem scores were significantly higher among girls in lower income households than those of girls in higher income households. Externalizing problem scores: <unk> JPY 3 million, 5.57<unk>3.73; JPY 3-5 million, 4.53<unk>3.33; JPY 6-8 million, 4.43<unk>2.59; JPY 9 million, 3.41<unk>2.33; p = 0.002. In regard to maternal education level, externalizing problem scores were significantly higher among girls whose mothers had a lower education level. Externalizing problem scores: compulsory education, 6.67<unk>2.50; upper secondary school, 4.93 <unk>3.34; up to four years at college/university, 4.54<unk>2.92; more than four years at college/university, 3.75<unk>2.65; p = 0.003. In regard to paternal education level, externalizing problem scores were significantly higher among girls whose fathers had a lower education level. Externalizing problem scores: compulsory education, 6.72<unk>3.77; upper secondary school, 4.78<unk>2.82; up to four years at college/university, 4.60<unk>2.65; more than four years at college/university, 3.90 <unk>2.85; p <unk> 0.001. --- The link between interparental conflict and children's emotional/ behavioral problems The associations between interparental conflict and children's outcomes were assessed using multiple linear regression with CPS and SDQ scores as outcomes (see Tables 3 and4). First, in regard to externalizing problems, Table 3 shows the results of the multivariate analysis of the relationships between interparental conflict and emotional/behavioral problems. Regarding boys, in Model 1-which included individual predictors-all predictors (i.e., cooperation, avoidance-capitulation, stonewalling, verbal aggression, physical aggression, and child involvement) were significantly associated with externalizing problems. In Model 2-which contained all predictors-cooperation was significantly inversely associated with externalizing problems (<unk> = -0.117, p = 0.022), while avoidance-capitulation (<unk> = 0.171, p = 0.001) and verbal aggression (<unk> = 0.164, p = 0.014) were significantly positively associated with externalizing problems. In contrast, only some of the predictors-namely, cooperation, stonewalling, and physical aggression-in Model 1 were significantly associated with externalizing problems in girls. In Model 2, cooperation was significantly inversely associated with externalizing problems (<unk> = -0.106, p = 0.048). Second, in regard to internalizing problems, Table 4 shows the results of the multivariate analysis of the relationships between interparental conflict and emotional/behavioral problems. Regarding boys, only one predictor-cooperation-was significantly associated with internalizing problems in Model 1. In Model 2, cooperation was significantly inversely associated with internalizing problems (<unk> = -0.110, p = 0.040). Analyses of data pertaining to girls produced different results. In Model 1, all predictors (cooperation, avoidance-capitulation, stonewalling, verbal aggression, physical aggression, and child involvement) were significantly associated with internalizing problems. In Model 2, cooperation was significantly inversely associated with internalizing problems (<unk> = -0.095, p = 0.012), while avoidance-capitulation (<unk> = 0.165, p = 0.002) and stonewalling (<unk> = 0.139, p = 0.044) were significantly positively associated with internalizing problems. --- Discussion The purpose of this study was to examine the relationship between specific interparental conflict tactics and children's internalizing and externalizing problems with a focus on gender. The findings of this study highlight the significant impact of specific interparental conflict on children's behavioral problems, demonstrating that these vary according to the gender of the child. More specifically, multivariate analysis targeting boys revealed that cooperation was significantly inversely associated with both externalizing and internalizing problems, while avoidance-capitulation and verbal aggression were significantly positively associated with externalizing problems. In contrast, multivariate analysis targeting girls revealed that cooperation was significantly inversely associated with both externalizing and internalizing problems, while avoidance-capitulation and stonewalling were significantly positively associated with internalizing problems. In short, this study found that constructive marital conflict was inversely related to externalizing and internalizing problems in both boys and girls. However, boys tend to respond to specific destructive marital conflict by manifesting adjustment problems in terms of externalizing behavior, whereas girls tend to respond with internalizing behavior. These findings are consistent with those of previous studies [3]. It is worth noting that destructive marital conflict associated with behavioral problems not only includes active conflict such as verbal aggression, but silent conflict such as avoidancecapitulation and stonewalling. Numerous studies have focused on active conflict tactics-such as verbal hostility and physical aggression-as forms of destructive conflict or understood destructive conflict as including both active and silent conflict tactics (e.g., stonewalling and withdrawal or avoidance). Such studies have suggested that these types of destructive marital conflict tactics negatively influence child outcomes [5][6][7]17]. However, this study found that active conflict tactics and silent conflict tactics-such as avoidance-capitulation and stonewalling-were independently significantly associated with behavioral problems. Avoidance-capitulation involves passive strategies that minimize confrontation and maintain harmony at all costs. Stonewalling is the passive-aggressive withdrawal from active conflict through behavior such as sulking and giving one's partner the "silent treatment." These strategies are relatively ineffective because they do not allow the underlying source of conflict to be resolved [24]. In contrast, cooperation is an effective conflict strategy that involves an attempt to "meet halfway," ensuring that the needs of both individuals are met. The spillover hypothesis suggests that the negativity or positivity experienced in the interparental relationship may influence or transfer to the parent-child relationship [32,33]. As such, silent conflict tactics may be transferred to the parent-child relationship. A lack of parental emotional or physical availability interferes with the child's ability to form secure attachments and receive emotional support [34,35]. Defined as the omission of sufficient care to meet a child's basic needs, child neglect is a major risk factor in psychopathology, including the development of internalizing and externalizing problems [36,37]. Poor parent-child relationships put children at risk of pervasive and cumulative consequences across their lifespan. In this study, destructive marital conflict tactics-specifically, avoidance-capitulation and verbal aggression-were significantly positively associated with externalizing problems in boys. In contrast, destructive marital conflict tactics-specifically, avoidance-capitulation and stonewalling-were significantly positively associated with internalizing problems in girls. Several mechanisms are likely to be different between girls and boys in terms of the relationship between marital conflict and the risk of developing emotional and behavioral problems. Although both boys and girls are vulnerable to the effects of marital conflict, gender appears to moderate the potential outcomes and processes by which this relationship occurs [3]. In other words, the reaction of children to marital conflict tends to differ according to gender. As noted, prior research has suggested that boys tend to respond to marital conflict by manifesting adjustment problems in terms of externalizing behavior, whereas girls tend to respond with internalizing behavior [3]. In this study, destructive marital conflict tactics were significantly positively associated with externalizing problems in boys, while destructive marital conflict tactics were significantly positively associated with internalizing problems in girls. The literature suggests some explanations for this. Gender differences in the socialization process may affect how boys and girls form appraisals and coping behaviors [38]. Boys may be more reactive to stress and better observers of marital conflict than girls [3]. Although there is evidence that boys and girls are similarly exposed to their parents' conflicts, some studies suggest that parents may feel boys are more resilient than girls and consequently feel less obligated to shield them from conflict [39]. In this study, while boys and girls are similarly exposed to their parents' conflicts, boys tend to be exposed to more strict parenting attitudes than girls (see S1 Table ). Boys have also been found to be more likely to propose task-oriented interventions for parental conflict than girls [40]. Providing a perspective on how parents' relationships influence the relationship experiences of children in adulthood, social learning theory suggests that children learn social behavior, in part, from observing their caregivers' social interactions and relationships [41]. Indeed, boys exposed to marital conflict may be more likely to replicate parental anger [42]. Boys may feel especially threatened by marital conflict and react with aggressive behavior, often responding to adult anger with aggression and anger. As such, appraisals of coping efficacy and the threat posed by marital conflict may be more crucial for boys because boys tend to respond with adjustment and behavioral problems. In contrast to boys, girls exposed to marital conflict tend to evidence more internalizing symptoms. Girls are more likely to react to marital conflict with fear [40] and have been found to exhibit distress in the face of adult anger [43]. It may be that the change from a secure to insecure environment and the resultant loss of emotional security as a result of marital conflict feels especially threatening to girls [3]. They tend to respond to stress with self-blaming behavior and other cognitions associated with internalizing symptoms. As such, evidencing a tendency toward self-blame for parental conflict, girls tend to develop internalizing problems. --- Limitations This study has several limitations. First, the study design was a cross-sectional study. The direction of effect between marital conflict and children's behavioral problems is usually assumed to be that marital conflict impacts upon children's behavior. However, some studies have reported bidirectional relations between interparental conflict and children's behavioral problems, noting that a child's problematic behavior is likely to interact with interparental conflict in predicting developmental outcomes [44]. There are also bidirectional relations between a child's irritable and defiant temperament and destructive marital conflict. For instance, temperamental precursors, physiological responsivity to stress, and other child characteristics have been shown to have a reciprocal relationship with the environment to influence the development of psychopathology [45,46]. Second, in this study, the CPS and SDQ were only completed by caregivers, likely introducing reporting bias. Regarding the CPS, questionnaire data are a less robust means of quantifying parental discipline than direct observation. Consequently, the completion of a single observation opinion-based questionnaire can be considered a crude and potentially inadequate means of obtaining data about marital conflict. Future research should explore marital conflict strategies from the perspectives of both children and parents. Regarding the SDQ, reports from other parties-such as teachers-may help in evaluating the dynamics more accurately. As such, future research should combine teacher and caregiver SDQ scores. Third, as the purpose of this study was to examine the relationship between specific interparental conflict tactics and children's internalizing and externalizing problems, we did not include parenting styles in the analysis. Future studies should look at whether specific marital conflict resolution mechanisms match parenting styles in order to test this spillover hypothesis. Fourth, the impact of certain marital conflicts may be influenced by cultural differences. For instance, a previous study verifying differences in how marital conflict is operationalized in Japan versus the United States suggests that the degree of conjugal verbal and physical aggression was exceedingly high in American spouses followed by Japanese couples [47]. This finding may reflect the nature of culture in each society, specifically an expressive American culture and reserved Japanese culture. As this study considers Japanese subjects, it may underestimate the impact of verbal and physical aggression on children in comparison to other countries. Fifth, this study's definition of 'parents' did not require that they be biologically related to the subject. The mixed sample-comprising both biologically related and unrelated parentsmay have influenced the link between specific marital conflict tactics and children's mental health symptoms. As such, further study should consider biological relatedness. Finally, this study did not use a genetically informed design, preventing the exploration of genetics or biological factors. This may be worth pursuing in future research. For instance, marital stress is associated with elevations in child cortisol levels and the later emergence of behavioral developmental symptoms [48]. It is also important to consider child temperament as it may moderate the association of family adversities with child outcomes or may act in reciprocal relationships with these factors. As such, further study should take genetic factors into account. --- Conclusion The findings of this study demonstrate that interparental conflict is associated with children's behavioral problems. This study found that constructive marital conflict tactics were significantly inversely associated with externalizing and internalizing problems in both boys and girls. Destructive marital conflict tactics-specifically avoidance-capitulation and verbal aggression-were significantly positively associated with the development of externalizing problems in boys. In contrast, destructive marital conflict tactics-specifically avoidance-capitulation and stonewalling-were significantly positively associated with the development of internalizing problems in girls. Thus, it is important to distinguish specific marital conflict tactics and consider the child's gender when examining the relationship between marital or interparental conflict and its impact on a child's psychological well-being. Furthermore, active conflict tactics (such as verbal aggression) and silent conflict tactics (such as avoidance-capitulation and stonewalling) were independently significantly associated with externalizing or internalizing behavioral problems. The associations between child symptoms and exposure to specific marital conflict highlight the need for effective prevention and intervention strategies. Moreover, these findings add to the substantial literature documenting the relationship between family processes and the development of disruptive behavior disorders in children. It is vital that further efforts to understand the association between marital conflict and child development focus on how parents express and manage conflicts in their relationship. --- All relevant data are within the manuscript and its Supporting Information files. --- Supporting information --- S1 Table. Exposure to marital conflict and parenting practices by child gender. (DOCX) --- Author Contributions Conceptualization: Rikuya Hosokawa. --- Data curation: Rikuya Hosokawa. Formal analysis: Rikuya Hosokawa.

Marital conflict is integral to children's psychosocial well-being. Extant research has shown that the effects of marital conflict on children are likely to vary by gender, indicating that gender plays a significant and complex role in the relationship between marital conflict and child adjustment. Focusing on gender, this study investigates the link between specific marital conflict tactics and children's mental health symptoms in families in which the parents live together.This study gathered data from 799 children and their parents in Japan by means of a questionnaire focusing on marital conflict and child behavioral problems. Marital conflict (verbal aggression, physical aggression, stonewalling, avoidance-capitulation, child involvement, and cooperation) was assessed using a Conflict and Problem-Solving Scale. Children's behavioral problems (externalizing and internalizing symptoms) were assessed using the Strengths and Difficulties Questionnaire.The findings highlight the significant impact of specific interparental conflict on children's behavioral problems, demonstrating that there are differences according to the child's gender. More specifically, multivariate analyses targeting boys revealed that cooperation was significantly inversely associated with externalizing problems and internalizing problems, while avoidance-capitulation and verbal aggression were significantly positively associated with externalizing problems. In contrast, multivariate analyses targeting girls revealed that cooperation was significantly inversely associated with externalizing problems and internalizing problems, while avoidance-capitulation and stonewalling were significantly positively associated with internalizing problems.

Introduction Norway is a welfare state of a social-democratic type. This implies that public welfare is universal, comprehensive, and generous when compared with other welfare regimes. The major income maintenance system is social insurance. All citizens who fulfill specific criteria are entitled to social insurance benefits. One crucial criterion for most benefits is a work record. Rights to social insurance (e.g., unemployment benefit, sickness pay) are earned by previous labor market participation. People who have not earned the right to or exhausted their rights to social insurance and are unable to support themselves, are eligible for social assistance. Unlike social insurance, social assistance provides the last safety net and is a means tested benefit. Usually, social assistance is not as generous as unemployment benefits. In 2005, approximately 3% of the general population in Norway over 17 years of age received social assistance [1]. Forty-two percent of these individuals were long-term social assistance recipients (LTRs) defined as having received social assistance as their main source of income for at least 6 of the last 12 months. These LTRs experience economic strain and have a simpler housing standard than the general population [2]. Of note, in 2005, 71% of LTRs reported serious financial difficulties compared to only 13% of the general population [3]. In general, LTRs are less educated, have less social resources, lower incomes, and poorer health than the general population [4]. In addition, LTRs and welfare recipients struggle with numerous health issues, (e.g., poorer functional health, depression, anxiety, increased risk of cardiovascular disease, pain), have a higher level of psychological distress, and reduced psychological well-being [5][6][7][8][9]. LTRs are more likely to experience domestic violence, experience feelings of loneliness, and report problems with alcohol and illicit drugs [4,6]. The mortality rate of this vulnerable and disadvantaged group is two to three times higher than that of the general population [10]. Chronic pain is a significant and rapidly growing health problem in the general population worldwide [11]. In fact, population-based studies suggest that chronic pain occurs in 11 to 30% of the general population in the United States and Europe [12][13][14][15]. Chronic pain is a medical condition in which biological, psychological, and social factors dynamically interact with each other [11]. In fact, numerous studies have demonstrated that chronic pain leads to negative outcomes for patients, including fear of pain, avoidance of activities that elicit pain, stress-related symptoms, and disability [16][17][18][19][20][21]. In addition, chronic pain has a negative impact on the health-related quality of life (HRQOL) of individuals in the general population, as well as of individuals with different chronic conditions [22][23][24][25][26][27][28][29]. However, only one study has reported on pain in a sample of social security recipients [8]. In this study, that compared pain locations in social security recipients and non-recipients, social security recipients reported pain more frequently in their hands and legs than non-LTRs. A variety of definitions of quality of life (QOL) are reported in the literature. In addition, researchers use a number of different paradigms to evaluate HRQOL. For example, many social scientists tend to focus on functional status and overall well-being, and how financial circumstances, social structures, and institutions influence HRQOL. In contrast, clinical researchers may focus on how biomedical and psychological factors influence the HRQOL of LTRs [30]. Four studies were found that evaluated the self-reported health status of welfare recipients or LTRs [5][6][7][8] and three of these studies compared welfare recipients or LTRs with non-recipients [5,7,8]. In a study that compared single mothers affected by welfare reform (Woman's Employment Study (WES)) with a national sample of woman, woman over 24 years in the WES sample had significantly lower levels of physical functioning [5]. In another study of 284 LTRs (97% female), two-fifths of the LTRs rated their health as fair or poor. Compared to the total state welfare population, LTRs were more likely to have mental and physical health problems [6]. Data from the National Population Health survey in Canada found that welfare recipients were more likely to report poor/fair health, poor functional health, and depression compared to non-welfare recipients [7]. In a Swedish study, social security recipients had significantly poorer health measured using the GHQ-12 than non-recipients [8]. Finally, in a study from Canada [9], 56% of the woman and 45% of the men on social assistance reported a higher level of distress than other individuals living in the same neighborhood. An individuals' HRQOL and the relationship between HRQOL and chronic pain can differ with gender [27,31], age [25], and employment status [24,32,33]. For example, in one study [33], younger individuals who were unemployed reported a lower QOL than employed individuals of the same age and older individuals who were employed [33]. In contrast, in a study of young unemployed adults, the majority (67%) reported their QOL as good [32].In a third study of young unemployed Australians, that used the SF-36 [34], lower health status was reported by those who were unemployed. In one study that examined the relationship between unemployment and QOL [32], the feeling of loneliness was evaluated. No differences in loneliness were found between the unemployed group and the reference group. However, a study of loneliness as a predictor of HRQOL among older caregivers found that loneliness was the most important factor that predicted lower HRQOL among caregivers, as well as older people in general [35]. Loneliness is defined by Peplau and Perlman as an unpleasant experience that arises when a person's network and social relations are deficient [36]. In this study, because a recent report suggested that loneliness was a problem in LTRs, the relationship between loneliness and HRQOL was evaluated. Several studies have examined the impact of alcohol and substance abuse on HRQOL [37][38][39][40]. However, in a recent review, the authors noted that it is difficult to draw valid conclusions about the impact of alcohol and substance abuse on HRQOL. One of the major reasons for these inconclusive results is the number of different ways that QOL was defined and measured across studies [37]. In addition, the study samples were rather heterogeneous. However, in a study that used SF-12 to measure HRQOL of adults treated for substance abuse, their HRQOL was lower than that of GP and as low as or lower than patients with other chronic medical conditions [38]. In summary, a limited amount of data suggests that LTRs struggle with a number of chronic health issues, report chronic pain and loneliness, and are more likely to abuse alcohol and illicit drugs. Taken together, all these factors may have a negative impact on HRQOL. However, no studies were found that evaluated the impact of these factors on HRQOL of LTRs with and without chronic pain. Therefore, the purposes of this study were to compare the HRQOL of LTRs with and without chronic pain and determine the effect of select demographic, social, pain, alcohol and illicit drug use characteristics on the physical and mental components of their HRQOL. --- Methods --- Design and data collection procedures This study is part of a larger study, named: ''The study of functional ability among long-term social assistance recipients''. The study was funded by the Directorate for Health and Social Affairs in Norway after an evaluation of ''The National Activation Trial'' from 2000 to 2004. ''The National Activation Trial'' was done to promote and support new ways to move LTRs away from benefit dependency into work. This evaluation showed that approximately 23% of the LTRs went back to work [41]. Because the results of the National Activation Trial were relatively modest, to better understand the LTRs 0 psychosocial characteristics and their functional ability, the current study was funded. This descriptive, cross-sectional study surveyed people receiving long-term social assistance in Norway about their health and social functioning. Data were collected from January to November 2005. The social welfare authority offices in each of 14 municipalities in Norway were responsible to locate the LTRs who met the study's inclusion criteria. The respondents were sent the survey questionnaires and returned them directly using a postage paid envelope to Oslo University College. LTRs who did not reply received two mailed reminders. Some LTRs who did not respond to the mailed reminders were telephoned; while others were reminded to complete the questionnaires by case workers. These extensive data collection procedures were used because previous experience demonstrated that LTRs are difficult to reach. Some relocate and change their addresses frequently or live at an unknown residence. Others stay temporarily in shelters, hospitals, institutions, or prison. The actual number of LTRs in this study, who were homeless or lived in shelters, is not known because this information was not obtained in the demographic questionnaire. --- Sample Participants were recruited from 14 of 433 municipalities in Norway. These municipalities were part of ''The National Activation Trial''. The selected municipalities provided geographic variability including both rural and urban municipalities in different parts of the country. The municipality with the fewest LTRs who satisfied the inclusion criteria had only 10, while the one with the largest number had 282 recipients. LTRs were included in this study if they had received social assistance as their main source of income for at least 6 of the last 12 months; were between 18 and 60 years of age; and were able to complete the study questionnaires. As shown in Fig. 1, 1,291 LTRs met the initial inclusion criteria. However, 225 of these individuals were prescreened by case workers as unable to complete the questionnaires because of severe substance abuse problems; insufficient mastery of the Norwegian language; extensive problems with reading and writing; or serious illness. Therefore, 1,066 LTRs were included and 562 responded (i.e., response rate of 52.7%). Eleven responders were excluded because they were above 60 years of age. An additional 100 participants were excluded because they were found to be in a work activation program and were no longer on long-term social assistance. Because 12 LTRs did not answer the screening question about having pain and 32 participants could not be clearly placed in either the chronic pain or the no pain group, they were excluded. Consequently, 405 LTRs are included in all of the subsequent comparative analysis. Administrative data (''FD-trygd'') were used to compare the 1,291 recipients who met the inclusion criteria with those who responded to the questionnaire. No differences in age, gender, previous receipt of social assistance or social security benefits were found between those LTRs who did and did not return the study questionnaires [42]. --- Ethical considerations When research is done with vulnerable groups, special attention needs to be given to research ethics. This study was planned and performed in a way that protected the LTRs from violations of their right to privacy. All questionnaires that were returned to the research office contained no personal identifying information. Completion of the questionnaires indicated informed consent. The study, including the number of reminders, was approved by the Data Inspectorate and the National Committee for Research Ethics in the Social Sciences and the Humanities. --- Instruments and scoring procedures The questionnaires that were sent to the LTRs provided information on socio-demographic characteristics, work, health indices, HRQOL, pain, use of alcohol and narcotics, social capital, and childhood difficulties. Only the data on socio-demographic characteristics, pain, feeling lonely, use of alcohol and illicit drugs, and HRQOL are presented in this paper. The questionnaire was finalized after a pilot test with twelve social assistance recipients in one municipality. Three of the researchers met the social assistance recipients and obtained feedback about the questionnaire. --- Socio-demographic characteristics Data on age, gender (female = 1, male = 2), marital status, education (1 = primary school, 2 = secondary school, 3 = college/university), living alone (yes = 1, no = 2), and work (yes = 1, no = 2) were collected of the LTRs. --- Pain Pain was assessed using a nine-item questionnaire that evaluated for the presence of pain, and if present, its cause, location, duration, intensity, and treatments. In this study, LTRs were categorized into pain groups based on their responses to a screening question about whether or not they were generally in pain. --- Categorization of chronic pain Chronic pain was defined as pain of [3 months duration [12][13][14]. For the LTR group who answered yes to the question ''Do you generally have pain?'' the response to the duration question was analyzed. Those LTRs whose pain duration was [3 months were classified as chronic pain patients. Those LTRs whose pain duration was B3 months were classified as not being in chronic pain (yes = 1, no = 2). --- Feeling lonely LTRs were asked ''Does it happen that you often (1), sometimes (2), seldom (3), or never (4) feel lonely?'' This question was used in previous studies of the Norwegian general population by Statistics Norway [43]. --- Alcohol and illicit drug use questionnaire Two items asked about whether the LTRs now or previously had experienced problems with alcohol and illicit drug use (range of responses from ''yes some'', ''yes'', collapsed to yes (1) ''not now, but earlier'', to ''no'', collapsed to no (2). The items on alcohol and illicit drug use were developed and pilot tested for this study. --- SF-12 HRQOL of the LTRs was evaluated using the Norwegian version of the SF-12, which consists of 12 questions about physical and mental health as well as overall health status [44,45]. The questionnaire is scored into two components that measure physical (PCS) and mental (MCS) health. SF-12 has been translated into several languages, including Norwegian and thoroughly tested for its psychometric properties [46]. Higher PCS and MCS scores indicate a better HRQOL. --- Data analyses Data were analyzed using SPSS for Windows (version 17.0). Descriptive analyses were done to assess the characteristics of the sample. Chi-square analyses and independent sample t-tests were used to evaluate for differences in demographic, social, and substance abuse characteristics and HRQOL between LTRs with and without chronic pain. Correlation analyses (i.e., Fishers exact test and Pearson's) were used to assess the bivariate relationships between selected variables. Multiple linear regression analyses were used to determine the effect of selected variables on SF-12 physical and mental health component scores. A P-value of <unk>0.05 was considered statistically significant. --- Results --- Differences in demographic, health, and social characteristics between LTRs with and without chronic pain In the sample of LTRs, 44% were categorized as having chronic pain. As shown in Table 1, LTRs with chronic pain were significantly older (P <unk>.001), more likely to be married (P =.002), more likely to feel lonely (P =.048), and more likely to have problems with alcohol (P =.035) than LTRs without chronic pain. --- Differences in HRQOL between LTRs with and without chronic pain As shown in Fig. 2 --- Discussion This study is the first to examine the impact of chronic pain on the HRQOL of LTRs. Consist with previous studies [23,28,29,47], LTRs with chronic pain rated both the physical and mental components of HRQOL lower than LTRs without chronic pain. These differences in HRQOL represent not only statistically, but clinically significant differences in both dimensions of HRQOL (i.e., d = 1.2, and d = 0.4) [48]. In addition, the fact that LTRs with chronic pain were older and had more problems with alcohol than LTRs without chronic pain is consistent with a recent Canadian study of predictors of chronic non-cancer pain [49]. It is interesting to note that LTRs with chronic pain had a significantly lower PCS score than normative data reported for individuals with chronic low back pain (PCS = 45.96, P <unk>.001) [45]. However, the LTRs without chronic pain had a mean PCS score that was significantly higher than normative data for the general population (PCS 50.3, P = 0.014, age 18-74) [50]. In fact, LTRs with chronic pain had a lower PCS score than patients with rheumatoid arthritis (PCS = 39.60, P <unk>.001) and cancer (PCS = 40.76, P B.001) [45]. A potential reason why the physical component of HRQOL of LTRs with chronic pain was.048 lower than that of an age-matched sample of patients with low back pain is that chronic pain in LTRs is a symptom of a number of chronic medical conditions that impact their HRQOL. Previous studies found that LTRs struggle with numerous health problems [5][6][7][8][9] and have chronic conditions that have a negative impact on their HRQOL [51,52]. Sometimes 157(39) 94 (42) 63 (36) Seldom 79 (20) 50 (22) 29 (16) Never 24 (6) 14 (6) 10 (6) In addition, LTRs are more likely to experience violence, which may result in chronic pain and decrease their physical health [6,53]. The mean MCS scores for both groups of LTRs were lower than population norms (i.e., 50.6, both P B.001) [50]. However, LTRs with chronic pain had lower MCS scores than LTRs without chronic pain. The fact that LTRs with chronic pain had a lower MCS score is consistent with several studies that found that chronic pain has a negative impact on the HRQOL [23,25,27,47] as well as on the ability of an individual to remain employed. One potential reason for the low mental score in both groups of LTRs is that these individuals have poorer health, less social resources, lower incomes, lower education [4], and experience more economic strain than the general population [2]. In addition, LTRs were more likely to have mental problems and depression symptoms [5,7,8]. Another potential reason for the low MCS scores is that these individuals experience a number of disadvantages over the course of their lives. LTRs experience more childhood difficulties [4,54] and have a lifestyle with higher rate of accidents or medical conditions associated with a poorer diet and higher rates of smoking and alcohol consumption than the general population [4,6,8]. In the present study, chronic pain explained the largest percentage of the variance in PCS scores. This result is not that surprising given the fact that chronic pain has a negative impact on physical function [27,29,49] and that physical function decreases with age [31]. Findings from this study suggest that clinicians who care for LTRs should screen these individuals for the presence of chronic pain. While chronic pain explained the largest percentage of the variance in physical health, loneliness explained the largest percentage of variance in the mental health scores. Only one study was found that evaluated loneliness as a predictor of HRQOL among elderly caregivers [35], and no studies have evaluated the impact of loneliness on the HRQOL of LTRs. Loneliness is not the same as being alone, but people with small social network usually feel more loneliness than people with larger social networks [55,56]. In addition, women report more loneliness than men; older people report feelings of loneliness more often than younger individuals, excluding young people between the ages of 19 and 29 who feel more loneliness than adults [43]. One study found that loneliness was the most important factor predicting low HRQOL of older caregivers as well as older people in general [35]. Recent findings suggest that loneliness may lead to depression, sleep disturbances, anxiety, and desperation [57]. A recent study found that social loneliness impacted QOL in individuals with serious mental illness who lived in a group home [58]. While loneliness is emerging as a concept that influences HRQOL, additional research is warranted to replicate the findings from this study. In the present study, illicit drug use was associated with poorer mental health. This finding is consistent with a previous study [38]. However, a recent review noted that it was difficult to draw valid conclusions about the impact of alcohol and substance abuse on HRQOL because of heterogeneous study samples and different ways that QOL was defined and measured [37]. Additional research is warranted on this relationship. Several limitations of this study need to be acknowledged. First, only a limited amount of information is available on those LTRs who did not return the study questionnaires. When administrative data from 2005 were used to compare the recipients who met the inclusion criteria to those who completed the questionnaire, no significant differences were found in gender, age, work experience, previous receipt of social assistance, and social security benefits [42]. Another limitation is that all of the information was obtained through self-report measures, and some of the questions may be subject to recall bias. It should be noted that one of the questions on SF-12 asked about how pain had impaired on individual's work and daily life which is likely to be related to the PCS score. However, the bivariate correlation between chronic pain and PCS was 0.59. It is not that high, so chronic pain is not all that the PCS score is measuring. Finally, the QOL scores of the LTRs in this study may be higher than the total population of LTRs, because LTRs with serious illness or severe substance abuse problems were excluded from this study. --- Conclusion Findings from this study suggest that chronic pain in LTRs is associated with poorer physical health. However, both groups of LTRs had lower mental health scores than normative data for the general population. These findings warrant replication in future studies. In addition, longitudinal studies are needed to evaluate the long-term impact of chronic pain on the physical health of LTRs.

Purpose The purposes of this study were to compare the health-related quality of life (HRQOL) of long-term social assistance recipients (LTRs) with and without chronic pain and determine the effect of select demographic, social, pain, alcohol, and illicit drug use characteristics on the physical and mental components of their HRQOL. Methods In this cross-sectional study, which is part of a larger study that evaluated the health and functional abilities of LTRs in Norway, 405 LTRs of which 178 had chronic pain were recruited from 14 of 433 municipalities. Results LTRs with chronic pain were older (P \ .001), more often married (P = .002), feeling more lonely, (P = .048), and had more problems with alcohol (P = .035). The final regression model explained 41.2% (P \ .001) of the variance in PCS scores and 32.2% (P \ .001) of the variance in MCS scores. Being in chronic pain (29.7%), being older (4.7%), and never married (2%) predicted worse PCS scores. Feeling lonely (11.9%), having problems with illicit drug use (5.9%), and being in chronic pain (2.9%) predicted worse MCS scores. Conclusion LTRs with chronic pain rated both the physical and mental components of HRQOL lower than LTRs without chronic pain. The MCS score in both groups was negatively effected.

Introduction World population growth over the next quarter-century is projected to be heavily concentrated in urban areas, especially in megacities of the developing world, with area population greater than 10 million. Associated trends may include increases in social and economic inequalities, stressors linked to rapid urbanization, and related deterioration in health, particularly mental illnesses [1]. This process has already started in a number of sentinel areas that can be studied to provide a forewarning of the future of health in developing countries. Although its unique historical, economic, and cultural backgrounds distinguish the Sa <unk>o Paulo Metropolitan Area (SPMA) from other megacities in the developing world, it could be viewed as one such area and it was chosen to conduct the Sa <unk>o Paulo Megacity Mental Health Survey (SPMHS), the Brazilian segment of the World Mental Health (WMH) Survey Initiative, under the auspices of the World Health Organization [2]. Located in southeastern Brazil, SPMA holds more than 10% of the Brazilian population [3] and is the fifth largest metropolitan area in the world, with around 20 million inhabitants. It is regarded as an especially important industrial and commercial center in the Latin America and Caribbean (LAC) region. Between 1997 and 2007, the urbanization process increased the population by 16%: 10% in the city of Sa <unk>o Paulo and 25% in peripheral areas and surrounding municipalities [3]. This growth is partially a consequence of rural-to-urban mobility of migrants from the poor regions of Brazil to the outskirts of SPMA, who seek job opportunities, education, medical care, and better living conditions [4]. As in other metropolitan areas [1], these changes lead to inordinate land occupation, housing shortage, widespread of informal work sector, and aggravating social deprivation in some neighborhoods [5,6]. This environmental context also increases the level of social isolation and dissolution of primary family relations. Associated impoverishment can yield escalated violence and homicide rates, with resulting dissemination of insecurity over the metropolitan area [7,8]. All these structural and psychosocial circumstances mirror and underscore historical social inequalities and long-term income disparities in Brazil [9]. The impact of living in urban areas at a given moment in time [5], or exposure to urbanicity [1], along with individual factors may have consequences for mental health [10,11,12,13]. Knowledge on how urbanicity can affect mental health is still limited, but has been described as a priority [13,14]. With respect to Brazil, the 2005 estimates of the Global Burden of Disease Project [15] suggest that neuropsychiatric conditions accounting for 21.5% of all disability-adjusted life years (DALYs) (25.1% in women and 18.6% in men). Nevertheless, most of the data for these estimates have come from limited psychiatric epidemiologic studies [16] carried out in small communities [17], or selected neighborhoods in large cities [18,19,20], without providing comprehensive information about severity and disability. The current report aims extending previous Brazilian psychiatric surveys with data on prevalence and severity levels of recently active DSM-IV mental disorders. The use of services was assessed to guide planning and implementation of health services policies [21,22,23]. Also, along with examination of socio-demographic correlates, we inspected, in a general framing, some characteristics of urban life (i.e., migration status, exposure to crime-related traumatic events, exposure to an urban environment, and neighborhood social deprivation level) in relation to active mental disorders. --- Methods --- Ethics Statements The SPMHS procedures for recruitment, obtaining informed consent, and protecting human subjects during field procedures were approved by the Research and Ethics Committee of the University of Sa <unk>o Paulo Medical School. Respondents were interviewed only after informed written consent was obtained, and total confidentiality was assured. Eligible respondents were those who were 18 or older, Portuguese-speaking, and without any disability or handicap that would otherwise impair their ability to participate in the interview. --- Sample The SPMHS was designed to be a representative sample survey of household residents aged 18 years and older in the SPMA, an area formed by the state capital city of Sa <unk>o Paulo and its 38 surrounding municipalities, covering a geographical area of 8,051 km 2 [24]. At the time of data collection (May 2005 to May 2007), 11 million inhabitants were 18 years or older [24]. Detailed descriptions of sampling and weighting methods are presented elsewhere [2]. Briefly, respondents were selected through a stratified, multistage area probability sample of households. Within each household one respondent per dwelling was selected through a Kish table. In all strata, the primary sampling units (PSUs) were 2,000 cartographically defined census count areas [24]. Each municipality contributed to the total sample size according to its population size. The sample size, after sampling, recruitment, and informed consent, was 5,037. Initially, 7,700 households were selected to achieve the planed sample of 5,000 subjects, allowing for a 35% non-response rate. Using the strategy of releasing consecutive subsamples of 500 households, representing a random sub-sample of the whole sampling frame, the fieldwork was therefore interrupted with the release of the first 6,199 housing units selected. A total of 5,237 subjects agreed to participate, but 200 elderly respondents were considered not eligible due to cognitive impairment. The overall survey participation level was 81.3%. --- Measures Diagnostic Assessment. Respondents were assessed using the Composite International Diagnostic Interview (WMH-CIDI), a fully structured lay interview that generates diagnoses according to the DSM-IV criteria, translated and adapted to the Brazilian-Portuguese language. Face-to-face interviews were carried out by professional interviewers who received five-day standardized training. The Brazilian version of this instrument consisted of two parts. Part 1 included core diagnostic sections (major depression, mania, panic disorder, specific phobia, social phobia, agoraphobia, generalized anxiety disorders [GAD], adult separation anxiety [ASA], substance use disorders [SUD], intermittent explosive disorder [IED], attention-deficit/hyperactivity disorder [ADHD], oppositional-defiant disorder [ODD], and conduct disorder), and suicidal behavior. Additional sections with demographic information, daily functioning, and physical morbidity were administered to all respondents (n = 5,037). Part 2 included questions about risk factors, consequences, and other correlates, along with assessments of additional disorders (posttraumatic stress disorder [PTSD], obsessive-compulsive disorder [OCD]), and were administered to all respondents who met lifetime criteria for any disorder in Part 1, plus a probability subsample of other respondents in an effort to reduce the respondent's burden and control the costs of the study. Part 2 was administered to 2,942 respondents. DSM-IV disorders active within 12 months prior to the date of assessment are considered herein to include four classes of disorders as follows: anxiety disorders (panic disorder, GAD, agoraphobia without panic disorder, specific phobia, social phobia, PTSD, OCD, ASA), mood disorders (major depressive disorder, dysthymia, bipolar disorder I or II), impulse-control disorders [ICD] (ODD, conduct disorder, ADHD, IED), and SUD (alcohol and drug abuse and dependence). DSM-IV organic exclusion rules were used in making the diagnoses. Hierarchy rules were also used in diagnosing major depressive disorder, dysthymia, GAD, and ODD. For SUD, DSM-IV abuse was defined with or without dependence in recognition abuse often being a stage in the progression to dependence. Hierarchy-free diagnoses were consistently used in analyses of comorbidity. Blind clinical re-interviews using the Structured Clinical Interview for DSM-IV Axis I disorder (SCID-I) [25] with a probability subsample of WMH respondents found generally good agreement between WMH-CIDI diagnoses and SCID diagnoses [26]. Preliminary results of the clinical reappraisal study in the SPMHS with a probability subsample of 775 respondents (not included in the previous validation study cited above) showed a good total classification accuracy (range:76%-99%) and an area under the Receiver Operating Characteristics curve around 0.7 for any disorder. Severity. In order to give information on clinical significance and needs assessment, the WMH-CIDI includes extensive information on symptom persistence, distress, and associated disability, allowing the classification of cases in severity levels based not only in psychopathology or symptoms, but also taking into account impairment in several domains of functioning. Each diagnostic section contains explicit questions about impairment in various areas of functioning among 12-month active cases. Four of these questions are the Sheehan Disability Scale (SDS), which ask respondents to rate the impairment caused by a focal disorder during one month in the past year when it was more severe. The SDS assessed disability in work role performance, household maintenance, social life, and intimate relationship on 0-10 visual analog scales with verbal descriptors and associated scale scores of none, 0; mild, 1-3; moderate, 4-6; severe 7-9, and very severe, 10 [27]. Active cases were classified as'severe' if they had any of the following: (1) bipolar I disorder; (2) substance dependence with physiologic signs; (3) ever attempted suicide in the last 12 months and had at least one 12-month disorder; and (4) more than one 12month disorder and a high level of impairment on Sheehan Disability Scales i.e. at least 3 out of the 4 of the following must be true: score$8 in household maintenance domain, $7 in work role performance domain, $8 in intimate relationship domains, and $7 in social life domain. Among those who are not categorized as severe cases, respondents are labeled'moderate' if they had at least one disorder with a moderate level of impairment on any SDS domain or substance dependence without physiological signs. The remaining respondents with any active disorder were categorized as'mild'. Service Use. Treatment was assessed by asking respondents if they ever saw any professional for problems with their emotions, nerves, mental health, or use of substances [28]. Twelve-month treatment variables were created using a combination of disorderspecific treatment questions and details about services received from particular providers. Broad categories of health care and non-health care providers were created. Health care providers included mental health care professionals (psychiatrist, psychologist, social worker, mental health counselor) and general medical providers seen for treatment of emotional problems (primary care physician, other general physician, nurse, or any other health care professional). Non-health care providers included human services professionals (religious or spiritual advisor; counselor in a non-mental setting; complementaryalternative medicine [CAM] provider, as a chiropractor or folk healer; and self-help group). --- Correlates Socio-demographic. Socio-demographic correlates included age (18-34, 35-49, 50-64, and 65+ years old), gender (male/ female), completed years of education (0-4, 5-8, 9-11, and $12; referred to as low, low-average, high-average, and high, respectively), marital status (married/cohabiting, previously married, never married), and family income. Family income was defined in categories based on the respondent's household income per family member divided by the median income-per-familymember in the entire sample. Household income was defined as low if this ratio was 0.5 or less, low-average if the ratio was in the range 0.5-1.0, high-average if 1.0-2.0, and high if greater than 2.0. Exposure to crime-related traumatic events. Considering previous evidence of endemic urban violence in the SPMA [7] and the adverse consequence of crime victimization on mental health [29], seven crime-related traumatic events were selected from the list of events from the PTSD section of CIDI: i. kidnapped or held captive, ii. 'quicknapping' (a short term kidnapping), iii. stalked, iv. mugged or threatened with a weapon, v. witnessed anyone being injured or killed, or unexpectedly saw dead body, vi. witnessed atrocities or carnage, vii. witnessed a close person to be kidnapped, tortured or raped. The exposure to crime-related traumatic events was summarized as: none, one event, two events, and three or more events. Exposure over early years of the life course to urban environment (urbanicity). Respondents were asked if they were raised (i.e., spent most of their childhood and adolescence) in a large city or its suburbs, a small town or village, or a rural area. To address the impact of exposure over early years of the life course to urban environment as correlates of the four classes of disorders and disorders severity considered herein, three dummy variables were created to reflect level of exposure to urbanicity [5]. Those reported being raised in rural areas were considered with the lower exposure to urbanicity, followed by those raised in small town or village (medium level of exposure). Those raised in large cities were considered the highest level of exposure to urbanicity. Migration status. To assign the migrant status, respondents were asked if were born outside SPMA and their age of migration. Neighborhood social deprivation level. An index of neighborhood social deprivation (NSD) level was developed by the Center of Metropolitan Studies (http://www.centrodametropole. org.br) [6] and assigned to each census unit, to reflect social conditions in the SPMA geographical space using data from the 2000 Census [24]. This index represents a combination of socioeconomic deprivation dimension (income, level of education, family size, and percentage of families headed by a woman with low educational level) and the population's age structure. The NSD index ranges from 1 (no social deprivation) to 8 (high social deprivation; see Table S1 for details), with a concentric spatial distribution of deprivation increasing in peripheral neighborhoods. These eight levels were summarized in three indicators: no/low (combined index of 1, 2, and 3 NSD level), medium-low/medium (6 and 4), and high/very high NSD (5, 7, and 8). --- Analytic approach In order to consider the stratified multi-stage sample design, the analytic approach included conventional methods for variance estimation with complex sample survey data, and weights were used to adjust for differences in within-household probability of selection and non-response. A post-stratification weight was used to make the sample distribution comparable to the population distribution in the year 2000 Census on a cross-classification of socio-demographic variables (see [2] for details). Weights were used to address the coverage of survey variables in Part 1 and Part 2 of the assessment, with an additional weight used when Part 2 variables are considered (e.g., urbanicity; migration status, crimerelated traumatic events). Prevalence estimates within sub-samples were obtained with cross-tabulations. Multiple logistic regression analysis was used to study correlates of prevalence, disorder severity (severe/moderate vs. mild), and treatment. Analyses of correlates were conducted in three stages. First, multiple logistic regression models were built to examine the association between outcomes and socio-demographic characteristics. A second set of models was created to examine the exposure to crime-related traumatic events controlling for gender, age, and NSD, as correlates of the four classes of disorders. Third, models were elaborated to consider the potentially separable associations with migration status, level of exposure to urbanicity, and NSD, as correlates of the four classes of disorders and disorder severity, controlling for socio-demographic factors (gender, age, income, marital status, and education). These analyses were then repeated with the addition of higher order product-terms between gender (given its important modifier effect), migration status, level of exposure to urbanicity, and NSD to study whether the association of each of these factors was uniform across each class of disorder and disorder severity. When necessary, a stepwise backward approach was used to select between intercorrelated variables. Logistic regression coefficients and standard errors (SEs) were exponentiated. The resulting estimates are reported here as oddsratios (OR) with 95% confidence intervals (CIs). As the survey data used in the analysis were weighted and the sample was geographically clustered, SEs were based on the design-based Taylor series linearization method. These calculations were made using SUDAAN software [30]. Wald x 2 tests calculated from Taylor series coefficient variance-covariance matrices were used to evaluate the statistical significance of sets of coefficients, with twosided alpha set at 0.05. --- Results --- Prevalence and severity The proportion of SPMA household residents with at least one recently active DSM-IV/CIDI disorder under study was 29.6%, and these cases were evenly distributed across the severity gradient from mild (33.2%), moderate (33.0%) to severe (33.9%), such that about one in ten residents had a recently active severe mental disorder (10%). Anxiety (19.9%) and mood disorders (11%) were the most prevalent classes of disorder, followed by disturbances of impulsecontrol (4.2%), and substance use disorders (3.6%). Table 1 shows these estimates along with specific disorders. For example, 9.4% respondents suffered from recently active major depressive disorder and about one in nine residents (10.6%) had recent specific phobia. While most cases had just one active mental disorder, there was some comorbidity: about one in 16 respondents were found to have two active disorders (5.9%) and a roughly equal number have three or more disorders (5.8%). Severity was strongly related to comorbidity: an estimated one in five of the cases (19.5%) with only one disorder qualified as'severe'. By comparison, the corresponding severity estimates were 40.2% for comorbid cases with two disorders, and 71.3% for those with more than two active disorders. The distribution of severity also varied across classes of disorders, with the highest percentage of serious cases for SUD (56.3%) and the lowest for anxiety disorders (36.5%). Nonetheless, a majority of cases of certain anxiety disorders also qualified as'severe': agoraphobia without panic (57.4%), panic disorder (56.6%), and social phobia (55.6%). Among mood disorders, bipolar disorder had the highest percentage of'severe' cases (65.4%), which include all active cases of bipolar I disorders and cases of bipolar II associated with suicide attempt in the last 12month, or associated with high impairment in Sheehan Disability Scale. Among ICD, 82% of conduct disorders were classified as'severe'. The highest percentages of severe cases were found for alcohol and drug dependence (94.5% and 93.2%, respectively). Table S2 shows the prevalence of 12-month disorders by gender and age cohorts. Anxiety disorders were more frequent in women, but no gender differences were observed in social phobia, obsessive-compulsive disorders, and adult separation anxiety. Considering mood disorders, major depression and dysthymia were more frequent in women, whereas there was no gender differences for bipolar I or II. Only two of the four impulse control disorders assessed were more frequent in males: conduct and attention deficit disorders. Oppositional-defiant disorder and intermittent explosive disorders were equally distributed across gender. In three of the SUD, males had prevalence four times higher than females, with the exception of drug dependence. There are significant inter-cohorts variations for the four broad classes of disorders, with prevalence declining in the eldest cohort, with the exception of GAD, agoraphobia without panic, and dysthymia, in which no inter-cohort variation occurred. --- Socio-demographic correlates of disorders and severity Table 2 shows the results of modeling the occurrence of recently active case status, and severity level, as a function of sociodemographic variables. Based on these estimates, women were more likely to have mood, anxiety, and severe/moderate disorders than men, while men were more likely to have SUD than women (all p,0.05). For the ICD, no male-female differences were found. The three younger age groups were more likely than the oldest age group to qualify as recently active cases of mood, anxiety, SUD, and severe/moderate disorders. For ICD, active case status was concentrated in early adulthood. Being previously married was associated with an increased likelihood of presenting mood, anxiety, ICD, and severe/moderate disorders. Being in the lower income strata was associated with a reduced likelihood of ICD. Respondents with less than some primary education were more likely to present anxiety disorders, and those with less than college education being more likely to present SUD. --- Crime-related traumatic events The experience of crime-related traumatic events was common in the sample. An estimated 54.6% (SE:1.5) of the area residents had experienced at least one of these events at some time in their life. An estimated 6.1% (SE:0.5) of respondents had experienced three or more crime-related events, and 17.6% (SE:1.0) had experienced two events. Among the seven crime-related traumatic events examined, six were associated to at least one disorder (p,0.05). These events were: witnessed anyone being injured or killed, or unexpectedly saw dead body (experienced by 35.7% of respondents), being mugged or threatened with a weapon (34%), being stalked (5.5%), seeing a close person being kidnapped, tortured or raped (5.2%), witnessing atrocities or carnage (3.5%), being kidnapped or held captive (0.5%). 'Quicknapping' (experienced by 1.6%) was not associated with any disorder. Being a recently active mental disorder case was associated with the number of traumatic events experienced (Table 3). Elevated odds for mood, anxiety, and ICD were observed even for those who had experienced only one of the events considered. An exception was SUD, where an increased odd was found only among residents who had experienced three or more of these traumatic events. Exposure to urban violence was also associated with the severity distribution of these disorders. About 40% of those exposed to three or more events met criteria for a severe/moderate disorder, declining to around 20% for those exposed to one or two trauma. --- Exposure over early years of the life course to urban environment Roughly three of five SPMA urban residents were raised in an urban area, spending most of their childhood and adolescent years in SPMA or some other large urban center (57.9%; SE:1.8). About one in four had been raised in a small city (23.6%; SE:1.3), and only one in 5-6 were raised in rural areas (18.5%; SE:1.3). There was an excess occurrence of ICD in individuals raised in an urban area versus those raised in a rural area, as signified by an OR estimate of 1.8 (p,0.05; Table 4). Other mental disorders were not associated with this urbanicity variable. --- Neighborhood social deprivation level Roughly one-third of the SPMA residents (31.3%; SE:1.3) lived in neighborhoods at the higher levels of neighborhood social deprivation (NSD); corresponding estimates for no/low and lowmedium/medium NSD were 33% (SE:1.4) and 35.8% (SE:1.7), respectively. Being an active SUD case was associated with residing in a higher NSD area; the odds of an SUD were roughly twice as large for higher NSD area residents as compared with residents living with no/low NSD levels, controlling for the respondent's socio-demographic variables, including income and education (Table 4). There was a modest association between disorder severity and living in medium or higher NSD level areas of the SPMA, with an OR of 1.3 (p = 0.04 in the contrast of medium NSD versus no/low NSD area residents, as shown in the last column of Table 4). --- Migration status In our sample, 52% (SE:0.9) respondents had migrated into the SPMA after being born. Among the in-migrants, slightly more than one-third had come from rural areas (36.1%; SE:1.8); slightly more than one-third from small cities (37.0%; SE:1.8); about one in four had come from some other large city (27%; SE:1.7%). At the time of this survey, in-migrants tended to live in neighborhoods with some sort of deprivation: 36.8% (SE:1.8) in high/very high NSD and 36.6%; (SE:1.8) in low-medium/medium NSD. Only one fourth (26.6%, SE:1.9) was living in no/low NSD. Estimates of the association between the NSD level of SPMA residents and the odds of recently active mental disorders were generally unremark- able. The noteworthy exception involved recently active mood disorder: when compared to non-migrant SPMA residents, the inmigrants (born in other places) were less likely to present a mood disorder (p = 0.03; Table 4). --- Subgroup variation across urbanicity, neighborhood social deprivation, and migration status In our search for male-female differences and subgroup variation across the urbanicity, NSD, and migration status variables, the product-terms suggested some leads for future research on mood disorders, anxiety disorder, and impulse control disorders (p,0.05). For example, among women, the estimated odds of being an active case of a mood disorder varied considerably in relation to migration status and in relation to our measure of urbanicity based upon where the resident was born and raised. The subgroup of women most likely to have active mood disorder was non-migrants who had been raised in one of the less urbanized parts of the SPMA. When compared with this higher prevalence subgroup of non-migrant women, the nonmigrant women who had been raised in a more urbanized part of the SPMA had lower odds of mood disorder (OR = 0.38; 95%CI: 0.15-0.97; p = 0.038), as did the in-migrant women who had been raised in rural areas (OR = 0.3; 95%CI: 0.1-0.7; p = 0.004). With respect to being an active case of anxiety disorder, in general there was a consistent two-fold excess odds for women versus men in all of the subgroups analyzed. For example, in the comparison of non-migrant women living in no/low NSD conditions versus non-migrant men living in no/low NSD conditions, the estimated OR was 2.3 (95%CI = 1.5-3.5; p = 0.0003). Nonetheless, there was an important exception among migrant men and women, where the migrant women living in no/low NSD conditions were much more likely than men to have active anxiety disorder as compared to migrant men living in the same conditions (OR = 5.7; 95%CI = 2.9-1.3; p,0.0001). This contrast lends some support to the idea that migrant men living in no/low NSD conditions may be in a relatively favorable situation with respect to being a case of anxiety disorder. As compared to these no/low NSD migrant men, the migrant men living in middle and higher NSD conditions were more likely to have an active anxiety disorder, with OR of 2.8 for the middle NSD versus no/low NSD contrast of these men (95%CI = 1.1-7.1; p = 0.03) and with an OR of 2.2 for the higher NSD versus no/low NSD contrast (95%CI = 1.1-4.7; p = 0.03). With respect to ICD, in the primary study estimates there was no male-female difference (Table 2; p.0.05), no apparent effect of migration status (Table 4; p.0.05), and a non-robust gradient with no more than a modest association between living in middlehigher NSD conditions and being an active ICD case (Table 4, p.0.05). In the search for subgroup variation, we found some evidence that the subgroup of women born and raised in the SPMA might be more likely to be affected by active ICD. For example, among women living under conditions of high/very high levels of NSD, the non-migrant women were substantially more likely to have active ICD (OR = 2.8; 95%CI = 1.3-6.2; p = 0.007) than in-migrant women living higher NSD conditions of the megacity that might be in a relatively favorable situation. Migration status was not associated with ICD among women living in the other NSD conditions. Looking across NSD conditions, the only statistically robust association was found in the contrast of non-migrant women in the higher NSD conditions versus non-migrant women in the no/low NSD status, again with greater ICD prevalence among non-migrant women living in the higher NSD conditions (OR = 3.0; 95%CI = 1.1-8.1; p = 0.03). --- Service use by severity of disorders Table 5 shows estimates for the proportion of SPMA residents receiving mental health services as well as evidence that severity of disorder was associated with greater likelihood of receiving services during the 12 months prior to the date of assessment. An estimated one in 11 SPMA residents (8.7%) had received treatment for mental health problems during that interval. About one in 12-14 residents received mental health care from a general practitioner or other provider in the general health care sector (7.7%). About one in 20 SPMA residents had been treated in the mental health care sector (5.3%), and about one in 50 had received mental health are from the non-health care sector and from CAM providers (2.0%). A small proportion received care from more than one sector (3.2%), and severity level of the disorder was quite strongly associated with treatment in more than one sector. For example, an estimated 32.8% of the'severe' cases received mental health services in at least one sector, and an estimated seven percent of the'severe' cases received treatment in more than one sector. The corresponding estimates for the'moderate' cases were 12.6% and 1.8%, respectively. For'mild' cases, these estimates were 3.6% and 0.4%. This association between severity and treatment was statistically significant for treatment in the mental health specialty sector and in the non-healthcare setting, whereas in the general medical sector no association with severity occurred. Among respondents with no currently active WMH-CIDI disorder, an estimated 3.6% also received some sort of mental health treatment, possibly representing successful treatment of a previously active disorder or treatment of a mental disorder not covered in the WMH-CIDI assessment. Compared to respondents aged 65 years or more, the age cohorts of 35-49 yo and 50-64 yo presented significantly more use of service. Women used more services compared to men (OR = 2.4; 95%CI = 1.7-3.4; p,0.0001). Neither income, marital status, education, nor NSD were related to the likelihood of mental health treatment (p.0.05; data not shown in a table). --- Discussion This study provides the first empirical data on the prevalence of mental disorders and associated severity levels in the adult community population living in households within the Brazil's largest metropolitan area, which may serve as a model of what might be seen in other megacities of the LAC region specifically, and in the developing world generally. The results reveal that mental disorders are notably prevalent and the estimated 10% prevalence of'severe' cases indicates that in this megacity there are more than one million adults with impairment levels indicating special need for mental health care. Comorbidity is quite a common phenomenon, with most of the morbidity concentrated in around 40% of the active cases that present two or more disorders. In addition, this study offers (1) evidence on the burden of mental health in a developing country where prior epidemiological data are scarce; (2) a comparison of the results with estimates from other WMH surveys, since the same methods were applied in this consortium initiative; and (3) an examination of the relationships between psychiatric morbidities and facets of urban life, such as exposure to violence, neighborhood social deprivation, and migration status. Compared to corresponding prevalence estimates of WMH-CIDI-diagnosed DSM-IV mental disorders from the other 23 participating countries of the WMH Survey [31,32,33,34], our estimate of 29.6% is larger than the corresponding value in the United States (26.2%) and about two times the estimates seen for the other upper-middle income participating countries [34]. Also, by comparison with results from the other countries, the SPMA seems to have the largest proportion of severely affected cases (10%), well above the US estimate (5.7%), the New Zealand (4.7%) [32], and those from the 14 countries reported elsewhere [31]. In our megacity, the anxiety disorders qualify as the most frequently observed condition [31] and major depression emerged as one of the most prevalent disorders, with higher estimated prevalence than has been seen elsewhere in other participant countries [35]. The estimate of SUD prevalence in Sa <unk>o Paulo (3.6%) is higher than Colombia's and Mexico's, the other two LAC countries in the WMH surveys, which reported estimates of 2.8% and 2.5%, respectively [31,36]. With respect to impulsecontrol disorders, the SPMHS' prevalence of intermittent explosive disorders exceeds the estimate of US (3.1% vs. 2.6%) and stands as the highest IED prevalence estimate among the WMH sites that assessed this disorder [37,38]. The characteristics of our sample reflect the pattern of population growth of this megacity over the last decade: about one-half of the adult SPMA residents are in-migrants coming from other small cities and rural areas, most of them now living in suburban and peripheral deprived neighborhoods of the SPMA [6]. Concurrently, there has been a widespread scaling-up of urban violence [39], increasing the feeling of insecurity among people living in the megacity. As it happens, the SPMHSestimated level of exposure to violence rivals to what has been experienced in armed conflict countries such as Lebanon [40]. In Brazilian health statistics of recent years, violence and injuries have been found to be one of the main sources of morbidity and mortality by external causes [41]. In our survey, crime-related events were found to be associated with all classes of mental morbidities and disorder severity, confirming previous reports that SUD, PTSD, and depression are frequent among individuals exposed to traumatic events [42]. SUD may increase the risk of violence victimization, over and above any purported effects of SUD on crime or violent behavior [42,43]. A country's internal migration of workers due to economic reasons often has been described in relation to a 'healthy migrant effect' [44]. This favorable pattern was observed in the SPMA, with migrants less prone to present mood and ICD, as compared to non-migrants in the same area. Nevertheless, the potential effects of migration were observed unevenly in some subgroups of our sample, with several determinants possibly interacting with each other, e.g., being male or female, urban/rural origin, and neighborhood context, and some vulnerable subgroups were disclosed in our exploration of product-terms. For example, migration-related stressors in combination with high NSD might work to increase the likelihood of being an active case of anxiety disorder in men. In this context, our observed patterns of malefemale variations with respect to migration status, urbanicity, and NSD deserve more detailed future analysis, possibly with probing into issues that will clarify the forces that brought the in-migrants to the megacity, clarifying the temporal sequence of events and processes at play during the causal pathways that lead toward increasing risk, severity, or non-persistence of mental disorders. In these SPMHS estimates, previous exposure to an urban environment is associated with increased odds of presenting an ICD, and to a lesser extent, mood disorders and more severe disorders. These findings may be consistent with earlier reports that psychiatric disorders are more common among the inhabitants of urbanized areas [11,12,45]. A ''breeder

Background: World population growth is projected to be concentrated in megacities, with increases in social inequality and urbanization-associated stress. Sa ˜o Paulo Metropolitan Area (SPMA) provides a forewarning of the burden of mental disorders in urban settings in developing world. The aim of this study is to estimate prevalence, severity, and treatment of recently active DSM-IV mental disorders. We examined socio-demographic correlates, aspects of urban living such as internal migration, exposure to violence, and neighborhood-level social deprivation with 12-month mental disorders.A representative cross-sectional household sample of 5,037 adults was interviewed face-to-face using the WHO Composite International Diagnostic Interview (CIDI), to generate diagnoses of DSM-IV mental disorders within 12 months of interview, disorder severity, and treatment. Administrative data on neighborhood social deprivation were gathered. Multiple logistic regression was used to evaluate individual and contextual correlates of disorders, severity, and treatment. Around thirty percent of respondents reported a 12-month disorder, with an even distribution across severity levels. Anxiety disorders were the most common disorders (affecting 19.9%), followed by mood (11%), impulse-control (4.3%), and substance use (3.6%) disorders. Exposure to crime was associated with all four types of disorder. Migrants had low prevalence of all four types compared to stable residents. High urbanicity was associated with impulse-control disorders and high social deprivation with substance use disorders. Vulnerable subgroups were observed: women and migrant men living in most deprived areas. Only one-third of serious cases had received treatment in the previous year. Discussion: Adults living in Sa ˜o Paulo megacity had prevalence of mental disorders at greater levels than similar surveys conducted in other areas of the world. Integration of mental health promotion and care into the rapidly expanding Brazilian primary health system should be strengthened. This strategy might become a model for poorly resourced and highly populated developing countries.

subgroups of our sample, with several determinants possibly interacting with each other, e.g., being male or female, urban/rural origin, and neighborhood context, and some vulnerable subgroups were disclosed in our exploration of product-terms. For example, migration-related stressors in combination with high NSD might work to increase the likelihood of being an active case of anxiety disorder in men. In this context, our observed patterns of malefemale variations with respect to migration status, urbanicity, and NSD deserve more detailed future analysis, possibly with probing into issues that will clarify the forces that brought the in-migrants to the megacity, clarifying the temporal sequence of events and processes at play during the causal pathways that lead toward increasing risk, severity, or non-persistence of mental disorders. In these SPMHS estimates, previous exposure to an urban environment is associated with increased odds of presenting an ICD, and to a lesser extent, mood disorders and more severe disorders. These findings may be consistent with earlier reports that psychiatric disorders are more common among the inhabitants of urbanized areas [11,12,45]. A ''breeder hypothesis'' has been used to link the detrimental consequences of exposure to urbanicity to poor mental health status [11]. Other WMH sites that have surveyed urban areas, such as Colombia and European locations [11,46], also found higher prevalence of mental disorders in more urbanized areas than less ones. In contrast to this general pattern, non-migrant women raised in less urbanized areas of the SPMA seem to have been more vulnerable to mood disorders than women raised in more urbanized regions, or perhaps have more persisting mood disorder once it starts. Also, non-migrant women living in high NSD areas were also more likely to present an ICD than those from no/low NSD conditions. This might be due to the fact that in most peripheral deprived areas of the SPMA there is a predominance of woman-headed households with low education [6].Poverty among urban women may account for perpetuation of mechanisms of poor mental health [1]. The lack of male-female difference in ICD and drug dependence is in contrast with findings from other WMH countries [47], wherein for most externalizing disorders the estimates for men exceed those for women. Our data suggest a male-female convergence in externalizing disorders in the megacity, which might imply a growing burden of mental disorders in women [47,48]. The findings of greater male-female differences in migrants from rural areas in mood disorders and migrants living in no/low NSD in anxiety disorders is consistent with previous reports that migration places women in a more vulnerable position in relation to men. How gender interact with other social contexts to shape health of migrant population is still an open matter [49]. With respect to age, most mental disorders, particularly the moderate/severe cases, were more common in early adulthood and midlife, suggesting impact on role-functioning during the important years of employment in the labor force [50,51]. With respect to marital status, our finding that previously married residents were more likely to present an anxiety, mood, or ICD suggests the lack of social support of those divorced as one of complex pathways to mental disorders, as described by Kendler and colleagues in their research on depression in women [52]. The association linking loneliness and poor social relationships (including separation/divorce/widow status) with ill-health outcomes and mortality was recently clarified in a meta-analysis [53]. Changing marriage patterns, with increased social isolation, is considered both a predictor and a putative cause for poor mental health in urban areas [54], and of course, becoming separated or divorced may be a consequence of an active mental disorder as well. --- Use of services As expected, disorder severity was found to be related to treatment seeking and receipt of services, which we surmise to be linked with the distress and impairment that accompany mental disorders [33,36,40,55,56]. Nonetheless, the majority of SPMA adults with active mental disorders did not receive treatment services. The finding of one third of those with serious disorders in the previous year receiving treatment is similar to findings in upper-middle income countries in the WMH survey consortium [34], but the SPMA estimate is not quite one-half the mean value observed in higher income countries. Among severe/moderate cases, treatment in the specialty mental health sector was more common than general medical treatment, indicating an incipient mental service provision, contrasting with mental health care deregulation described in relation to our previous findings from a more circumscribed survey of neighborhoods in central Sa <unk>o Paulo. Nevertheless, inequality and lack of integration also were observed within the SPMA [57,58,59]. Possibly, the gap in mental health treatment in other regions of the country is even worse. --- Limitations Of course, this study has some limitations, and a few of the more salient ones should be mentioned. First, data are not representative of Brazil nor of the world's megacities in general; however, the detailed assessment of the population needs in this area is important for further tailoring policies and strategies to improve the mental health of the population to be served [60]. Second, the target population was restricted to people living in a large metropolitan area; generalization to rural or small city life is not warranted, even though an estimated 85% of the Brazilian population lives in urban areas [15]. To the extent that these two limitations exist, they are likely to increase the prevalence rates. Third, the migrant group is heterogeneous, coming from diverse settings. Different ages at migration, socio-economic condition, and lengths of residence in the SPMA could interfere in the adaptation and acculturation process. Future analyses will be carried on using survival models to account for time-varying and time-invariant characteristics. Fourth, only residents in households were surveyed, whereas the homeless and those institutionalized were not assessed. Fifth, household surveys relying on self-report assessments may induce unwillingness to participate and of non-disclosure; for instance, for alcohol or other drug use and problems. To the extent that these two biases exist, it will make our estimate conservative. Sixth, this report does not include some clinically important disorders -notably, non-affective psychosis and dementia. Although the WMH-CIDI inquired about psychotic symptoms, this information does not allow the diagnosis of non-affective psychosis. Previous studies have shown that these symptoms are overestimated in lay-administrated interviews [61][62][63][64]. However, non-affective psychotic subjects might be captured as cases, as many are comorbid with anxiety, depression, and substance use disorders [64]. Therefore, if severity is underestimated in the WMH-CIDI results will be conservative. The exclusion of elderly with cognitive impairments that was unable to answer the questionnaire did not allow detecting dementia, what can have lowered the rate of cases in this age group. Finally, the cross-sectional nature of our data does not allow determining the direction of association of sociodemographic variables with disorders assessed herein. --- Conclusion This epidemiological survey of mental disorders experienced by adults living in a large and heterogeneous urban area has produced findings that may be a basis for current and future concern -not only in Brazil, but also in the LAC region, and perhaps in other megacities of the developing world. The observed estimates for the prevalence of mental disorders are among the largest ever seen in corresponding epidemiological surveys that have been conducted in other countries, with comparable field survey methods. A large proportion, one-third, of the active mental disorder cases qualify as'severe' cases and most of these active and severe cases remain untreated. The heavy burden experienced by those with two or more disorders, as indicated by the association with severity, must be taken into account when planning services and prevention strategies. These results call attention for the public health impact of mental disorders and offer an important foresight to stakeholders and health care providers [65]. If the world human agglomeration will be settled mostly in large urban centers and megacities during the rest of this new century, the case of SPMA deserves attention as a potential forewarning of what might be occurring elsewhere. The low rate of treatment suggests that the incipient integration of mental health promotion and care into the rapidly expanding Brazilian primary health system [66][67][68] should be strengthened, reaching disadvantaged individuals without access to mental health services. Also, it is important to work with mental health promotion and early recognition of cases, particularly among young and males, those who are the group with less access to services in our survey. Given the substantial burden of these mental health problems, it is important enhance the role of non-specialist health workers and other professionals, such as teacher and community leaders, in the recognition, detection and, eventually treatment of mental disorders. One potentially useful approach in poorly resourced countries is known as task-shifting or task-sharing [69]. Under this approach, there is up-regulation of capacities of primary medical care providers and non-medical professionals for effective treatment of mental disorders; core packages of mental health services are integrated into routine primary care. When accompanied by careful supervision and mentoring by mental health specialists, this approach can be used to scale up the mental health workforce in highly populated developing countries, particularly in the context of disadvantaged or especially vulnerable groups living in more deprived areas that otherwise might be outside the reach of mental health specialists [70][71][72]. --- Supporting Information

Background: World population growth is projected to be concentrated in megacities, with increases in social inequality and urbanization-associated stress. Sa ˜o Paulo Metropolitan Area (SPMA) provides a forewarning of the burden of mental disorders in urban settings in developing world. The aim of this study is to estimate prevalence, severity, and treatment of recently active DSM-IV mental disorders. We examined socio-demographic correlates, aspects of urban living such as internal migration, exposure to violence, and neighborhood-level social deprivation with 12-month mental disorders.A representative cross-sectional household sample of 5,037 adults was interviewed face-to-face using the WHO Composite International Diagnostic Interview (CIDI), to generate diagnoses of DSM-IV mental disorders within 12 months of interview, disorder severity, and treatment. Administrative data on neighborhood social deprivation were gathered. Multiple logistic regression was used to evaluate individual and contextual correlates of disorders, severity, and treatment. Around thirty percent of respondents reported a 12-month disorder, with an even distribution across severity levels. Anxiety disorders were the most common disorders (affecting 19.9%), followed by mood (11%), impulse-control (4.3%), and substance use (3.6%) disorders. Exposure to crime was associated with all four types of disorder. Migrants had low prevalence of all four types compared to stable residents. High urbanicity was associated with impulse-control disorders and high social deprivation with substance use disorders. Vulnerable subgroups were observed: women and migrant men living in most deprived areas. Only one-third of serious cases had received treatment in the previous year. Discussion: Adults living in Sa ˜o Paulo megacity had prevalence of mental disorders at greater levels than similar surveys conducted in other areas of the world. Integration of mental health promotion and care into the rapidly expanding Brazilian primary health system should be strengthened. This strategy might become a model for poorly resourced and highly populated developing countries.

Introduction As China enters an aging society, the social adaptability of the aging population is gradually becoming an urgent problem in China. Entering old age not only means the decline of income and social prestige but also may mean the loss of some life goals. Changes in social roles and life patterns and psychological, economic, and social life problems make the elderly face considerable challenges regarding social applicability. In recent years, China's new media has shown a strong development trend under the background of a global economic slowdown. It not only becomes a new growth point in the process of Chinese economic development but also provides a new opportunity to alleviate the social adaptability dilemma of the elderly. Based on the investigation of new media helping the aged into the present situation of social life, this paper analyzes the new media to the aged social adaptability, its internal mechanisms and influence, and the obstacles of the aged using new media to participation in social life; thereby, putting forward policy suggestions to help improve the adaptability of them. --- Research background and concept definition 2.1 Research background By December 2021, the number of the aged over 65 years old in China had reached 200 million, accounting for 14.2% of the total population, indicating China has officially entered an aging society. It is expected that by 2030, the population over 65 will account for more than 20% of the total population, indicating an increasingly prominent aging problem in China. The 49th Statistical Report on the Development of Internet in China released by the China Internet Network Information Center (CNNIC) shows that by December 2021, the number of Internet users in China has reached 1.032 billion, an increase of 42.96 million compared with December 2020, and the Internet penetration rate reached 73.0%. Among them, the number of Internet users over 60 years old in China is 119 million. This means that 43.2 percent of China's 267 million senior citizens are already online. It can be seen that the increasingly low threshold of Internet technology has enabled more older people to get the opportunity to participate in social life through new media. However, compared with other young and middle-aged groups, the average participation rate of new media in the elderly group is more than 30.0% lower. Only 69.7%, 52.1%, and 46.2% of the aged Internet users could independently perform online activities such as presenting health codes, purchasing daily necessities, and searching for information, respectively. These data show that there is a big gap between the aged and the young in the breadth and depth of new media participation, and the old still belong to the "digital vulnerable group". --- Concept definition Different from broadcasting, newspapers, magazines, and other traditional media, the new media in this paper adopts digital technology as the support, based on wireless communication technology and network technology media form, such as computers, OTT(Internet TV), IPTV (interactive Internet TV), mobile terminal, etc. Mobile media is the most critical form of expression of new media [1]. It transcends the limitations of regions and computer terminals. The most significant feature of new media is that it breaks the boundary between media communicators and receivers. In addition, new media also shows the characteristics of outstanding personalization, customization, a more excellent choice, and real-time information release. In recent years, the development of Internet and mobile phone users in China has entered a plateau. In 2021, the number of mobile Internet users in China was 1.029 billion, an increase of 43 million. The number of OTT users of Internet TV reached 1.083 billion, an increase of 128 million. And the number of IPTV users was 348 million, an increase of 33 million (Table 1 Although the social adaptation of the aged has been widely concerned, the definition of its concept is not uniform. For example, Havighurst et al. believe that social adaptation refers to the process in which individuals or groups actively get used to the new social environment they feel, and the analytical dimension of social adaptation of the elderly should focus on the adaptation of daily life and interpersonal relationship [2]. Li Youlian et al. believe that social participation refers to individual participation in activities that enable two-way interaction between individuals and the external environment [3]. Chen Bo divides the social adaptation of the aged into two categories: "survival social adaptation" and "developmental social adaptation". "Survival social adaptation" refers to the degree to which the elderly can take care of themselves in real social life, and "developmental social adaptation" refers to the degree to which the aged can give play to their potential and expand their self-worth in real social life [4]. In this paper, it can be regarded as a certain degree of social adaptation, as long as the elderly carry out the following two characteristics of social adaptation: (1) Sociality: they can contact others in society. (2) Interactivity: They have particular communication and interaction with others. --- The impact of the development of new media on the social adaptability of the elderly This paper believes that new media is not only a tool for the aged to maintain social interaction but also brings convenience to their life and provides entertainment. New media has become an important channel to improve the social adaptability of the elderly. This paper believes that new media has the following four advantages for the aged: --- Slowing down the decline of the aged's cognitive ability Human cognitive abilities usually include memory, thinking, and language. The deterioration of physiological function and brain structure is the main reason for the decline of cognitive ability in the elderly. Although scientists proved the inevitable connection between intelligence and age is nonexistent, the decline rate of cognitive ability and abstract thinking of the aged with a strong willingness to continue learning is relatively slow [4].In the process of integrating the aged into new media, only through continuous learning and practice and specific information skills can allow the aged make better use of Internet services [5]. --- Improving the level of social participation of the aged The aged who were born in the 1960 s in China or before spend most of their time with newspapers, radio, and television. Although the one-way transmission media type for the aged to understand social change blend in society has also had a certain positive effect, the information resources of one-way communication and passive acceptance are not social participation itself. In the relationship-centered new media environment, some of the aged successfully obtain the rights of expression, communication, action, and other aspects through the use of new media, realizing the reconstruction of "self" identity in the network world. This has solved a large extent of the problem of social participation of the aged. --- Optimizing the social relations of the aged With the expansion of the social circle, the family relationship is at the core of the social relationship. New media also help produce this modest intimacy between two or three generations of a family. In the interview, numerous of the aged mentioned that they often use computers to help third-generation children find tutoring materials. They said, there was no Internet in the past, so they could not imagine that they could take on these roles and tasks while caring for the third generation. The aged withdraw from their original units and begin to take the path of "individuation". Through WeChat moments, most of the aged can integrate into the community and join associations, like hometown associations. Under the premise of limited social resources, new media bring broad social resources and development space for the aged, optimize declining interpersonal relationships, and make them feel no longer lonely [6]. --- Strengthening the social psychological adaptability Social psychology refers to the whole social psychological state that pervades society and its groups in a specific period and reflects in people's general life emotions, attitudes, and comments. First, with the changes in the living environment after retirement, the elderly are prone to psychological problems such as loneliness, depression, and low self-confidence. Thus, they can obtain information about health and life through new media, enabling them to enhance their selfconfidence [7]. Second, retirement does not mean they quit mainstream society and the possibility of contact with other people. On the contrary, new media gives them a "sense of belonging" to return to the community again. --- The digital divide: the barrier for the aged to use new media to participate in social life People have also seen a multitude of media reports on the difficulties faced by the aged in integrating into an intelligent society emerge, the so-called "digital divide". The aged have challenges in using mobile terminals to buy goods, showing health code declarations, using intelligent face recognition, and other new scenarios. The causes of the "digital divide" among the elderly are very complex. None of these scenarios is possible without Internet access or digital terminals. When the aged use smartphones and electronic devices, most of them need help from others. According to the differences in people's use of new media, there are three main types of the digital divide: Desire, Access, and Skill. --- Desire The subjective initiative of the aged is a prerequisite for integrating into new media. The elderly not only need to overcome the habit of passively receiving information but also participate in the expression of information in new media actively. Suppose governments want more older people to participate in new media. It is pivotal for them to be aware of the benefits of new media in terms of information services, intergenerational communication, social participation, and spiritual nourishment [8]. New media education for the elderly needs to understand their real needs to stimulate their potential needs. --- Access The popularity of mobile Internet and smartphones has enabled more of the aged to cross the gate of new media. However, the proportion of elderly Internet users still has much room for improvement. The objective factors that hinder the elderly's integration into the digital world are mainly reflected in financial ability, physical function, psychological cognition level, etc [9]. --- Skill The aged need specific information skills to expand the breadth and depth of digital integration. Then they can enjoy diverse services provided by new media, including opinion expression, emotional communication, and relationship construction. Moreover, the digital space dominated by young people should actively accept the equal participation of the aged and provide more suitable content, such as providing various services on WeChat official accounts, live streaming applications, and other platforms [10]. --- Policy suggestions and conclusions: using new media to improve the social adaptability of the aged The progress of digital technology and the emergence of new media pose challenges and great opportunities for the aged. In order to encourage them to remove the "digital refugee" label of vulnerable groups in the Internet world, enrich their lives, enjoy the new media dividend in the digital era, and become beneficiaries of new media technology, this paper puts forward the following four suggestions: --- Remodeling the positive image of the aged using new media to enhance social adaptability Governments should actively publicize the rich scenes of the aged participating in social life in the new media environment and guide them to improve their ability to master information technology in the process of contacting and using new media. Once the aged are familiar with using new media technologies and resources, they can also provide experience and innovative solutions for the online world to continue promoting social progress. --- Advocating the young generation to carry out "digital feedback" and "technological feedback" on the aged's new media literacy In the face of the inevitable penetration of mobile payment, online shopping, and other technological floods into the daily life of modern society, whether the elderly can smoothly integrate into the new media digital world depends to a large extent on material support and technical training from family between generations. Family members have become a vital force in promoting the popularization of new media among the aged. --- Helping and organizing the aged to learn the use of smart terminals in life scenarios The community should organize a variety of learning activities for them to help each other. This training is more effective because the members are relatively fixed, have similar interests, and trust each other. In this way, the aged are able to obtain new information and entertainment through the Internet and plan their trips through mobile maps. Only by allowing the elderly to truly perceive the benefits of new media technology in various scenarios can they use it much better. --- Playing a coordinating and promoting role in narrowing the "digital divide" With the implementation of the "New Digital Infrastructure" strategy, the government should clear the "digital life" infrastructure barriers for the aged in economically backward areas, provide Internet access opportunities, and stimulate their demand for new media technologies. The network supervision department should also further improve the management system, and create a good information environment and privacy security of the new media culture, for those who use the Internet to carry out fraud and other damage to the elderly groups of illegal acts resolutely crack down. --- Conclusions So far, most of the aged have no chance to access the learning opportunities of new media devices because of their decline in learning ability. Therefore, at the national, social, and individual levels, people should work together to help them better adapt to the new media era. In contemporary society, various places hold activities to narrow the "digital divide" to help the aged, and the quality of life of the aged gradually enhances. --- ASSSD 2022 Volume 21 (2023)

This paper investigates the development of new media in China and the current situation of China's aging population. Based on the definition of the social adaptability of the aging population, it analyzes the influence mechanism of new media on it in China. The results show that, compared with traditional media, new media significantly improves the cognitive ability, social participation level, social relations, and social psychological adaptation ability of the aged. This paper also analyzes the "digital divide" faced by the aged in integrating into new media from the aspects of desire, access, and skill. Meanwhile, different policy suggestions are put forward from the national to the individual level to promote the integration of the elderly into the digital new media so as to help them better adapt to society.

Introduction Job quality is important to individuals and is a central policy concern as countries strive to promote economic growth and manage the threat of a low birth rate and an aging population [1]. It is important to maintain and improve job quality to make work sustainable and enable people to work longer. According to South Korean employmentrelated indicators in 2019, temporary employment accounted for 24% of all workers; this was the fourth highest rate of countries in the Organization for Economic Co-operation and Development (OECD) [2], and the rate of low-pay workers was 17%, the sixth highest in the OECD [3]. Although minimum wage relative to average wages of full-time workers was the sixth highest in the OECD [4], the ratio of employees working below the minimum wage was 16.5% [5]. In addition, the average annual hours actually worked per worker was 1967, the third highest in the OECD and 300 h longer than the OECD average [6]. The proportion of employees who were satisfied with their overall job in their workplace was low, at 32.3% [7]. These phenomena also differ greatly by gender. Working conditions for women were found to be poorer compared to those for men because women are marginalized or have unstable positions in the labor market due to the stereotype in the patriarchal system that men must be responsible for the family and to the gender segmentation of the labor market. Conditions for women workers, such as having a child, were found to be poor [8,9]. In 2018, the gender employment gap was nearly 18%, the fourth largest in the OECD, and the gender wage gap was about 34%, which is the widest in the OECD against an OECD average of about 13% [6]. Even though gender equality is not only a basic human right but also an essential foundation for a peaceful, prosperous, and sustainable world [10], it is not guaranteed in the Korean labor market. Research over the past several years has emphasized the importance of work-life balance, and it has been reported that a lack of such balance can negatively affect the quality of life and mental health of individuals and their families [11]. From the viewpoint that the quality of work and the quality of family life should be managed from one integrated perspective rather than as separate dimensions, even in organizations, work-life balance has been established as a very important concept [12,13]. However, despite institutional efforts such as companies' family-friendly systems [14] and the government's work-family compatibility support policy [15], work-life balance has not been successfully realized in South Korea. According to the results of a 2020 survey by the Better Life Index, a comprehensive quality of life measuring instrument of the OECD, South Korea's work-life balance is very low, ranking 37th out of a total of 40 countries [16]. In particular, in the case of female workers, quality of work shows a close association with work-life balance [17,18]. Women's participation in society has been increasing; however, they often remain overloaded with housework [19], and this gender role difference can hinder their work-life balance in Korea [20]. In South Korea, on average, employed women" spent 2 h and 24 min on housework in 2019, which was 2 h and 13 min longer than that of men in dual-income households. In 2019, the hourly wage of female wage workers was 69.4% of that of men, and while the gender gap is narrowing, the wages of female workers are still lower compared to those of male workers [21]. Excessive working hours, irregular working time, and work-related time pressure can increase the burden of raising children [22], and job stressors such as a high job burden and low job autonomy may lead to work-life imbalance [23]. In particular, for female employees, research findings have indicated that the higher the physical demand, the more work-life conflict experienced [24]. The job demand-resources (JD-R) model is a useful theoretical approach for understanding the relationship between work quality and work-life balance [25][26][27]. This model divides the characteristics of work into demands and resources [28]. Job demands refer to the features of the job that demand physical and mental effort. Job demands are not necessarily negative, but if excessive effort and expense are required to meet those demands, they can become a stress factor and cause negative reactions. Job demands include time pressure, excessive workloads, role ambiguity, and conflicts in interpersonal relationships experienced when carrying out the job [29,30]. Job resources refer to the characteristics of a job that reduce the costs associated with job demands or motivate workers in achieving goals. Job resources include factors such as job autonomy, participation in decision making, diversity of skills, and feedback provision as well as factors at the organizational level such as support from supervisors and colleagues, wage levels, job stability, and organizational fairness [30][31][32]. According to this model, the level of work-life balance of workers becomes high when job demands are low, and when there are many job resources available, even if job demands are high. In the JD-R model, job demand and job resources are related to each other, but the relationship varies according to the job or job characteristics [33]. Therefore, many studies using this model organize the dimensions of job demands and job resources according to the population before carrying out an analysis [34][35][36]. In this study, job quality indices were composed of seven areas based on the EWCS report [37]. These indices comprehensively reflect job demands and resources, or the processes that affect them, in various aspects of job characteristics, but according to the JD-R model, we classified the physical environment, work intensity, working time quality, skills, and discretion into demand factors and social environment, prospects, and earning into job resources factors. Meanwhile, the quality of a job is multifaceted and requires consideration of both the objective situations and the subjective evaluation of the workers who judge the situ-ations [37]. Previous studies that mainly approached working conditions as individual or integrated variables did not sufficiently reflect the multidimensional interrelationship between work conditions and work-life balance [38][39][40]. Latent profile analysis has an advantage in that it enables the classification of the potential types of respondents into groups while comprehensively considering the levels of various observation variables and analyzing the differential effects of the various patterns of responses regarding work quality on workers. In addition, it enables the identification of the distributions of sociodemographic characteristics such as age and career, which are closely related to the characteristics of work, by subgroup, as well as occupational characteristics, such as occupations and positions, alongside the differences in work-life balance. Consequently, tailored interventions that fit the characteristics of heterogeneous subgroups according to the quality of work will be possible. Therefore, this study attempted to categorize subgroups according to the seven types of work quality of female workers, investigate the sociodemographic and professional characteristics of each group, and identify the effects of these types on work-life balance (Figure 1). The research questions for this study are as follows: (1) How do the latent profiles appear according to the quality of work of female workers? (2) How are the sociodemographic and occupational characteristics distributed by job quality latent profile? (3) What are the differences in the levels of work-life balance according to job quality latent profile? --- Materials and Methods --- Participants This study utilized data from the Korean Working Conditions Survey (KWCS) conducted by the Korea Occupational Safety and Health Agency. The KWCS collected data [41] with an aim to understand factors of overall working conditions, such as working types, employment status, occupational groups, sectors, exposure to risk factors, and job security, for employees of at least 15 years of age nationwide (e.g., self-employed workers, business owners, employees). The present study used data from the fifth KWCS (2017) and included 15,723 female employees out of a total of 50,205 survey participants. --- Measures 2.2.1. Job Quality Indices Seven job quality indices were used to identify latent profiles: (1) physical environment, (2) work intensity, (3) working time quality, (4) social environment, (5) skills and discretion, (6) prospects, and (7) earnings. "Physical environment" was measured with 15 items for ambient, biological, chemical, and ergonomic risks in participants" workplaces. "Work intensity" was measured with 12 items for quantitative and emotional demands and pace determinants of the job. "Working time quality" was measured with 19 items for duration, atypical working time, working time arrangements, and flexibility. "Social environment" was measured with 15 items for management quality, social support, and adverse social behaviors such as bullying and violence in the workplace. "Skills and discretion" was measured with 15 items for cognitive dimension, decision latitude, organizational participation, and training. "Prospects" was measured with seven items for employment status, career prospects, and job security. "Earnings" was measured using average monthly income received from work. Each item of six of the job quality indices was measured on a dichotomous or 5-7-point Likert scale, and participants responded to one item, "earnings", on a continuous scale. --- Demographic and Occupational Characteristics The demographic and occupational characteristics that were selected were age, education, sector, occupation, workplace size, and employee status, and they were used to examine the characteristics of the classified latent profiles. In the 5th KWCS, sectoral analysis was conducted based on the Korean Standard Industrial Classification (KSIC) and occupational analysis on the Korean Standard Classification of Occupation (KSCO). In this study, 21 sections of the KSIC were reclassified into 10 categories based on the 6th EWCS. --- Work-Life Balance Work-life balance was measured with one positive item and five negative items. An example of a positive item was whether a participant's working hours were appropriate for having a successful family or social life. Responses were measured on a four-point Likert scale ranging from "not suitable at all" to "very suitable", with higher scores indicating work-life balance. The five negative items consisted of three work-family conflict items and two family-work conflict items. The items about work-family conflict were: "I worry about work even when I am not working," "I am too tired to do household chores after work," and "I do not have enough time to spend with my family due to my work." The items about family-work conflict were: "I do not have enough time to work because of what happens at home," and "I feel that I am unable to devote time to work because of my responsibility to my family." Responses were measured on a five-point Likert scale ranging from "not at all" to "always"; higher scores indicated more conflict. --- Data Analysis Descriptive analyses were conducted to understand means and standard deviations of all variables using SPSS (IBM, Armonk, NY, USA). Latent profile analysis (LPA) was used to determine latent profiles based on the seven job qualities using Mplus 8.4 (Muthén & Muthén, Los Angeles, CA, USA). Before the original LPA, missing data were imputed using mean values. The six job quality indices, excluding earnings, were calculated as mean index scores by converting the responses to each item into scores ranging from 0-100 points, with positive responses receiving higher scores. For earnings, responses were converted into logs and applied. In LPA, the scores of all job quality indices were standardized using DEFINE in Mplus. Z-score is a standardized score that subtracts the mean from each value and then dividing by the standard deviation [42]. We started with a two-profile solution and increased the number of extracted profiles until the model fit no longer improved [43]. To determine the number of latent profiles, we comprehensively considered statistical and theoretical criteria [43]. Bayesian information criterion (BIC) [44], entropy [45], and the Lo-Mendell-Rubin adjusted likelihood ratio test (LMR-LRT) were used as statistical criteria [46]. For BIC, lower values indicate better model fit. Entropy refers to the accuracy of individuals" assignments to different groups, and values higher than 0.70 and close to 1 are preferred. LMR-LRT compares k group models to k -1 group models and shows that lower significance values (p <unk> 0.05) have a better fit. To comprehensively consider interpretability, the results of the sixth EWCS were used as a reference for theoretical criteria. After determining the number of profiles, we conducted a chi-square test to understand the demographic and occupational characteristics of each profile using most-likely class membership, which was obtained based upon posterior distribution [47]. Finally, the associations between work-life balance and latent profiles were compared using the Bolck-Croon-Hagenaars (BCH) auxiliary method [48]. The BCH auxiliary method determines whether there are statistically significant differences between the profiles on an outcome variable of interest, again accounting for possible errors in classification [47]. --- Ethical Considerations The study was approved by the Institutional Review Board (IRB no 1041078-201906-HRSB-185-01) of Chung-Ang University on 14 June 2019. Potential ethical issues were addressed, including plagiarism, misconduct, data fabrication and/or falsification, double publication and/or submission, and redundancy. --- Results --- Job Quality Profile Models To classify profiles according to the seven job quality indices, latent profiles were examined in consideration of various statistical criteria (Table 1). As the number of latent profiles increased from two to six, the BIC gradually decreased, and all comparison results of the LMR-LRT model were found to be significant. However, the BIC showed a smaller decrease when the number of potential profiles changed from four to five, compared to when the number changed from five to six. When the participants were classified into six profiles, a group with a potential profile classification rate of 0.5% was identified; thus, it was difficult to regard the group classification as being representative. As a result of comprehensively considering the various criteria above, a model with five potential profiles was selected as the final one. --- Five Job Quality Profiles Regarding job quality patterns, female employees were classified into five profiles: "high-flying", "smooth", "footloose", "strict" and "manual" (Figure 2). The "high-flying" profile was a subgroup to which 31% (n = 4813) of the female employees belonged. These employees received the highest scores on most indicators. In particular, their incomes and job prospects were high, and they performed work that required highly skilled techniques. Furthermore, the intensity of their work was high, and the quality of their working time was low. The "smooth" profile was the largest subgroup, which included 39% (n = 6084) of the female employees. For this profile, the seven job quality index scores were generally shown to be average. The "footloose" profile was a subgroup to which 9% (n = 1335) of the female employees belonged. Unlike the high-flying profile, low work intensity and high quality of working time were noticeable in this group; however, these employees generally had the lowest income and worst job prospects out of all the subgroups. The "strict" profile, to which 18% (n = 2855) of the female employees belonged, showed the lowest quality of working time compared to other profiles. These female employees' physical environment and work intensity (reversed) scores were lower than average; however, their earning, prospects, skills and discretion, and social environment scores were slightly higher than average. The "manual" profile was the smallest group, comprising 4% (n = 636) of the female employees. The employees in this group showed below average scores for most indicators. In particular, physical environment scores were the lowest and work intensity was the strongest, compared to the other profiles. Job prospects were also shown to be somewhat poor. --- Female Employee Distribution in Job Quality Profiles Compared with other age groups, female employees aged 49 years or younger showed a relatively large distribution in the "high-flying" subgroup, while those aged 50 years or older showed a larger distribution in the "footloose" subgroup. Regarding education level, female employees who were middle school graduates or below were very strongly represented in the "footloose" profile (36%), while those with college degrees or above most frequently belonged to the "high-flying" profile (47%). High school graduates showed a relatively large distribution in the "strict" profile. In relation to workplace size, most employees at micro-companies had "smooth" jobs, while the majority of employees at large companies had "high-flying" or "strict" jobs. By employment status, regular employees were relatively more frequently distributed in the "high-flying" profile, and temporary or other employees showed relatively large distributions in the "footloose" profile (Figure 3). By sector, employees in the agriculture and public administration fields showed relatively large distributions in the "footloose" profile, and about half of the employees working in financial services or education belonged to the "high-flying" profile. Those with industry or construction jobs showed relatively large distributions in the "manual" profile. By occupation, most managers had "high-flying" jobs, as did approximately half of the professionals and clerks. Service or sales workers were highly represented in the "strict" profile. Additionally, workers in crafts and related trades and plant or machine operators were typically represented in the "manual" profile. Elementary workers showed a large distribution within "footloose" jobs (Figure 4). --- Association between Job Quality Profiles and Work-Life Balance All female employees showed statistically significant differences in work-life balance by job quality profile (p <unk> 0.01; Figure 5). Employees with the "footloose" profile showed not only high work-life balance between working hours and personal time but also the most positive work-life balance, as they had less work-family conflict. However, employees with the "manual" profile showed the highest level of conflict between work and family. The "strict" profile showed the worst fit between working time and personal time and a high level of work-family conflict. Employees with either "high-flying" or "smooth" profiles showed average levels for most indicators. --- Discussion This study started from the limitations of previous studies, which did not reflect the multifaceted aspect of the quality of work-life balance of South Korean female employees. Using the KWCS, which is a representative survey of Korean workers, we classified latent profiles to include various variables indicating job quality and analyzed the distribution of demographic and occupational characteristics and the difference in work-life balance among the profiles. The results suggest an alternative to the research flow, which has so far focused only on specific working conditions. In addition, they illustrate the need to attend to job quality as experienced by female employees and, in particular, policies and practical interventions reflecting the characteristics of each profile with regard to the work-life balance of female employees. Female employees were classified into five profiles-"high-flying", "smooth" "footloose", "strict", and "manual". Although direct comparisons are difficult due to cultural differences and the targeting of only female employees, these results are slightly different from those in the sixth EWCS, where the profiles were classified as "high-flying", "smooth running", "active manual", "under pressure", and "poor quality." The "under pressure" profile in the EWCS showed a low social environment; however, South Korean female employees showed similar social environment levels across all five profiles. Furthermore, the "poor quality" profile in the EWCS was low for all seven job quality indices; however, it did not appear among the profiles in the present study. However, South Korean female employees were categorized into "footloose" and "strict" profiles, which had the highest and lowest working time quality, respectively. The employees in the "high-flying" profile simultaneously experienced a high level of job demand and resources. They accounted for about one-third of all female employees. Many of these included highly educated employees, managers, and professionals. These employees worried about work when they were at home because their jobs required a high level of skill; however, their work-life balance should have been promoted since they had many job resources such as work autonomy, social support, and high wages [29,49]. However, research results are contradictory on this topic, indicating that the higher the income and position, the more conflicts there are between work and life, may be due to the tendency to be more devoted to work [50,51]. Thus, the provision and utilization of many job resources that can alleviate the foregoing stress should be promoted. Furthermore, although "women's" entry into managerial and professional positions is gradually expanding as the level of education increases, the proportion of female managers in South Korea is still low at 21% [52]. In the case of workplaces with a high proportion of female managers, support for work-life balance appears to be well equipped [52]. Therefore, a support strategy is required to promote the advancement of female workers to management positions. The "smooth" profile formed the largest subgroup, with 36% of employees. This group has moderate job demands and resources. The participants in this group were mainly over 50 years of age and engaged in small workplaces or in the agriculture or elementary field. Although this profile generally showed average scores across all seven job quality indices and work-life balance, as the employment activities of middle-aged and older workers are becoming more important due to aging and the low birth rate, efforts to improve the quality of their work are required. In South Korea, the retirement age of 60 is mandatory. The quality of employment and wage levels are greatly reduced as middle-aged and older workers leave their main jobs without preparing for retirement, and many are re-employed in temporary, daily, and non-regular jobs [53]. In this environment, job satisfaction and the level of wages in preparation for later years will enable middle-aged and older workers to continue working, and this is also linked to work-life balance [54][55][56]. Therefore, the design and arrangement of suitable jobs, the provision of education and training, and continuous support at the government level are necessary to enhance the job satisfaction of middle-aged and older workers. The "footloose" profile showed the most positive work-life balance. The employees in this profile had the lowest earnings and prospects and the highest working time quality among the job resources. However, among the job demands, skill and discretion were the lowest and work intensity (reversed) was the highest. The work-life balance of the footloose profile group was the highest among all profiles, and the work-family conflict was the lowest. This is consistent with the JD-R model theory that the level of work-life balance of workers is not simply the absolute value of job demand or job resources; instead, a moderate effect between the two is more important [34]. This profile had the lowest earnings and prospects, suggesting that a lower contribution to overall household income was associated with better well-being [57]. Therefore, some female employees may do things using their careers, or earn little money, but do not have many financial difficulties. However, most of the employees in this profile were temporary or daily employees and worked jobs requiring low-skilled labor. Additionally, there were many employees who received low wages. This is likely connected to the situation of female employees in South Korean society [21]; thus, the good balance between work and life in this study may not be reflected in reality. Furthermore, the job insecurity can lead to anxiety in workers and negatively affect work-family balance [58]. Therefore, it is necessary to conduct more empirical studies on the "footloose" profile. The "manual" profile showed the lowest scores for physical environment and work intensity and the highest level of work-family conflict. A poor physical workplace environment negatively affects employees' health, which can increase work-family conflict by increasing employees' physical and psychological stress [24,[59][60][61]. Furthermore, given that mainly craft employees and plant or machine operators belonged to this profile, the intensity of work that must be performed in accordance with production goals could also induce job stress, negatively affecting work-life balance [62]. Therefore, to promote work-life balance, it is necessary to provide systematic management and education for employees' health and create an appropriate workplace environment. The "strict" profile had good job resources (prospects, earnings); however, the level of job demand (the lowest quality working time) was also high, leading to a poor fit between working hours and personal commitments. Moreover, this could negatively affect employees' families due to the physical and mental stress caused by long working hours [29,63,64]. Shift working time may also have affected such outcomes. The possibility of adjusting working time in the commerce and hospitality fields, to which the employees with this profile mainly belonged, was found to be very low-approximately 20%-indicating that working time and location were relatively inflexible in these types of employment [65]. When the nature of the job makes it is difficult to introduce flexible work arrangements, it is necessary to consider a plan to give employees the right to choose vacation dates first, and allow them to use an alternative vacation when their days off and holidays overlap. --- Conclusions We classified latent profiles based on job quality indices according to the JD-R model and investigated differences in demographic and occupational characteristics and work-life balance between profiles among female employees in South Korea. Although the latent profiles in this study, analyzed using data from the fifth KWCS, cannot be generalized and applied to all workers, the results of this study enabled the identification of the working conditions and sociodemographic and occupational characteristics reflected by each profile as well as which characteristics of organizations should be improved for balance. As mentioned in the discussion, ensuring job security, preparation of a work-related mental and physical stress management system, support for long-term vacations, reflection of preferences for work schedules, provision of social support systems, and provision of educational opportunities for continuous self-development required according to the characteristics of each profile can be considered as strategies for the work-life balance of South Korean female workers. In addition, for these interventions to be carried out in harmony with the strategies for promoting work-life balance currently being implemented by companies and the government, policy and social awareness should be spread and supported. This study has the following limitations. First, only the variables included in the raw data were used in the secondary data analysis. Although working conditions were divided into seven job quality indices, and efforts were made to approach them as comprehensively as possible, it was difficult to determine latent groups that were not included in the raw data. Additionally, although the occupational characteristics of the classified profiles were identified, family characteristics, such as marital status, number of children, and how respondents utilized their leisure time, could not be identified. Therefore, studies to analyze potential groups using other data sources should be conducted in the future. Second, although various policies are being implemented to promote work-life balance in South Korea, this study could not measure whether the policies had been applied for the participants. To prepare more effective policies for work-life balance, additional studies will be required to consider whether current policies are applied as well as their effects. Finally, as this was a cross-sectional study, the associations between latent groups and work-life balance were identified; however, causal relationships could not be determined. Therefore, to develop and apply strategies to promote work-life balance according to each latent profile, longitudinal studies to identify causal relationships should be conducted. --- Data Availability Statement: Publicly available datasets were analyzed in this study. This data can be found here: https://oshri.kosha.or.kr/oshri/researchField/downWorkingEnvironmentSurvey.do (accessed on 26 April 2019). --- Author Contributions: H.L. designed the study, reviewed the literature, and wrote the manuscript. E.Y.C. performed the statistical analyses, reviewed the literature, and wrote the manuscript. S.-H.C. reviewed the literature and wrote the manuscript. All authors have read and agreed to the published version of the manuscript. --- Conflicts of Interest: The authors declare no conflict of interest.

Women's participation in society has been increasing; however, they often remain overloaded with housework, and this gender role difference can hinder their work-life balance in Korea. Therefore, this study classified latent profiles according to job quality indices for South Korean female employees and examined the characteristics of each profile and how they affect work-life balance. This study was a secondary analysis of data collected through the fifth Korean Working Conditions Survey in South Korea. The Bayesian information criterion, entropy, and the Lo-Mendell-Rubin adjusted likelihood ratio test were used to determine the number of latent profiles. Chi-square tests were conducted to understand the characteristics of each profile. Comparisons between work-life balance and the latent profiles were made using the Bolck-Croon-Hagenaars method. Female employees in South Korea were classified into five profiles: "high-flying", "smooth", "footloose", "strict" and "manual". The "footloose" profile showed the most positive work-life balance, and the "manual" profile had the highest level of work-family conflict. Therefore, policies and social supports should be created with the aim of improving the implementation of current strategies promoting work-life balance to better fit each working condition.

Introduction Th e Nordic value climate has traditionally been constructed on Western values that emphasize democracy, individual freedom and civil rights on the one hand, and on the basis of societal thinking that underscores collective responsibility on the other POZNA<unk> UNIVERSITY OF ECONOMICS REVIEW Volume 13 Number 1 2013 a Laurea Tikkurila, Ratatie 22, 01300 Vantaa, Finland, e-mail: [email protected]. b School of Health Care and Social Work, P.O.Box 158, 60101 Seinäjoki, Finland, e-mail: timo. [email protected]. hand. In this article 1, we examine the relationship between these values and entrepreneurial intention: Do they serve as factors that inhibit or further inhibit entrepreneurship? Th e target of this examination is Finnish young people and their social values, societal attitudes and entrepreneurial intention. According to the Flash Eurobarometer report [2009], Finnish people's interest toward entrepreneurship has increased throughout the 2000s. Nevertheless, if the majority of Finns had a free choice, they would rather work as employees than entrepreneurs. In this sense, Finnish entrepreneurial willingness remains below average compared to other European Union member states [Flash Eurobarometer 2009]. According to the Global Entrepreneurship Monitor (GEM) survey, the actual entrepreneurial intention of the Finnish adult population is the lowest among Nordic countries. Moreover, growth orientation of entrepreneurs as well as new innovative entrepreneurship in Finland are scarce [Stenholm et al. 2011]. In contrast, external factors for the framework of entrepreneurial activity are at least at the same level as in many other European countries. Th e target of this research work was the Uusimaa region in southern Finland. Uusimaa is geographically a small area (3% of Finland's land area), but in terms of population and industrial production it represents approximately one-third of Finland. Th e Uusimaa region consists of the Helsinki metropolitan area and the surrounding region of smaller cities and rural areas. We asked how the relationship between social values and societal entrepreneurship attitudes becomes visible among the Uusimaa students. Moreover, what kind of a relationship is there between social values and entrepreneurial intention? We also ask about the relationship between societal entrepreneurship attitudes and entrepreneurial intention among Finnish young people and analyze the relationship between diff erent social values [Figure 1]. Young people's entrepreneurship attitudes have previously been studied mainly from the perspective of entrepreneurial education and through broad survey research. Several studies have attempted to explain entrepreneurial intentions by means of various psychological factors, such as those from entrepreneurial orien-1 Th is article is part of the "Enhancing Young Entrepreneurship in the Finnish Uusimaa Region EER 2012" project. Th e research is funded by European Social Fund. tation [Covin & Slevin 1991;Lumpkin & Dess 1996]. Th e explanatory models have been complemented by examining various environmental factors and the environment's normative expectations [e.g., Ajzen 1991;Krueger, Reilly & Carsrund 2000]. However, little research has been carried out on the impact of social values on young people's entrepreneurial intention. Social values can be understood in diff erent ways. Martti Puohiniemi [2002] and Klaus Helkama and Antero Olakivi [2012] have done large value surveys in Finland. Th is study is focused on societal or social political values. We analyzed values that form a basis of the Finnish societal model. Likewise the concept of attitude can be defi ned in diff erent ways [Eagly & Chaiken 1993]; it can be understood as a property or a trait of the individual as well as a social concept [de Rosa 1993]. Th is means that attitudes are, at least partially, socially constructed and that societal discourses build attitudes [Vesala & Rantanen 2007]. Th us, we approached societal entrepreneurial attitudes by examining the discourses of entrepreneurship in Finland. We examined the attitudes of the general level not, for example, attitudes toward someone's behavior [see Ajzen 1991;Ajzen & Fishbein 2000]. --- Social values in Finland Th e Finnish social values are closely connected to the Nordic value world and the idea of the welfare state. Th e term 'welfare state' can refer to a broad social political system and the value world it is based on. Th e existing welfare states can be categorized into Nordic, Continental European and Anglo-American states [Esping-Andersen 1990]. Th e categorization is mostly based on the situation in the 1980's and should hence be regarded a little cautiously [see Hiilamo et al. 2010]. Nevertheless, it provides one starting point to the discourse on welfare states and the rationale behind them [Moreno 2010]. Th e Nordic welfare state, including Finland, is grounded in the notion of universal welfare services. Th e state has a central role as the guarantor and producer of welfare, which stresses the standpoint of advancing the common good and support to less advantaged people. It is striven to achieve a good society by providing everyone with equal opportunities for, among other things, education and health care; regardless of people's geographical or social reference group. In this sense, the objective of the Nordic welfare state is to produce social security [Ervasti et al. 2008]. During the past two decades, the Finnish welfare state has changed in numerous ways. A sector of increasingly wide-range private welfare services has emerged next to the public service production [Toikko & Gawel 2012]. Th is has reduced the public sector's responsibility for the actual service provision and means that it is no longer automatically the only producer of social security. Moreover, the GINI index that measures income distribution demonstrates the growth in economic inequality that began towards the end of the 1990's [Jutila 2011;Saari 2011]. Instead of collective responsibility, individual rights and responsibilities have become more pronounced. Th is change is predicted to refl ect a broader shift towards individualism and individual freedom as well. Hence, in international comparisons, Finland is defi ned as an individualistic society [Hofstede]. Th e welfare state can be seen as a compromise between individualism and collectivism on the one hand; on the other hand, also as a reconciliation of values concerning security and freedom. Th ere is an interesting discrepancy in the development of the Finnish society where collectivism-based social security is underscored while individualism and individual rights and freedom it embraces are simultaneously highlighted. Th e Nordic welfare state, which emphasizes the collective value system, is still fi rmly supported by citizens [Muuri 2008] who simultaneously endorse individual values based on the democratic system. --- Entrepreneurship discourse and its criticism Traditionally, entrepreneurship in Finland has been considered a signifi cant manifestation of the society's freedom. Entrepreneurs can even be seen as ideal citizens who simultaneously realize a Western individual's right to personal freedom and keep the wheels of economy turning. According to numerous studies, diligence, perseverance and hard work are accentuated in the image of entrepreneurship [e.g. Kivelä 2002;Nevanperä 2003;Hyytiäinen & Pajarinen 2005;Home 2007]. Th e cultural dimensions of entrepreneurship have also been examined through Geert Hofstede's cultural value theory by using the concepts of individualism and collectivism [e.g. Mueller & Th omas 2000;Lindsay 2005;Linan & Chen 2009]. It has been proposed that low collectivism and high individualism belong to entrepreneurship-oriented cultural values. Strong emphasis on an individual's autonomy is traditionally connected with the very core of individualism, which can be considered as an important motive for entrepreneurship. Th e relationship between entrepreneurship and individualism has certainly been put under critical scrutiny as well. Th e empirical research fi ndings of Patrick Kreiser, Louis Marino and K. Mark Weaver [2001], for instance, show that there is no signifi cant correlation between individualism and risk-taking willingness. Th ey suggest that an explanation for this can be found in the notion that dependence is non-linear, and individualism taken to its extreme level may be a disincentive to en-trepreneurial behaviour. In his analysis of images of entrepreneurship, Kari Vesala [1996] in turn juxtaposes the individualistic image with a relationistic image of entrepreneurship, which emphasizes the central role of stakeholder cooperation. Th e relationship of the individual pursue for private fi nancial profi t, inherent to entrepreneurial activity, with the Finnish thinking that gives priority to collective social responsibility is also not fully unproblematic. Indeed, two contradictory conceptions of entrepreneurship and the societal signifi cance of entrepreneurs exist and are traditionally apparent in Finnish research of attitudes. Entrepreneurs have been seen not only as diligent ideal citizens with a strong sense of responsibility but also as exploiters who are power-hungry and take advantage of others [e.g. Pitkänen & Vesala 1988, pp. 79-80]. In the Finnish political discourse, entrepreneurship has become increasingly emphasized throughout the 2000's. Entrepreneurial activity is seen as a prerequisite for creating new jobs, as well as for national competitiveness. In many statements, entrepreneurship has been seen as a solution for the challenges of both regional viability and employment of individuals. Th ere are various kinds of programs to support innovative opportunities of businesses. Entrepreneurship has become a core part and task of Finnish politics [Turunen 2011]. Entrepreneurial discourse in Finland is related to the trend of neoliberalism which sees entrepreneurial activity and free markets are seen as the best solution to advancing people's welfare [Harvey 2007;Clarke 2008]. According to Heikki Patomäki [2007], however, hardly anyone in Finland is a self-declared neoliberal. Th e majority of Finns still believe in the welfare state and the principle of collective responsible inherent to it. Finland has been reformed for nearly two decades consistently with the neoliberal agenda which, nevertheless, has not condensed to be as strong ideology as in many other countries. Th e reform of the Finnish society has been more pragmatic than ideological. Reforms have been made because they are seen as an imperative solution to globalization and maintaining national competitiveness. According to Patomäki [2007], the neoliberal reforms applied in Finland often originate from international commissions in which both civil servants of the Ministry of Finance and experts of both administration and business economy have participated [see Alasuutari & Rasimus 2009]. OECD, IMF and the meetings and conferences of the European Union have recommended neoliberal reforms. In this sense, we can claim that in a certain way neoliberalism has, unlike in many other countries, been a project of the elite of civil servants rather than a political movement. In Finland, the neoliberal revolution has been technocratic. It is the experts of diff erent fi elds that hold the power in a technocratic society: civil servants, researchers and consultants. Entrepreneurship has made a breakthrough also in the Finnish educational system. Schools want to bring up individuals into entrepreneurial citizens who themselves are responsible for their own employment and wellbeing. Teachers and stu-dents are trained for internal and external entrepreneurship at all school levels [e.g. OPM 2004]. Entrepreneurial education is seen as learning that promotes active and self-initiated way of functioning which provides the students the opportunity to develop their own skills. Patricia Mccaff erty [2010] even speaks about a neoliberal pedagogy. Within the Finnish entrepreneurial education research community, the neoliberal entrepreneurship discourse and its dominance has also been critically evaluated. According to Risto Ikonen [2006, pp. 35-36] the concept of entrepreneurship has been appropriated as part of neoliberal rhetoric; however, it has also always been part of the expression that defends the Nordic welfare state. In these discourses, also the meanings of entrepreneurship are crucially divergent: Whereas neoliberalism conceives the markets as the only factor regulating the economy, the welfare state-oriented tradition sees that the goals of the economy are subordinate to common decision-making. Ikonen [2006] makes a division between the two concepts of entrepreneur education and entrepreneurial education. Along with the promotion of economic enterprise, he sees democratic education and the upbringing of an active citizen as the central goals of entrepreneurial education. Intellectual education, democracy education and entrepreneurial education together form a foundation on which a capable and autonomic citizenship is built. At the same time, the promotion of the ability to see diff erently, criticism of corporate power and media literacy, among other things, become part of entrepreneurial education [Ikonen 2006]. However, the citizenship education as the goal of entrepreneurial education has been called into question in Finnish entrepreneurship research. S. Keskitalo -Foley, K. Komulainen and P. Naskali [2010, p. 21], for instance, emphasize that the entrepreneurial self that is produced by entrepreneurial education is the ideal subject of the new economy: citizenship is fi rst and foremost defi ned by its relationship with the markets. An individual has a role as a consumer, as well as a producer and an employee. Expressly the concept of agency lies in the background of the critical analysis of entrepreneurship discourse. According to Nikolas Rose's and Peter Miller's [1992] analysis concerning government, the neoliberal discourse works -despite the markets' apparent freedom of choice -as a new form of social government. An individual's activity is built on constant coercion to make a choice in the markets. From an individual's perspective, entrepreneurial agency contains the possibility of independence, personally signifi cant experiences, and materially rewarding way of life. On the other hand, entrepreneurship discourse signifi es a model of social government and making politics where responsibility is to be carried by an individual [Pyysiäinen 2011]. --- Research objective, research questions, and hypotheses Previous research depicts a multidimensional and even somewhat contradictory image of the social value premises of entrepreneurship discourse and entrepreneurial education. Interest is raised by the type of relationship between collective responsibility, emphasis on individual rights and entrepreneurship from the perspective of young people. Furthermore, it is interesting to analyze young people's societal entrepreneurship attitudes and the criticism of neoliberal entrepreneurial education that they possibly contain. Is the entrepreneurial intention of young people connected to social values or is it mainly a question of a pragmatic career choice? What are the ideological premises that Finnish entrepreneurship discourse and its criticism connect to? In this research, we focused our interest on Finnish youth's social values, societal entrepreneurship attitudes and entrepreneurial intention. We examined two types of social values: the individual's democratic rights and social justice. Similarly, we studied two types of entrepreneurship attitudes: the general entrepreneurship attitude (a social appreciation of entrepreneurship) and critical entrepreneurship attitude (critique of entrepreneurial discourse). Our examination is limited to the Helsinki-Uusimaa region. We sought to answer the following four research questions: 1. 2. Th e basis of these hypotheses is the traditional assumption of the Finnish image of entrepreneurship being divided into positive and negative entrepreneurship images and that this division is connected with social values. Th e assumption is that appreciation of entrepreneurship is closely connected to individualism and an individual's democratic rights. Correspondingly, we assumed that values connected to the social justice relate to criticism of neoliberalism, critical entrepreneurship attitude and unwillingness to become an entrepreneur. We also analyzed contradictory conceptions that entrepreneurial emphasis is well suited to the welfare state discourse [Ikonen 2006] and that Finnish neoliberalism is not in fact so much an ideological trend but rather a pragmatic emphasis [Patomäki 2007]. --- General description of the research data We collected our research data by using an electronic questionnaire we sent to secondary schools in the Uusimaa region located in the Southern part of Finland in January-March 2012. Th e respondents (N = 873) were 2 nd grade students in altogether 13 high schools and vocational schools. Most of the students were 17-18 years old. Th e questionnaire contained altogether 72 questions the majority of which were Likert-type scale items (1= Strongly disagree,..., 5 = Strongly agree). Th e questions were related to entrepreneurial intention, conceptions concerning entrepreneurship, societal entrepreneurial attitudes, social values and certain social-psychological background factors (subjective norm, perceived behavioural control and outcome expectation). In this article, we examine the part of the data that is specifi cally related to social values, societal entrepreneurship attitudes and entrepreneurial intention [see Rantanen 2013]. Th e results were statistically analysed. Th e sum variables were variables formed as averages by means of factor analysis (Generalized Least Squares, Varimax with Kaiser Normalization. Rotation converged in 5 iterations). Th e reliabilities of the sum variables were calculated (Cronbach's alpha) and the normality of the distributions was examined by using the Kolmogorov-Smirnov test. In calculating the correlations, we used Spearman's rank correlation coeffi cient and the Mean scores were examined by using a t-test. 464 high school students and 409 vocational school students responded to the questionnaire. Th e entrepreneurial intentions of these groups were not signifi cantly divergent from each other (t = 0.572; p = 0.568), and hence the groups are examined together from now on. Th e used questionnaire was pre-tested with 19 students. On the basis of the test only small changes needed to be made. Electronic data collection proved to be quite feasible and the respondent percentage was 71.0%. Th e representativeness of the survey appeared quite good in terms of both the native language of the respondents (the proportion of Swedish-speaking Finns in the sample was 6.8% and 8.6% in the population) and their residential area (the proportion of the Helsinki Metropolitan Area was 71.1% in the sample and 68.4% in the population). Also the used measures proved to be feasible and the reliabilities were rather good (the reliability of one sum variable is below 0.70). However, the sum variable distributions do not quite follow the normal distribution. --- Research factors At fi rst, we formed sum variables related to social values and social entrepreneurship intentions by means of factor analysis. We got 44.0% for the coeffi cient of determination of the four factor model (see Table 1). By means of factor analysis, we formed four new variables focusing attention on factor loadings above 0.5. On the basis of factor 1 we formed the sum variable "general entrepreneurship attitude", on the basis of factor 2 the sum variable "an individual's democratic rights" and on the basis of factor 3 "critique of entrepreneurial discourse". When forming the sum variable "social justice" we also included question "eff orts should be made to prevent the growth of income inequality" in factor 4, even though its factor loading was below 0.5 (see Table 2). Th e reliabilities of sum variables formed this way were quite good (above 0.7) except the variable social justice. In accordance with the Kolmogorov-Smirnov test, the variables did not quite follow the normal distribution, even though they were quite close to it when briefl y looked at. --- Young people's social values Th e respondents related very positively to an individual's democratic rights and questions concerning social justice (see Table 3). Opinions were divided the strongest by the question "Eff orts should be made to prevent the growth of income inequality" but still clearly over half of the respondents agreed and only 10% disagreed with it. 64% agreed with "Western democracy is a core value in our society" and one third took a neutral stand. We can assume that the abstract quality of the concept Western democracy partly explains the multitude of a neutral position with this question. As concerns the rest of the questions, 75-85% of respondents agreed with each one. Th e results are in harmony with the previous ones. In concern with an individual's democratic rights the respondents largely agreed with the claims. More specifi cally, 80% of the respondents agreed with the claim "individual freedom is one of the core social values". Hence, the results support the view of the Finnish society's individualistic quality [Hofstade]. On the other hand, the results also support the assumption that the basic value premise of the welfare state is also strongly endorsed amongst young people [see Muuri 2008]. Democratic rights of an individual and social justice were strongly correlated (R = 0.486; p <unk> 0.000). Hence, our fi rst hypothesis proved to be valid: Th e social values of the Finnish youth form an entity in which an individual's democratic rights and the social justice are combined. Even though individualism and collectivism divert from each othe r in regard to their basic premises, they become intertwined in the Finnish young people's social values. --- Social values and societal entrepreneurship attitudes Next, we focus on societal entrepreneurship attitudes. We separately examine the general entrepreneurship attitude and, on the other hand, the critical entrepreneurship attitude (criticism of entrepreneurship discourse). Th e distribution of responses to these questions is shown in Table 4. All in all, young people's relationship with entrepreneurship seems to be fairly positive according to the research results. In particular, entrepreneurs were considered diligent and responsible, which also is in accordance with the previous research fi ndings [e.g. Kivelä 2002;Nevanperä 2003;Hyytiäinen & Pajarinen 2005;Home 2007]. In contrast, a neutral stand was pronounced on questions concerning entrepreneurship discourse criticism. Approximately one third of the respondents estimated that young people are encouraged to become entrepreneurs with too unsubstantial rationale and entrepreneurship is oft en discussed with too positive tones. Next, we analyse whether these entrepreneurship attitudes of young people are explained by social values. Th e correlations between the sum variables are shown in Table 5. Democratic rights of an individual clearly correlated with the social appreciation of entrepreneurship as we had assumed. Hence, hypothesis 2 is valid. In other terms the correlation coeffi cients were fairly small. Th e correlation between social justice and entrepreneurship discourse criticism points to the right direction but is only almost signifi cant (hypothesis 5). Our two other hypotheses were not supported: Democratic rights and critical entrepreneurship attitude do not correlate with each other (hypothesis 4). Th e correlation between social justice and social appreciation of entrepreneurship in turn was, against our assumption (hypothesis 3), faintly positive. Hence, social justice in fact correlated positively with both general and critical entrepreneurship attitudes. All in all, social entrepreneurial attitude does seem to be related to social values to some extent. Th e obtained results are in accordance with Ikonen's [2006] view that emphasis on entrepreneurship and welfare state discourse are well-suited to each other. Similarly, the positive correlation between an individual's democratic rights and positive conception of entrepreneurship is rather natural from the viewpoint of Ikonen's conception of citizenship. A critical entrepreneurship attitude correlated only quite faintly with social values. Th is is rather surprising, taking into account the neoliberal tones related to new entrepreneurship discourse. Perhaps an explanation lies in Patomäki's [2007] analy-sis, according to which the neoliberal emphasis in Finland has been more pragmatic than ideological. Hence, neither would criticism of entrepreneurship discourse be related to social values. --- Social values and entrepreneurial intention Lastly, we analyse the relationship between social values and entrepreneurial intention. Sum variable entrepreneurial intention is formed of four questions which were connected not only to the actual entrepreneurial willingness but also to how likely a career choice entrepreneurship is considered by a young person. Th e reliability of the formed sum variable was quite good (alpha = 0.899). Questions concerning entrepreneurial intention and the distribution of their responses are shown in Table 6. As Table 6 shows, the proportion of young people intending to become entrepreneurs was fairly small. Th e question that compared entrepreneurship and employment as career choices received a larger proportion of those who disagreed than those who agreed, which is in line with the GEM survey. Less than one fi ft h of the respondents agreed with the other questions. Th e correlation coeffi cients and their signifi cance between social values, societal entrepreneurship attitudes, and entrepreneurship intent are shown in Figure 3. Th e correlations between societal entrepreneurial attitudes and entrepreneurial intentions were in accordance with the assumptions: social appreciation of entrepreneurship is in a positive (hypothesis 8) and critical entrepreneurship attitude is negative relation with entrepreneurial intention (hypothesis 9). Also hypothesis 10 is valid: general entrepreneurial attitude is negatively dependent on critique of entrepreneurial discourse. Social justice in turn correlated negatively with entrepreneurial intention as we assumed (hypothesis 7). On the contrary, an individual's democratic rights do not correlate with entrepreneurial intention; that is, hypothesis 6 did not prove to be valid. Th is is interesting also from the point of view that an individual's democratic rights and, again, general entrepreneurship attitude in turn correlated signifi cantly with entrepreneurial intention. According to the research fi ndings, the relationship of social values with social entrepreneurial attitudes and entrepreneurial intention is very complex and all connections and interactions between them are insubstantial and incoherent. Th e relationship of democratic rights with social appreciation of entrepreneurship is clearly positive (R = 0.315). Other correlations are quite low (R <unk> 0.15). Social values explain entrepreneurial intention clearly weaker than, for instance, the expectations of a young person's close environment, faith in one's own capacities and faith in one's own success [Rantanen 2013]. It is possible that there is also a common social psychological phenomenon in the background: general attitudes (such as relating to the society or social values in general) explain rather poorly the behaviour of an individual, whereas more specifi c attitudes (such as attitude towards entrepreneurship) have a clearly better explanatory capacity [see Eagly & Chaiken 1993;Ajzen 1991]. --- Conclusions and discussion Our research results showed that the Finnish young people's world of values contains two closely connected entities. On the one hand, young people emphasise an individual's democratic rights, and on the other hand, they are committed to the value premise of the Nordic welfare state. Young people share the Finnish value climate, which is a combination of individualism and collective responsibility. How can individualism and collectivism then be so well reconciled? One possible interpretation is connected to the Finnish welfare state's current historical phase. In an institutionalized welfare state, the core of collective responsibility is the state's responsibility to all citizens rather than an individual's commitment to joint liability. Hence, welfare state-oriented collectivism is not an obstacle to individualism. In the cultural models of entrepreneurial attitudes, high individualism has been related to entrepreneurship-oriented cultural values [e.g., Lindsay 2005] and entrepreneurial orientation [Mueller & Th omas 2000]. According to our research fi ndings, there is a clear connection between highlighting an individual's democratic rights and social appreciation of entrepreneurship. A positive conception of entrepreneurship can be seen as a natural continuation of individualism that underscores individual rights. However, this connection remains largely at the level of attitudes. Young people's concrete entrepreneurial willingness remains at a modest level [Flash Eurobarometer 2009;Stenholm et al. 2011]. Our core perception is indeed the weak connection between social values and entrepreneurship. It is likewise apparent in our fi ndings that criticism of entrepreneurship discourse has little to do with social values. One explanation for these perceptions may be that young people consider entrepreneurship as the fi rst and foremost pragmatic career option rather than an ideological choice. Similarly, entrepreneurship discourse and its assessment are perceived more from a practical perspective than from ideological criticism of neoliberalism [see Saari 2001;Patomäki 2007]. According to Ikonen [2006, p. 35], entrepreneurship can be emphasised from the discourse premises of both neoliberalism and the welfare state. Ikonen suggests that it is erroneous to assume that the importance of entrepreneurial education is justifi ed only with one of the two narratives as the point of departure. According to our research fi ndings, entrepreneurial intentions of young people have an insubstantial connection with social values. Hence, promoting entrepreneurship does not necessarily need to be supported by any great social narrative.

Th e article is focused on Finnish youth's social values, societal entrepreneurship attitudes and entrepreneurial intention. Th e study addresses how the relationship between social values and societal entrepreneurship attitudes becomes visible among Finnish young people. What is the relationship between social values and entrepreneurial intention? What is the relationship between societal entrepreneurship attitudes and entrepreneurial intention? We also analyze the relationship between diff erent social values of the Finnish welfare state. Survey data (N = 873) were gathered in electronic format from secondary and vocational schools in the Helsinki-Uusimaa region, and questions were based on a multiple-choice Likert scale. Th e analysis was undertaken using statistical methods. We found that Finnish young people consider entrepreneurship fi rst and foremost a pragmatic career option, which is not supported by ideological arguments or assumptions. On the other hand, the connection between social values and entrepreneurial orientation remains largely at the level of attitudes. On a practical level, entrepreneurship is not thought to be an attractive career option.

Introduction There is growing recognition that mediation between research producers and users is necessary to increase research dissemination and use to improve public services (Cooper & Levin, 2010;Levin, 2008;Lomas, 2007;Nutley et al., 2007;Tseng, 2007;Ward et al., 2009). The Social Sciences and Humanities Research Council (SSHRC) of Canada defines knowledge mobilization 2004). Some attribute this growth of intermediaries to the international climate demanding better evidence-based decision-making and use across public service sectors, especially in relation to health and education (Nutley et al., 2007). As these third party agencies become more involved in mediating research use in education, many funders (e.g. William T. Grant Foundation) and prominent scholars in the field (such as Sandra Nutley and her colleagues) are highlighting the importance of intermediaries' roles in KMb and emphasizing the need for empirical work on third parties in the KMb process (e.g. Davies & Nutley, 2008;Honig, 2004;Nutley et al., 2007;Levin, 2004Levin,, 2008)). This paper is organized in three sections. First, it provides a literature review of research mediation-exploring terminology, models and empirical work (albeit sparse) across health, business, and education sectors. Second, it proposes three conceptual contributions: 1) A conceptualization of intermediaries' roles in knowledge mobilization occurring in the white space of broader public service systems; 2) A typology of the kinds of Canadian research brokering organizations (RBOs) that exist in education, including empirical data mapping RBOs across Canada; 3) A framework of knowledge brokering characteristics along seven dimensions: mission, resources, staff roles, political affiliation, autonomy, message, and linkages. Third, it provides empirical data about the RBOs that exist across Canada. Ultimately, this paper explores the increasingly prominent role of RBOs in strengthening connections between research policy and practice in education. --- Literature Review --- Intermediaries Multiple terms and models for intermediaries. What counts as an intermediary in education, or other sectors, is not clear from the existing literature. Many terms (Table 1) that describe mediating processes are often utilized interchangeably, such as knowledge brokers (Jacobson, Butterill & Goering, 2003), intermediaries (Honig, 2004), third party agencies (Levin, 2008), facilitators, and boundary spanners (Ward, House & Hamer) among others. These definitions differ largely by sector. The definitions from the health sector all identify the role in terms of connecting researchers and producers for the purpose of knowledge translation (an analogous term to KMb)and, as a result, might be usefully applied to the education sector. The business sector has an expansive literature on intermediaries, but these conceptions primarily deal with innovation in competitive corporate environments; hence, they are less useful in understanding the role intermediaries might play increasing KMb in education or other public services. The term 'broker' means different things in different areas: In business, a broker is an agent, promoter, dealer, fixer, trader, someone who buys and sells; in politics, a broker is a diplomat, mediator, go-between, negotiator; in the information world, a broker is someone who knows how to access or acquire information and who provides a gateway to information resources; in education, a broker is a proactive facilitator who connects people, networks, organizations and resources and establishes the conditions to create something new or add value to something that already exists. (Jackson, 2003, p. 4) Table 1 Popular terms used in various sectors to describe third party roles in research use --- Term Sector Definition & Source Intermediaries Education Intermediaries are organizations that occupy the space in-between at least two other parties. Intermediary organizations primarily function to mediate or to manage change in both those parties. Intermediary organizations operate independently of these two parties and provide distinct value beyond what the parties alone would be able to develop or to amass by themselves. At the same time, intermediary organizations depend on those parties to perform their essential functions. (Honig, 2004, p. 67) Innovation broker Innovation brokers help to mobilise innovations, identify opportunities that the current system undervalues and they broker relationships between disparate parts of the system. These organisations mediate both knowledge and relationships for their clients. (Horne, n.d., p.3) --- Knowledge broker Middlemen, intermediaries, or agents who act as negotiators, interpreters, messengers or commissioners between different merchants or individuals. ("broker", 2010) Health Knowledge brokers mediate between researchers and user communities. Individuals serving as brokers must understand both the research process and the users' decision-making process. (Jacobson, Butterill & Goering, 2003, p. 98) Knowledge brokering links researchers and decision makers, facilitating their interaction so that they are able to better understand each other's goals and professional culture, influence each other's work, forge new partnerships, and use research-based evidence. Brokering is ultimately about supporting evidence-based decision-making in the organization, management, and delivery of health services. (CHSRF, 2003, p. 2) Knowledge brokering is the various people-based actions of knowledge exchange and adoption....knowledge brokering is typically used to refer to processes used by intermediaries (knowledge brokers) in mediating between sources of knowledge (usually science and research) and users of knowledge. Knowledge brokering is usually applied in an attempt to help knowledge exchange work better for the benefit of all parties. (Land & Water Australia, 2006, p. 7) Business Individuals or organizations that cross policy and practice divides. (Sin, 2008, p. 86) Knowledge brokers can play an important role in open innovation processes. They act as catalysts, accelerating the combination of complementary knowledge and skills necessary to solve innovation problems, by making the right connections and links with solvers and seekers. In this way, knowledge brokers can help increase collaborative advantage. (Sousa, 2008, p. 22) Third parties who connect, recombine, and transfer knowledge to companies in order to facilitate innovation. (Cillo, 2005, p. 404) Research Broker --- Business Those who package and retail the intellectual outputs of the research community to policymakers. (Sundquist, 1978in Sin, 2008, p.86) --- General Research brokers make ideas matter and use their intellectual authority to verify certain forms of knowledge as more accurate, persuasive or objective.... promote ideas and attempt to push them onto the public/government agenda ('soften' the climate of opinion towards particular alternatives). (Stone, Maxwell & Keaton, 2001, p.35) Mediator General This is the intellectual worker as enabler, fixer, catalyst and broker of ideas. Perhaps the salient feature, though, is the association of mediators with movement. The mediator is simply the one that gets things moving. (Osborne, 2004, p.440) Jackson's definition of broker in relation to education is useful for the conceptualization of intermediaries ultimately offered in this article in a number of ways. First, it defines the role as proactive. Secondly, it outlines a number of important aspects such as connections between people, networks, organizations and resources, and lastly, it highlights that brokers add value. A review of the literature in the education sector produced very few definitions: Honig's (2004) definition of intermediaries arising from an empirical study on policy implementation in the US, to be described more fully later, and a new term coined by Matthew Horne in the UK, innovation broker, that has recently emerged in the education sector paralleling the business sector conception of a knowledge broker. Horne critiques the term 'intermediary' on the grounds that it is "commonly used in technical and policy documents but sounds a little passive -a mere go-between. Broker is a more active term indicating a role that connects people but also generates and facilitates innovation" (Horne,n.d.,p. 37). Honig identifies intermediaries' role as managing change between two parties, whereas for Horne the central function is to mediate innovation. I use the term research brokering organization (RBO) to describe third party intermediaries whose active interaction between research producers and users is a catalyst for increased KMb and research use in the education sector. I chose research brokering organization, rather than knowledge mobilization intermediary or other terms because I think the term RBO includes the function of these organizations more clearly in that the type of knowledge being mobilized (research) is clearly stated. In addition to the multiple terms that exist for the role of intermediaries, there are also a number of knowledge brokering models (Table 2). These models originate predominantly in health and business, but many of the functions and dimensions listed are relevant to education. Empirical studies on intermediaries from across sectors. As the recognition of the increasing number and importance of intermediaries involved in KMb processes across sectors has grown, studies have begun to examine research mediation. Lavis Robertson, et al. (2003) surveyed 265 directors of applied research organizations (both applied health research organizations, N= 134, and applied economic/social research organizations, N=131). They defined applied health research organizations "as research groups studying the effectiveness and efficiency of clinical services and health care systems" (p. 230). They defined economic and social research organizations "as research groups studying the effectiveness and efficiency of government economic/social programs and economic/ social policy systems" (p. 230). Their sample included four types of organization: autonomous research groups, semiautonomous research groups in universities, semiautonomous research groups in federal or provincial government departments, and semiautonomous research groups in Québec's largest regional health authorities. They excluded university departments or schools, virtual networks of researchers, management-consulting firms, marketing-research firms, professional membership organizations and research groups that had existed for less than a year. Their sample was made up primarily of intermediary organizations, although they do not use this terminology, that attempt to cultivate stronger relationships between research and practice in a public service sector. As a result, this study can make a significant contribution to understanding these organizations in education. Though undeniably different sectors, there are also compelling similarities between the function and purpose of public services, such as continuous public scrutiny, a unionized workforce, diverse users, pressure to serve all Canadian citizens, different levels and kinds of organizations (schools are analogous to hospitals, with both having district or regional authorities) all governed by a central ministry, among others. (Lavis, Robertson, et al., 2003) This model is a five prong organizing framework: (1) the message, (2) the target audience, (3) the messenger, (4) the knowledge transfer process and supporting communications infrastructure, (5) evaluation. Lavis emphasizes that importance of credibility and trust, and suggests that researchers working through trusted intermediaries (knowledge brokers) as messengers might address researchers' time constraints, limited interest of, and skills applicable to KMb, while at the same time enhancing the messenger's credibility; therefore, ultimately increasing research uptake by users. (Land & Water Australia, 2006) (1) Network Knowledge Brokers are members of a specific network, for example the World Health Organisation (WHO) or the Australian Wildlife Health Network. They use their networks to transfer information between the ABCRC and that network. --- Health (2) Issues-based Knowledge Brokers champion particular issues so that programs respond to high priority issues and stakeholders have a single point of contact for information arising from multiple research projects. (3) Program-based Knowledge Brokers are Research Program coordinators who ensure research projects are integrated across programs. (4) Project-based Knowledge Brokers are members of a research project team. They work with the research team and the end-users to ensure that expectations of the research project are managed and that the needs of the end users are met, leading to improved research adoption. (Jacobson, Butterill & Goering, 2005) Six stage model of consultancy that could be applied to different roles that KMb brokers could play in user organizations: (1) Pre-entry: in which the context for the consulting project is set (2) Entry, in which the consultants and clients define the central issues and the project scope (3) Diagnosis, in which consultants assisted by clients gather and analyze data (4) Intervention, in which clients and consultants interpret the analyse data (5) Exit, in which consultants write and present report (6) Post-exit in which the client does or does not implement the recommendations. This model involves four types of work: business work (budgeting and hiring), project management work, substantive work (gathering, synthesizing, and applying knowledge) and political work (interpersonal and political context). (Cillo, 2005) This model is based on (1) cognitive distance between the contexts and (2) the complexity of the knowledge to be transferred. Information-Broker (low distance/low complexity): core function is transfer, sporadic interaction among groups. Knowledge Coder (high distance/ low complexity): core function is knowledge codification, sporadic interaction among groups; Integrated Knowledge Broker (low distance, high complexity): core functions access and transfer, continuous interaction among groups, knowledge transferred by directly interacting with two parties needing to share knowledge; Pure Knowledge broker (high distance, high complexity): core functions are access, recombination and transfer, involves continuous interaction among groups. (Sin, 2008) Five consultancy approaches to knowledge brokering: (1) Cross-pollinators work across sectors and, by virtue of these interactions, can often identify and apply benefits among sectors (2) Matchmakers help bring research producers and users together in order to build shared understanding among stakeholders (3) Translators and processors interpret and adapt research to suit particular contexts and users (4) Multiple dissemination routes: These brokers make research available in diverse formats, using a variety of techniques in order to increase impact (5) Articulators of user perspectives: These brokers introduce users to new evidence while simultaneously giving feedback to research producers about the needs of users (summarized and adapted from pp. 93-96) Lavis, et al. (2003) found that even in these intermediary organizations, with an explicit focus on knowledge translation (KT is an analogous term to KMb used in the health sector), only about one third had developed strategies beyond the simple transmission of research reports and summaries or had actionable messages. They also found that while 60% of these organizations tailored KT approaches to specific audiences, only 39% of respondents dedicated resources to get to know their audiences. Capacity building was not prioritized either externally with target audiences or internally with staff members who were responsible for KT. Only 20% of these intermediaries dedicated resources to skill building among their target audiences. Few organizations used resources to enhance capacity through skill building among KT staff (22%), getting to know the research literature on effective approaches to KT (21%), or learning what constitutes a 'credible' message for their audiences (17%). Research organizations within the Lavis, et al. study, however, did have dedicated staff with KT duties (63%), and a significant minority created explicit incentives (e.g. performance goals/measures, targeted stipends) for staff to engage in KT activities (42%). In these organizations, an average 14% of their research budget was allocated to KT. Almost all used websites to supplement interactive processes (91%), with 60% using newsletters and 33% using listservs. Only 10% of these organizations reported any type of evaluative activity related to KT. --- Health --- Business --- Business The overall finding was that health research organizations quite often reported transferring research knowledge in ways consistent with our understanding of how best to undertake such activities, more frequently than economic/ social research organizations. Even in intermediary organizations, however, KT efforts remain modest across a number of areas. While the amount of staff with explicit roles and the fact that some resources are dedicated explicitly to this work were promising, "directors...were remarkably frank about their not evaluating their knowledge transfer activities" (p. 240). The need to evaluate KT efforts is critical to understanding which strategies are more and less effective in different contexts. Another interesting finding from this study was the relationship between audiences and KT practices: Canadian research organizations that identified [multiple] audiences tended to report transferring research knowledge in ways consistent with our understanding of how to undertake such activities more frequently than did research organizations that identified fewer possible groups as target audiences...this may reflect a greater commitment to KT among those research organizations that exist to serve multiple target audiences (i.e., serving multiple target audiences is more complicated, so more resources are dedicated to it, a possibility borne out by the gradient in both the mean and median proportions of research budgets spent on knowledge transfer). (p. 242) Hence, looking at intermediaries that deal with more stakeholder groups might teach us more about the different types of KMb strategies that are needed with different groups in education. Another recent study by Lomas (2007) surveys 400 knowledge brokers in the health sector, only a few of whom have full time designation in this role. He found that knowledge brokers spend about 30% of their time on transforming knowledge (reading and disseminating research) and 20% of their time on facilitating research mediation (actually linking decision makers and researchers). The remaining time was spent in management duties or teaching. Lomas categorized knowledge brokers in relation to their location within the broader system and found that 30 % were based in universities, 10 % were in foundations or research funding agencies and the remaining 60 % resided in different levels of the health system such as hospitals or regional health authorities. Lomas (2007) outlines a number of attributes and skills of knowledge brokers from his extensive work in this field such as "entrepreneurial (networking, problem solving, innovating); trusted and credible; clear communicator; understands the cultures of both the researcher and decision making environments; able to find and assess relevant research in a variety of formats; facilitates, mediates and negotiates, and; understands the principles of adult learning" (p. 130). Lomas (2007) describes four major brokering activities, utilizing the example of the Canadian Health Services Research Foundation (CHSRF): Setting the research agenda (consulting with key stakeholders to increase chances of research uptake and linking funding to collaboration with organizations within the system); facilitating applied research (graduate student awards to ensure work in this area, inclusion of decision makers of coinvestigators as a formal requirement, co-production of research-syntheses with people who can implement the results); disseminating research (plain language summaries, virtual networks along priority theme areas, organizing face-to-face events among multiple stakeholders on priority areas); getting research used (funding and evaluating selected knowledge brokers, providing workshops for health professionals on tools and techniques for research use, fellowship training programs for decision makers in research application) (p. 131). Robinson et al. (2005) conducted a parallel case study exploring the utility of linking systems in heart health promotion across three provincial dissemination projects of the Canadian Heart Health Initiative (CHHI). They define a linking system as "interactions between public health resource groups and user groups in the development, transfer and use of knowledge, practices and programs. The goal of a linking system process is to enhance capacity for, and the transfer and uptake of, a given set of practices or programs by public health user groups" (p. 499). A linking system is analogous to the many terms being used across sectors around intermediary roles in research mediation. The study included qualitative (key informant interviews) and quantitative data (project reports) collected from Prince Edward Island, Ontario and Manitoba. All three of these provincial initiatives explicitly embraced a linking system approach within CHHI. Robinson et al. found that the three provincial cases differed in scope of the linking systems: PEI had a community scope targeting a heart health coalition; Manitoba had a regional scope involving five rural community committees; and Ontario's linking system had a provincial scope and spanned all 37 local public health units. Robinson et al. (2005) list a number of linking activities aimed at supporting research uptake and evidence-based practice in their study of research use in the health sector including: regular communication, training/retreats, collaboration, co-sponsorship, networking, facilitation, informal training, advocacy, research information, volunteer development, research, monitoring/feedback, provincial resource center, research dissemination, technical support, resource provision, modular training, informal training and supporting existing groups. The list of activities is diverse and each could be conducted by a RBO, but it is not always clear how these are distinct activities (for example research versus research information, or the differences between collaboration, networking and facilitation). Robinson et al. maintain that these common linking functions and activities fit the characterization by Anderson et al. (1999) of linking activities as focusing on (1) awareness, (2) communication and (3) interaction, but this study adds a fourth function of capacity building. Facilitators and barriers affecting linking systems included skilled and committed people, funds/resource, priority/buy-in, leadership, communication, partnerships and structure. Overall: The findings do suggest that whether a linking system operates at a community, regional or provincial/state level, similar conditions for success emerge. Two-way exchange and active involvement of resource and user groups depend on commitment and communication channels. Linking systems center on interaction between diverse groups, hence senior leader buy-in and the presence of appropriately skilled people in facilitation roles are essential. (p. 510) In the end, while Robinson et al. found improvements to capacity enhancement and implementation of heart health programs; they could not draw any conclusions between specific types of linking mechanisms used and outcome measures reported. Honig's (2004) study of four groups involved in policy implementation in the US is one of the only empirical studies explicitly investigating intermediaries in the education sector, although it is not specifically about knowledge mobilization intermediaries, but about program or policy implementation. She labels intermediaries "the new middle management". At the outset of her study, Honig states her intention to address the knowledge gap surrounding intermediaries, maintaining that "despite their growing number, research and experience teach little about intermediary organizations" (p.65). She attempts to address this knowledge gap by answering three questions: "1) What defines intermediary organizations as a distinct organizational population?; 2) What functions do intermediary organizations serve in education policy implementation?, and; 3) What conditions constrain/enable intermediary organizations in carrying out their functions?" (p.66). Honig draws on organizational ecology literature in order to answer the first research question by identifying two dimensions of likeness which define an organizational group: "1) similar technical core (functions), and; 2) dependence of population members" (p. 67). She then outlines five dimensions along which intermediaries vary: (a) levels of government (or types of organizations) between which they mediate; (b) composition of intermediaries (membership); (c) location (internal versus external intermediary organizations); (d) scope of intermediaries' work (within a single district or across multiple jurisdictions), and; (e) funding/revenue sources Honig (2004) also highlights a number of functions of intermediary organizations arising from her study including: knowledge of sites and policy systems, regular meetings, documentation and dissemination of information, simplified information about experience, ongoing knowledge building processes, social and political ties to sites and policy systems, translation of sites' demands into actionable terms, buffers for sites, administrative infrastructure, site and central office systems for resource allocation, staff time, standards and accountability. This list is diverse and reveals the range of activities in which intermediaries can be involved when dealing with different organizations; part of this arises from different organizations having different needs in the change process. Taken together, these studies contribute to our knowledge base on intermediaries by elaborating on what dimensions define intermediaries, where they are located in the system, what attributes contribute to their effectiveness and what type of KMb activities they are facilitating. Barriers: A word of caution. There are a number of barriers also associated with knowledge brokers' role in translating research to suit various contexts. One concern relates to the quality of the interpretation of research by intermediaries. Sin (2008) cautions about some possible negative consequences of using intermediaries: It cannot be assumed that all types of intermediaries are adept at interpreting the range of evidence required for a variety of purposes. This may be particularly so when evidence may not have been produced with intermediaries in mind. It is, moreover, clear that different intermediaries (whether individuals or organizations) have their own agendas and vested interests and these can all have a range of direct and indirect impacts on how and in what ways the worlds of evidence, policy and practice are linked (p. 97). While intermediaries have the potential to play an important role in knowledge mobilization, it cannot be assumed that they are a panacea in connecting research, policy and practice. Other barriers to RBOs mediating research use include buy-in from the organizations they work with, lack of empirical evidence of what KMb strategies are most effective in what context, as well as trust and credibility issues associated with being an 'outsider'. Measuring the impact of research and brokering is a complex challenge that is being taken up by the health sector (see Lavis, Ross et al., 2003;Kuruvilla et al., 2006), however approaches to measure impact in education still need to be developed. --- Hypotheses about RBOs in Education RBOs function predominantly in the white space of the education system. In education, we often try to identify what areas of an organization or system have the largest capacity for improvement. This is critical to ensuring that resources are targeted at the right area in order to reap the largest possible benefits from public investments. The term "white space", in visual arts, refers to the space between text and images; it is not considered blank or insignificant space, but rather an important aspect of how people interpret and understand particular messages (Boulton, 2007). This concept has been adapted by Rummler and Brache (1991) in process management where white space is articulated as the area between the boxes in an organizational chart. Often, in organizations and systems, no one is explicitly in charge or responsible for the white space even though critical interactions and functions happen between these clearly demarcated boundaries, departments and organizations. This is where things fall between the cracks as no one takes explicit ownership which often results in misunderstandings or a lack of progress. Rummler and Brache (1991) maintain that the white space is the area in which an organization has the greatest potential for improvement: All organization structures have white space. The mission is not to eliminate white space. The mission is to minimize the extent to which white space impedes processes and to manage the white space that must exist. If you organize by product, there's white space between products. If you organize by function, there's white space between functions.... there is...white space between projects, between processes...and between people (emphasis in original, p.183). The oft-cited gaps that occur between research, practice and policy happen in the white space of the education system: between universities, funding agencies, ministries of education, school districts, schools, professional associations, community organizations and the many other organizations which comprise the broader system. This paper conceptualizes KMb and the work of intermediaries as occurring in the white space of the public education system (Figure 1). The broader education system is displayed on the left side of the figure with RBOs in the white space between the diverse organizations. Individual organizations from each group on the left can also be looked at separately (shown on the right side of the figure) which reveals white space between roles, departments, levels of leadership as well as between policies, processes, resources, and outcomes. KMb occurs predominantly through research mediation in the white space of a system or organization. Part of what makes KMb so challenging is that its success is predicated upon linkages and connections between and within diverse organizations. Predominantly, KMb work is not explicitly designated within OR between organizations; hence, it does not get prioritized. Rather, KMb (if it happens at all) occurs mostly in an ad hoc manner (Cooper et al., 2009;Nutley et al., 2007). There is also disagreement surrounding whose role it is to do KMb; some argue that it the role of researchers to make research more accessible, others that users should seek it out, with a third view being that it should be the role of specialized intermediaries rather than researchers or users as they have different professional roles (Cooper, 2012). This paper conceptualizes intermediaries as operating predominantly in the white space of education, spanning organizational boundaries in order to connect and facilitate interaction among various stakeholders. This analogy arises from the literature that consistently highlights the fact that intermediaries have an in-between vantage point that is critical to their function. This in-between vantage point occurs between groups, organizations, disciplines, sectors and countries depending on the context and mandate of the intermediary. The Organisation for Economic Co-operation and Development (OECD) for instance is situated between multiple countries. Regardless, the role of connectivity across diverse boundaries delineates the work and essence of what intermediaries do. A typology of brokers, intermediaries and mediators. Many organizations do KMb intermediary work as one part of a much broader mandate. This paper uses the term research brokering organization (RBO) to describe third party intermediary organizations that (a) connect research producers and users; (b) have explicit KMb mission statements, and; (c) dedicated resources to address research-practice-policy gaps. Due to the brokering role being about connecting diverse stakeholders, organizations that connect researchers to researchers or practitioners to practitioners are not RBOs. Studies across sectors have highlighted the influence of organizational context to research use; because different organizations have diverse functions within the education system, the nature and frequency of research use varies across organizational contexts, domains and disciplines (Amara, Ouimet & Landry, 2004;Belkhodja et al., 2007;Biddle & Saha, 2009;Coburn & Stein, 2010;Cordingley, 2008;Landry et al., 2001;Nutley et al., 2007). For example, in policy-making environments, such as ministries of education, timeliness of research might be more influential, whereas in practice environments, such as schools and classrooms, practical adaptations of research products might be more crucial. The same logic can be applied to the various intermediaries that exist in education. Diverse types of intermediaries can have very different roles depending on their purpose and which target audiences they deal with; so, considering the type of intermediary, its purpose and target audience will be important in exploring KMb efforts, especially when comparing different kinds of organizations. What counts as an intermediary in education, or other sectors, is not clear from the existing literature. Part of the confusion surrounding intermediaries is that many types of individuals and organizations are mentioned in the literature. Nutley, Walter and Davies (2007) list a variety of knowledge brokers including "charitable foundations, different kinds of research centres, government agencies, bridging organizations, professional organizations and individual researchers" (p. 63). Levin (2004) contributes others to this list such as the media (mass and professional), lobbyists, interest groups, think tanks, labour groups, policy entrepreneurs, private companies and consultants as well as popularizers (well-known figures who integrate research into their work with educators and the public). Honig (2004) notes that intermediaries are particularly difficult to identify and study because many studies refer to intermediary organizations without defining what makes them intermediary, and many organizations identify themselves as intermediary organizations (often, this is one more designation added to a host of others): These trends make it difficult to discern what intermediary organizations are, what they do, and how they operate. Accordingly, research, policy and practice provide weak guides for what may be productive and appropriate roles for this increasingly prominent participant in education policy implementation. (p. 65-66) However, Sin (2008) highlights the importance of differentiating among intermediaries: It is meaningless, however, to discuss intermediaries as an amorphous monolithic entity. Instead, the evidence-based policy and practice enterprise should engage in sustained discussion around the identification of who intermediaries may be, why they may play brokerage roles in particular contexts, how they perform such roles, and what this impact might be. It is likely that roles and functions may be fluid and context-dependent. A greater understanding of such intermediaries and the roles they perform will be beneficial to a more sophisticated understanding of the process of linking policy to practice. (p. 98) This paper develops a typology of RBOs in education in order to heed the call for more nuanced understanding of these organizations and roles arising from the literature. In order to study relationships between research, policy, and practice in education, it is necessary to identify the various organizations and groups that are involved in KMb processes. Coburn (2005) explores the relationship between state instructional policy and classroom practice using the case of reading instruction in California. She highlights the tendency of studies to focus narrowly on formal policy systems, such as district, state, and country, into schools, despite the fact that this formal system does not exist in a vacuum detached from other external influences and players. Coburn (2005) describes two types of actors in education: system actors are "individuals and organizations that constitute state and local governance of schooling", whereas non-system actors are "not formally part of the system" (p. 24). She outlines various types of non-system actors based on Rowan's (2001) Coburn maintains that the role of these external organizations has rarely been explored, especially in relation to policy implementation and classroom practice: "Studies that have addressed this issue provide evidence that nonsystem actors are a key mediating link between policy and practice" (p. 23). Hence, she urges that researchers consider both system and nonsystem actors when looking at educational phenomena as well as the interaction between these groups. As a result, this study considers system and non-system RBOs. To address the lack of differentiation among intermediaries throughout the literature, a typology of RBOs was developed (Table 3). Four broad categories are utilized to differentiate RBOs according to their location in the system and major funding sources: governmental, not for profit sector, for profit and organizations that collect fees from their members (Coburn, 2005;Honig, 2004;Rowan, 2001). Each category is further disaggregated in relation to various types of organizations listed throughout the literature (Levin, 2004;Nutley et al., 2007). This typology will be utilized in the third section of this article to map the frequency and types of RBOs that exist across Canada. (2004) as organizations that " make public interest claims either promoting or resisting social change that, if implemented, would conflict with the social, cultural, political, or economic interests or values of other constituencies and groups" (p. 481). (People for Education) --- Issue Based Organizations mobilize research around a particular issue (for example literacy or learning disabilities). (Learning Disability Association of Ontario, the Centre) 1.2.4 Think tanks are defined by Rich (2004) as "non-profit public policy research organizations either independent or associated with a college or university" (p.13). (Atlantic Institute for Market Studies, Fraser Institute) 1.3.0 For-profit Intermediary RBO (non system actors; external; private funding from business sector) --- Textbook publishers, instructional program vendors especially where these organizations create tools and resources for KMb (Thompson Corporation) This means that KMb is a major activity of the organization. RBOs' involvement in research use goes beyond a rhetorical commitment. They go beyond "telling"; hence, they do not This framework might be useful in future research in order to distinguish between the different kinds of intermediaries that exist in education, especially in relation to their roles in KMb. --- Research consulting companies: --- Methodology The next section of this paper answers the following research question: What types of RBOs exist in Canada? The primary focus of this study is organizations whose major focus and activity is knowledge mobilization. Since virtually no empirical data exist on intermediaries in education, two of the challenges associated with this study were 1) how to define intermediaries, and; 2) how to create a systematic sampling approach that fairly identifies RBOs that exist across the national landscape. The next two sections describe the study's approach to addressing these challenges. --- Methods Inclusion criteria. This study used two inclusion criteria to determine educational RBOs for the sample: 1. Target Audience: KMb intermediaries are organizations who link both research producers and research users, and; 2. KMb Related Mission Statement: KMb intermediaries are organizations where KMb is a major activity of the organization

This paper explores the increasingly prominent role of research brokering organizations (RBOs) in strengthening connections between education research, policy and practice across Canada. This paper is organized in three sections. First, it provides a literature review of research mediation-exploring terminology, models and empirical work (albeit sparse) across health, business, education sectors. The second section provides three conceptual contributions to the field: RBOs' roles in knowledge mobilization occurring in the white space of broader public service systems, a typology of Canadian RBOs that exist in education using four broad categories: governmental, not-for-profit, for-profit and membership RBOs, and a knowledge brokering framework along seven dimensions: mission, resources, staff roles, political affiliation, autonomy, message and linkages. The third section provides empirical data about the frequency and types of RBOs that exist across Canada.

' involvement in research use goes beyond a rhetorical commitment. They go beyond "telling"; hence, they do not This framework might be useful in future research in order to distinguish between the different kinds of intermediaries that exist in education, especially in relation to their roles in KMb. --- Research consulting companies: --- Methodology The next section of this paper answers the following research question: What types of RBOs exist in Canada? The primary focus of this study is organizations whose major focus and activity is knowledge mobilization. Since virtually no empirical data exist on intermediaries in education, two of the challenges associated with this study were 1) how to define intermediaries, and; 2) how to create a systematic sampling approach that fairly identifies RBOs that exist across the national landscape. The next two sections describe the study's approach to addressing these challenges. --- Methods Inclusion criteria. This study used two inclusion criteria to determine educational RBOs for the sample: 1. Target Audience: KMb intermediaries are organizations who link both research producers and research users, and; 2. KMb Related Mission Statement: KMb intermediaries are organizations where KMb is a major activity of the organization. Priorities of organizations are often reflected in their mission statements, goals and strategic plans (Bart & Tabone, 1998;Morphew & Hartley, 2006); therefore, to be included in the sample, organizations' mission statements, goals and/or strategic plans must be explicitly related to knowledge mobilization in some way and to increasing connections between research, policy and practice (although these aims might be articulated using different terminology). Organizations that met both criteria were included in the sample. Sample selection. Maximizing diversity in the sample of multicase studies is suggested by many methodology scholars (Firestone, 1993;Merriam, 1998;Miles & Huberman, 1994;Stake, 2006). In order to accomplish this, this study utilizes purposeful sampling based on the typology of RBOs (Table 3) to compare and contrast the many approaches to research mediation that exist across the Canadian education sector. After disaggregating the four broad categories of RBOs, there are 14 different types of organizations. Of these, three types, textbook publishers and instructional vendors; media organizations; consulting companies, are not conducive to this study because they are not primarily concerned with research use. Therefore, 11 different types of RBOs from the typology were included in this study. Three sampling strategies were utilized to ensure systematic sample selection and consider a majority of Canadian educational organizations. Sampling strategy one: Using the Ki-Es-Ki to determine the Canadian sample. For over 35 years the Canadian Educational Association (CEA), a national educational organization, has published the KI-ES-KI Handbook -Directory of Key Contacts in Canadian Education. The KI-ES-KI contains over 4,000 individuals and organizations involved in the Canadian education sector. It includes contact names, addresses, telephone numbers, fax numbers, e-mail addresses and websites of departments of education, educational organizations, universities and colleges, school districts, faculties of education and federal departments and agencies, and education publications The contact list of educational organizations provided by the KI-ES-KI was one the main source used to find and contact intermediaries in Canada (Table 4 shows the relevant categories from the KI-ES-KI to this study). Four hundred and eighty-three Canadian educational organizations were considered using this sampling strategy by visiting websites to determine if organizations met the two inclusion criteria. --- TOTAL Sampling strategy two: Internet searching. In addition to the KI-ES-KI, a second sampling strategy utilized systematic searching of major search engines (e.g. Yahoo, Google) as another way to map RBOs across Canada. Combinations and permutations of key terms (Table 5) were utilized. Internet searches were recorded in order to use each search engine in a systematic way (Table 6). Organizations that met both the target audience and mission statement inclusion criteria were included in the study. Sampling strategy three: Organizations arising from empirical studies in RSPE. A third strategy for finding RBOs was through Dr. Levin's Research Supporting Practice in Education Program (RSPE) at OISE (more information on this work is available at www.oise.utoronto.ca/rspe). This program includes empirical studies as well as activities that involve RBOs. Canadian RBOs from the empirical studies of RSPE that meet both the target audience and mission inclusion criteria were included in the sample. Sample. Three sampling strategies resulted in 541 potential organizations across Canada that were considered for inclusion in this study. Twenty-four were excluded because they did not have websites listed in the KI-ES-KI, and 67 were excluded because they were French and had no English website version. 2 The 450 remaining websites were each visited in order to determine whether organizations met the target audience and mission statement inclusion criteria. Table 7 shows the results from the application of all three sampling strategies. Out of the 450 organizational websites considered for the sample, 44 organizations (10%) met both inclusion criteria and were included as RBOs in the study. Most of the think tanks included in the sample cover various areas of social policy, not just education. Think tanks were included when a major area of their organization targeted education. The final sample shows the various types of RBOs that exist across Canada according to the RBO typology (Table 8). Governmental RBOs comprise 16% of the sample (3 national organizations, 3 from Ontario and 1 from Manitoba). The majority of RBOs across Canada (71%) are not-for-profit organizations. Twelve of these not-for-profit organizations are issue based (topics include learning disabilities, mental health, literacy and early childhood education and development). Membership RBOs, organizations that are funded by their members, constitute 14% of the RBOs across Canada. Scope and distribution of educational RBOs across Canada. RBOs are located in nine provinces in Canada (Figure 3). Thirty percent of Canadian RBOs were national in their scope. Thirty-nine percent of the sample was from Ontario, which is not surprising given the fact that approximately 40% of the Canadian population is in Ontario. RBOs in the Maritime provinces comprised almost ten percent of the sample. --- TOTAL --- Discussion and Implications Providing clear definitions and examples of how an organizational population is 'intermediary' allows others to contextualize how the literature relates to their area. While the use of many terms and models associated with research mediation obscures a clear understanding of the field, consensus on these issues is unlikely especially in light of sector specific language. Regardless of the term or model used, it is important to provide clear definitions, descriptions and examples, so that diverse audiences can contextualize the information arising from the literature. The more important issue (beyond debates about terminology and frameworks) is the need for further empirical work on what these organizations actually do. The sparse empirical work that does exist suggests a focus on passive transmission rather than capacity building or actionable messages, with virtually no attention given to evaluation of KMb efforts. Current studies suggest that even among intermediaries, much of KMb work focuses on transmission of research reports or summaries without a focus on actionable messages. There is little attention given to capacity building among both intermediaries and groups that they work with. Across studies, there was also virtually no evaluation related to KMb and the impact of various initiatives. Where impact measures did exist, the relationships between different KMb strategies and outcomes were unclear. More empirical work investigating RBOs is needed in order to better understand research brokering in education. More empirical work is needed to map the activities of intermediaries in order to better understand the structures and processes of research brokering. This will provide a necessary foundation to develop concrete tools and measures to assess KMb efforts and the impact of this work. Exploring the effectiveness of the various strategies, processes and activities will be an important step to guiding future improvement initiatives. The hypotheses about RBOs offered in this paper will also need to be interrogated empirically. The typology of RBOs, as well as the framework of brokering characteristics, provides scaffolding to explore the similarities and differences among these diverse organizations. A necessary first step to developing our understanding of these underexplored roles was to discover the range of intermediaries that exist in Canada. --- Conclusion If empirical data reinforce what many suspect, intermediaries have the potential to enhance KMb through a unique ability to span and connect the many balkanized organizations, departments and stakeholder groups that comprise our education system. Despite the many challenges associated with the work of intermediaries spanning diverse contexts, the potential benefits of research mediation in improving public services should not be underestimated. Professionals in both research-producing and research-using contexts might not have the dedicated time necessary to undertake KMb initiatives in addition to their other professional responsibilities without support, even if there is considerable desire and organizational readiness to do so. In these cases, the dedicated resources and specialized knowledge about research brokering that an intermediary provides might be an asset to implementation of KMb efforts. --- Notes 1 Some have interrogated this element of the framework, stating that the most effective intermediaries are often advocacy groups and those with partisan missions. I owe this point to Judy Sebba, a well-known scholar from the UK. 2 The principal investigator is not bilingual and, hence, did not have the proficiency to conduct analysis in French Dr. Amanda Cooper, Assistant

This paper explores the increasingly prominent role of research brokering organizations (RBOs) in strengthening connections between education research, policy and practice across Canada. This paper is organized in three sections. First, it provides a literature review of research mediation-exploring terminology, models and empirical work (albeit sparse) across health, business, education sectors. The second section provides three conceptual contributions to the field: RBOs' roles in knowledge mobilization occurring in the white space of broader public service systems, a typology of Canadian RBOs that exist in education using four broad categories: governmental, not-for-profit, for-profit and membership RBOs, and a knowledge brokering framework along seven dimensions: mission, resources, staff roles, political affiliation, autonomy, message and linkages. The third section provides empirical data about the frequency and types of RBOs that exist across Canada.

Introduction As life expectancy increases and population fertility rates decline, populations are aging at an accelerating rate globally [1]. The aging of the population is the inevitable result of demographic transition and an important issue facing human society in the 21st century [2]. Aging can be defined as a dynamic process where the proportion of the elderly population increases within the total population due to a decrease in the number of young people and an increase in the number of elderly people. According to international consensus, when the elderly population over 60 years old accounts for 10% of the total population in a country or region, or the elderly population over 65 years old accounts for 7% of the total population, that country or region is considered an aging society. Referring to the World Population Prospects (2019 Revision) released by the United Nations, from 2000 to 2020, the proportion of the elderly population aged 60 and above increased from 9.9% to 13.5% [3]. Projections suggest that by 2035, the global aging process will continue to advance, and the proportion of people aged 60 and over in the total population will rise to 17.8%. By 2050, the world is predicted to enter a moderately aging society, with the proportion of elderly people aged 60 and overreaching 21.4%. The aging of the population has thus emerged as a major challenge for all countries worldwide. In this context, it is crucial to explore strategies for achieving sustainable economic development. In parallel with these demographic shifts, the rapid advancement of urbanization has been driving a significant change in the population's place of residence, from rural to urban areas. This rural depopulation is a global phenomenon, observed in regions like Australia, Japan, Europe, and North America [4]. As per United Nations data, about 56% of the world's population resided in urban areas by 2021, a proportion projected to reach 61% by 2031. Moreover, the latest State of the World's Cities 2022 report by UN-HABITAT predicts that the global urban population will swell by 2.2 billion by 2050, raising its share to 68% [5]. This population migration primarily involves the young and middle-aged labor force moving to cities and towns, resulting in accelerated aging of the rural population. This shift has triggered a series of issues. The aging of the rural population directly impacts agricultural production, primarily through a sharp decline in the labor force. This reduction leads to the abandonment of arable land and the downsizing of agriculture. Moreover, this rural aging phenomenon also contributes to the gradual "hollowing out" of villages, reflected in the long-term idleness of numerous rural houses and significant land wastage. In light of today's food security concerns and rural revitalization efforts, realizing efficient utilization of land resources becomes paramount. In China, we face the above problems as well. Like many other countries, China's reform and opening-up in the late 1970s sparked rapid urbanization and industrialization, resulting in a significant migration of rural populations to cities [6]. According to statistics, the rural population dwindled from 790 million to 560 million between 1978 and 2018 [7]. In stark contrast, the total area of homesteads ballooned by 14 million hectares from 1995 to 2014 [8]. As of 2018, China's idle rate for rural homesteads was at least 20% [9], while China is currently facing a contradiction between the red line of arable land and urban construction land expansion. According to the third national land survey, the total area of national construction land increased by 85,333.3 square kilometers compared to the second survey, marking a growth rate of 26.5%. Concurrently, the cultivated land area decreased by 75,333.3 square kilometers. China's existing cultivated land spans 1.278 million square kilometers. If the decline continues at this pace, it is projected that within 10 years the area may fall below the set red line of 1.2 million square kilometers, potentially jeopardizing the food security of 1.4 billion Chinese people. In response to this situation, the "Rural Revitalization Strategic Plan (2018-2022)" was formulated and implemented by the central government of China. Meanwhile, the plan has emphasized the need to guide rural collective economic organizations to unleash the potential of collective land and other resources and assets. Thus, the urgent need to revitalize rural idle homesteads and promote intensive and efficient use of rural land resources is evident. Given this situation, strategies for revitalizing rural homestead resources and unveiling their asset value have become an important facet of China's rural land system reform. To tackle the above issues, the Chinese central government has rolled out a series of policies aimed at cautiously advancing the reform of the rural homestead system. In 2015, the central government approved 15 counties and cities as pilot sites for this reform, with a focus on exploring mechanisms for voluntary homestead withdrawal with compensation. By 2020, the number of pilot sites had been expanded to 104 counties and cities and three prefecture-level cities. The No. 1 document issued by the Central Government from 2017 to 2023 addresses rural homestead reform and encourages farmers to voluntarily withdraw from the homestead with compensation according to law. Nevertheless, farmers are often reluctant to leave their homesteads, mainly due to worries about the cost of living upon relocating to the city [10]. This reluctance is particularly pronounced in the context of increasing rural aging, as the burden of supporting the elderly has become a significant factor impeding farmers' withdrawal with compensation from their homesteads [11]. According to the seventh national census data, the proportion of elderly individuals aged 60 and over in rural areas is 23.81%, which is 7.99 percentage points higher than in cities and towns [12]. Compared to a 4.3 percentage point gap in 2015, this difference has grown significantly. As an important security asset of farmers' families, withdrawal with compensation from the homestead not only involves the property income of farmers, but also is closely related to the old-age security of farmers' families. The potential impact of rural aging on homestead withdrawal with compensation cannot be overlooked, but current compensation policies seem to pay scant attention to the old-age security of farmers [13]. Therefore, in the face of the practical problems of the increasing aging of the rural population, it is necessary to explore the relationship between the aging of the population and the willingness to withdraw from the homestead and their compensation preference. Research on population aging originated from the United Kingdom, France, and other leading industrialized countries in Western Europe [14]. As the problem of global population aging becomes increasingly prominent, the related research on aging has been continuously expanded and deepened. Typically, the research mainly involves the impact of population aging on social and economic development [15][16][17], the impact of population aging on medicine [18][19][20], the impact of population aging on the construction of social security systems for the elderly [21][22][23], and research on the evolution trend of population aging [24][25][26][27]. In addition, some Chinese scholars have analyzed the impact of population aging on agricultural production [1,28,29]. The vast majority of foreign countries have adopted private ownership of land, thereby focusing foreign scholars' research on aspects such as farmland conversion and rural land transfer [30][31][32][33]. However, the concept of the rural homestead holds a unique place within the Chinese background. In China, a rural homestead refers to land that is owned by the rural collective, but where individual Chinese citizens hold the right to build houses, by law. The academic community has shown an increasing interest in the complex issue of rural homesteads in China recently. Currently, scholars have conducted extensive theoretical and empirical studies on the matter of homesteads. These studies span a wide range of methodologies and topics. For example, Lu Xiao et al. employed CiteSpace and VOSviewer to perform a visual analysis and mapping of articles in homestead-related fields [34], while Bao et al. utilized the case analysis method to delve into examples of local homestead reform [35]. Su et al. focused on the functional evolution and dynamic mechanism of homesteads, using the comprehensive index model evaluation method [36]. Furthermore, binary logistic models [37,38], structural equation models [39][40][41], and mediating effect models [42,43] are among the most common methodologies that scholars employ to explore farmers' willingness and behavior regarding withdrawing from rural homesteads from various angles. In terms of content, homestead withdrawal is a hot topic in current research. This topic encompasses several sub-areas, primarily including practical exploration [44], mechanism construction [45], and the behavioral intention associated with compensation for rural homestead withdrawals. Notably, among these, the research focusing on farmers' willingness to withdraw from their homesteads is the most extensive. Some scholars have identified the fact that farmers' personal characteristics or family characteristics significantly influence their willingness to withdraw from the homestead with compensation, through field research [46][47][48]. Some scholars also found that ownership consciousness [49] and risk expectation [50] also had an impact on their willingness to withdraw from the homestead with compensation. These explorations have underscored that a farmer's decision to withdraw from the homestead with compensation is not solely dictated by objective individual conditions, but also significantly influenced by subjective factors such as individual cognition. Despite the fact that there are large extensive studies, a significant portion has overlooked the reality of the intensifying issue of rural population aging in China. Only Sun et al. investigated the effects of this demographic shift on the farmers' behavior regarding the withdrawal with compensation from homesteads [51]. Their findings suggested that the larger the proportion of family members over 60 years old, the stronger the inclination to retain homesteads. Indeed, the interplay between factors such as farmer differentiation [52], their property rights cognition [53], and their willingness to withdraw from the homestead with compensation comprises a complex mechanism. The farmers' value cognition of their homestead and local attachment serve as intermediary factors, while intergenerational differences play a regulatory role [54,55]. Previous studies have established that age differ-entiation can result in variations in individual behavior and cognition and that the farmers' value cognition of the homestead significantly impacts their willingness to withdraw with compensation [54]. Despite these findings, no research has yet explored the relationship between these three factors. Researchers such as Wang et al., Chen Ming, and Gong et al. have systematically studied how farmers' heterogeneity impacts their preferences for homestead withdrawal compensation [56][57][58]. Their findings indicate that the heterogeneous characteristics of farmers' family income differentiation, regional living differences, and urban housing ownership can influence these preferences. Additionally, some scholars have quantitatively analyzed the impact of homestead withdrawal compensation methods and standards from the perspective of farmers' interaction [59], and farmers' functional cognition [60]. However, few studies have focused on the relationship between the aging of rural families and farmers' homestead withdrawal compensation preferences. Considering the existing gaps in research, this paper integrates the aging of the rural family population, farmers' value cognition of homesteads, the willingness for homestead withdrawal with compensation, and the compensation preference for homestead withdrawal into a unified analytical framework. Relying on the survey data from 403 rural families in Shenyang, Liaoning Province, China, this study utilizes the binary Logit model and the mediating effect model, based on the theory of neoclassical economics and the theory of cognitive psychology, to empirically analyze the influence and mechanism of rural family aging on the willingness and compensation preference for homestead withdrawal with compensation. Furthermore, this paper explores the role of homestead value cognition throughout this process. This investigation aims to offer a reference for the formulation of homestead withdrawal policies against the backdrop of rural population aging. Meanwhile, China's experiences with land system reform can provide valuable lessons for other countries, particularly those in the developing world. The remainder of this paper is structured as follows. Section 2 presents the theoretical analysis and research hypotheses. Section 3 introduces the data sources, variable selection, and model design. Section 4 presents and analyzes the empirical results. Section 5 describes the discussion. Section 6 gives the conclusions. --- Theoretical Analysis and Research Hypothesis --- Characterization of Age Differentiation In previous studies, scholars have commonly employed a variety of indicators such as the aging rate, the dependency ratio of the elderly population, the proportion of the child population, and the average age to measure the degree of family aging. Among them, the aging rate is the most commonly used indicator to measure the degree of population aging [61]. In this paper, we adopt the population aging rate of families to measure the degree of population aging within families. Defined as the proportion of the elderly population aged 60 and above in the total population of families, the population aging rate of families effectively illustrates family aging. Therefore, the larger the proportion of the elderly population, the greater the degree of family aging, and vice versa. --- The Direct Impact of Family Population Aging on Farmers' Willingness to Withdraw from the Homestead with Compensation and Compensation Preference The essence of farmers' withdrawal from the homestead is the disposal of homestead assets. According to the theory of neoclassical economics, farmers, acting as "rational economic man", withdraw from their homesteads with compensation primarily to pursue the maximization of economic interests. Only when the risk associated with withdrawal from the homestead falls within the farmers' tolerance, and the benefits derived from the withdrawal outweigh the associated costs, will farmers choose to withdraw from the homestead [62]. This paper constructs a theoretical analysis framework, as depicted in Figure 1. This paper posits that rural families with a high degree of population aging have less of a competitive edge in urban employment. These families often rely on their homesteads to provide a self-sufficient lifestyle, with their existence and productivity largely dependent on agriculture, which effectively minimizes living costs. Farmers' daily living expenses tend to surge when they surrender their homesteads. The compensation offered by the government in exchange for relinquishing the homesteads fails to offset the farmers' long-term livelihood costs. As a result, the benefits derived from surrendering the homesteads are outweighed by the costs incurred, which makes these highly aged rural families more reliant on their homesteads and prone to retain them. In contrast, rural families experiencing a relatively lower degree of population aging tend to carry a smaller family pension burden. Members of these families typically reside in urban areas and towns, exhibiting a lower dependence on their homesteads and incurring fewer costs upon their withdrawal. Simultaneously, the opportunity to monetize their assets through paid withdrawal from homesteads presents itself. The compensation helps alleviate some pressures of urban living for these farmers to a certain extent. The benefits of homestead withdrawal outweigh the costs, leading these families to opt out of their homesteads. The issue of family pensions remains a crucial factor influencing farmers' choice to withdraw and the type of compensation they choose. Farmers with varying degrees of population aging exhibit different sensitivities toward compensation methods. Farmers experiencing a higher degree of population aging bear the significant burden of providing for the aged. Their desire for stability inclines them towards non-monetary compensations such as housing or social security, which offer basic living security. Thus, they tend to favor non-monetary compensation methods. However, families with a relatively lower degree of population aging often have stable residences in cities and towns, and carry a smaller burden of family pensions. Therefore, they tend to opt for monetary compensation methods, which can provide capital for their multiple future choices. This analysis leads us to our hypotheses: H1: The aging of the family population inhibits the willingness of farmers to withdraw from the homestead with compensation. --- H2: The aging of the family population promotes farmers to choose non-monetary compensation methods. The concept of farmers' homestead value cognition is established upon the elucidation of perceived value as observed in the marketing field. Perceived value, as understood from an individual's perspective, enables the customer to assess the value of a The concept of farmers' homestead value cognition is established upon the elucidation of perceived value as observed in the marketing field. Perceived value, as understood from an individual's perspective, enables the customer to assess the value of a product according to their understanding of the product's functionality, quality, economy, etc. [63]. When speaking about farmers' value cognition of homesteads, it predominantly refers to the farmers' holistic evaluation of the multi-functional aspects of a homestead. Reflecting on the current scenario, offering residential and retirement facilities appears to be the most critical function of rural homesteads. Nonetheless, as urbanization rapidly progresses, the function of homestead assets has become increasingly pronounced. There is an observable variance in behavioral cognition among individuals of different ages [54]. This paper creates an analytical framework, as depicted in Figure 2. Families in areas with a pronounced aging population often have a strong demand for homestead security due to their adherence to rural life and lower living costs. As a result, these families possess a deep understanding of the security value of homesteads. When considering asset value cognition, because the realization and security functions of asset functions such as homestead renting, buying, and selling cannot coexist, families with a highly aging population have a weak cognition of this value. For families with a less aged population, a majority of the members gradually transition to urban areas due to reasons such as work and the living environment. Depending primarily on non-agricultural labor in cities for income, they no longer rely on homesteads for survival. This situation leads to a shallow comprehension of the security value of homesteads, shifting their focus towards the value of homestead assets. Therefore, the impact of an aging rural family population on the cognition of homestead value is reflected in the fact that families with a more substantial aging population have a deeper understanding of homestead security functions and a lesser grasp of homestead asset functions. In other words, the aging of the family population positively impacts the cognition of homestead security value and negatively affects the recognition of homestead asset value. --- Impact of Homestead Value Cognition on Farmers' Willingness to Withdraw from the Homestead with Compensation Cognitive psychology theory underscores that cognition is fundamental to intention and behavior, with individuals' cognition shaping their preferences and thus influencing their decision-making. Consequently, farmers' value cognition of homesteads is bound to exert a certain degree of influence on their willingness to withdraw from the homestead with compensation [54]. As farmers age, their economic expenditure patterns and risk tolerance fluctuate, leading to variations in the cognition of homestead security value and asset value at different ages. The security value of a homestead is demonstrated --- Impact of Homestead Value Cognition on Farmers' Willingness to Withdraw from the Homestead with Compensation Cognitive psychology theory underscores that cognition is fundamental to intention and behavior, with individuals' cognition shaping their preferences and thus influencing their decision-making. Consequently, farmers' value cognition of homesteads is bound to exert a certain degree of influence on their willingness to withdraw from the homestead with compensation [54]. As farmers age, their economic expenditure patterns and risk tolerance fluctuate, leading to variations in the cognition of homestead security value and asset value at different ages. The security value of a homestead is demonstrated in its ability to provide basic living conditions for farmers and to effectively lower living expenses. Hence, the deeper a farmer's understanding of the security value of homesteads is, the more likely they are to retain them. On the other hand, the asset value of a homestead is displayed through the potential for descendants to inherit and gain benefits via leasing, selling, or collecting from homesteads. Voluntarily withdrawal from homesteads with compensation is one of the significant methods of realizing this asset value. Therefore, the deeper the farmers' cognition of the value of homestead assets, the more inclined to withdraw from the homestead with compensation. This analysis leads us to our hypotheses: H3: The cognition of homestead security value has a negative mediating effect with regard to family population aging affecting farmers' willingness to withdraw from the homestead with compensation. --- H4: The cognition of homestead asset value has a negative mediating effect with regard to family population aging affecting farmers' willingness to withdraw from the homestead with compensation. --- The Impact of Homestead Value Cognition on Farmers' Homestead Withdrawal Compensation Preference Individual cognition determines one's preference, and farmers' cognition of homestead value is bound to influence their preference for homestead withdrawal compensation. As a "rational economic man", when farmers choose to withdraw from the homestead, they will choose the compensation method to maximize their interests. The deeper the farmers' cognition of the value of homestead security, the more they pay attention to the basic living conditions that the homestead can provide. The increase in living costs caused by the withdrawal from the homestead will make them tend to choose non-monetary compensation methods such as replacing it with urban housing that can provide more basic living security. The deeper the farmers' cognition of the value of the homestead assets, the more they pay attention to the economic value that the homestead can provide. The economic advantages brought by withdrawal from the homestead can provide strong support for improving the quality of urban life and job selection. Therefore, they tend to choose a more flexible distribution of monetized compensation methods such as one-time capital compensation. This analysis leads us to our hypotheses: H5: The cognition of homestead security value has a positive mediating effect with regard to family population aging affecting farmers' homestead withdrawal compensation preference. --- H6: The cognition of homestead asset value has a negative mediating effect with regard to family population aging affecting farmers' homestead withdrawal compensation preference. --- Data Sources, Variable Selection, and Model Design --- Data Sources and Sample Description --- Data Sources Population aging is an undeniable trend in China. Notably, the northeast region is grappling with the country's most severe population aging challenges. Data from the seventh national census reveal that the aging rate of Liaoning Province tops the nation at 25.72%, marking it as the province with the most pronounced population aging. A combination of low birth rates and high net migration rates primarily drives the aging issues in the three provinces of Northeast China. A declining economy, widening of regional differences in urbanization level, aggravation of the contradiction between urban and rural areas, and continuous negative growth of population render the rural development of the three provinces of Northeast China volatile [64]. As the capital of Liaoning Province and the largest central city in Northeast China, Shenyang demonstrates outstanding political, economic, and cultural-center functions. This prominence generates a powerful radiative effect and drive, luring the rural population to migrate to urban areas, and leading to a widespread idleness of surrounding rural homesteads. Shenyang (41.20 • <unk>43.04 • N, 122.42 • <unk>123.81 • E) is located in the south of Northeast China and the central part of Liaoning Province, which is the center of the Northeast Asian economic circle and the Bohai economic circle (Figure 3). Shenyang spans a total area of 12,860 square kilometers and encompasses 13 county (district) level administrative regions, including 10 municipal districts, one county-level city, and two counties. By the end of 2020, Shenyang housed a permanent population of 9.073 million, consisting of 7.668 million urban dwellers and 1.405 million rural residents, resulting in an urbanization rate of 84.51%. Approximately 600,000 rural homesteads exist within the city, spanning an area of about 568.7 square kilometers. On average, each homestead covers an area of about 836.7 square meters. Roughly 21,000 homesteads remain idle, occupying an area of about 18.2 square kilometers, yielding an idle homestead rate of 3.5%. In 2020, Shenyang was designated as one of the pilot areas for the new round of rural homestead system reform in the country, which has offered a vast number of samples in support of this research. The data of this study are derived from a sample survey of farmers in Shenyang conducted in July 2021. This research adopts a mixed approach of stratified sampling and simple random sampling to select sample farmers. Firstly, in adherence to the principle of far, middle, and near to the county, three streets were randomly selected at three levels. Secondly, following the principle of high, medium, and low homestead idle rates, each street randomly selected three villages within three tiers. Finally, 12 farmers from differing families were randomly chosen from each village. A total of 405 questionnaires were gathered from four districts, 13 streets, and 35 administrative villages. After eliminating the questionnaires with distorted or missing key information, 403 valid questionnaires were secured, boasting an effective rate of 99.51%. The farmer questionnaire survey primarily employed a method of a "oneto-one" interview between the farmer and the investigator. The main contents of the questionnaire encompass the farmers' family situations, their understanding of homestead value, subjective satisfaction, and so on. --- Sample Description According to the statistical results of the questionnaire, among the 403 surveyed farmers, farmers aged 60 and over accounted for 53.85%, indicating that the rural aging problem in the surveyed areas is serious. The proportion of the labor force in rural families generally exceeds 0.5, representing 86.35% of the total sample size. The ratio of part-time farmers reaches a substantial 99.26%. In the survey on the willingness of farmers to withdraw from the homestead with compensation, 309 families have indicated their willingness to withdraw from the homestead with compensation, accounting for 76.67% of the total sample. Among them, 164 families chose monetary compensation, accounting for 53.07% of the total number of farmers willing to withdraw from the --- Sample Description According to the statistical results of the questionnaire, among the 403 surveyed farmers, farmers aged 60 and over accounted for 53.85%, indicating that the rural aging problem in the surveyed areas is serious. The proportion of the labor force in rural families generally exceeds 0.5, representing 86.35% of the total sample size. The ratio of part-time farmers reaches a substantial 99.26%. In the survey on the willingness of farmers to withdraw from the homestead with compensation, 309 families have indicated their willingness to withdraw from the homestead with compensation, accounting for 76.67% of the total sample. Among them, 164 families chose monetary compensation, accounting for 53.07% of the total number of farmers willing to withdraw from the homestead with compensation, and 145 families chose non-monetary compensation, accounting for 46.93% of the total number of farmers willing to withdraw from the homestead with compensation. --- Variable Selection --- Explained Variables In this paper, farmers' willingness to withdraw from the homestead with compensation and compensation preferences are selected as explained variables. To gauge the farmers' willingness to withdraw from the homestead, we designed the questionnaire with the question, "Are you willing to withdraw from your homestead with compensation?" The responses were coded as binary dummy variables: value 1 for willingness to withdraw from their homesteads, and 0 for unwillingness. Similarly, we aimed to understand farmers' compensation preference for homestead withdrawal by posing the question, "Which withdrawal compensation method are you more inclined to choose?" If farmers lean towards monetary compensation, the response was coded as 1. For a non-monetary compensation preference, we assigned a value of 0. --- Core Explanatory Variable This paper selects the aging degree of the rural family population as the core explanatory variable. Referring to the relevant research, in the empirical study, the proportion of the elderly population in the total population, the average age, the elderly dependency ratio, and other indicators are generally used to measure the degree of aging. Based on the international definition of aging, this paper uses the family population aging rate to characterize the degree of family population aging. The family population aging rate refers to the proportion of the elderly population aged 60 and above in the family compared to the total family population. --- Mediator Variables This paper selects the value cognition of farmers' homesteads as the mediator variable, which is subdivided into the security value cognition and the asset value cognition. In the survey, farmers' judgments on the two survey questions of "the homestead can be used to live and reduce the cost of living" and "the homestead can be left as property to future generations" were used to refer to their corresponding homestead value cognition [54]. The index adopts a Likert five-point scale, where 1 means "extremely unimportant", 5 means "extremely important". The higher the score, the deeper the value cognition of farmers. --- Control Variables Considering other factors that may affect farmers' willingness to withdraw from the homestead with compensation and compensation preferences, this paper mainly selects control variables from three aspects: householder characteristics, family characteristics, and farmers' satisfaction: (1) Variables of householder characteristics including gender, age, and education level; (2) Family characteristic variables including the number of the non-agricultural labor force, the total non-agricultural income, the number of left-behind elderly, and the familiarity of the second generation of farmers with agricultural farming; (3) The satisfaction of farmers including their satisfaction with rural infrastructure, their satisfaction with the rural ecological environment and their satisfaction with the rural living consumption level. The descriptive statistical analysis results of the data with farmers' willingness to withdraw from the homestead with compensation and farmers' compensation preference as the explained variables are shown in Tables 1 and2. --- Variable Name Variable Meaning and Assignment Average --- Model Design --- Binary Logit Model The Logit model is also a "logistic regression", which is a commonly used method for empirical analysis. In this paper, the dependent variables of "farmers' willingness to withdraw from the homestead with compensation" and "which type of compensation is more favored" are assigned to 0 and 1, so the binary Logit model is selected for regression analysis. The model is defined as follows: Y i = c 0 + cX i + <unk> 2 Z i + e 1(1) In Formula (1), Y i represents the willingness to withdraw or compensation preference of the farmer's homestead; X i is the population aging rate of the family; Z i is the control variable; c 0 is a constant term; c and <unk> 2 are the parameters to be estimated, where the coefficient c is the total effect of the family population aging rate on the willingness to withdraw from the homestead with compensation or the preference for compensation; e 1 is a random error term. --- Mediating Effect Model To further investigate whether the population aging rate of families has an impact on the willingness to withdraw from the homestead with compensation and the compensation preference through the cognition of the value of the homestead, this paper adopts the mediation test procedure proposed by Wen et al. [65]. The mediation effect is examined based on the total effect of the family population aging rate on the farmer's willingness to withdraw with compensation and compensation preferences. The test process is shown in Figure 4, and the specific model is defined as follows: M i = a 0 + aX i + <unk>Z i + e 2(2) Y i = b 0 + c X i + bM i + <unk>Z i + e 3 (3 ) Land 2023, 12, x FOR PEER REVIEW 13 of 26 --- Model Design --- Binary Logit Model The Logit model is also a "logistic regression", which is a commonly used method for empirical analysis. In this paper, the dependent variables of "farmers' willingness to withdraw from the homestead with compensation" and "which type of compensation is more favored" are assigned to 0 and 1, so the binary Logit model is selected for regression analysis. The model is defined as follows: Y c cX <unk> Z e(1) In Formula (1), Y represents the willingness to withdraw or compensation preference of the farmer's homestead; X is the population aging rate of the family; Z is the control variable; c is a constant term; c and <unk> are the parameters to be estimated, where the coefficient c is the total effect of the family population aging rate on the willingness to withdraw from the homestead with compensation or the preference for compensation; e is a random error term. --- Mediating Effect Model To further investigate whether the population aging rate of families has an impact on the willingness to withdraw from the homestead with compensation and the compensation preference through the cognition of the value of the homestead, this paper adopts the mediation test procedure proposed by Wen et al. [65]. The mediation effect is examined based on the total effect of the family population aging rate on the farmer's willingness to withdraw with compensation and compensation preferences. The test process is shown in Figure 4, and the specific model is defined as follows: M a aX <unk>Z e(2) Y b c′X bM <unk>Z e In Formula (2), M i is the value cognition level of the farmer's homestead, and coefficient a is the effect of the aging rate of the family population on the value cognition of the farmers' homestead; in Formula (3), coefficient b is the effect of farmers' cognition of homestead value on the willingness or compensation preference of homestead paid withdrawal; the coefficient c' is the direct effect of the family population aging rate on the willingness to withdraw from the homestead with compensation or the preference for compensation; e 2 and e 3 are random errors. According to the mediating effect test process proposed by Wen et al. [65], the first test is whether the coefficient c in Formula (1) is significant; secondly, the significance of coefficients a and b in Formulas ( 2) and ( 3) is tested in turn, to judge whether the indirect effect ab is significant; finally, if the indirect effect is significant, the c' significant situation in Formula ( 3) is judged to be a complete mediating effect or a partial mediating effect. At the same time, it is necessary to compare the direction of ab and c' symbols. If ab and c' are the same, the results are explained by the mediating effect. If ab and c' are different, the results are explained by the masking effect. --- Empirical Results and Analysis Considering that there may be multicollinearity among multiple variables, the multicollinearity test is first performed on all explanatory variables. The results show that the VIF values of all explanatory variables are less than 10, and the Mean VIF is less than 2, indicating that there is no multicollinearity among the existing explanatory variables. Then, stata16.0 software is used to empirically test the mechanism of family population aging rate affecting farmers' willingness to withdraw from the homestead and compensation preference. The regression results of the model are shown in Tables 345. --- Total Effect Analysis The regression results are shown in Table 3. In Model 1, the aging rate of the family population has a significant positive impact on the willingness of farmers to withdraw from the homestead with compensation and the coefficient c 1 = 2.072. That is, the higher the level of family population aging rate, the more farmers are inclined to withdraw from the homestead with compensation, invalidating Hypothesis 1. The reason is that since the reform and opening-up, with the increasing advancement of China's urban and rural policies, the relationship between urban and rural areas has changed significantly, showing a trend from urban-rural division to gradual integration, and the economic links between urban and rural areas have become closer. Economic development has made most of the current rural farmers become part-time farmers. Family income has increased year by year, and farmers' requirements for quality of life have been increasing. At the same time, young family members tend to settle in cities and towns. The feeling of missing relatives and the inconvenience of leaving their children's lives lead to the desire of farmers to move to cities and towns to live with their children. The relatively sound infrastructure and developed medical level of the town make it convenient for farmers to provide for the aged while improving the quality of life and improving living conditions. The compensation obtained by withdrawing from the homestead can alleviate the pressure of family pensions to a certain extent. Changes in the external environment have changed the willingness of the elderly population to withdraw from

Population aging presents a significant global challenge. In China, the aging of the rural population coincides with inefficient rural homestead utilization. While the Chinese government has enacted policies to address this, their impact remains limited. Utilizing survey data from 403 rural families in Shenyang, Liaoning Province, China, this study applies the binary Logit and mediating effect models to analyze the impact of rural family population aging on farmers' willingness to withdraw from homesteads with compensation and their compensation preference. Key findings include: (1) Family population aging intensifies farmers' willingness to withdraw from homesteads, with a stronger preference for non-monetary compensation as aging increases. (2) Regarding the willingness to withdraw with compensation, farmers' cognition of homestead security value masks the effect by 4.71%, while asset value cognition has no mediating effect. ( 3) With regard to promoting non-monetary compensation choices, farmers' homestead asset value cognition fully mediates at 16.01%, but security value cognition is without mediating effect. Based on these findings, it is recommended that the government crafts tailored homestead withdrawal policies considering farmers' family age structure. Further, efforts should aim at refining farmers' understanding of homestead values, promoting a blend of non-monetary and monetary compensations.

. That is, the higher the level of family population aging rate, the more farmers are inclined to withdraw from the homestead with compensation, invalidating Hypothesis 1. The reason is that since the reform and opening-up, with the increasing advancement of China's urban and rural policies, the relationship between urban and rural areas has changed significantly, showing a trend from urban-rural division to gradual integration, and the economic links between urban and rural areas have become closer. Economic development has made most of the current rural farmers become part-time farmers. Family income has increased year by year, and farmers' requirements for quality of life have been increasing. At the same time, young family members tend to settle in cities and towns. The feeling of missing relatives and the inconvenience of leaving their children's lives lead to the desire of farmers to move to cities and towns to live with their children. The relatively sound infrastructure and developed medical level of the town make it convenient for farmers to provide for the aged while improving the quality of life and improving living conditions. The compensation obtained by withdrawing from the homestead can alleviate the pressure of family pensions to a certain extent. Changes in the external environment have changed the willingness of the elderly population to withdraw from the homestead with compensation. Therefore, the greater the proportion of the elderly population in the family, the more farmers are inclined to withdraw from the homestead with compensation. In Model 2, the aging rate of the family population has a significant negative impact on the compensation preference of farmers' homestead paid withdrawal and the coefficient c 2 = -0.897. That is, among farmers who have the willingness to withdraw from the homestead with compensation, the greater the aging of the family population, the more farmers tend to choose non-monetary compensation, and Hypothesis 2 is verified. The results of this study confirm the previous theoretical analysis that long-term and stable housing security is more attractive to the elderly population, and the "stability" mentality makes it more sensitive to non-monetary compensation methods such as housing or social security that can provide basic living security. Therefore, rural families with a large proportion of elderly members tend to choose non-monetary compensation methods. --- Mediating Effect Analysis --- The Mediating Effect of Homestead Value Cognition in the Aging of Family Population on Farmers' Willingness to Withdraw from the Homestead The regression results are shown in Table 4. In Model 3 the aging rate of the family population has a significant positive impact on the farmers' cognition of the value of homestead security and the coefficient a 1 = 0.372. That is, the higher the aging rate of the family population, the deeper the cognition of the value of homestead security. In Model 5, the farmers' cognition of homestead security value has a significant negative impact on farmers' willingness to withdraw from the homestead and the coefficient b 1 = -0.275. That is, the deeper the cognition of farmers' security value, the weaker their willingness to withdraw from the homestead. The coefficients a 1 and b 1 are significant, indicating that the security value cognition plays a mediating role and Hypothesis 3 is verified. At the same time, the direct effect is significant and the coefficient c 1 = 2.170, but its symbol is opposite to a 1 b 1. Explaining the results according to the masking effect, the proportion of the effect is calculated to be 4.71%. The cognition of farmers' security value significantly reduces the willingness of farmers to withdraw from the homestead with regard to family population aging rate and willingness to withdraw. In Model 4, the impact of family population aging rate on farmers' cognition of homestead asset value is not significant and the coefficient a 2 = -0.224. In Model 6, the direct effect is significant and the coefficient c 2 = 2.086. The influence coefficient b 2 of asset value cognition on farmers' willingness to withdraw from the homestead is 0.077, which is not significant. In summary, it can be seen that Hypothesis 4 is not established, indicating that the aging rate of the family population does not affect the willingness of farmers to withdraw from their homesteads through their cognition of the value of homestead assets. --- The Mediating Effect of Homestead Value Cognition in the Aging of Family Population on Farmers' Homestead Withdrawal Compensation Preference The regression results are shown in Table 5. In Model 7, the aging rate of the family population has a significant positive impact on the value cognition of the farmers' homestead security and the coefficient a 3 = 0.433. That is, in the families with the willingness to withdraw from the homestead with compensation, the higher the level of the aging rate of the family population, the deeper the farmers' cognition of the value of homestead security. In Model 9, the direct effect is significant and the coefficient c 3 = -1.034, which indicates that the family population aging rate has a significant negative impact on the compensation preference of farmers' homestead withdrawal. That is, in the families with the willingness to withdraw from the homestead with compensation, the higher the level of family population aging, the more farmers tend to choose the non-monetary compensation method. The influence of security value cognition on the compensation preference of farmers' homestead withdrawal is not significant and the coefficient b 3 = 0.242. The influence coefficient a 3 is significant and b 3 is not significant. According to the mediating effect test process provided by Wen et al. [65], a Bootstrap method is needed to test a 3 b 3. The indirect effect is not significant, that is, the cognition of security value does not play a mediating role, indicating that the aging of the family population does not affect the compensation preference of homestead withdrawal through the cognition of farmers' security value, and Hypothesis 5 is not established. In Model 8,the influence of the aging rate of the family population on the cognition of the value of farmers' homestead assets is significant and the coefficient a 4 = -0.433. This shows that the aging rate of the family population has a significant negative impact on the cognition of the value of farmers' homestead assets. That is, in the families with the willingness to withdraw from the homestead with compensation, the higher the aging level of the family population, the shallower the cognition of the value of farmers' homestead assets. In Model 10, the influence of asset value cognition on farmers' homestead withdrawal compensation preference is significant and the coefficient b 4 = 0.288. This shows that farmers' asset value cognition has a significant positive impact on farmers' homestead withdrawal compensation preference, that is, the deeper the farmers' asset value cognition is, the more likely they are to choose the monetary compensation method. The coefficients a 4 and b 4 are significant, indicating that asset value cognition plays a mediating role and Hypothesis 6 is verified. At the same time, the direct effect is not significant and the coefficient c 4 = -0.779. Therefore, the value cognition of farmers' homestead assets plays a complete mediating role in the influence of family population aging on the compensation preference of farmers' homestead exit. The mediating effect is calculated to be 16.01%. An aging family population enhances the willingness of farmers to choose non-monetary compensation by inhibiting the value cognition of farmers' assets. The results of this study also confirm the previous theoretical analysis, that is, rural households with a large proportion of elderly members have a heavy burden of old-age care, and old-age security is in the primary position. Therefore, the shallower the farmers' awareness of the value of homestead assets, the more inclined they are to choose non-monetary compensation methods that can provide basic living security. --- Robustness Test 4.3.1. Replace the Core Explanatory Variable With the advancement of medical standards, the average life expectancy has gradually increased, so the aging age limit will be further tightened. In this section, the proportion of the elderly population over 65 years old is used as the basis for the division of population aging, to verify the impact of family population aging on farmers' willingness to withdraw from the homestead and their compensation preferences. Based on this, Logit regression and mediating effect are used for regression analysis. The empirical results are as shown in Tables 678. The results are basically consistent with the results of the population aging model based on the standard statistic of 60 years old, indicating that the stability of the model results is good. --- Replacement Model Since the willingness to withdraw from the homestead with compensation and the compensation preference in this study are two-category variables, the core explanatory variable and control variables are kept unchanged, and the Logit model is replaced with the Probit model for regression analysis to further test the robustness of the model. According to the analysis, the regression results are consistent with the above results in terms of significance and coefficient symbol, which verifies the reliability of the above conclusions. In view of the limitation of space, it is not repeated here. --- Discussion --- Comparison with Existing Studies on Homesteads The aging of the population has become an inexorable trend in societal development. In the face of rapidly accelerating urbanization and the increasingly severe aging of the rural population, exploring how the aging of the family population affects farmers' willingness to withdraw from the homestead with compensation and their compensation preferences is crucial. Such an exploration will help the efficient use of homesteads and promote rural revitalization. This paper empirically analyzes the impact of rural family population aging on farmers' willingness to withdraw from the homestead with compensation and their preference for withdrawal compensation and the mechanism of homestead value cognition. Based on our test results, it was observed that aging in rural families significantly increased the farmers' willingness to withdraw from the homestead with compensation. Interestingly, this finding contradicts the results of research by Sun et al. [51]. We hypothesize that the possible reason for this discrepancy is that, with economic development and improvements in living standards, the elderly's attitude towards their homesteads has evolved. Older farmers often find it difficult to carry out high-intensity agricultural labor, so even the elderly with local support are gradually inclined to withdraw from the homestead and choose to live in cities or towns with a higher quality of life. In general, there is a complex mechanism linking the aging of the family population with farmers' willingness to withdraw from their homesteads. Understanding this mechanism requires a multifaceted approach that takes into account diverse influencing factors. In terms of compensation preference, we found that the greater the aging of the rural family population, the more inclined they are to opt for non-monetary compensation. This is similar to the findings of Wang et al. [56], who suggest that older farmers are more willing to accept resettlement as a form of compensation. Although we conducted separate studies on families and individuals, both of them reveal that the elderly and young people have different life needs and expectations, reflecting the significance of life security for the elderly population. With regard to mediating effect analysis, the method we used is consistent with that of Xie et al. [42]. Both studies employ the causal step method proposed by Baron and Kenny [66], which is effective for testing mediating effects. Unlike Shi et al. [6], who concentrates on the direct impact of farmers' policy cognition on their willingness to withdraw from homesteads, we integrate cognitive psychology theory into our mediating effect analysis. This allows us to reveal both the role of farmers' value cognition of homesteads as a mediator and the underlying psychological mechanisms affecting their withdrawal willingness and compensation preferences. It can be seen that farmers' cognition of homestead value will have a certain degree of influence on their willingness to withdraw from the homestead with compensation and compensation preference, which will provide important enlightenment for the formulation of homestead withdrawal policy. --- Policy Recommendations Based on the research findings, considering the increasingly aging rural population, this paper proposes the following policy recommendations to enhance farmers' willingness to withdraw from the homestead with compensation: (1) Differentiated compensation policies for homesteads should be devised, aligning with the age structure of farmers' families. A key aspect of this should be developing and improving the social old-age security system for families that withdraw from their homesteads. Having a well-structured security system is crucial to encouraging farmers' compensated homestead withdrawal. Policies must prioritize farmers' interests, ensuring basic security for their housing and economic conditions. It is crucial to acknowledge that highly aged rural families pay greater attention to the security value of homesteads. Thus, public service systems like pensions and healthcare should be further enhanced, improving the quality of life and retirement benefits of the elderly. The provision of diverse employment conditions for farmers withdrawing from homesteads should be promoted to stimulate their employment and income, reducing their pension burdens. The legitimate land rights of urban-settled farmers should be protected, encouraging lawful, voluntary homestead transfers. At present, the majority of Chinese farmers do not have a high-level social security system. Therefore, the current rural homestead reform should not be hasty. (2) Circulation of information resources should be strengthened to guide farmers towards reasonable cognition of homestead value. Relevant departments should routinely organize village officials to explain homestead withdrawal policies to farmers and use the Internet to publicize successful homestead withdrawal cases, helping farmers make more rational decisions. Additionally, establishing and perfecting the mechanisms and systems of compensated homestead withdrawal is a significant prerequisite for promoting such withdrawals. Hence, the government should formulate a stable and legally effective mechanism for compensated homestead withdrawal, standardize transparency in farmers' participation in the withdrawal process, and prevent conflicts of interest and withdrawal concerns due to policy changes, thereby enhancing the efficiency of compensated homestead withdrawal. (3) In designing the homestead withdrawal compensation scheme, the combination of non-monetary and monetary compensations should be considered, catering to farmers' diverse needs. The diversity and complexity of different farmers' homesteads and variations in family economic conditions should be recognized. Compensation methods and standards that meet the actual needs of heterogeneous farmers should be established. Throughout the compensated homestead withdrawal process, farmers' interests should be effectively protected, solving the living needs and development needs of farmers after they withdraw from the homestead, and ensuring housing, livelihood sources, and old-age security for those who withdraw from their homesteads. --- Research Contributions and Limitations Under the background of population aging, this paper delves into the impact of family population aging on farmers' willingness to withdraw from the homestead with compensation and their compensation preference. This paper extends the existing research on the withdrawal with compensation of farmers' homesteads and introduces a novel perspective on compensation related to farmers' homestead withdrawal. Additionally, it enriches the literature in the field of population aging. While offering valuable insights to the academic realm, it serves as a crucial reference in motivating farmers to withdraw from their homesteads, aiding the development of rural revitalization policies, and crafting a social security system tailored for the elderly. A detailed exploration of the various modes and preferences concerning withdrawal compensation reflects the real needs and expectations of farmers in the face of aging challenges, which helps to ensure that policies and measures are more practical and humane. Internationally, in the context of an aging population around the world, this paper not only provides a reference for China, but also provides unique insights and experiences for other developing countries or countries with similar situations. However, it is worth pointing that our sample is mainly from Shenyang City, Liaoning Province, China, which means that the sample area is relatively single. In the future, with the gradual deepening of the reform of China's homestead system, the team will further expand the research scope and sample size, consider incorporating samples from other regions of China to test the results of this study, and analyze the regional differences in farmers' willingness to withdraw from rural homesteads. Simultaneously, the team will investigate other factors that might influence the connection between population aging and farmers' willingness to withdraw from homesteads, delving deeper into the underlying dynamics between them. --- Conclusions Based on the survey data of 403 rural families in Shenyang, Liaoning Province, China, this paper employs the binary Logit model and the mediating effect model to empirically analyze the impact and mechanism of rural family aging on farmers' willingness to withdraw from the homestead with compensation, and their compensation preference. The study's findings are as follows: (1) The aging of the family population significantly increases farmers' willingness to withdraw from the homestead with compensation. Furthermore, the greater the family population's aging, the more inclined farmers are to opt for non-monetary compensation methods. (2) With regard to family population aging to promoting withdrawal willingness from the homestead with compensation, farmers' cognition of the security value of the homestead presents a masking effect of 4.71%. This effect indirectly suppresses farmers' willingness to withdraw from the homestead with compensation, whereas the farmers' cognition of the asset value of the homestead does not have a mediating effect. (3) With regard to family population aging towards promoting farmers' non-monetary compensation choices for the homestead, farmers' cognition of the value of homestead assets plays a fully mediating role with a magnitude of 16.01%. This significantly boosts farmers' inclination to choose non-monetary compensation, yet there is no mediating effect on the farmers' cognition of the homestead's security value. According to the characteristics of different farmer groups, measures such as cultivating farmers' reasonable cognition of the value of the homestead and formulating differentiated compensation policies for homestead withdrawal can be taken to enhance farmers' willingness to withdraw from the homestead. --- Data Availability Statement: Not applicable. --- Conflicts of Interest: The authors declare no conflict of interest.

Population aging presents a significant global challenge. In China, the aging of the rural population coincides with inefficient rural homestead utilization. While the Chinese government has enacted policies to address this, their impact remains limited. Utilizing survey data from 403 rural families in Shenyang, Liaoning Province, China, this study applies the binary Logit and mediating effect models to analyze the impact of rural family population aging on farmers' willingness to withdraw from homesteads with compensation and their compensation preference. Key findings include: (1) Family population aging intensifies farmers' willingness to withdraw from homesteads, with a stronger preference for non-monetary compensation as aging increases. (2) Regarding the willingness to withdraw with compensation, farmers' cognition of homestead security value masks the effect by 4.71%, while asset value cognition has no mediating effect. ( 3) With regard to promoting non-monetary compensation choices, farmers' homestead asset value cognition fully mediates at 16.01%, but security value cognition is without mediating effect. Based on these findings, it is recommended that the government crafts tailored homestead withdrawal policies considering farmers' family age structure. Further, efforts should aim at refining farmers' understanding of homestead values, promoting a blend of non-monetary and monetary compensations.

Background In 2017 there were approximately 1.24 billion adolescents in the world, which represents 16% of the total global population [1]. Half of the global population of adolescents are categorized as very young adolescents, defined as those aged 10-14 years of age [2]. Intervention programming and research on adolescents has often focused on a wide range of ages and developmental stages of adolescence (10-19 years of age), with less focus on very young adolescents (VYAs) ages 10 to 14 years [3][4][5]. As a result, the unique developmental needs of very young adolescents tend to be overlooked [6,7]. Research on very young adolescents have found that the first few years of adolescence, marked by the onset of puberty, are characterized by a period of rapid growth, adaptation, reproductive maturation and expanded cognitive processes [8][9][10]. Adolescent brains experience rapid growth and reorganization of neural circuitry that shape individual experiences and processing of those experiences [11]. Findings from adolescent developmental science indicate that neural responses to rewards, particularly social rewards, motivate adolescent social behaviors and emotional processing of social experiences [12]. Very young adolescents are particularly sensitive to social emotional learning experiences. This sensitivity results from a unique combination of stability and plasticity in developing neural networks of an adolescent brain and motivates adolescents to engage in highly salient social emotional learning experiences [13]. Further, research findings on adolescent social emotional programming suggests that learning experiences that are most salient to adolescents are those that include messages that harness adolescents' deepest motives-their desire to attain respect and status in the eyes of peers or adults whose opinions they value [13]. Social emotional learning experiences shape how adolescents build their individual identities, establish behaviors, gain social knowledge and make sense of their relationships, and shape their values and beliefs [8]. During the developmental window of early adolescence, adolescents often experience heightened expectations to adhere to socially constructed norms, roles, traits, behavior, status and power that are associated with gender [14]. Gender socialization differs across cultural contexts, and are derived from collective social expectations of appropriate behaviors [15]. Harmful gender norms can drive gender inequities in the short and long-term and impact health and well-being. Globally, studies have reported that girls often face discrimination that restricts their choices, opportunities, voice, and, agency [14,[16][17][18]. While it is recognized that restrictive gender norms play a greater role in shaping adolescent developmental trajectories in mid to late adolescence, in many contexts, early adolescence signaled by the onset of puberty heralds a time when girls' behaviors are increasingly constrained to traditional social roles. For example, girls are often assigned domestic work in the home, lose freedom of mobility outside the house, may withdraw from school, experience greater control over female sexuality or experience coercion to enter early marriage [2,19]. In contrast boys are more likely to be excused from domestic chores, granted more freedom outside the home, encouraged to study, to take on leadership positions and to engage in income-generating activities [19]. Harmful gender norms impact adolescents learning and experiences and research indicates that in comparison to boys, girls are more likely to have less education, enter early marriage, experience unwanted pregnancy, and are at increased risk for gender based violence [19]. Studies report that for boys, harmful gender norms can increase risk of perpetuating physical violence, substance use, HIV/AIDs and other sexuallytransmitted diseases, and mental health disorders [20][21][22]. A study conducted with very young adolescents in Tanzania found that cultural norms around gender often result in separation of boys and girls during and after puberty, and are associated with a divergence in experiences at school, in the home and in the community [23]. In Tanzania, restrictive gender norms often result in girls being given a disproportionate share of household chores with less opportunity for mobility outside of the home or to pursue interests [7,19]. A cultural prototype of a chaste female child is highly valued in Tanzania [24,25]. At the same time, girls in Tanzania are at risk for sexual exploitation and transactional sex for financial gain makes girls especially vulnerable to gender-based violence, unwanted pregnancy and early marriage [26,27]. Gender disparities in primary learning outcomes are larger in Tanzania than elsewhere in the region. Girls have lower passing rates on the primary school examination that allows entry to secondary education than boys [28]. Only a third of children that start primary school enroll in secondary school with approximately 21% of boys joining secondary schools compared to 16% of girls [29]. According to Tanzania's Demographic Health Survey (2015-2016) adolescent girls that are out of school are five times more likely to have children, with 27% of adolescents ages 15-19 already pregnant with their first child [30]. In Tanzania, schools may force girls to undergo pregnancy tests and can expel girls who are found to be pregnant or who have given birth [28,31]. Many schools in Tanzania are mixed-gender schools. However, schools often segregate classroom seating by gender with girls on one wide of the classroom and boys on the other which limits opportunities to learn in mixed-gender groups. Schools often include time for sports and while some games tend to be segregated by gender, some activities do allow mixed gender play and provide a positive opportunity for mixed-gender teamwork and social cooperation-an experiential opportunity to support positive gender norms and behaviors [28]. In Tanzania, social norms that drive separation of girls and boys in academic contexts, play and social activities intensifies after sexual maturation. Therefore, mixed gender activities for very young adolescents, prior to sexual maturation, represents a unique socially acceptable opportunity to encourage mixed-gender social emotional learning. Researchers and development partners are increasingly attuned to the potential for investments in programs for very young adolescents to shape developmental trajectories in health and well-being. Programs that include gender transformative content for VYAs can be an important strategy to reduce health and well-being disparities between girls and boys in both the near and longterm [13]. One recent study conducted in India to assess the relative effect of intervening in early compared with late adolescence found that younger boys ages 13-14 years showed greater improvement in gender practices and attitudes compared to older boys ages 15-19 [32,33]. Evidence suggests that programs that target very young adolescents can have sustaining impacts such as decreasing the spread of HIV/AIDS [34], delaying sexual debut [35], unwanted pregnancies [36], and improving a variety of health and well-being outcomes [37]. Adolescent programs that target and are tailored to very young adolescents may be particularly effective at reducing gender disparities in health and well-being. The developmental science of adolescence can enhance intervention approaches for adolescents by matching program design and content to impactful window of opportunity in adolescent developmental trajectories. Program design can leverage findings from developmental science on the ways that rapid physical, social, emotional and cognitive changes develop in concert with changes in social roles, responsibilities and relationships to shape development. The developmental science of adolescence supports the critical importance of social emotional learning during early adolescence as adolescents seek and experiment with different roles, belief systems and behaviors [38]. Developmental science also underscores the critical importance of peers, parents and trusting relationships to reinforce social emotional learning. Effective intervention designs should be tailored to the social, cultural, economic, political and historical context to identify unique challenges and opportunities to amplify the impact of very young adolescent programs [9]. To evaluate the efficacy of developmental science informed adolescent programming to support gender equity, more qualitative research is required to identify intervention components and content that are most salient and have the greatest impact on very young adolescents. The qualitative study reported in this article is part of the Discover Learning Intervention (Discover) that was launched in 2016 with the primary goal of testing a social emotional learning intervention that leverages findings from developmental science to promote gender equity among very young adolescents in the lowresource context of Tanzania. Since its inception, Discover has embraced a highly experimental and adaptive approach where each round of intervention was designed to leverage successes and mitigate challenges of the previous intervention implementation. Discover has embraced bold ideas, tested use of technology in resource-poor communities, and engaged peer, family, school, community and policy stakeholders. Of particular importance to Discover was the unique opportunity to support gender equity and transform gender norms, beliefs and behaviors. Discover targeted very young adolescents, ages 10 to 11, to leverage the sensitive maturational period before the onset of puberty. The intervention was designed to provide content on social emotional mindsets and skills woven together with gender transformative content and paired with experiential social emotional learning opportunities to actively practice learning in small, mixed gender groups. This article describes the qualitative methods and results from the implementation of Discover Learning, a six-week, after-school intervention designed to introduce positive, social emotional, experiential learning. The primary aim of Discover is to evaluate the comparative effectiveness of a three-arm trial on social emotional mindsets and skills, and gender norms, beliefs and behaviors. A secondary aim of Discover is to identify intervention components with the greatest impact on outcomes. The third aim of Discover is to test the effectiveness of implementing the program in a low-resource setting to identify potential for reaching scale in Tanzania and to inform other programs for very young adolescents in low-resource contexts. This article seeks to evaluate the effect of Discover on gender norms, beliefs and behaviors and to identify the components of Discover that were most salient to participants and parents/caregivers. --- Methods --- Research design --- Overview of discover Five hundred seventy-nine very young adolescents (10-11-year-old) enrolled in Discover were introduced to seven adaptive social emotional mindsets and skills through viewing of Ubongo Kids video episodes on each of the social emotional mindsets and skills (Table 1). Ubongo Kids is a Tanzania-based organization that creates culturally relevant learning content for school-age children and adolescents across Africa. Ubongo Kids focuses on promoting social and behavioral change for children, adolescents and their parents/caregivers. This study curated existing animated videos from Ubongo Kids and co-created content on social emotional mindsets and skills. Prior to inclusion in the study, episodes were pilot tested on a group of 15 students between the age of 10-14 years, and reviewed by teachers, parents and representatives from the Ministry of Education in Tanzania. Study participants were randomly allocated to three intervention groups in order to determine what components of the intervention were most effective in achieving improved outcomes. At each school, an event was held where participants were invited to stand in lines outside their classrooms. A research assistant held a box with pencil sharpeners of three different colors inside. The box had a small hole large enough to fit a hand through but small enough that students could not see the pencil sharpeners. Each participant was invited to pick one sharpener at random. Participants were then assigned to Group A, B or C depending on whether they picked pink, yellow or blue pencil sharpeners respectively. A group was matched to a particular sharpener color at random. Group A participants received six sessions and watched Ubongo Kids videos on each of the seven social emotional mindsets and skills in large classrooms of up to 26 participants. Group B participants watched the Ubongo Kids videos and participated in reflective discussions in small mixed-gender groups. Within these small groups of 4-5 participants were provided with themed reflections cards to guide a group discussion. Group C received 18 sessions (3 sessions for 6 weeks) where participants watched Ubongo Kids videos paired with technology enabled experiential learning activities in small, mixed-gender groups of 4-5 participants. Each experiential learning session was facilitated by a trained young adult facilitator recruited from the local community. Facilitation principles were co-created with locally hired facilitators from the study setting [1,2]. The objective of the principles was to guide facilitators in scaffolding positive, gender transformative, social emotional learning experiences. The six facilitation principles included: (1) scaffolding learning to create safe exploratory space for learners, (2) emphasis on learning over education, (3) withholding judgment, (4) encouraging teamwork and positive group dynamics, (5) disrupting gender norms and (6) encouraging a growth mindset. Table 2 includes a detailed description of Discover's facilitation principles. Adolescents used tablets as an interactive tool to practice social emotional mindsets and skills in mixedgender groups. Tablet activities included collaborative games, mind-mapping, and creative expression. For example, one collaborative activity included using tablet drawing applications to create and design a traditional batik print and proverb that could be used to create a kanga, a traditional Tanzanian fabric worn in a variety of ways or displayed in homes and communities that holds important cultural significance in Tanzania and in other East African communities [39]. The tablet design of the kanga was used to create actual kanga textiles which were subsequently presented to parents/caregivers and community members during a celebratory community event. The event included study participants, parents/caregivers, teachers, education officials and other important community stakeholdersto showcase the youth-led project. This event was important for communicating to parents and the community what participants had learned from the study, and to reinforce positive social norms such as encouraging parents and the community to recognize the achievements of girls and boys working together as equals. In addition to the 18 sessions, Group C participants were provided with a youth-parent/caregiver workbook that included activities and reflective discussion prompts that were matched with each of the seven social emotional mindsets and skills. Figure 1 represents a summary of the intervention components for each group. --- Study setting This study was carried out in primary schools within the Temeke District of Dar es Salaam, Tanzania. Temeke is one of the city's five administrative districts and is comprised of a peri-urban population. The schools that were selected included Umoja Primary School, Sokoine Primary School, Twiga Primary School and Miburani Primary School. Each school met the inclusion criteria for Discover; 1) government-run public schools; 2) did not participate in a social-behavioral intervention of any type 12 months before the current study; and 3), had a socio-demographic profile that matched the general school population in Dar es Salaam. The average number of students enrolled in the study schools was 956 students. The average classroom size was 63 students and each school had an average teacher: pupil ratio of 1: 42. This study was conducted from July to November 2019. --- Sample A purposive sampling frame was used to select adolescent participants in Discover and their parents/caregivers for participation in a qualitative study to capture the insights and experiences from adolescents and their parents/caregivers with Discover and the impact on gender norms, beliefs and behaviors. --- Study procedures Research activities were completed by Health for a Prosperous Nation (HPON), a local nongovernmental health research organization in Tanzania. HPON worked in collaboration with researchers from the University of California Berkeley, and actively participated in the design, development, piloting and revision of all qualitative in-depth interview, focus group and participant observation guides. The team revised interview questions to ensure cultural relevance and comprehension by adolescents ages 10-11 years. All qualitative tools were translated into the local language, Swahili. The adolescent in-depth interview guides consisted of open-ended questions related to the following topics, 1) comprehension and understanding of the key social emotional mindsets and skills, 2) experiences of learning in mixed gender peer groups, 3) experiences with the parentyouth workbook, 4) transformation of gender norms, beliefs and behaviors, and 5) experiences with using technology to learn. Parent/caregiver interview guides consisted of open-ended related to the following topics, 1) experiences of their children during Discover, including with the use of technology to learn, 2) how well Discover was implemented, 3) observable changes in their children's behavior, and 4) experiences with the parentyouth workbook. The adolescent focus group guide included the following topics, 1) comprehension of Discover social emotional mindsets and skills, 2) working in mixed-gender teams, and 3) experience with using Prior to the inception of Discover, HPON and the University of California Berkeley led the formation of a national advisory board (NAB) and a community advisory board (CAB) that included representatives from the Ministry of Education, Ministry of Health, members of the local government, international and Tanzanian nongovernmental organizations, teachers and community members. The community advisory board provided valuable input and feedback on the design of Discover. With the CAB, Discover developed a protocol for referring participants who became distressed during in-depth interviews and focus groups to local support services. Support services were provided by a representative appointed by the CAB and participants were provided with a card with printed contact information to report any discomfort or adverse experiences. In addition, during implementation of the intervention, the study provided a community "drop box" where students could report questions, concerns and provide feedback during the intervention. Additional --- Data collection All data collection activities were completed by HPON, local Tanzanian health research partners. Parents/caregivers of adolescent participants were provided with information pertaining to the purpose of the qualitative study, risks and benefits of participation and were asked to provide informed consent for their own participation and informed consent for their adolescent's participation. If parents/caregivers gave consent for adolescents to participate in the qualitative study, their adolescent was provided with the purpose of the study, risks and benefits of participation, and was asked to provide verbal assent to participate in the study. No participant names were recorded and unique identification numbers were assigned to all participants. After the Tanzanian research team obtained consent and assent, trained interviewers selected a location for the interview or focus group that would allow for privacy and disclosure. All interviews were conducted in private and no information was shared outside the research team. All in-depth interviews and focus groups were conducted in Swahili and were audio-recorded. Translation was completed by a professional translator from Swahili to English. Interviewers wrote field notes during each interview to complement the audio-taped responses. The field notes were examined with the translated transcripts for important contextual interpretation of data which may have otherwise been lost in translation. The field notes also explored impressions, behaviors and nonverbal cues that the interviewer thought important to the study. The translations were cross-checked by the Tanzanian research team and discussed with researchers at the University of California Berkeley. Interviews and focus groups began with open-ended questions designed to establish rapport so that participants felt comfortable answering questions. Interviewers used probes to explore topics in greater depth. In-depth interviews lasted 45-60 min in length. Each focus group discussion was comprised of 4-8 adolescent participants and included a facilitator and note-taker that lasted 45-60 min in length. Parents/caregivers were provided compensation for their time equal to 5USD, in the form of mobile phone airtime credits. Adolescents received a notebook and pencil as compensation for their time estimated to be valued at less than 2USD. This compensation was considered appropriate after consultation with the research team, teachers, and parents/community members. Trained observers conducted 54 participants observations to assess the implementation of facilitation principles during experiential learning activities. Observers rated facilitators on each principle ranging from 1 to 5 (1 = Not at all; 5 = Very well). Data collection was completed in the months of October and November 2019. --- Data analysis Each transcript was identified through the assigned unique identifier and entered into Atlas.ti [40,41]. A grounded theory approach was used to identify emergent themes [42,43]. This method of data analysis was selected because it is based on a constructivist epistemology which recognizes that meaning is co-created through discourse within a particular cultural context. The analytical steps were conducted by two separate analysts. Line-by-line coding of each transcript was used to identify initial codes that captured implicit meanings, and common relationships and significance between codes [42]. Where appropriate codes were left in vivo to preserve participant language and meaning. Next, focused codes were developed from the most significant and/or frequent initial codes to make analytical sense of the data. Axial coding was used to represent the content of focused codes and to connect relationships between codes, categories and concepts. During the application of focused and axial coding, analysts met to discuss and revise codes until consensus was reached. Final coding structure was applied to each transcript using Atlas. Ti software. Researchers wrote memos to capture connections and to construct analytic notes. Researchers held discussions to help identify emergent themes and connections between themes through an iterative deductive process [42,44]. Exemplar quotes were selected to illustrate emergent themes. We attempted to control for interpretation bias by having two separate analysts interpret the data. Intercoder agreement checks were carried out on each transcript. After each check, the analysts discussed coding discrepancies for all codes applied. Any discrepancies were resolved to develop an initial codebook. The thematic codebook was revised as necessary to reflect any changes to code definitions. Further refinement was completed after the focus group transcripts and observation notes were coded. --- Results Sample demographics are shown in Table 3. The final adolescent sample included 117 participants in focus groups and 102 in-depth interviews. Sixty parents/caregivers completed in-depth interviews, 25% of whom were male and 75% female. The ages of parents/caregivers ranged from 19 to 66 with the mean age 37.8. Fifty-four participant observations were conducted across 12 sessions. Results from participants observations on a scale of 1-5, with 1 = not at all and 5 = very well, found the average rating across all six facilitation principles was 4.8. Thematic analysis of in-depth interviews and focus group discussions uncovered four main themes: (1) Transformation of gender norms, beliefs and behaviors; (2) Novelty, motivational learning and mastery with technology; (3) Extending learning, practice and reflection outside the classroom; and (4) Demonstrating social emotional mindsets and skills. Table 4 shows the emergent themes and representative quotes from the study. --- Transformation of gender norms, beliefs and behaviors The most commonly reported learning experiences in Discover were the novel experiences of working in small mixed gender teams. Adolescents reflected on how this set of experiences was different from what they were used to in a traditional classroom where seating assignments are segregated by gender. Importantly, both boys and girls reflected on how working in mixed gender groups was a positive aspect of Discover and an experience that they found striking. "We don't discriminate each other; at first we used to sit girls on our side and boys on their side, but Discover has helped us until today we love each other." (Girl, 11, 4 th Grade) "We used even to be afraid of going to ask ladies questions but now we are asking each other questions." (Boy, 10, 4 th Grade) "I have learned to collaborate with boys, at past I used not to like to sit with boys." (Girl, 11, Group C, 4th Grade) "I used not to like to sit with girls and when my friends saw me with girls, they used to call me a gay something which made me not to like sitting with girls, I was also fighting with girls when they provoke me. When this project came, I started to hear about gender balance and we were taught that there are no special works for boys or for girls only. From there I started to play with girls, to wash dishes and do other works also." (Boy, 11, Group C, 4th Grade) Participants reported the importance of working together to learn and to solve problems including day-today real-life challenges and the equal value of both boys and girls in finding solutions to problems. For example, participants described that they had been competitive with peers in the past and resistant to helping one another, but after their experience with Discover they embraced cooperation and collaboration. "We used to quarrel in choosing the right answer for the questions given but I advised my colleagues Learning in mixed gender teams challenged normative gender roles, beliefs and behaviors. In addition to gender transformative content, trained facilitators were able to guide groups in reflective discussions or during activities to identify gender inequities and suggest more equitable mindsets and behaviors. The active practice and reflection on gender norms, beliefs and behaviors extended outside of the classroom as adolescents described changes in their mindsets and behaviors during regular social play with peers in the community. Participants described practicing more equitable gender behaviors such as completing chores in the home typically ascribed to be completed by one gender over the other. Moreover, adolescents described motivation to share learning around gender with siblings, friends and community members. "I told them [Parents] that we need to collaborate to do works at home and I also told them that all works are equal; there are no works which are special for boys only or girls only." (Boy, 11, 5 th Grade) "Today before I came to school, I went to put on my shoes and clothes and I started to sweep, my grandmother told me not to sweep and my sister will come to sweep, I told her that works does not choose gender, I can also wash dishes and cook." (Boy, 10, 3 rd Grade) Parents described examples of changes in their children's beliefs, attitudes and behaviors around gender. For example, many participants described the importance of gender equity in job aspirations. In particular, girls reported that they felt new agency to aspire to take on jobs in male-dominated industries such as law and engineering. Participants also demonstrated and practiced their shifting beliefs around gender. The most common example was that household chores were no longer viewed as chores separate for girls and for boys. As a result, many participants self-initiated taking on chores that were previously reserved for the opposite gender. Importantly, many adolescents were able to vocalize their changing beliefs and attitudes surrounding gender equity to their peers, siblings and parents. Parents themselves "It was hard to use one laptop since everyone wanted to sit near the laptop so they had to sit in any how so long as everyone to watch the video, but they had conflict with another since no one wanted to stay far. Another conflict was the time of drawing the symbol, everyone wanted to be the leader to lead others on how to draw, in that way it brought a conflict." "The youth respond to the session positively; they were happy and participated well. For example, writing their purpose and presenting it in front of others was an exciting activity." "My child has been so much curious. She can ask you complex questions. One day she came and asked me what menstruation was. I failed to give her the answer. Now days she has a lot of questions. She is now more curious than she used to be." "I started to observe initial changes because he used not to be able to stand in front of the teacher and read a book, but now days he has confidence, even if he wants to do something, he will do it with confidence." "Before the project, she just used to cry whenever she faced any problem but now days when this happens, she can solve them. She follows her friends and adults for help." described the effect these discussions had on their own beliefs. "There are some tasks which I was supposed to help my wife do, but at first, I used to leave her to do all those tasks alone. I have now started to participate in doing those tasks like sweeping our surrounding environment and arranging items inside the house. I used to see all these jobs as the responsibility of women only, but I discovered that I need also to help my wife. Therefore, gender balance was a good exercise." (Father, 34, Business owner) "I can now see that male and female children can work together." (Sister, 28, unemployed) "The aspect of gender equality helps to bring equality because when she comes home there is a lot of work so it is not like she can do everything! She needs to have time to study. She needs to have time to learn about different things so that there are similar opportunities for boys and girls. That was very interesting to me." (Father, 26, Entrepreneur) --- Novelty, motivational learning and mastery experiences with technology Use of tablet technology in Discover provided a novel experience for adolescents. While many participants were familiar with Ubongo Kids videos, it was a unique experience to view visual content on social emotional mindsets and skills in a mixed-gender, social setting. Participants named characters from the videos and the associated a learning construct. For example, for the episode on gender equality, participants recalled the song about boys and girls being at liberty to do any job. Such connections were easy to conceptualize, memorize and share with others. Interviewee: "In those videos of Discover, Kibena wanted to learn about carpentry though she was a lady, Koba also wanted to learn about cookery though he is a boy. Their teacher prohibited them; Kibena wanted to make a chair, she was refused to do so but she did not hear. One day they were passing along the way, they smelled a good flavor of pilau and when they went there, they found Koba cooking; they asked him why is he cooking while he is a boy? He told them that he learned from his mother, his mother taught him how to cook. They told him that carpentry is the work for boys, but he told them that even boys can cook pilau." Interviewer: "What do you think you have learned from these videos?" Interviewee: "I have learned that there is no need for gender segregation and that woman and men can work together." (Boy, 11, 4 th Grade) "Currently the world is globalized. If you know how to use the phone, you can see and learn many things. You can even receive a degree by using the phone. I see that it has been good for her to learn through this tablet and the videos which they have been watching by using the projector...children understand more if you teach them through practicals." (Father, 36, Mechanic) Learning with technology encouraged risk taking, persistence and reinforced a growth mindset. For example, Discover activities often required the practice of persisting with multiple attempts to complete a task (repeatedly failing and trying again). "I have learned to repeat something several times when I make a mistake until I know how to make it. I have also learned to be persistent." (Girl, 10, 4 th Grade) "I have learned not to give up even if you lose you have to try more and more." (Boy, 11, 5 th Grade) Practicing persistence to obtain mastery of a skill frequently benefitted from collaboration and sharing with peers. At the beginning of the project, most participants had limited exposure to technology. Learning to use technology was a novel experience and enhanced motivational learning. One of the first activities of Discover included a simple orientation to tablets, and several participants reported that one of their most memorable and exciting achievements working with a tablet was simply learning to turn it on and off. Over the six-week intervention, participants were able to reflect on their growth in technology skills and tie these experiences to the social emotional mindsets and skills included in the content of Discover. Facilitators were able to help scaffold participant experiences of mastery. "We first learnt how to switch it [the tablet] on and off. We did not also know how to draw, and we used to make errors and erase it to the extent that we [team] used to finish the last, we did not give up until we knew how to." (Girl, 10, 4 th Grade) Interviewer: "Tell me about an interesting thing which you did in the tablet." Interviewee: "What interested me were the Batiki's designs." Interviewer: "Why?" Interviewee: "Because we made errors in most of the designs and we tried to erase them until we mastered how to do it." (Girl 10, 4 th Grade) --- Extending learning, practice and reflection outside the classroom Many adolescents mentioned that they discussed Discover content and experiences with their parents/caregivers, siblings and friends who were not part Discover participants. Learning was reinforced across different contexts and relationships. In particular, parent/caregiver involvement with Discover and the Parent/caregiver workbook allowed parents to reinforce social emotional mindsets and skills in the home. "I felt good and comfortable, even if I don't know how to answer the question, she [mother] directs me, she does not give me the answer but directs me on how to get the answer, if I miss it, she will direct me several times until I get the right answer." (Girl, 11, 4 th Grade) Many participants demonstrated a desire to use what they had learned to help and teach others. For example, participants described sharing lessons about generosity with parents and friends. "Generosity is all about helping fellows when they experience a problem, to help my parents and to respect all other people. They will love you." (Girl, 10, 4 th Grade) "She (mother) used the workbook to ask me questions like "What does being generous help you with? And I told her that generosity is to help a person so that another day he may also help you." (Boy, 11, 5 th Grade) Parents reported observation of positive changes in their adolescent's peer relationships and with siblings and extended family members. "Working in collaboration within the groups has made her not to be afraid even of asking questions. It has helped her to know that she has the right to be listened to and even if she is wrong, she will be corrected, and this is a way of learning." (Mother, 35, Entrepreneur) "I have witnessed him resolving a fight between two of my neighbors' children. He asked them why they were fighting instead of taking books and reading. He asked them to go with him so that he could show them what he had learnt at school." (Mother, 40, self-employed) An emergent theme in parent/caregiver in-depth interviews was the opportunities for parents/caregivers to actively reinforce learning through use of the parent/ caregiver-youth workbook. Parents described improved relationships with their child and these reflections were provided by mothers, fathers and extended family members. "The relationship with my grandchild has been closer because of that book. There are many things which are discussed there like the issue of collaboration, love etc. Our closeness has increased because of that book." (Grandmother, Age unknown, unemployed) "First, we have become friends because at first, we used to fear one another. She used to come and ask me to teach her and I direct her to her older siblings. Due to the nature of our jobs, we normally come home late and very tired and don't like to be bothered by questions. But she told me that she was told that I should also pass through that book, we should do this and learn together." (Father,36,Mechanic) Parents noted additional value of the workbook as a record of learning to return to and reference after completion of Discover. "The workbook can be used to store records to remember your goals which you set, the goals which you spoke in words and wrote down. It also becomes like a reminder to a child so that when she goes astray you remind her about her goals which she had set and tell her that she needs to achieve those goals. The book will act as a reminder tool for a child." (Father, 34, Business Owner) Involvement and contribution to the community was an important sub-theme. In particular the youth-led activity to create a community Kanga naturally bridged learning to the community. The kanga's connection to historical and culturally grounded traditions in the community were conceived, designed and completed by Discover adolescents. Having a culturally relevant, communityoriented project allowed youth to draw connections between learning in the classroom and experiences in the community. Figure 2 represents an artifact of the Kanga designs that were printed on fabric and gifted to the community. "Batiki was meaningful to me because we can make Batiki and it can bring development to the community. They can also teach people to read words which are written on the Batiki; once they read them, it can bring unity and love within the community." (Girl, 10, 4 th Grade) --- Development of emotional mindsets and skills Several participant responses focused on the importance of developing new learning mindsets and skills included in the content design of Discover. Parents/caregivers similarly expressed happiness with the ways that these new mindsets and skills provided their adolescent with a sense of purpose and motivated learning. This was reflected in responses from both parents/caregivers and adolescents. "I started to observe initial changes because he (child) used not to

Background: Inequitable gender norms, beliefs and behaviors, are shaped by learning experiences during key developmental stages in an individual's life course, and can have negative impacts on health and well-being outcomes. Very early adolescence represents one stage when formative learning experiences about gender inequity can have the potential to support or hinder more equitable gender norms, beliefs and behaviors. The aim of this qualitative study was to evaluate the effect of a gender transformative, social emotional learning intervention for very young adolescents (VYAs) that included experiential learning with peers, parents/caregivers and community members. Methods: This study examined the effects of an intervention designed to provide social emotional learning opportunities for adolescents ages 10-11 in Dar es Salaam, Tanzania. The qualitative sample included 279 participants. Qualitative methods included 102 in-depth interviews with VYAs, 22 focus groups with 117 VYAs, 60 indepth interviews with parents/caregivers and 54 participant observations. A grounded theory approach was used to identify emergent themes. Results: Participants reported growth in targeted areas of social emotional mindsets and skills, including a shift in gender norms, beliefs and behaviors. VYAs reported that experiential learning in mixed gender teams provided opportunities to actively practice and reflect on gender norms, beliefs and behaviors. VYAs also reported active practice of social emotional mindsets and skills with peers, parents/caregivers and the community. Parents/ caregivers reported changes in VYAs' social emotional mindsets and skills within the home, with the community and with siblings and peers. Both adolescents and parent/caregivers reported positive change towards more equitable gender norms, beliefs and behaviors through participation in experiential learning activities and reflective discussions.

a naturally bridged learning to the community. The kanga's connection to historical and culturally grounded traditions in the community were conceived, designed and completed by Discover adolescents. Having a culturally relevant, communityoriented project allowed youth to draw connections between learning in the classroom and experiences in the community. Figure 2 represents an artifact of the Kanga designs that were printed on fabric and gifted to the community. "Batiki was meaningful to me because we can make Batiki and it can bring development to the community. They can also teach people to read words which are written on the Batiki; once they read them, it can bring unity and love within the community." (Girl, 10, 4 th Grade) --- Development of emotional mindsets and skills Several participant responses focused on the importance of developing new learning mindsets and skills included in the content design of Discover. Parents/caregivers similarly expressed happiness with the ways that these new mindsets and skills provided their adolescent with a sense of purpose and motivated learning. This was reflected in responses from both parents/caregivers and adolescents. "I started to observe initial changes because he (child) used not to be able to stand in front of the teacher and read a book, but these days he has confidence, even if he wants to do something, he will do it with confidence" (Mother, 40, Self-employed) "She told me that, in the 'purpose' part of the project, she chose to be a lawyer, she asks me 'dad is this lawyer's course worthwhile? And can it get us out of the pool of poverty?' You see, I told her that she would make it; she would get money if she defended people legally" (Father, 36, Mechanic) --- Discussion Discover's theory of change posits that very early adolescence presents a window of opportunity to provide salient experiences of social emotional learning. Discover was designed to pair support for learning social emotional mindsets and skills with gender transformative content with active experiential learning practiced in mixed-gender small groups. Gender norms are shaped and reproduced by norms in institutions, cultural practices and social relationships and can directly or indirectly affect a multiple of health outcomes [45]. For example, a global systematic review conducted in 2006 found that gender stereotypes and different expectations about appropriate sexual behavior influenced sexual decision making [46]. This study found strikingly similar expectations of men's and women's behavior. Men were expected to be highly heterosexually active, and women chaste-women's virginity at marriage often had high social value [46]. Matching gender transformative and social emotional learning opportunities to a sensitive window of development (ages 10 and 11) was particularly effective in this context because cultural norms lead to increasing gender segregation after sexual maturation. Parents/caregivers and community members endorsed mixed-gender group learning for VYAs. Additionally, targeting VYAs aligned with evidence from developmental science highlighting the unique opportunity for investment in early adolescence-before and during the onset of puberty-when the developing brain is most sensitive to social and emotional learning [47]. Moreover, the design of Discover included the hypothesis that the effects on social and emotional outcomes and gender equity outcomes would be amplified by opportunities to engage parents/caregivers and the community in the learning process. Bronfenbrenner's ecological model of human development recognizes the importance of factors at the individual, microsystem (family and peer relationships), mesosystem (community) and macro level of influence in child and adolescent development outcomes [48]. While research in high-resource contexts provides evidence for the importance of parental engagement for positive adolescent development, less research has focused on the importance of parental engagement in low-resource contexts [49]. In addition, research programming for adolescents often excludes involvement of the community in intervention designs. Particularly in low-resource contexts in East Africa, community members serve an integral role in child and adolescent development [50][51][52]. Discover was designed to include parents/caregivers, teachers and community members in the intervention. Parental/caregiver and community involvement provided opportunities for active engagement in learning. These opportunities extended adolescent's social emotional learning climate outside of program sessions. Research indicates that adolescent social emotional climate is important to reinforcing and supporting development of social emotional mindsets necessary to motivate use of social emotional skills [13]. Other programs in Tanzania have highlighted the importance of including adults and the community. The Vitu Newala Project in Tanzania focused on gender empowerment and provision of safe spaces for adolescent girls and results showed that in addition to empowering young female adolescents who participated, the gender norms, beliefs and behaviors of boys and adults in the community were also impacted [53,54]. One of the most notable lessons learned from implementing Discover, was the effect on parental/caregiver and community members, through supported engagement and learning with adolescents. Several fathers involved in Discover, who are often overlooked in gender transformative programming, described shifts in their own gender norms, beliefs and behaviors. Fathers expressed recognition that their daughters needed time to study, rather than completing household chores. Fathers reported encouraging their daughter's goals and enthusiasm for learning. One father described his motivation to change his own behavior and share household chores equally with his wife after using the parent-youth workbook and completing activities and reflective discussions with his child. These types of experiences are critically valuable for girls who often face harmful gender norms that limit their pursuit of heartfelt goals. Receiving reinforcement and recognition from parents/ caregivers and at the same time, witnessing their parents/caregivers modeling those changes in their own gender norms, beliefs and behaviors can be extremely impactful at supporting gender transformative learning. Research indicates that it is possible to challenge dominant normative gender norms when masculinity and femininity is modeled in ways counter to inequitable gendered beliefs [55]. Parents/caregivers and extended family also described feeling closer to their adolescent through use of the workbook. Recognition of their child's goals and dreams that contrast socially accepted norms can reinforce positive social and emotional development during a pivotal developmental window. Another important theme that emerged from qualitative results, was the way Discover's content appears to have transferred to siblings and peers through adolescent agency in communicating and practicing learning. Adolescents and their parents/caregivers described adolescents feeling empowered to actively share their learning with siblings and peers. This natural motivation to Fig. 2 Adolescents designed Kangas printed on fabric share learning has been shown in other gender transformative interventions. For example, a study found that boys were motivated to change their behavior after receiving appreciation from their sisters [56]. Similarly, in Discover, boys expressed the importance of sharing gender roles with their sisters and female peers. Parents explained that they had witnessed changes in boys, with boys taking on tasks usually relegated to girls. Qualitative interviews also revealed the support and engagement offered by extended family and community members. Grandmothers, teachers and young adult facilitator inclusion provided a multi-generational reinforcement of adolescent learning. The community event was an important component of Discover, bringing together those who had participated in the community advisory board, teachers, parents/caregivers and extended family to recognize and praise the learning of adolescents. In addition, by providing creative means for adolescents to express their perspective in a tangible form (the kanga), a cultural artifact with deep meaning, adolescents were able to actively participate in bringing to fruition their own ideas while also demonstrating reverence for an important cultural tradition. Consistent with [formative research results], adolescents, parents/caregivers and community members were enthusiastic about the use of technology for learning. Utilizing technology was a novel experience for most adolescents and offered a modality to support motivational learning, positive risk taking and natural curiosity in a stimulating social context. Through exploration of technology, adolescents expressed the highly arousing thrill of overcoming challenges and the social rewards associated with mastering skills in a collaborative learning environment. These positive learning experiences with technology will shape experiences in later adolescence as technology becomes increasingly pervasive. These findings suggest that challenging gender inequities and norms through reflection, experiential learning and engagement with peers, parents/caregivers and community during very young adolescence has the potential to transform gender norms, beliefs and behaviors in the short term and could have a sustainable impact on longer-term health and well-being outcomes. Early adolescence is a uniquely opportune window of time to shape adolescent's beliefs and behaviors towards more gender-equitable norms before social norms increasingly limit mixed-gender interactions. While social emotional learning is particularly important and naturally aligned with this window of development, experiential activities that allow adolescents to actively practice and reflect on social emotional learning in mixed gender groups can lead to powerful, salient experiences. These experiences are enhanced by opportunities to feel admired by peers, recognized for achievements and valued as equals. Research on the developmental science of adolescence has found that adolescents are particularly sensitive to and naturally motivated to achieve social rewards and admiration from peers [57,58]. Adolescent programming that leverages the developmental sensitivity to social reward may enhance and reinforce social emotional learning. Engagement with parents/caregivers and the community provides additional opportunities to model and reinforce learning. Our results indicate that parents/ caregivers reported their own gender norms, beliefs and behaviors changing as a result of participation in Discover. Parents/caregivers play a critical role in challenging or perpetuating harmful gender norms. Girls are often burdened with an unequal share of household responsibilities in comparison to boys and these experiences can lead to social isolation that limit girls' ability to explore their own interests. The potential of adolescents to themselves be changemakers in their parents/ caregivers and communities gendered beliefs can help to challenge harmful gender norms and practices that pose risks to both girls' and boys' healthy development. Programs targeting early adolescence should capitalize on the opportunity to include gender transformative content during early adolescence. Introducing positive gender norms, beliefs and behaviors early in adolescent development can help reduce gendered health disparities that can amplify in later adolescence. --- Limitations One limitation of this study was the difficulty in assessing the impact of the intervention on peers, siblings and community members not included in the qualitative study. In addition, this study conducted all interviews in Swahili, the native language, transcribed from audio and then translated to English. Data analysis was based on the translated scripts. It is possible that some meaning was lost during translation from Swahili to English. An attempt was made to control for this possibility by listening to the audio three times before transcribing, cross-checking the translations among the local research team and working with a data analyst who was a native Swahili speaker. While the local research team was trained in qualitative data collection methodology, there is a possibility of social desirability bias between the adolescent participants and interviewer or focus group moderator. However, both participant observations and indepth interviews with parents/caregivers supported emergent themes from adolescent interviews and focus group discussions. This study was conducted in a periurban setting in Dar-es-Salaam Tanzania; therefore, the results may not be generalizable to other contexts. Despite these limitations, the findings from this study demonstrate the importance of parent/caregiver, peer and community engagement in gender transformation programs for very young adolescents. --- Conclusion The findings of this study provide evidence of participant experiences with Discover, a social emotional learning intervention for very young adolescents. Study findings indicate changes in participant and parent/caregiver gender norms, beliefs and behaviors. Social emotional learning interventions that incorporate gender transformative content, and engage peers, parents/caregivers, and community members have the potential to take advantage of a unique window of opportunity in adolescent development that can amplify effectiveness of adolescent programing. Opportunities to leverage findings from adolescent developmental science can reinforce social emotional learning. Investment in very young adolescents can support positive developmental trajectories and empower adolescents to be agents of change towards more gender equitable communities. --- Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to the sensitive age of the study participants (10-11year-old) at baseline but are available from the corresponding author on reasonable request. The author will vet requests to be certain that appropriate IRB approvals and data safety guidelines are in place before distribution. --- Supplementary Information The online version contains supplementary material available at https://doi. org/10.1186/s12939-021-01395-5. --- Additional file 1. --- Additional file 2. Abbreviations VYA: Very Young Adolescent; CAB: Community Advisory Board; NAB: National Advisory Board --- Authors' contributions The original Discover study design was conceived of and designed by MC, RD, CS, LS and PN. Recruitment of participants, management and project implementation was performed by CS. Development of survey instruments and evaluation was done by MC and SL. Manuscript preparation was carried out by MC and SL. All authors contributed critically and significantly to drafting a final manuscript. All authors approved the final version. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. --- 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: Inequitable gender norms, beliefs and behaviors, are shaped by learning experiences during key developmental stages in an individual's life course, and can have negative impacts on health and well-being outcomes. Very early adolescence represents one stage when formative learning experiences about gender inequity can have the potential to support or hinder more equitable gender norms, beliefs and behaviors. The aim of this qualitative study was to evaluate the effect of a gender transformative, social emotional learning intervention for very young adolescents (VYAs) that included experiential learning with peers, parents/caregivers and community members. Methods: This study examined the effects of an intervention designed to provide social emotional learning opportunities for adolescents ages 10-11 in Dar es Salaam, Tanzania. The qualitative sample included 279 participants. Qualitative methods included 102 in-depth interviews with VYAs, 22 focus groups with 117 VYAs, 60 indepth interviews with parents/caregivers and 54 participant observations. A grounded theory approach was used to identify emergent themes. Results: Participants reported growth in targeted areas of social emotional mindsets and skills, including a shift in gender norms, beliefs and behaviors. VYAs reported that experiential learning in mixed gender teams provided opportunities to actively practice and reflect on gender norms, beliefs and behaviors. VYAs also reported active practice of social emotional mindsets and skills with peers, parents/caregivers and the community. Parents/ caregivers reported changes in VYAs' social emotional mindsets and skills within the home, with the community and with siblings and peers. Both adolescents and parent/caregivers reported positive change towards more equitable gender norms, beliefs and behaviors through participation in experiential learning activities and reflective discussions.

relevant information and vaccine recommendations and build a higher level of trust among those groups with lower coverage. NIS-CCM is a nationally representative random-digit-dialed mobile telephone survey of households with children and adolescents aged 6 months-17 years. NIS-CCM interview data collected from 94,838 respondents during September 26, 2021-September 30, 2022, <unk> were used to assess racial and ethnic differences in COVID-19 vaccination coverage, parental intent to vaccinate, and behavioral and social drivers of vaccination among children and adolescents aged 5-17 years. Survey respondents were those who reported being knowledgeable about the child's or adolescent's vaccination status (parent). Interviews with parents of an unvaccinated child or adolescent, or a child or adolescent who received <unk>1 COVID-19 vaccine dose <unk> during December 2020-September 2022 were included. White persons were designated as the referent group for most racial and ethnic comparisons because this group has the largest population size and the most social advantage (6). Kaplan-Meier estimation methods were used to calculate cumulative <unk>1-dose COVID-19 vaccination coverage as of <unk> Respondents interviewed during September 26, 2021-September 30, 2022, were included; month and year of vaccination occurred during December 2020-September 2022. <unk> Assessed by response to the question, "Has [child's name] received at least one dose of a COVID-19 vaccine?" Month and year of first dose was assessed by asking, "During what month and year did [child's name] receive [his/her] first COVID-19 vaccine?" August 31, 2022.** First-dose vaccination month and year were hot deck imputed <unk> <unk> for 20.2% of children and adolescents with parent-reported vaccination but without a vaccination date (7). Differences in <unk>1-dose coverage were assessed by race and ethnicity and stratified by sociodemographic subgroups. Pairwise comparisons were conducted to assess differences in <unk>1-dose estimates for all races and ethnicities. Survey data during July 1-September 30, 2022, <unk> <unk> (26,961) were pooled to calculate proportions of children and adolescents who 1) were unvaccinated, but parental intent to vaccinate was ascertained, 2) initiated COVID-19 vaccination (received <unk>1 dose), 3) completed the primary series (received <unk>2 doses), Coverage with <unk>1 COVID-19 vaccine dose by August 31, 2022, was higher among children and adolescents aged 12-17 years, those whose mothers had obtained a college degree, who lived in a household with yearly income <unk>$75,000, who always or often wore a mask in public during the previous 7 days, and who had received <unk>1 influenza vaccine dose (Table 1). Coverage among Asian and Hispanic children and adolescents was higher in most sociodemographic subgroups compared with coverage among White children and adolescents. Black, White, and other/ multiple race children and adolescents had the largest variation in coverage by sociodemographic and behavioral characteristics. <unk> <unk> Information on whether the child or adolescent was immunocompromised was not ascertained in NIS-CCM; thus, booster dose coverage estimates might include immunocompromised children and adolescents who received 3 primary COVID-19 vaccine doses. *** Assessed by responses to six questions covering 1) concern about the child or adolescent getting COVID-19, 2) confidence in COVID-19 vaccine safety, 3) confidence in COVID-19 vaccine importance, 4) percentage of friends and family who had vaccinated their children (social norms), 5) health care provider recommendation for COVID-19 vaccination, and 6) school COVID-19 vaccination requirements. https://www.cdc.gov/vaccines/imzmanagers/nis/downloads/NIS-CCM-Questionnaire-Q3-2022.pdf <unk> <unk> <unk> The CASRO response rate is the product of three rates: 1) the proportion of telephone numbers that can be identified as either for business or residence (resolution rate), 2) the proportion of qualified households that complete the screening process (screening rate), and 3) the proportion of contacted eligible households for which a completed interview is obtained (cooperation rate). Data collected during July 1-September 30, 2022, indicate that overall, 47.2% of children and adolescents received <unk>1 COVID-19 vaccine dose; 43.3% completed the primary series (<unk>2 doses) (Table 2). Among children and adolescents aged 5-17 years, primary series coverage was highest among Asian persons. Monovalent booster dose coverage was low overall (14.7%) and was highest among Asian children and adolescents (22.4%) and lowest among Black children and adolescents (9.3%). Parents of White children and adolescents of all ages reported the highest level of reluctance <unk> <unk> <unk> (40.3%) to have their child vaccinated. Parents of vaccinated children and adolescents reported high levels of confidence in the importance (93.1%) and safety (78.8%) of vaccination overall and by race and ethnicity (Supplementary Table 2, https://stacks.cdc.gov/view/ cdc/122811). Confidence in vaccine importance remained high (76.7%), but confidence in vaccine safety was considerably lower (40.2%) among parents of unvaccinated children and adolescents who might get their child vaccinated (reachable children****). Parents of reluctant and reachable children and adolescents reported substantially lower percentages of friends and family had vaccinated their children and adolescents (reflection of social norms) (6.4%-21.2%) and reported having received a provider recommendation (27.9%-35.9%) for vaccination compared with parents of vaccinated children (72.9% and 61.8%, respectively). The magnitude of these differences was similar by race and ethnicity. Overall, reluctant parents expressed less favorable attitudes and opinions regarding vaccination than did parents of vaccinated and unvaccinated but reachable children. Among all reluctant parents, those of Black and Hispanic children and adolescents reported the highest levels of concern about their child getting COVID-19 and expressed the most confidence in the importance of the vaccine. --- Discussion --- COVID-19 vaccination coverage was low among children and adolescents aged 5-17 years overall, but highest among Asian and Hispanic children and adolescents. By August 31, 2022, Asian children and adolescents had substantially higher coverage than did all other children and adolescents overall and when stratified by factors associated with lower coverage for all children and adolescents, indicating a willingness across demographic and behavioral characteristics in this population to receive vaccination. During July 1-September 30, 2022, <unk> <unk> <unk> Unvaccinated children and adolescents whose parents responded that they definitely or probably will not vaccinate their child (reluctant). **** Unvaccinated children and adolescents whose parents responded that they definitely, probably will, or are unsure if they will vaccinate their child (reachable). overall and among all racial and ethnic groups, most children and adolescents who initiated a primary COVID-19 vaccination series also completed the primary series, an encouraging sign of COVID-19 vaccine access and acceptance among parents who intend to vaccinate, but efforts are needed to achieve much higher coverage levels for all children and adolescents. Lower coverage with <unk>1 COVID-19 vaccine dose associated with some demographic and behavioral characteristics point to opportunities to improve coverage. Frequent mask use in public and receipt of influenza vaccine were associated with higher COVID-19 vaccination coverage among all children and adolescents; however, among Black and Hispanic children and adolescents with these characteristics, the increase in coverage was smaller. Less than one half of parents of Black and Hispanic children and adolescents had confidence in COVID-19 vaccine safety, which might indicate reluctance to be vaccinated among a population receptive to other public health behaviors. During July 1-September 30, 2022, large proportions of Hispanic and Black children and adolescents were unvaccinated but reachable (26% and 29%, respectively), suggesting that coverage might increase over time with strengthened public health interventions. A higher proportion of parents of other/multiple race and White children and adolescents were reluctant to vaccinate their child (36% and 40%, respectively) than were considered reachable (15%), suggesting potential difficulty achieving high vaccination coverage among these children and adolescents. Implementation of evidence-based practices described in CDC's COVID-19 Vaccination Field Guide <unk> <unk> <unk> <unk> could help increase vaccine coverage. Community members should serve as trusted messengers to advocate for vaccination among parents of unvaccinated children and adolescents and should deliver tailored messages to strengthen confidence in vaccine safety and <unk> <unk> <unk> <unk> https://www.cdc.gov/vaccines/covid-19/downloads/vaccination-strategies.pdf 57.9 (51.1-64.9) <unk> <unk> 53.9 (50.9-57.0) <unk> <unk> 47.0 (39.8-54.8) Abbreviations: MSA = metropolitan statistical area; NR = not reported; Ref = referent group; SVI = Social Vulnerability Index. * Race and ethnicity were reported by the parent or guardian. Children and adolescents identified as Asian, Black or African American, White, or other or multiple races were reported by the parent or guardian as non-Hispanic. Children and adolescents identified as being of other or multiple races had more than one race category selected, or were identified as American Indian or Alaska Native, or Native Hawaiian or other Pacific Islander. Children and adolescents identified as Hispanic might be of any race. <unk> Cumulative percentage vaccinated with <unk>1 dose was estimated using Kaplan Meier survival analysis techniques with the event defined as the month and year of vaccination and the censoring variable defined as the date of interview. <unk> Column percentages might not sum to 100 because of rounding. <unk> White persons were designated as the Ref for racial and ethnic comparisons because this group has the largest population size and the most social advantage. https://pubmed.ncbi. nlm.nih.gov/26599027/ ** Statistically significant (p<unk>0.05) difference compared with the indicated Ref (column) level (White). <unk> <unk> Statistically significant (p<unk>0.05) difference compared with the indicated Ref (row) level. <unk> <unk> Estimates were suppressed because they did not meet standards for data reliability (CI >20, relative SE >30, or sample size <unk>30). <unk> <unk> Urbanicity was determined from household reported city and county of residence and was grouped into three categories: MSA principal city, MSA nonprincipal city, and non-MSA. MSA and MSA principal city were as defined by the U.S. Census Bureau (https://www.census.gov/programs-surveys/metro-micro.html). Non-MSA areas include urban populations not located within an MSA and completely rural areas. *** https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf <unk> <unk> <unk> Categorization of National Immunization Survey-Child COVID Module data into an SVI level was based on zip code of residence reported by the respondent. https://www.atsdr.cdc.gov/ placeandhealth/svi/index.html <unk> <unk> <unk> Data on receipt of influenza vaccine were collected via interviews conducted during October 1, 2021-June 30, 2022. importance. Provider recommendation is an impactful driver of vaccination (8). A multifaceted approach with community collaboration and provider recommendation are essential to increasing childhood COVID-19 vaccination coverage. The findings in this report are subject to at least five limitations. First, the survey response rate was low (18.1%). Data were weighted to account for household and provider nonresponse and for households without telephones and weighted to the COVID-19 vaccine administration data (<unk>1 doses) reported by jurisdictions to CDC. However, some bias might remain. Second, child and adolescent COVID-19 vaccination receipt was parent-reported and might be subject to recall or social desirability biases. However, limited recall bias is expected because of the recency of COVID-19 vaccination recommendations. Third, small sample sizes were available for American Indian or Alaska Native and for Native Hawaiian or other Pacific Islander children and adolescents; therefore, these data were aggregated in the other/multiple race category. Fourth, aggregated racial and ethnic data might --- Summary What is already known about this topic? Some racial and ethnic groups are at increased risk for COVID-19-associated morbidity and mortality because of systemic and structural inequities. Vaccination is effective in preventing severe COVID-19-related outcomes. What is added by this report? Among children and adolescents aged 5-17 years, <unk>1-dose COVID-19 vaccination coverage was low overall, but highest among Asian and Hispanic or Latino children and adolescents. Parental intent to vaccinate their child varied by the child's age, race, and ethnicity. Parents of unvaccinated children and adolescents reported low confidence in vaccine safety, and a low percentage reported receipt of a provider vaccination recommendation. --- What are the implications for public health practice? To increase overall coverage and address disparities in child and adolescent COVID-19 vaccination coverage, providers and trusted messengers should provide culturally relevant information and vaccine recommendations. Abbreviations: Black = Black or African American; Hispanic = Hispanic or Latino. * <unk>1 dose coverage; Kaplan-Meier survival analysis was used to estimate vaccination coverage based on the month and year of first dose receipt; estimates reflect the cumulative percentage vaccinated as of the end of each month. <unk> Race and ethnicity were reported by the parent or guardian. Children and adolescents identified as Asian, Black, White, or other or multiple races were reported by the parent or guardian as non-Hispanic. Children and adolescents identified as being of other or multiple races had more than one race category selected or were identified as American Indian or Alaska Native, or Native Hawaiian or other Pacific Islander. Children and adolescents identified as Hispanic might be of any race. Definitely or probably will not get child/ adolescent vaccinated obscure differences in coverage that are apparent in disaggregated subgroups (9). Data on racial and ethnic subgroups were collected, but the sample size was inadequate to analyze the disaggregated data. Finally, reporting of month and year of vaccination was incomplete for one fifth of children and adolescents who were reported to be vaccinated, requiring imputation of missing dates. Public health efforts to increase coverage with the primary COVID-19 vaccination series in all age groups and the bivalent COVID-19 booster dose <unk> <unk> <unk> <unk> among eligible persons should continue. These efforts should be tailored to differences in parental intent, behavioral and social drivers of vaccination, and by the child's or adolescent's age, race, and ethnicity. Programs should provide culturally relevant information and employ evidence-based strategies, including tailored messages delivered by trusted messengers and strong recommendations from vaccination providers, to increase vaccine confidence and coverage among all groups, and to eliminate the disparities for those with lower vaccination coverage. All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed. <unk> <unk> <unk> <unk> As of December 9, 2022, persons aged <unk>6 months are recommended to receive a bivalent booster dose, even if they already received a monovalent booster dose. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stayup-to-date.html

Some racial and ethnic groups are at increased risk for COVID-19 and associated hospitalization and death because of systemic and structural inequities contributing to higher prevalences of high-risk conditions and increased exposure (1). Vaccination is the most effective prevention intervention against COVID-19-related morbidity and mortality*; ensuring more equitable vaccine access is a public health priority. Differences in adult COVID-19 vaccination coverage by race and ethnicity have been previously reported (2,3), but similar information for children and adolescents is limited (4,5). CDC analyzed data from the National Immunization Survey-Child COVID Module (NIS-CCM) to describe racial and ethnic differences in vaccination status, parental intent to vaccinate their child, and behavioral and social drivers of vaccination among children and adolescents aged 5-17 years. By August 31, 2022, approximately one third (33.2%) of children aged 5-11 years, more than one half (59.0%) of children and adolescents aged 12-15 years, and more than two thirds (68.6%) of adolescents aged 16-17 years had received ≥1 COVID-19 vaccine dose. Vaccination coverage was highest among non-Hispanic Asian (Asian) children and adolescents, ranging from 63.4% among those aged 5-11 years to 91.8% * CDC's Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the Pfizer-BioNTech COVID-19 vaccine for persons aged ≥16 years on December 12, 2020, 12-15 years on May 12, 2021, and 5-11 years on November 2, 2021. ACIP recommended use of an additional homologous primary dose of Pfizer-BioNTech vaccine after an initial series in immunocompromised persons aged ≥12 years on August 13, 2021. ACIP recommended monovalent booster doses for persons aged 16-17 years on December 9, 2021, 12-15 years on January 5, 2022, and 5-11 years on May 19, 2022. among those aged 16-17 years. Coverage was next highest among Hispanic or Latino (Hispanic) children and adolescents (34.5%-77.3%). Coverage was similar for non-Hispanic Black or African American (Black), non-Hispanic White (White), and non-Hispanic other race † or multiple race (other/multiple race) children and adolescents aged 12-15 and 16-17 years. Among children aged 5-11 years, coverage among Black children was lower than that among Hispanic, Asian, and other/multiple race children. Enhanced public health efforts are needed to increase COVID-19 vaccination coverage for all children and adolescents. To address disparities in child and adolescent COVID-19 vaccination coverage, vaccination providers and trusted messengers should provide culturally † Race and ethnicity of the child or adolescent were reported by the parent or guardian and were available for all study participants. Asian, Black, White, or other/multiple race children and adolescents were reported by the parent or guardian to be non-Hispanic. Other/multiple race children and adolescents had more than one race category selected, or were identified as American Indian or Alaska Native, or Native Hawaiian or other Pacific Islander. Hispanic children and adolescents might be of any race.

Gay and bisexual (G/B) stimulant-using homeless men are at high risk for one or more incarceration episodes. In one study, approximately 51% of G/B men had a previous prison term (Alarid, 2000). However, among this understudied population, correlates of incarceration are not well understood. While similar to heterosexual counterparts, pathways to homelessness among lesbian, gay, bisexual and transgender (LGBT) young adults result from leaving home early due to familial conflict over sexual orientation, need for freedom, and physical abuse (Cochran, Stewart, Ginzler, & Cauce, 2002). In a national sample, nearly half (46%) of LGBT young adults who were homeless had run away because of family rejection of sexual orientation or identity (Durso & Gates, 2012). As is prevalent in the literature, drug abuse often is connected with criminality (Fletcher & Chandler, 2012) and subsequent incarceration (Mumola & Karberg, 2006). Among young men (17-28 years of age) who have had sex with men (MSM) and have been homeless, exposure to drugs such as powder cocaine (60%), 3,4 methylenedioxy methamphetamine MDMA (60%), hallucinogens (41%), crack cocaine (22%), and heroin (20%) (Clatts, Goldsamt, Yi, & Gwadz, 2005) are common and are risk factors for subsequent incarceration. Prior studies have explored the relationship between substance use and risk-taking behaviors (Hudson et al., 2009;Nyamathi et al., 2010) and incarceration (Mumola & Karberg, 2006). In one report of LGBT, 53% have reported a history of alcohol and substance abuse, and nearly one third (31%) had contact with the juvenile justice system (Durso & Gates, 2012). A number of other factors that have been proposed in the literature are associated with incarceration. Type of social networks and support is an important contributing factor for continuation of drug use as peers may use drugs together. In a study among treatmentseeking drug users, increased time spent with those who are involved in drug use and criminal activities increased the propensity for crime (Best, Hernando, Gossop, Sidwell, & Strang, 2003). Race/ethnicity, age, education and poor cognitive abilities may also be significant factors impacting history of incarceration. For example, black MSM were more likely to report recent arrest history as compared to white MSM (Lim, Sullivan, Salazar, Spaulding, & Dinenno, 2011). Drug use patterns may similarly differ by age and this can be seen with methamphetamine use. When considering age, among state prisoners, those between 25-34 had a higher percentage of methamphetamine use in the month before the offense compared to those 24 or younger, 35-44, 45-54 or 55 or older (12.6% versus 11% versus 11.5% versus 7.7% versus 3.3%) (Mumola & Karberg, 2006). For those who have abused drugs, cognitive capacity may also be affected. According to Moon et al. (2007), methamphetamine use damages the frontal lobe and leads to impaired executive function. While similar to amphetamine, methamphetamine, a potent stimulant affects the central nervous system and has been found to affect the function and structure of the brain affecting visual memory (Moon, Do, Park, & Kim, 2007). Survival on the streets necessitates an understanding of street economy, a term coined to explain how a non-linear exchange may occur for drugs, sex and money (Lankenau, Clatts, Welle, Goldsamt, & Gwadz, 2005). While sex trading is driven by the need to obtain drugs or shelter (Newman, Rhodes, & Weiss, 2004); these particular types of activities often lead to interaction with law enforcement and criminality (Clatts et al., 2005). Among gay and transgender youth, nearly 44% reported being asked to exchange sex for money for food, drugs and shelter (Sifra-Quintana, Rosenthal, & Krehely, 2010). Among MSM, 71.4% of those who were bisexual had engaged in sex trade; 58% used methamphetamine in the past week, and 69.3% injected drugs in the past week (Newman et al., 2004). Interaction with law enforcement due to drug use may be prevalent as 32% of state and 26% of federal prisoners used drugs at the time of their offense (Mumola & Karberg, 2006). For G/B exoffenders who are exiting institutions into community supervision, challenges with reintegrating into society may be a significant issue; however, the majority of the literature focuses on adolescents and youth and combines LGBT youth without primarily focusing on adult men between the ages of 18 to 46 years of age. Thus, the aim of this study was to primarily focus on G/B homeless stimulant-using men as there is limited literature which focuses on this high risk for incarceration among this subpopulation. Raising awareness and an understanding of correlates in this subgroup is important as it may lead to the development of culturally-sensitive intervention approaches. --- Comprehensive Health Seeking and Coping Paradigm (CHSCP) The components of the Comprehensive Health Seeking and Coping Paradigm (CHSCP) which has guided this study include socio-demographic factors, situational, cognitive and social factors and coping responses. Sociodemographic factors that might be relevant to predictors of incarceration among G/B adults include age, education, and being born in the U.S. Situational factors such as being homeless (Cochran et al., 2002) and having a history of family rejection (Ryan, Huebner, Diaz, & Sanchez, 2009) may likewise influence a history of incarceration. Social factors that might negatively predict incarceration may include poor social support, and support coming from drug users; while cognitive factors may include knowledge of hepatitis. Lack of consistent social relationships has been associated with more sexual partners and unprotected sexual activity (Seal et al., 2003). Finally, emotion-focused coping strategies not only includes use of drugs and alcohol, but as well poor decision-making leading to continuing use of these risky behaviors (Reyna & Rivers, 2008) and increased psychological distress (Ireland, Boustead, & Ireland, 2005). We believe that these variables influence the main outcome variable in this study which is self-reported incarceration. --- Methods --- Participants Baseline data were analyzed among G/B homeless men who were enrolled in a randomized controlled trial focused on reducing stimulant use and other illicit drugs as well as promoting hepatitis B Virus (HBV), hepatitis C virus (HCV) and HIV disease prevention. In total, 353 stimulant (methamphetamine and/or powder cocaine and/or crack cocaine)-using men participated in the study. Eligibility criteria was a) age 18-46; b) self-reported being homeless; c) G/B identity; d) stimulant use within the previous three months; and e) no self-reported participation in drug treatment in the last 30 days. Stimulant use was confirmed by urine screening or by hair analysis, if the urine screening could not detect stimulant metabolite within the previous three months. --- Procedure Data were collected from October 2009 to March 2012 in a community research center in Hollywood, California. Two methods of recruitment were utilized: flyers were distributed by the staff in the Hollywood area and short in-service presentations were made at local community-based sites. If individuals were intoxicated or cognitively impaired (hallucinating or talking to themselves), they were excluded from the study. Potential participants received a comprehensive description of the study, an overview of the informed consent form in a private location, and a short (2 minute) screening assessment to confirm eligibility. The screening assessed demographic characteristics, homeless status, and substance use and abuse using the Texas Christian University Drug Screener (Simpson & Chatham, 1995). Participants provided a blood sample which was tested for the HBV and HCV. After two days, research staff asked participants to return to receive results provided by the study nurse; at this time, a second informed consent was reviewed and signed to allow administration of the baseline questionnaire. Thereafter a rapid HIV test was administered by oral swab. A baseline assessment was administered by the research staff well trained in confidential data collection, which included respecting each individual as a person, not judging the participant on reported behaviors, and in administering questionnaires in a private location. Participants were paid $10 to complete the screening questionnaire and $20 to complete the baseline questionnaire. Both the UCLA and the Friends Research Institute, Inc. Institutional Review Boards approved the study. --- Measures Sociodemographic Information. The screening survey assessed for eligibility criteria of age, homeless status, G/B identity and stimulant use. Homelessness was assessed by asking where the potential participant spent the last evening. Options included homeless or transitional shelter, abandoned car, friend's home or on the street. An individual was defined as homeless if they lacked a fixed, regular, and adequate nighttime residence, and they had a primary nighttime residence that was a supervised publicly or privately operated shelter designed to provide temporary living accommodations (Hoben, 1995). G/B status was selfreported by the individual of his perceived sexual identity: options included gay, bisexual or heterosexual. Stimulant use was determined by asking if a stimulant (such as amphetamine, methamphetamine, cocaine or crack) was used over the last three months. Stimulant use was also confirmed by urine screening or by hair analysis, if the urine screening could not detect substance abuse (SA) metabolite. The baseline questionnaire assessed the following sociodemographic variables: age, education, race/ethnicity, marital status, relationship status in terms of being partnered or not, country of birth, having children, employment status and where participants have spent the last 30 nights. Participants were also asked if they saw a physician in the previous four months. Participants were also asked if they had been given any information about Hepatitis. Responses included yes/no. Health Status. A self-reported one-item measure was used to assess general health status which asked about general health, ranging from excellent to poor and dichotomized as fair/ poor vs. good/very good/excellent. Bodily pain was assessed by a single item asking about bodily pain in the past four months; answers on a six point scale ranged from none to very severe. For analytic purposes, responses were dichotomized as moderate/severe/very severe pain vs. less bodily pain (Stewart, Hays, & Ware, 1988). Social Support was measured by a categorical item asking respondents who they turn to for friendship and support. Possible responses were primarily drug or alcohol users, primarily non-users of drugs or alcohol and equally divided by users and non-users and no one. Injection drug use was assessed by asking participants if they had injected any recreational or illegal drugs. Responses included yes, within the last 30 days, yes, within the last 4 months, yes, more than four months ago and no, never. For analytic purposes, it was dichotomized as never used vs. ever used. History of Incarceration was assessed by asking if the participant had ever spent time in prison or in both jail and prison. --- Statistical Analyses Descriptive statistics, including means, standard deviations, frequencies and percentages, were computed to present the sample sociodemographic and other background characteristics. Unadjusted relationships between these characteristics and having been incarcerated were examined using chi-square tests and t tests, depending on underlying distributions. Characteristics that were associated with incarceration history at the.10 level were then used as predictors in a logistic regression model for incarceration. Predictors in the resulting model with P values greater than 0.10 were removed one at a time in descending order to identify independent correlates of past incarceration that were significant at the.10 level in a multivariate context. Using p-values higher than the standard.05 to identify predictors for a regression model reduces the chance of overlooking important relationships and failing to include important control variables in the model. Assuming over fitting (too many variables in the model) is not a problem, allowing predictors with p-values a little higher than.05 to remain in a multivariable model also serves to include adjusted relationships that might be more important in other samples. Of note, the SAS linear modeling procedure uses.50 and.10 as default significant levels for stepwise forward and backward techniques, respectively. However, when reporting results, care should be taken to focus on stronger associations. The final model was assessed for multicollinearity, and was not found to be a problem. Model goodness of fit was verified with the Hosmer-Lemeshow test (Hosmer & Lemeshow, 2000). Statistical analyses were conducted using SAS Version 9.1. --- Results --- Sociodemographic Characteristics of Participants The mean age of the sample (N = 353) was 34.6 <unk> 8.1 years (Table 1). The sample was nearly equally represented by Caucasian/whites (38%) and African American/black (36%); nearly three-quarters had never been married. Slightly over one-third of participants (38%) reported recent injection drug use (IDU). One-fourth reported fair/poor physical health. Moreover, 31%% were positive for hepatitis C virus (HCV) and 16.3%were positive for HIV. Nearly half (43.6%) of the sample reported a history of incarceration in prison specifically. --- Unadjusted Associations between Sociodemographic Characteristics and Prison History A number of categorical background variables were associated with prison history (Table 2). These included being US born and having children. In particular, men with a incarceration history were more likely to have been born in the US, and to report children than those without this history (97% vs. 90% and 43% vs. 22%, respectively). Race/ethnicity, having a sexual partner, history of employment, and poor/fair health were not related to history of incarceration. Additionally, when race/ethnicity was collapsed to Caucasian/white/nonwhite, men who were Caucasian/white were more likely to have reported being in prison than those who were not Caucasian/white (44% vs. 34%, p =.043, data not shown). Continuous correlates of incarceration included both age and education: older age and less education were found to be associated with prison or jail history. Physical and mental health care were also related to having been in prison or jail. In particular, having seen a physician in the previous four months and requesting treatment for a mental health condition were highly associated with incarceration history. Less strongly associated was receiving hepatitis information. Finally, in terms of drug use, those who used injection drugs in their lifetime were more likely than those who did not to have a history of incarceration (75.2% vs. 51.8%). Moreover, either having no social support or receiving social support from substance users was also related to incarceration (35.5% vs. 22.8%, p <unk>. 01). --- Adjusted Analysis Logistic regression analysis indicated that age, having children and having been born in the US were directly related to incarceration history (Table 3). In contrast, education was inversely related to incarceration history. Lifetime injection drug use, having seen a doctor in the previous four months, poor social support and having received hepatitis information were also associated with incarceration history. --- Discussion Among G/B homeless adults, several factors influence a history of incarceration; these included being older, US-born, having children, having poorer education, injection drug use (IDU), seeing a physician in the previous 4 months, having been in receipt of hepatitis information, and receiving poor support. In our sample, G/B men with a history of incarceration were disproportionately affected by poor education. Our findings support those found by Alarid (2000), wherein in a sample of G/B men (N=56), the highest level of education was 11.6 years. In another sample of homeless men on parole (N=297), over two thirds of the total sample (69%) graduated from high school (Nyamathi, Marlow, Branson, Marfisee, & Nandy, 2012). These findings point to several areas of consideration. First, it may be necessary to encourage successful completion of a GED. Second, moving beyond high school, it is necessary to link clients into vocational training which would enable them the ability to have a sustained income. Low educational attainment and skill levels should be considered major challenges that place G/B and other vulnerable populations at risk for incarceration. Findings demonstrated that G/B men who had received hepatitis information were more likely to have been incarcerated. It is plausible that they may have received this information in the community prior to their incarceration or during their prior incarceration. In our study, we also found that among G/B homeless men, IDU was associated with incarceration. As over one-third of our sample had a history of IDU, receiving information about HCV would be likely because many may have learned they had HCV while incarcerated. Further, sexual health information could have been given while incarcerated. These findings highlight the need to promote ongoing health information and linkage into care. Findings also indicated that receiving no social support or only receiving social support from another substance user was related to a history of incarceration. The type of social support one may receive may have a significant impact on behavior as it can provide either protection or lead to problematic consequences; in particular, one study found that social networks of women in recovery may include positive social support as well as those who enable drug use (Falkin & Strauss, 2003) as well-meaning family members may provide basic necessities such as money which may enable drug use (Strauss & Falkin, 2001). It is important to understand the nature of social support among high-risk populations as lack of support has the potential to increase or decrease positive behaviors. We also found that being older and being born in the US was related to a history of incarceration. In one national sample, the average age of inmates was 39 years of age and 47.3% were sentenced to prison due to a drug offense (Federal Bureau of Prisons, 2013). Thus, it is plausible that older age is correlated with incarceration as many G/B men may have previous strikes against them which may increase their likelihood for incarceration. According to the Federal Bureau of Prisons, nearly three quarters (74.6%) of the incarcerated population has US citizenship (Federal Bureau of Prisons, 2013). It is important to note that in this sample, the majority 93.2% were born in the US; thus, are disproportionately represented in this sample. Indeed our data also finds that those who were in prison were more likely to have seen a health care provider in the previous four months. It is probable that individuals who have interaction with the criminal justice system similarly interact with healthcare providers. This finding requires further exploration as there is clearly a window of opportunity for health care linkage and intervention for G/B homeless youth; however, it is probable than many are not adequately linked into care post release or jail. As G/B homeless stimulant users are not well understood, this group is combined with other sexual minorities which may have unique needs. As a result, minimal intervention work may be particularly tailored to age, drug types, frequency of use and past histories of incarceration-all of which may affect future illicit drug cessation and circumvention of recidivism. Our findings point to several areas of intervention; namely, G/B homeless men are a population at risk for incarceration. Our findings indicate that being older and having less education were associated with self-reported incarceration. Poor education may also present challenges in terms of the ability to obtain employment due to poor job skills. Such lack of employment opportunities combined with a history of IDU may lead to the poor outcome of incarceration. While our data our promising, in this study, the data are based on a self-report baseline questionnaire from a cross-sectional study. Thus, inferences regarding causality cannot be made between variables. Further, the study used a convenience sample limited to a very specific population of G/B men between 18-46 years of age, from one geographic area; all of which limits the ability to extrapolate to a larger population. Furthermore, as this study did not compare G/B men to a non G/B sample, it is not possible to confirm that any of these findings are specific to G/B males only as opposed to a homeless male stimulant-using population. Nevertheless, as many G/B men had seen a practitioner and received hepatitis information, a window of opportunity to promote this information exists. As poor social support is likewise associated with incarceration, future research should be focused on designing comprehensive programs aimed at working with G/B homeless adults in an effort to promote culturally-sensitive linkage to positive social support and health care and drug treatment. --- Author Manuscript Nyamathi et al. Page 10

Gay and bisexual (G/B) homeless adults face multiple challenges in life which may place them at high risk for incarceration. Yet, little is known about this understudied population in terms of risk for incarceration. Baseline data collected from a longitudinal study between October 2009 to March 2012 in Hollywood, California explored correlates of self-reported incarceration among G/B homeless stimulant-using adults (N=353). Findings revealed older age, less education, having children, as well as a history of injection drug use (IDU) and being born in the United States (U.S.) were positively associated with incarceration. Moreover, having poor social support and having received hepatitis information were also correlated with a history of incarceration. Our findings help us gain a greater awareness of homeless G/B adults who may be at greater risk for incarceration, which may be used by health care providers to design targeted interventions for this underserved population.

highly!arbitrary!it!is!a!common!practice!in!Mexico!to!formalize!ownership!after!a!certain! period!of!undisputed!settlement.!Until!a!final!verdict!is!reached,!however,!the!disputed! stretch!of!land!is!technically!considered!as!being!"under!litigation",!that!is,!no!party!can! lay!claim!on!it.!! What!seems!to!happen!is!that!given!the!complexity!of!the!case!and!the!economic!stakes! involved!government!and!judicial!authorities!simply!let!the!process!drag!on,!prolonging! it!with!all!sorts!of!conditions!and!requests.!This!creates!a!situation!of!uncertainty!that!is! exploited!by!the!Zaragoza!Family.!And!time!is!on!the!side!of!the!Zaragozas.!By!the!end!of! 2011!only!13!families!continued!to!live!in!the!neighborhood,!five!of!them!inside!the!gatT ed!compound,!and!eight!families!who!struggle!to!survive!across!the!new!highway!built! to!connect!San!Jerónimo!with!Juárez,!constantly!watched!by!patrolling!guards!on!horseT back!or!in!cars!(Mu<unk>oz!Ram<unk>rez,!2011,!Jim)2011).!! These!developments!have!been!going!on!almost!unnoticed.!All!media!attention!is!turned! to!the!ongoing!excessive!violence!in!Ciudad!Juárez.!An!increasingly!powerful!global!narT rative!of!a!"murder!city"!(Bowden,!2010)!emerges!that!appears!to!threaten!a!profitable! economic!development!model!that!depends!on!promises!of!progress!and!modernization.! In!what!follows,!I!seek!to!show!how!maquila!decisionTmakers!are!able!to!stabilize!this! model!even!at!times!of!extreme!social!and!economic!crisis.!I!argue!that!the!killings!assoT ciated!with!drug!trafficking!play!an!ambivalent!role!in!the!reproduction!of!order!in!JuáT rez.!At!first!sight,!the!narco!violence!is!a!threat,!unmasking!as!it!does!a!regional!develT opment!model!as!failure.!DecisionTmakers!accordingly!respond!by!doing!everything! possible!to!distance!the!maquiladora!industry!from!the!violence.!On!the!one!hand,!this!is! to!the!violence!against!women!in!the!city.!And,!according!to!this!logic,!it!is!mostly!their! own!fault.!Perceived!as!a!threat!to!the!fineTtuned!production!process,!plant!managers! are!constantly!on!alert,!looking!for!"unruly"!women!who!pose!a!risk!for!production.!And! overflows!between!inside!and!outside!can!be!kept!largely!invisible!and!their!irritating! potential!be!contained!they!have!a!stabilizing!effect.! In!such!an!environment!it!is!difficult!indeed!to!imagine!alternatives,!and!even!more!diffiT cult!to!realize!them.!All!this!makes!Juárez!an!exemplary!case!of!how!capitalism!works!in! a!world!where!markets!dissolve!into!meandering!supply!and!value!chains,!"shoring!off"! brackish!tidelands!that!are!rapidly!yet!invisibly!articulated!and!disarticulated!to!global! and!local!capital!circuits.! From!the!perspective!informing!this!paper,!"the!capitalist!economy"!is!neither!a!thing! and!separate!ontological!realm!nor!simply!a!social!construction!independent!from!"the! reality"!it!seeks!to!represent.!It!is!a!naturalized!effect!of!the!division!between!a!fortified! territory!of!market!exchange,!instrumental!rationality,!value,!scarcity,!individual!properT ty,!and!the!hinterlands!of!gifts,!social!and!cultural!norms,!values,!abundance,!and!collecT tivist!land!use.!The!problem!with!such!a!naturalization!of!the!"the!economy"!is!that!a! certain!understanding!of!its!essentials!is!being!taken!

Using an ongoing land conflict in Ciudad Juárez as a case study, I seek to show how maquiladora decision makers stabilize a regional development model even at times of extreme social and economic crisis. I argue that the current killings associated with drug trafficking play an ambivalent role in the reproduction of order in Juárez. At first sight, the violence is represented as a threat, unmasking as it does a regional development model as failure. Decision makers accordingly respond by doing everything possible to distance the maquiladora industry from the violence. On the one hand, this is being done by familiar means, not unlike in previous moments of crises. But on the other hand the events around Lomas del Poleo additionally assume a new quality, as maquiladorization goes hand in hand with an explicit strategy of spatial distanciation, integrating places and people that have hitherto been linked only marginally to the industry. And it is here that the narco-related violence plays different roles: as a convenient veil that allows what might be termed 'ordinary' assertions of brute force to be used under the cover of extraordinary, excessive, violence; and as a welcome excuse in moments of emergency that legitimize violent measures for the sake of a greater good.

INTRODUCTION The rural Black Belt region in the Southeastern United States, known and named for its rich soil, has predominantly African American communities that have the highest cardiovascular disease mortality in the USA (Washington, 1901;Kyalwazi et al., 2022). This region also contains mostly rural communities living in low socioeconomic circumstances (Wimberley, 2010). The high mortality rates may be due in part to the fact that compared to whites, African Americans have higher prevalence of uncontrolled hypertension (Safford et al., 2007;Guo et al., 2012). Americans living in rural Southeastern communities may experience unique stressors that limit their ability to manage chronic health conditions, including lack of social support and poor understanding of their medical conditions due to low health literacy, contributing to worse health outcomes (Dave et al., 2013;Cuffee et al., 2020). This may be particularly critical to evaluate as the extent of disparities experienced by rural communities is not fully reported (Probst et al., 2004). Low health literacy has been associated with worse health outcomes in African American communities (Mensah et al., 2014). Health literacy refers to 'the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others' (CDC, 2021). This includes a patient's ability to navigate interactions with healthcare providers, as well as properly utilize fundamental resources including discharge instructions, educational materials, and medical technology (McDonald and Shenkman, 2018). In rural African American communities, poor health literacy may be reinforced by education disadvantage that limits individuals' access to resources, including occupations with health insurance and routine health care visits (Probst et al., 2004). Individuals who reside in rural communities have been shown to have lower health literacy, as compared to individuals who reside in urban communities (Zahnd et al., 2009). This is further exemplified by the fact that those with low health literacy tend to have more hospitalizations and higher healthcare expenditures in part due to limited preventative measures, as well as an inability to effectively communicate health concerns and understand health instructions (Davis et al., 2020). This includes being less likely to engage in preventative measures, including mammography screening and influenza vaccines (Berkman et al., 2011). For those with chronic diseases like hypertension, this can be particularly detrimental, leading to worse health outcomes and a 75% increased risk of mortality (Mackey et al., 2016). Social isolation reflects insufficient social connections or interactions, which has also been shown to have a negative impact on overall health. In the USA, more than a quarter of older adults live alone and more than a third of older adults report chronic loneliness (Vespa et al., 2012). Social isolation has also been demonstrated to cause more deleterious consequences for those with lower socioeconomic status and for non-white ethnic groups, such as the African American population in the Black Belt. Black men and women have been found to have fewer close relationships and participate in less groups, making them more likely to report social isolation (Alcaraz et al., 2019). Individuals may further face isolation as a result of poverty and rurality, as well as experienced racism and medical distrust within their community (Connell et al., 2019). The U.S. census reports a higher percentage of people of color in the southeastern region, almost 58% of African Americans in the USA. The impact of social isolation on health has been amply documented, including health related quality of life and premature mortality (Uchino et al., 1996;Hawton et al., 2011). These factors may contribute to social isolation and loneliness, which have consistently been linked to poorer health and worse health outcomes (Steptoe et al., 2013;Rico-Uribe et al., 2016). Studies suggest that social relationships may play a significant role in moderating the effect of health literacy on health outcomes (Berkman et al., 2011;Smith et al., 2018). Particularly because people frequently consult friends and family about health concerns, social support can be a critical influence on health management (Verbrugge and Ascione, 1987). High social support may overcome low health literacy by serving as an additional source of medical information. By providing decision-making support and behavioral cues, social relationships may help individuals with low health literacy manage various aspects of their health (Smith et al., 2018). Understanding the various ways in which social functioning relates to health literacy may be critical to helping patients manage and comprehend their health. This may be an especially important goal in rural communities, which have been noted to have lower health literacy than urban populations (Aljassim and Ostini, 2020). The consequences of social isolation and poor health literacy have been demonstrated to be worse for those with lower socioeconomic status and from non-white ethnic groups, such as the Black Belt population. Patients with low health literacy and more social isolation are significantly more likely to report limiting, chronic disease (Smith et al., 2018). Studies suggest social relationships and health literacy influence one another, but the prevalence and significance of this effect on a rural population living with chronic disease is unknown. If social support can overcome some of the deleterious effects of low health literacy in rural African Americans, interventions designed to improve social support could be implemented in this rural region to improve health outcomes. Given the significant disparity in health outcomes compared to the rest of the USA and demonstration of low health literacy and social isolation, these factors should be thoroughly evaluated in rural southeastern African Americans. The Southeastern Collaboration (SEC) to Improve Blood Pressure Control is a large trial currently underway in the Black Belt regions of Alabama and North Carolina that aims to eventually enroll 2000 African Americans with persistently uncontrolled hypertension. The trial is testing the effectiveness of two interventions designed to improve blood pressure control among hypertensive patients-peer coaching and practice facilitation (Cherrington, 2016). Trial participants completed a survey at baseline that included validated instruments assessing social support and health literacy, providing an opportunity to examine the relationship between social support and health literacy. In this population of African Americans who live with persistently uncontrolled hypertension in the Black Belt, we expected: (i) participants would have low levels of social functioning (social isolation, instrumental functioning, and emotional functioning) as well as low health literacy; and (ii) greater social support would be associated with higher health literacy in this population. --- METHODS --- Sample This study was conducted in the context of the SEC, a pragmatic trial comparing the impact of four approaches to improving blood pressure control in rural African Americans: practice facilitation, peer coaching, both practice facilitation and peer coaching, and enhanced usual care (Cherrington, 2016). The setting is the Black Belt region, a remote rural area of the Southeast with a predominantly African American population and a heavy burden of chronic diseases including hypertension. Poverty rates are more than 40% greater than Southern communities not in the Black Belt (Driskell and Embry, 2007). Medical resources are scarce; the Kaiser Family Foundation estimated that the availability of primary care providers is as low as one tenth of the national average (Kaiser Family Foundation, 2020). The SEC trial was designed to enroll 2000 participants who self-identify as African Americans aged 19-85 years with persistently uncontrolled hypertension (defined as mean systolic blood pressure 140 mm Hg or greater over the previous year). Participants had to reside in the Black Belt, in a self-reported rural setting, have no advanced illness causing limited life expectancy or advanced chronic kidney disease, and not have plans to move out of the area for the next year. Approximately 50 primary care practices in the Black Belt of Alabama and 30 primary care practices in the Black Belt of North Carolina were recruited and 25 participants were recruited at each practice. Baseline data included the Patient Reported Outcomes Measurement Information system (PROMIS) social functioning scales, Chew's 3 item health literacy scale, as well as sociodemographics and cognitive functioning. --- Measures Main exposure: social functioning Social functioning was evaluated using the PROMIS social functioning scales, including perceived social isolation, emotional support, and instrumental support. Each scale contains 4 items with response options of 'never', 'rarely','sometimes', 'usually', or 'always' (see Supplementary materials). A cumulative raw score from 4 to 20 was calculated and converted to a standardized T-score to allow comparison to the U.S. population, which set 50 as the mean with a standard deviation of 10. In order to compare and identify those with low or high social functioning in this naturally skewed data, 50 was used to dichotomize each domain of emotional support, instrumental support, and social isolation (Cella et al., 2010). --- Dependent variable: health literacy Health literacy was evaluated using Chew's 3 item health literacy scale. The questions are: (i) How often do you have someone help you read instructions, pamphlets, or written materials from your doctor or pharmacy? (ii) How confident are you filling out medical forms by yourself? (iii) How often do you have problems learning about your medical condition because of difficulty understanding written information? (Chew et al., 2004). Items 1 and 3 have four response options: 'all of the time','most of the time','some of the time', 'a little of the time' or 'none of the time'. Item 2 has four different response options: 'extremely', 'quite a bit','somewhat', 'a little bit', and 'not at all'. Items 1 and 3 were analyzed as dichotomous variables with participants who responded 'none of the time' considered to have adequate health literacy and all others to have inadequate health literacy. Item 2 was analyzed as a dichotomous variable with participants who responded 'extremely' considered to have adequate health literacy and all others to have inadequate health literacy. For purposes of operationalizing modeling, we created a dichotomous variable: Individuals with inadequate health literacy on all three questions were considered to have inadequate health literacy and all others were considered to have adequate health literacy. We selected this dichotomy to screen participants for adequate health literacy if they subjectively have absolutely no difficulty understanding medical information. Those who have difficulties at least some of the time with each question were considered to have inadequate health literacy. --- Covariates We included data on covariates that are known to confound the relationship between health literacy and social functioning. These covariates included age (18-64 and 65+ years), gender, annual household income (<unk>$20 000 and <unk>$20 000), and educational attainment (<unk>high school and <unk>high school). Cognitive impairment was assessed via the Six-Item Screener; patients with a score <unk>3 were defined as being cognitively impaired. This screener assesses participant's cognition by asking basic questions, including orientation to time and 5-minute word recall in order to understand participants' ability to apprehend and discern information. It is a validated and sensitive screener of cognition (Callahan et al., 2002). --- Statistical analysis We began by examining the distribution of the outcome (health literacy) and main exposure (social functioning) in the population. We then described characteristics of the sample with low and high social isolation. We used logistic regression to estimate crude and multivariable adjusted odds ratios (OR) and 95% confidence intervals (CI) to investigate the relationship between each social functioning domain and health literacy separately. We then used ordinal logistic regression to estimate crude and fully adjusted OR and 95% CI to examine the relationship between the social functioning domains and health literacy simultaneously. --- RESULTS In total, 1221 subjects were included in our analytic sample, reflecting ongoing recruitment in its final year. The majority (72.0%) of individuals were between 18 and 65 years old, 61.0% were women, 82.0% had more than high school education, 64.0% were unmarried, and 40.0% had annual income of $20 000 or less (Table 1). Within the sample, 409 (33.5%) had a score >50 on the social isolation PROMIS scale, 317 (26.0%) had a score >50 indicating low instrumental support, and 440 (36.0%) reported low emotional support (Supplementary Tables 1 and2). Those with more social isolation tended to be between the ages of 18 and 65 (80%) and women (65.8%). The majority (56.2%) of these individuals had an annual income less than $20 000. Only 124 (30.3%) of those reporting more social isolation were married and 5.1% of individuals with more social isolation had cognitive impairment, compared to 2.2% for those with less social isolation (Table 1). In contrast, 774 (63.4%) reported inadequate health literacy. Of those with inadequate health literacy 68.0% were younger (between 18 and 65), 55.3% were women, 53.5% had annual income greater than $20 000, 36% were married, and 24.9% had more than a high school education (Table 2). Of the sample, inadequate health literacy was more common in those with less social support across all three domains of social support (Figure 1). Furthermore, 476 (39.0%) responded that they needed help reading instructions, pamphlets, or written materials from their doctor or pharmacy; 600 (49.1%) responded less than extreme confidence in filling out medical forms independently; and 493 (40.4%) responded that they had problems learning about their medical condition because of difficulty understanding written information at least 'a little of the time' (Figure 2). When considering each item in the health literacy scale separately for each social support domain, lack of confidence and difficulty learning about medical conditions due to difficulty reading were more common in those with low emotional and instrumental support (Figure 2). All three domains of low health literacy were more common in those reporting social isolation (Figure 2). Low emotional support, low instrumental support, and more social isolation were all individually significantly associated with inadequate health literacy in crude analyses (Table 3). After adjusting for sociodemographics and cognition, low emotional support and social isolation remained statistically significantly associated with low health literacy (adjusted OR 1.54 CI [1.17, 2.02] and 1.77 CI [1.34, 2.34], respectively). When all social support domains were modeled simultaneously, emotional support and social isolation but not instrumental support were associated with low health literacy in the crude analysis. In the fully adjusted model, only social isolation remained independently associated (adjusted OR 1.62 CI [1.20,2.20]). There was no significant interaction by either age or gender for these relationships. --- DISCUSSION In this sample of rural Southeastern African Americans with persistently uncontrolled hypertension enrolled in a community-based randomized trial, a large minority reported low emotional support, low instrumental support, and social isolation, and nearly two thirds reported inadequate health literacy. Low health literacy was significantly associated with low social support, with the strongest effect observed for social isolation. In all domains of health literacy assessed, those with more social isolation were particularly more likely to have low confidence in their ability to fill out medical forms independently. Social isolation may play a more significant role in overall social functioning, than emotional or instrumental support. This may be because social isolation impacts the other domains, as someone with isolation is also likely to have low emotional and instrumental support. Further evaluation of the interactions between emotional and instrumental support and social isolation may be warranted. The effects of poor social support in minority communities may be compounded as they are surrounded by similar minority communities, leading to widespread, institutional disadvantage. This disparity may be improved with increased resources and human capital to create social structures that more effectively reach all residents to prevent social isolation (Probst et al., 2004). Prior studies have suggested that those who are older, unmarried, and male are more likely to experience social isolation (Smith et al., 2018). We adjusted for sociodemographics and cognition to eliminate the effect factors such as age or mental capacity could have on participants' ability to engage with others. Individuals in rural a Health literacy was comprised of 3 questions: (i) How often do you have someone help you read instructions, pamphlets, or written materials from your doctor or pharmacy? (answers range from 'None of the time'-'All of the time'), (ii) How confident are you filling out medical forms by yourself? (answers range from 'Extremely'-'Not at all') and (iii) How often do you have problems learning about your medical condition because of difficulty understanding written information? (answers range from 'None of the time'-'All of the time'). Participants were considered to less than ideal health literacy if they did not respond 'None of the time' or 'Extremely' to all 3 questions. areas tend to report significant social isolation and loneliness, which may be more severe for those who cannot access support because of personal or cultural factors. Despite residing in a remote rural region, the majority of this sample did not report high levels of social isolation. Some studies have suggested that this variation may be because some rural communities may be tightly knit, and this may be true in the African American rural communities in which these trial participants lived (Henning- Smith et al., 2019). It may be worthwhile to further investigate how certain demographic factors influence the social isolation experienced by individuals living the Black Belt. This study suggests that social support may be a strategy to overcome low health literacy, especially in regions with scarce resources. The SEC includes a peer group intervention arm, which could function to improve patients' understanding of medical conditions and compliance to medical regimens. Furthermore, trained peers can serve as a model to help individuals learn about their health conditions and the role of self-management, improving confidence in the ability to manage health (Lee et al., 2004). In past studies, the most consistent improvement after participating in a coaching intervention is greater confidence in the ability to self-manage chronic diseases, a concept known as self-efficacy. The peer coaching model being tested in the SEC is wellsuited to these African American rural communities, where low health literacy is common. Risk factors for low health literacy have traditionally included lower education level, male gender, younger age, and non-White ethnicity, (Christy et al., 2017) which were consistent with the findings in our sample. However, more studies may help evaluate the way in which these demographics intersect and effect low health literacy. This study is one of the first to evaluate the relationship between health literacy and social functioning in this rural, remote African American population using a validated health literacy scale and PROMIS social functioning scales. Examining this large sample of individuals provides insight to the differences in social functioning and health literacy within a minority group with chronic disease. Though the SEC was still recruiting participants at the time of the study, we felt this large sample size was appropriate to investigate this critical relationship, in order to guide future studies. Our study has limitations worth noting. The sample was composed of individuals enrolled in a randomized trial, possibly limiting generalizability. Our measure of health literacy emphasizes the understanding of written information, without evaluating the specific ability to understand verbal information which may skew results for certain participants. Our dichotomization of the Chew health literacy scale designated those reporting any difficulty understanding health information or filling out forms as having inadequate health literacy, which may not be practical for this subjective scale. Additionally, this population had relatively high social functioning, possibly reflecting the tightly knit communities in the Black Belt but limiting generalizability to other rural communities. Nevertheless, the very high burden of chronic diseases and short life expectancy in the southeastern Black Belt warrants study of this unique population. Additionally, this was an observational study thus we could not determine causality between social functioning and health literacy. In conclusion, in this sample, most participants reported high social functioning despite their rural environment. Those who reported low social functioning differed from prior studies in that they tended to be younger women, rather than older men. A majority of the sample had inadequate health literacy, with younger men with low educational attainment at significant risk for low health literacy, consistent with past studies. Those with low social functioning were more likely to have inadequate health literacy, suggesting that social support may have a significant role in a patient's ability to learn about and understand healthcare information. Of the three social functioning domains, social isolation, which may be most easily identified in patients, was most strongly associated with inadequate health literacy, an effect that was similar for both genders and older and younger individuals. These findings support the promise of peer support interventions to assist individuals with chronic diseases living in the remote rural Black Belt region. --- Supplementary Material Supplementary material is available at Health Promotion International online.

African Americans living in low socioeconomic circumstances are at high risk of poor health outcomes; this is particularly true for those with hypertension. Many African Americans with chronic hypertension living in the rural impoverished Southeastern USA have low health literacy and are socially isolated. These factors are known to have a negative impact on health outcomes, but it is possible that social support may overcome some of the effect of low health literacy. Since little has been reported about this association, we examined the association between social functioning and health literacy in a rural African American population in the Southeast USA. We used baseline data from participants in the Southeastern Collaboration to Improve Blood Pressure Control, a pragmatic trial that recruited rural African Americans with persistently uncontrolled hypertension and collected survey data. Overall, 33.5% of the 1221 person sample reported social isolation, 26.0% reported low instrumental support, 36.0% reported low emotional support, and 63.4% had inadequate health literacy. All three domains of low social functioning were significantly associated with low health literacy, and this effect was robust to multivariable adjustment for sociodemographics and cognitive functioning for social isolation (adjusted odds ratio 1.62, 95% confidence intervals 1.20-2.20). In conclusion, the majority of this sample living in the NC and AL Black Belt had high social functioning but inadequate health literacy. Tests of interventions to improve social support, especially social isolation, may be warranted to overcome low health literacy in this high-risk rural population.

Background This paper reviews the design and methods of a multiarm, randomized cluster evaluation of the Adolescent Girls Empowerment Programme (AGEP) in Zambia. The programme was designed as a multi-sectoral intervention targeted to vulnerable, rural and urban adolescent girls ages 10-19. Embedded in the design of the programme was a rigorous, randomized evaluation that recruited a cohort of eligible adolescent girls invited to participate in the programme and girls residing in control areas. The evaluation sample was interviewed at baseline in late 2013 and early 2014 and is being tracked annually through 2017, with mid-term results collected in 2015 immediately after the end of the intervention and endline results in 2017, two years post programme termination [1]. Adolescent girls in less developed countries face a variety of risks and challenges in achieving positive and successful transitions to adulthood [2]. In Zambia, a significant proportion of girls enter marriage and/or begin childbearing early, even prior to the expected age of school leaving. As indicated by the 2013-2014 Zambia Demographic and Health Survey (DHS), nearly one in three girls aged 20-24 had married by age 18, with a similar percentage having begun childbearing [1]. The prevalence in rural areas is nearly double that of urban areas for both early marriage (39% versus 22%) and early childbearing (42% versus 21%) [3]. Not surprisingly, given rates of early marriage and childbearing, the risk of school leaving for girls during the school age years is high, with 18% of primary school age girls and 59% of secondary age girls not currently attending school [1]. The Zambia DHS also indicates that girls in Zambia begin sexual activity early, have low rates of condom use and have risk behaviours that increase their chances of acquiring sexually transmitted infections (STIs), including HIV. For instance, the median age of sexual debut is 17.7 years, approximately 1 year prior to marriage, and the prevalence of sexual initiation among 15-19 year olds is 27%. Further, of those who are currently engaging in premarital sexual activity, only 36% reported using a condom at last sex. The low rate of consistent condom use implies exposure to STIs, with 4% of adolescents 15-19 reporting having an STI or symptoms of a sexually transmitted disease and 5% having acquired HIV. The prevalence of HIV more than doubles by the time girls reach the ages of 20-24 years [1]. The literature indicates that women and adolescent girls in many less developed settings are lacking the needed assets and capacities required to make more positive and healthier transitions that would facilitate their breaking out of persistent poverty and closing the economic and livelihoods gap between men and women. In such settings, women and girls' opportunities are inhibited by traditional practices, adverse gender norms and roles, and weak institutions and laws [4,5]. For instance, Duflo argues that inequality, poverty and the lack of access to economic assets, opportunities and labour markets are primary drivers for the persistent disadvantage of women relative to men [5] Other studies have directly linked gender power inequality to HIV risk behaviours and exposures [6]. Women and girls who have limited social capital and are more isolated engaged in riskier sexual behaviours, are more likely exposed to sexual violence and less likely to be tested for HIV [7,8]. To address these disadvantages, the Population Council, working in collaboration with the YWCA, Making Cents International, the National Savings and Credit Bank of Zambia (Natsave) and the Zambian Ministry of Health designed AGEP, a multi-sectoral and girlcentered intervention. The theory of change underlying AGEP (Fig. 1) proposed that working directly with adolescent girls to build their economic, health and social assets would facilitate positive change across a broad set of critical adolescent girls' experiences and outcomes, including early marriage and first birth, schooling attainment, age of sexual debut, sexual risk behaviour, and transmission of sexually transmitted infections, including HIV. The theory underlying AGEP defines assets as a store of value that can be drawn upon by adolescent girls to address challenges and overcome vulnerabilities [9][10][11][12]. It was posited that an asset-building framework operates by enhancing girls' knowledge and capacities, building confidence and efficacy, strengthening social networks, changing aspirations, and providing access to both health and financial services and resources. Further, it was theorized that such changes at the individual-level would percolate up to changes in the contextual environment within the family and community. --- Intervention design The goal of AGEP was to reach a minimum of 10,000 adolescent girls ages 10-19 across ten sites in four of the ten provinces of Zambia; half of the sites were urban areas and half rural areas. Provinces were purposefully selected in collaboration with the donor, weighing feasibility, resources for the programme and evaluation, and the objective of representing vulnerable adolescent girls. As the programme was specifically designed to reach the most-vulnerable adolescent girls, high-density urban housing compounds were targeted, while a more general sample of rural residential communities were targeted. --- Girls group meetings The AGEP intervention operated for a period of two years in each site from late 2013 and early 2014 through late 2015 and early 2016. Implementation of the programme was initiated sequentially by site, after the baseline evaluation survey was completed in each site. The core component of AGEP was group meetings in which 20 to 30 girls met at a local community space for one to two hours per week, most often on weekends. A community-based model was selected as school-based sexual reproductive health programs have been known to have limited impact because teachers find it hard to break out of their typical teaching styles and programs are adversely affected by an already low quality of schooling [13,14]. In addition, school-based programs exclude out-of-school girls, which were meant to be included in the intervention. The girls' groups were stratified by age (10-14 and 15-19) and by marital/fertility status; girls stayed with their original groups as they aged or otherwise changed status. The group sessions were based on three core curricula (Table 1) and used illustrative vignettes, role play and participatory methods to maximize impact. The meetings were led by an older, young woman from the community who had been trained to initiate and guide educational sessions and exercises on a variety of subjects. The mentors were trained in groups at central locations at the beginning of the programme, with one refresher training approximately one year into the program. Monthly mentor meetings also took place with site coordinators to address mentor questions, experiences and provide short reviews of curriculum topics. All the girls who were assigned to the intervention were invited to participate in AGEP girls' groups. Two additional programme components were randomly assigned to some of the girls groups. The additional components were: 1) the provision of a health voucher and, 2) an offer to open a bank savings account. Eligibility for these add-on components was determined by whether or not the girl group was located in a cluster that was randomized to receive the additional components of the intervention. The assignment of girls to the programme component is discussed further in the evaluation design section below. --- Health vouchers Girls who attended AGEP in randomly-selected areas to receive a health voucher targeted to improve access to ten general health and sexual and reproductive health services at partner public and private health providers (Table 2). The design and implementation of the AGEP health voucher was done in consultation with the Ministry of Health at the national, provincial and district level [15]. A published review of the literature found that health vouchers had been successful at increasing service utilization and improving the quality of health services provision across a variety of health care and developing country settings. The review, however, noted that the breadth and scientific quality of evidence was limited and more rigorous assessments of effectiveness were needed [16]. A study of a programme that provided health vouchers specifically to adolescent girls in Nicaragua found that it directly reduced many of the barriers to adolescent sexual reproductive health care, including improving provider knowledge around adolescent health issues, attitudes and communication practices [17]. These studies suggested the potential for improving SRH care among adolescents in Zambia and the value of implementing a voucher programme embedded within a rigorous evaluation design. In addition to the sexual and reproductive, nutritional and general health knowledge building during the weekly girls' groups, two additional programme elements supported the AGEP health voucher component: 1) the Nutrition needs during pregnancy, infant feeding, child feeding and growth monitoring Note: Two additional sessions developed for the end of the programme that helped girls to plan for "life after AGEP". There was also an additional session for girls in Arm 3 providing details about the savings account <unk> denotes sessions only for girls who were aged 15 and older at baseline. training of health facility staff in providing adolescent girl-friendly health services, and 2) a results-based financing of service provision at health facilities [18]. All participating health facility providers and staff were given a two-day training on adolescent girl-friendly health services that followed a set curriculum specifically designed for AGEP and supported by the Ministry of Health. Monthly monitoring and quality assurance visits to health facilities were also conducted [19]. The training sessions provided an overview of AGEP and the mechanisms of the health voucher, but also covered topics geared to improve the quality of service delivery for adolescents, including values clarification about family planning, HIV and STIs, communicating and counselling adolescents, identifying and addressing barriers to adolescent health care and the sexual and reproductive health rights of adolescents. The results-based financing component of the health voucher also provided a basis from which to reimburse the health facility and provider for service use among adolescent girls. At private and non-governmental organization facilities, AGEP reimbursements were based on negotiated fees for each service provided. At public facilities, as health services are generally free, the payments to the facilities for each service, whose rates were agreed on with MoH and were uniform for all public facilities, were distributed by fixed percentages: to the providers (50%), to the health facilities for supplies (25%), for per-diems to the district health staff to assist in monitoring service provision (20%), and to the District Health Office for overall management of the programme (5%). Reimbursements were a function of the total number of girls with vouchers obtaining services and the number of services that they accessed during the period that the vouchers were usable. It should be noted that unlike other programme elements, due to delays in finalizing the arrangements, the health voucher started after one year of the programme and continued one year after the AGEP girls groups ended. --- Savings accounts While the girls groups provided capacity building in money management, budgeting and savings, the provision of a bank account was designed to provide a mechanism for knowledge and skills to be operationalized in practice. The bank account, provided to girls who would not otherwise typically have access to financial services, was hypothesized to reinforce girls' money management skills, promote economic asset building, grow a culture of savings, facilitate economic independence and provide assets in cases of emergencies or other basic needs. Savings accounts, as opposed to microcredit, were used as studies had shown in other settings limited results for such programs [20] and that micro-credit was not an appropriate first exposure to formal financial services for vulnerable adolescents [21]. Savings accounts, when appropriately designed for adolescents, had been shown in other contexts to improve financial literacy, increase the self-efficacy and savings behaviours [22]. Even in resource poor environments among vulnerable populations, savings accounts were found to increase savings and improve positive opinions about HIV prevention methods [23]. The bank account component was implemented in partnership with the National Savings and Credit Bank of Zambia (NatSave). The AGEP "Girls Dream" savings account provided adolescent girls a formal place to store money. The girls who were eligible for the savings account were provided an orientation in the girls' group sessions and a field trip was organized to the nearest NatSave branch to provide additional information and to open accounts. Girls who were under the age of 18 years were required to have co-signatories present at the account opening. The bank account was specifically tailored to the financial needs of the girls, with a very low minimum opening balance of KW 2.5 (US $0.50) and the ability to deposit or withdraw funds with no fees. The girls who opened accounts could deposit on their own, although for girls under age 18 years the accounts required their co-signatories to withdraw funds. While no direct financial resources in the form of grants or loans were provided to AGEP girls, market research based on focus group discussions conducted during the pilot period suggested that adolescent girls had a variety of sources of income that may be used to build their savings, including cash from parents, paid piecemeal work, agricultural production, selling goods made and transactional sex [24]. --- Intervention population As noted previously, AGEP was designed to serve a minimum of 10,000 vulnerable adolescent girls in Zambia aged 10 to 19 in ten sites located within four of the ten provinces of Zambia. The study provinces and the number of sites per province were selected purposefully through discussions with the donor regarding representation of the target population and consideration of the feasibility of operating AGEP while also conducting a randomized evaluation. Study sites within provinces were selected randomly from a sampling frame of potential sites, anchored to proximally-located health and banking facilities. The sampling frames of potential sites for urban and rural areas were developed separately. For urban areas, a list of high-density residential compounds was created, and sites selected randomly from the list, while in rural areas sites were randomly selected among areas that met the following conditions: that they were located within 15 km from a health facility and within 65 km of a NatSave bank branch. AGEP was also designed to draw participants who expressed multiple levels of vulnerability through their residential location and the socio-economic characteristics of their households. To avoid over-representing girls in AGEP who have already experienced the outcomes that were to be prevented by the programme (early marriage, becoming pregnant, dropping out of school), these indicators were not directly used to identify vulnerability. Instead, an indicator of vulnerability was created using whether girls were behind in school for their age as a proxy, which also permits characterization of the vulnerability of girls younger than those who already have been married, pregnant or dropped out of school. Conceptually, the measure captures adolescents who are at risk of adverse outcomes, given the primacy of education in a child's life at these ages. Early in the schoolgoing process, many children fall behind in school due to late entry, repetition of grades, and temporary withdrawal from school; all of these events are a reflection of some degree of personal and household vulnerability. The information used to develop the measure of vulnerability was collected along with other household socioeconomic characteristics via a household survey in all study clusters, which was subsequently used as a sampling frame to determine eligible girls for participation in the programme with the most vulnerable girls selected from the list to receive invitations to participate. --- Evaluation methods and design The objective of the AGEP evaluation was to implement a rigorous randomized design to more confidently attribute the changes in girls' lives to their participation in AGEP. It was expected that the programme would have a positive impact on the longer-term demographic, reproductive and health outcomes of participating adolescents. It was also expected that the impact of the programme on these longer-term outcomes would be mediated through a set of individual assets or skills that the girls acquire through the programme. Given that the AGEP evaluation has multiple components that may lead to improved outcomes, the study was designed and statistically powered to evaluate the impact of each of these components on adolescent girl outcomes, independently for rural and urban areas. --- Randomised cluster design The AGEP evaluation was designed as a multi-arm randomised cluster trial where clusters within the ten study sites were randomised to receive different combinations (arms) of AGEP. The experimental and control arms of the study are displayed in Table 3, along with their associated components. Clusters assigned to the first intervention arm were assigned only the weekly girls' group sessions. Clusters in the second intervention arm were assigned the health voucher in addition to the weekly girls' group sessions, while clusters in the final intervention arm were assigned all components, including the bank account. The multi-arm evaluation provided for a rigorous assessment of the marginal benefit, as well as the incremental cost-effectiveness of each additional component of the intervention. All girls selected for participation in AGEP within a cluster were assigned to the intervention that was randomly selected for that cluster; girls in clusters for the control arm received neither interventions nor placebo exposures. A cluster in the AGEP evaluation was delineated by Census Supervisory Areas (CSAs) that were compiled by the Zambia Central Statistical Office (CSO) for the 2010 national census. CSAs contained approximately 750 households in urban areas and 300 households in rural areas, although the average number of households varies considerably as population densities vary geographically. CSAs in urban areas were spatially relatively small, perhaps a few hundred metres long and wide, while CSAs in rural areas encompassed multiple kilometres. The assignment of CSAs to the experimental and control arms was conducted through a random selection process at a public lottery. The public lottery was conducted to maximize the transparency and community acceptance of AGEP. Local political and community leaders were invited to participate in the lottery, conducted at a centrally-located public facility. The lottery was conducted via a two-step selection process in which a CSA was first randomly selected for participation among all CSAs in the site and then an AGEP arm assigned through a second random selection process. --- Study outcomes The overall objective of AGEP was to make a meaningful change in the traditionally observed trajectories of vulnerable adolescent girls in Zambia as they pertained to early family formation, low schooling attainment and poor sexual and reproductive health. The process of change was posited to advance in phases, with the more immediate changes in the girls' assets and empowerment deriving from their participation in AGEP, translating into positive As the concept of empowerment, mediating and longerterm outcomes are potentially broad and multifaceted, a set of representative indicators was used to epitomise their operationalization in the evaluation as noted in Table 4. The indicators of empowerment ranged across the broad domains of social, economic and health and included measures of self-efficacy, social connections, positive gender normative beliefs, financial literacy, access to savings and sexual and reproductive health knowledge, among others. The longer-term indicators of programme impact ranged across three domains, socio-demographic, educational and health. --- Hypotheses The study will test several hypothesis to assess the impact of AGEP and its components. The hypothesis tests reflect the causal pathways as illustrated in the theory of change (Fig. 1). The impact of the intervention is posited to have operated through four general and domainspecific mechanisms, 1) by improving factual knowledge and building skills, 2) increasing self-confidence and efficacy, 3) increasing adolescent aspirations and motivations and, 4) improving access to key resources and services. The first set of hypotheses reflect the expectation that AGEP is having a strong and positive effect on the array of assets that girls can build upon and utilize to affect change. These are measured as immediate programme outcomes indicators in Table 4. A second set of hypotheses is made regarding the impact of the intervention on what are conceptualized here as mediating factors, reflected through HIV and pregnancy risk reduction behaviours, improved attendance in school and possessing greater economic resources and opportunities. The indicators used to reflect these hypotheses are presented as mediating outcomes indicators in Table 4. Finally, the overall objective and ultimate goal, of the programme is to improve the wellbeing of adolescent girls, reflected in specific ways, by reducing early marriage, early pregnancy and births, increasing educational attainment and reducing the acquisition of HIV and the Herpes Simplex Virus Type -2 (HSV-2). --- Weekly girls groups meetings As noted above, all three intervention arms included weekly meetings in which girls met with a mentor and each other to engage with a curriculum topic for the week, generally discuss their experiences and to socialize with each other. Given the randomized design, it is possible to assess the impact of the girls groups alone. The weekly girls' group meeting is hypothesized, in particular, to have positive effects on the girls' sexual and reproductive health, financial and nutritional knowledge, as well as build their communications, money management and self-advocacy skills. The group meetings also targeted the girls' social assets, including the number of friends reported, the quality of those relationships and whether they report a role model in their lives. Participation in the groups is also hypothesized to reduce social isolation and provide access to community spaces. These relationships and opportunities are, in-turn, hypothesized to weaken regressive gender norms and roles, move aspirations, and improve mediating behaviours, such as attending school. In the domain of schooling attainment, these changes are hypothesized to improve school participation, performance and, ultimately, attainment. If confirmed, these hypothesizes will result in strong and positive relationships between the indicator of randomization to the girls group only study arm and the indicators noted along this continuum of outcomes. --- Health voucher As with the bank account component, the health voucher intervention is hypothesized to directly increase access to health facilities and resources, as well as to increase efficacy and decision-making control over the utilization of health facilities and resources. The effect of the heath voucher component is expected to be distinguishable empirically over and above what is realized through the weekly girls groups alone. In the immediate term, the health voucher is hypothesized to increase the use of sexual and reproductive health services, including the use of modern contraception. Improved sexual and reproductive health, e.g., by obtaining counselling, care and treatment for STIs, is hypothesized to reduce HIV acquisition in the longer-term, while access to contraception is hypothesized to reduce unwanted pregnancy and birth outcomes. In general, it is hypothesized that as specific health issues are prevented or resolved, girls will have more positive assessment of their overall health. --- Bank accounts As noted in Table 1 above, the weekly girls' group curriculum includes 19 sessions on setting financial goals, budgeting and managing savings and expenditures. While the lessons themselves are hypothesized to directly increase knowledge and improve financial and entrepreneurial aspirations, the bank account component of AGEP was designed to provide a direct link and access to financial services to catalyse change. It is hypothesized, therefore, that the provision of a bank account will have positive impact on informal and formal savings behaviour. Increased access and control over economic resources is hypothesized to reduce the need for adolescent girls to rely on household resources from which they have less control to obtain personal items such as clothing and hygiene products, schooling supplies and/or pay school fees. Access to bank accounts is also hypothesized to depress the need for adolescent girls to rely on older and potentially riskier partners and exchange-based sexual relationships. These changes are hypothesized to reduce the prevalence of sexual exchange and, ultimately, reduce girls' acquisition of sexually transmitted infections, including HIV and HSV-2. --- Research population and sample sizes Participants for the research study were randomly selected among all invited AGEP participants who were never married at baseline, stratified by site and age group. For comparability, selection of the control girls followed a parallel process for identifying and selecting vulnerable girls, specifically a ranking of girls by their vulnerability score and randomly selecting girls below a set threshold, with the threshold determined by the total number of girls needed for recruitment into the programme at each site. As the ultimate objective of the funder and the programme was to improve the wellbeing of adolescent girls, the longer-term outcomes in Table 4 served as the focal indicators for the sample size calculations. As limited evidence was available for a sample size determination based on known effect sizes, minimally detectable effects were estimated using Optimal Design Plus Software Version 3.0 for a multi-site randomized trial to determine the most efficient sample size (number of clusters and respondents per cluster) given the budget available for fieldwork [25]. Sample sizes were estimated for the evaluation after four years, with conservative estimates of attrition, 20% for the younger cohort and 35% for the older cohort. The samples were stratified by the younger and older cohorts (10-14 and 15-19) and urban and rural. The age stratification was necessary as there was no age mixing of groups in the weekly girls groups and certain aspects of the curricula were adjusted for age-appropriateness by cohort. The minimally detectable effect sizes were estimated for comparison of each programme component against the control; estimates of effect sizes were not obtained for comparisons between the intervention arms themselves as little prior information was available to guide such an estimation approach. Given a total of ten study sites, it was determined that a total of 40 clusters per arm (four clusters per arm per site) and 20 participants per cluster was the most efficient combination. Baseline (control) estimates of study indicators by age group and residential status were obtained from the 2007 Zambia Demographic and Health Survey [26]. Statistical power of 0.80 and an alpha coefficient of 0.05 were set, while the effect size variability was fixed at 0.00, as analyses would control for site fixed effects [25]. Table 5 provides estimates of prevalence in the control sample and minimal detectable effect sizes, by outcome and study stratifications. The sample size calculations indicated that 3200 girls would be needed at the end of the study to assess all key study impact indicators: 800 girls (within 40 study clusters) in each of the three AGEP arms and in the control arm. An additional 400 girls (within 20 clusters) were designated to be sampled for urban areas in nearby high-density components. These girls and clusters were designed to serve as external controls given the potential for contamination between AGEP and control girls within the same site. Never married girls were targeted at baseline as a significant proportion of older girls would have already experienced the key outcomes that were meant to be impacted by the programme. To achieve the target sample of 3600 girls at the end of the study, the sample size was inflated for non-eligibility and non-response at baseline, attrition from the cohort and refusals for biological specimen collection. Thus, the final estimated sample to be collected at baseline was 7200 or 4800 in AGEP clusters, 1600 in internal control clusters and 800 in external control areas. --- Research instruments A household survey instrument was implemented prior to baseline to determine eligibility for the intervention and for selecting cases in designated control clusters. The household instrument included a roster of all household members with basic socio-demographic information on each member, household asset ownership, housing quality, recent household shocks, access to financial resources and distances to key resources, including schools, roads, health facilities, banks, etc. Comprehensive annual surveys were conducted at baseline and for four subsequent years. The baseline survey is included as an Additional file 1. The surveys instruments measure changes in attitudes, behaviour, transition status, social assets and cognitive skills that may occur over time regarding: educational attainment and schooling transitions; sexual activity, relationship status and sexual partners; marriage and marital dissolution; sexual and physical coercion and violence; gender attitudes, self-efficacy and locus of control; labour force participation and savings behaviour; living arrangements and household resources; mobility and migration; literacy, numeracy and cognitive skills; and ability; financial literacy and knowledge. Surveys conducted after the baseline also include questions of exposure to the intervention to address potential spillover impacts. All questionnaires were translated into Nyanja, Bemba and Kaonde. Survey instruments were implemented by electronic data capture. Computer-Assisted Personal-Interviewing (CAPI) was used for questions that are non-sensitive. CAPI is a process of data capture in which the interviewer reads the question from a computer screen and enters the participant's response directly into a handheld or tablet device. For sensitive questions, including sexual behaviour, sexual violence, HIV risk perception, unwanted pregnancy and abortion, Audio Computer-Assisted Self-Interviewing (ACASI) was used. With ACASI the respondent listened with headphones to pre-recorded questions and response categories, while, if desired and if the participant was literate, simultaneously reading the question on the device screen. The participant entered a response by touching a designated number or option. ACASI maximizes confidentiality and privacy of response, as no one could hear or Not powered at 0.80 to detect programme impact see the question being read, nor the response option selected. Biological markers were collected from adolescents aged 15 and older at baseline (Round 1), after Round 3 (at the end of AGEP), and Round 5 (at the end of the evaluation). HIV status was determined via capillary blood draws obtained from finger pricks. HIV tests were conducted by trained and certified voluntary counselling and testing (VCT) staff. In accordance with Ministry of Health guidelines, we conducted serial testing using DetermineTM and Uni-GoldTM [27]. Both tests have a very high sensitivity (100%) and specificity (>99%) in controlled clinic evaluations, including a controlled laboratory setting in rural Kenya [28]. The respondent was provided the test results. Post-test counseling was guided by National Guidelines for Testing and Counselling [29]. The HSV-2 biological specimens were collected via finger prick. A sample of whole blood was collected and stored in microtainers and laboratory tested. To conduct the laboratory test, serum was derived from the whole blood and the Kalon ELISA assay used, for which the sensitivity and specificity have been found to be high (92% and 98%) respectively in African populations when compared to Western Blot [30]. Indeterminate results were not retested since their prevalence was so low as to make it impractical. After specimen collection all participants were provided information about HSV-2 detection, symptoms, safe sex practices and treatment options. Respondents were provided vouchers with identification numbers to receive their test results at AGEP participating health centers. A validation of the HSV-2 laboratory testing procedures was conducted prior to testing of specimens for the main study to assure the quality of laboratory testing protocols. --- Economic evaluation The study also includes an economic evaluation to rigorously assess the cost of implementing AGEP, as well as to assess the incremental cost-effectiveness of the addon components (health voucher and savings account) relative to the girls group intervention alone.. Direct programme costs were collected from AGEP budgets and financial reports and included both start-up and programme delivery costs for the Population Council and its partners. Participant-specific out-of-pocket and indirect costs data for participation in AGEP and uptake of services were also obtained. The relevant costs for these analyses are the real resource costs of delivering the programme services, not including the costs related to project evaluation. A decision analytic model will be constructed to generate estimates of the incremental costs per negative health outcome averted and positive progress achieved on non-health indicators from participating in AGEP. Incremental cost-effectiveness ratios (ICERS) comparing the add-ons to the girls group only intervention will be calculated to assess whether costeffectiveness varies by study arm. --- Analysis The primary objective of the evaluation is to assess the impact of AGEP on adolescents' intermediate empowerment and longer-term outcomes using the above-noted hypothesis as test criteria. Important as well, analysis will be conducted to understand the underlying processes by which change occurred in the key areas of interest. As a first approach for assessing the impact of AGEP on empowerment and longerterm outcomes, an intent-to-treat analysis (ITT) will be conducted using the original randomised assignment to study arm as the primary indicator of impact. The average treatment effect of the programme on the adolescents in clusters randomised to AGEP relative to girls in clusters randomised to the control will be empirically assessed. The analysis will estimate models that are both unadjusted and adjusted for baseline covariates; both approaches accounting for strata and intraclass correlations within clusters. To accommodate for any baseline differences between AGEP and control clusters that may exist in the outcomes, a difference-in-differences (DID) calculation will be made for each indicator. The mid-term assessment after Round 3 focused on the immediate and mediating indicators as primary outcomes, while in the final assessment after Round 5 the mediating and longerterm outcomes will be the empirical focus. As girls were invited to participate in AGEP, many choose not to do so, intermittently missed the weekly sessions or left the programme before the programme was completed. Therefore a secondary analysis will be conducted that uses a measure of participation intensity as the indicator of impact rather than the study's random assignment. It is important to recognize the statistical estimation problems that arise from self-selection into AGEP, and the degree of participation in it, with the characteristics of girls predicting both their uptake of and exposure to the programme and key outcomes and behaviours of interest. A two-stage instrumental variables estimation approach will be used in which the first stage will predict programme participation, using the exogenous randomised assignment as the key instrumental variable, observed baseline covariates will also be included. The second stage will then use the predicted participation intensity from the first stage along with baseline covariates to test the relevant hypotheses. Appropriate tests, including F-tests on excluded instruments, the Wald F-statistic, and the Hansen statistic for over-identification will quantitatively assess the credibility of the selected instrumental variable. --- Discussion AGEP was an intervention whose objective was to improve important adolescent transitions of girls in Zambia, with the expectation that improved outcomes for girls would lead to life-long improvements in the well-being of women and their children. The rigorous randomized evaluation and cohort study to evaluate AGEP outlined in this protocol paper was designed to address information gaps and the weaknesses recognized in the existing literature, including non-randomized study designs, a lack of information on vulnerable and disadvantaged populations, and short-term durations of assessments [31]. As noted in the literature, the benefits from finding out what works, under what conditions and how for adolescents in a setting such as Zambia is large, as demographically the "cohort of young people age 10-24 is the largest in history," while epidemiologically developing countries face multi-burdens from diseases and are "characterized by high levels of all types of adolescent health problems" [32]. AGEP was a multi-sectoral intervention built off of the core concept of mentor-led, weekly girls' group meetings whose primary objective was to build and empower girls by 1) enhancing their knowledge and skills, 2) building their self-confidence and efficacy, 3) changing their aspirations, and 4) providing access to services and resources. The AGEP programme is unique in the amount of investment in this effort, with over two years of weekly programme activities devoted to girls' empowerment across a range of domains, including sexual and reproductive health, financial literacy, life skills and nutrition. AGEP was not, however, limited to the weekly girls groups, as two additional components, a bank account and health voucher, enhanced the potential impact of the group learnings by providing girls direct access to resources that typically did not exist for them or have high barriers to use. The multi-arm randomized evaluation was designed to assess whether each of these programme components provided additional value added in terms of impact. Determining the impact of AGEP is important in order to provide needed evidence for governments, donors, and other stakeholders to develop policies and programs for adolescent girls. Delineating costs of the programme and the investment needed for added programme components can provide additional critical information about the investment needed to scale the programme and the incremental costs of investments in each intervention component. To achieve this additional aim, the study research protocol included an embedded economic evaluation that collected programme implementation and participant costs. The economic evaluation will provide cost-effectiveness information for each study arm and an opportunity to compare AGEP with alternative programmes that address the needs of adolescent girls in the areas of early marriage and childbearing, education and sexual and reproductive health. --- Availability of data and materials Materials related to this study can be found on the Population Council: http://www.popcouncil.org/research/adolescent-girls-empowermentprogram. --- Additional file Additional file 1: AGEP Baseline Survey. ( Author's contributions PcH, KA, ESH, JB, and FB designed the study with review and suggestions from UKAID-DFID staff and an independent consulting company hired as an external reviewer. PcH, ESH, FB, KA and JB drafted the study protocol and instruments. PcH drafted the manuscript, KA, ESH, JB, FB, NJ, MB reviewed the draft manuscripted, contributed text and provided and feedback. All authors read

Background: Adolescents in less developed countries such as Zambia often face multi-faceted challenges for achieving successful transitions through adolescence to early adulthood. The literature has noted the need to introduce interventions during this period, particularly for adolescent girls, with the perspective that such investments have significant economic, social and health returns to society. The Adolescent Girls Empowerment Programme (AGEP) was an intervention designed as a catalyst for change for adolescent girls through themselves, to their family and community. Methods/design: AGEP was a multi-sectoral intervention targeting over 10,000 vulnerable adolescent girls ages 10-19 in rural and urban areas, in four of the ten provinces of Zambia. At the core of AGEP were mentor-led, weekly girls' group meetings of 20 to 30 adolescent girls participating over two years. Three curriculasexual and reproductive health and lifeskills, financial literacy, and nutritionguided the meetings. An engaging and participatory pedagogical approach was used. Two additional program components, a health voucher and a bank account, were offered to some girls to provide direct mechanisms to improve access to health and financial services. Embedded within AGEP was a rigorous multi-arm randomised cluster trial with randomization to different combinations of programme arms. The study was powered to assess the impact across a set of key longer-term outcomes, including early marriage and first birth, contraceptive use, educational attainment and acquisition of HIV and HSV-2. Baseline behavioural surveys and biological specimen collection were initiated in 2013. Impact was evaluated immediately after the program ended in 2015 and will be evaluated again after two additional years of follow-up in 2017. The primary analysis is intent-to-treat. Qualitative data are being collected in 2013, 2015 and 2017 to inform the programme implementation and the quantitative findings. An economic evaluation will evaluate the incremental costeffectiveness of each component of the intervention. Discussion: The AGEP program and embedded evaluation will provide detailed information regarding interventions for adolescent girls in developing country settings. It will provide a rich information and data source on adolescent girls and its related findings will inform policy-makers, health professionals, donors and other stakeholders. Trial registration: ISRCTN29322231. March 04 2016; retrospectively registered.

To achieve this additional aim, the study research protocol included an embedded economic evaluation that collected programme implementation and participant costs. The economic evaluation will provide cost-effectiveness information for each study arm and an opportunity to compare AGEP with alternative programmes that address the needs of adolescent girls in the areas of early marriage and childbearing, education and sexual and reproductive health. --- Availability of data and materials Materials related to this study can be found on the Population Council: http://www.popcouncil.org/research/adolescent-girls-empowermentprogram. --- Additional file Additional file 1: AGEP Baseline Survey. ( Author's contributions PcH, KA, ESH, JB, and FB designed the study with review and suggestions from UKAID-DFID staff and an independent consulting company hired as an external reviewer. PcH, ESH, FB, KA and JB drafted the study protocol and instruments. PcH drafted the manuscript, KA, ESH, JB, FB, NJ, MB reviewed the draft manuscripted, contributed text and provided and feedback. All authors read and approved the final manuscript. --- Competing interests The authors declare that they have no competing interests. --- Consent for publication Not applicable. --- Ethics approval and consent to participate The research protocol was approved by the Population Council Institutional Review Board (PCIRBprotocol #581), which has a Department of Health and Human Services (DHHS) federal-wide assurance number of FWA00000279. The Population Council IRB has established procedures that adhere to the U.S. Federal guidelines for human subjects as set forth in Title 45, Part 46 of the Code of Federal Regulations (Department of Health and Human Services 1991). The protocol was also reviewed by the University of Zambia's Research Ethics Committee (UNZA-RECprotocol 008-11-12) with federal-wide assurance number is FWA00000338. All study investigators and staff were certified in human subject's protection training prior to study initiation. All study participants provided written consent if they were age 18 and older; assent and guardian written informed consent was obtained for all participants under the age of 18. A two staged consent process was conducted, the first for the behavioural survey and the second for the biomarker data collection. Author details

Background: Adolescents in less developed countries such as Zambia often face multi-faceted challenges for achieving successful transitions through adolescence to early adulthood. The literature has noted the need to introduce interventions during this period, particularly for adolescent girls, with the perspective that such investments have significant economic, social and health returns to society. The Adolescent Girls Empowerment Programme (AGEP) was an intervention designed as a catalyst for change for adolescent girls through themselves, to their family and community. Methods/design: AGEP was a multi-sectoral intervention targeting over 10,000 vulnerable adolescent girls ages 10-19 in rural and urban areas, in four of the ten provinces of Zambia. At the core of AGEP were mentor-led, weekly girls' group meetings of 20 to 30 adolescent girls participating over two years. Three curriculasexual and reproductive health and lifeskills, financial literacy, and nutritionguided the meetings. An engaging and participatory pedagogical approach was used. Two additional program components, a health voucher and a bank account, were offered to some girls to provide direct mechanisms to improve access to health and financial services. Embedded within AGEP was a rigorous multi-arm randomised cluster trial with randomization to different combinations of programme arms. The study was powered to assess the impact across a set of key longer-term outcomes, including early marriage and first birth, contraceptive use, educational attainment and acquisition of HIV and HSV-2. Baseline behavioural surveys and biological specimen collection were initiated in 2013. Impact was evaluated immediately after the program ended in 2015 and will be evaluated again after two additional years of follow-up in 2017. The primary analysis is intent-to-treat. Qualitative data are being collected in 2013, 2015 and 2017 to inform the programme implementation and the quantitative findings. An economic evaluation will evaluate the incremental costeffectiveness of each component of the intervention. Discussion: The AGEP program and embedded evaluation will provide detailed information regarding interventions for adolescent girls in developing country settings. It will provide a rich information and data source on adolescent girls and its related findings will inform policy-makers, health professionals, donors and other stakeholders. Trial registration: ISRCTN29322231. March 04 2016; retrospectively registered.

INTRODUCTION Over the last 15 years, the nature of federal housing assistance in the United States has undergone dramatic changes. As a result of public and political dissatisfaction with public housing projects and an increasing emphasis on poverty deconcentration, public housing projects are rapidly being replaced by other forms of rental assistance such as housing vouchers that provide rent reductions for private market units. 1,2 Not only did the construction of federally owned public housing come to a halt in the 1980s, but more recent US Department of Housing and Urban Development (HUD) programs have funded the demolition of existing developments. In particular, the HOPE VI program, launched in 1992, has funded the demolition of nearly 100,000 public housing units at over 200 sites. 3 While many of these units have been redeveloped, the HOPE VI program has resulted in a net loss of nearly 50,000 units available to very-low-income households. 3 In this sense, HOPE VI has contributed to the broader goal announced by HUD in 1995 of eventually replacing all public housing developments with voucher-based assistance. 4 While public housing in this country serves a racially diverse population, recent demolition initiatives have particularly targeted predominantly black public housing developments in large urban areas. 5 For example, HUD estimates indicate Keene and Geronimus are with the University of Michigan, Ann Arbor, MI, USA. Correspondence: Danya E. Keene, University of Michigan, Ann Arbor, MI, USA. (E-mail: [email protected]) that 95% of those displaced by HOPE VI between 1993 and 2001 were persons of color and 79% were African American. 5 Some have argued that the shift away from public housing has occurred without evidence supporting its benefit for the health and wellbeing of public housing residents. 4,6,7 Conditions in and around many public housing communities are without a doubt in need of improvement, particularly as a result of cuts to maintenance budgets that have left many buildings in disrepair and persistent urban poverty and unemployment that have contributed to neighborhood crime. 2,8 However, some have argued that these conditions are no worse than what is available to low-income families in the private market. 5 Additionally, advocates of public housing demolition have often failed to consider the positive aspects of public housing communities that may be lost as buildings are demolished and residents are dispersed. For example, a significant body of ethnographic literature has documented the important role that social networks and community-based social support resources play in specific public housing communities. [8][9][10][11][12] Public housing residents in these studies describe not only networks of mutual assistance and material exchange, but also a sense of community that is rooted in trust, common goals, and shared challenges. 11,13,14 This community-situated social support may be more accessible to residents of public housing projects than to other low-income families as a result of the greater residential stability that exists in federally owned projects 15 and on account of tenant organizations that provide unique opportunities for collective organizing and social interaction. 9 The important contribution of social integration to health is well-established 16,17 and some research suggests that the health benefits of social integration are significant and may rival in strength the health costs of known risk factors such as cigarette smoking. 18 A large body of literature has documented the important role that social networks play in providing material and psychosocial support 19,20 and buffering against the health consequences of stress. 21 In low-income communities such as public housing developments, ethnographic literature indicates that the pooling of risks and resources across social networks is a critical survival strategy employed to mitigate the health costs associated with limited economic opportunity. 12,19,20 Research indicates that support from family, friends and neighbors may be particularly significant for the health and wellbeing of black Americans, serving as an important resource for coping with race-related stressors and providing identityaffirming alternatives to the dominant cultural frameworks which often marginalize them. 22 James 23 posits that the manner in which low-income black Americans respond to race-related environmental stressors may depend on the size and strength of their social networks and their access to such alternative cultural frameworks. Thus, policies that threaten the integrity of social support resources may have a particularly significant effect on the health of low-income black Americans, who as a population already shoulder a disproportionate burden of morbidity and mortality. 22 Additionally, research suggests that black Americans may face added challenges in the private rental market on account of racial biases among prospective landlords. 24,25 In light of these reasons, and given that black public housing residents have been disproportionately affected by public housing demolition, it is particularly important to better understand the impact of recent policy shifts on the health and wellbeing of black public housing residents. The goal of this study is to add to our understanding of how recent shifts in federal housing policy may affect black public housing residents by examining the association between type of rental assistance and community-based social support. Specifically, we use data from the Survey of Income and Program Participation (SIPP), which provides a nationally representative sample of rent-assisted households, to examine the association between housing-assistance type and reports that neighbors count on each other, watch each other's children, help each other out, can trust each other to intervene in the face of danger or harm, and have access to help from friends to family. Our central hypothesis is that public housing residents will report greater access to social support than other rent-assisted households. While several studies have documented the presence of social support resources in specific federally owned public housing projects, 8,9,11 the current study is the first to provide quantitative measures of these resources in a nationwide sample. Additionally, in order to determine the significance of the SIPP social support measures for the wellbeing of our particular study population, we examine the relationship between the above measures of social support and food insecurity and child education outcomes, indicators of wellbeing that are available in the SIPP. --- METHODS --- Data We use data from the 1996 to 2001 panels of the Survey of Program Participation. The SIPP, conducted by the US Census Bureau, is a stratified probability sample of US households whose main objective is to provide accurate and comprehensive information about the income and program participation of individuals and households in the United States. 26 Participants in each SIPP panel are interviewed every 4 months, producing 12 waves of data over 4 years for the 1996 panel and 9 waves of data over 3 years for the 2001 panel. For the 1996 and 2001 panels, the retention rates for the final waves of data are 65.5% and 70%, respectively. 26 A set of core questions (pertaining to income, expenditures, program participation, and residence) is repeated at each interview, and a set of unique topical questions are asked once (occasionally twice) during the multi-year panel period. Our analyses rely on 2 cross-sectional SIPP samples. The first uses data from the SIPP's child wellbeing questionnaire, which was administered in wave 12 of the 1996 panel and wave 7 of the 2001 panel. This file contains parents' assessment of community support in their neighborhood and information on educational outcomes for their children. The second sample uses data from the SIPP's adult wellbeing questionnaire which was administered in wave 8 for both the 1996 and the 2001 panels. The adult wellbeing file contains questions about access to help from family and friends and also information about food insecurity. Table 1 describes the content and organization of the adult and child wellbeing files. While the SIPP surveys over 35,000 households in each panel, we analyze data from a small subsample of SIPP participants who receive housing assistance and selfidentify as black. For analyses that utilize the adult wellbeing file, we limit our analyses to heads of households, the only SIPP participants who are asked questions about access to help. For these analyses, our final sample size is N=905. For analyses utilizing the child wellbeing file, we further limit our sample to the designated primary guardians of children, the only SIPP participants who are asked questions about community-based support. For these analyses our final sample size is N=454 adults and N=831 children ages 5-17. The 1996/2001 SIPP is ideal for this analysis, not only because it includes one of the largest samples of public housing residents of any social demographic survey, but also because it captures a snapshot of public housing during the early phase of the significant transformations that have occurred over the past decade and a half. --- Measures The core files for all SIPP waves contain measures of public housing residence ("Is this unit in a public housing project, that is, is it owned by a local housing authority?") and rent assistance, ("Is the federal, state or local government paying all or part of the rent for this unit?"). The core files also contain demographic variables that we include as controls in our analyses including, education (for our analyses, categorized as no high-school degree, high-school diploma or equivalent, and at least some college) marital status (for these analyses, dichotomized as married versus not married) and income. We use a measure of total monthly household income that is calculated as an average of the total household income reported for the 4 months of data provided in each SIPP wave. Finally, we use a measure of total household size that is also averaged across 4 months of data. The SIPP child wellbeing files contain several measures that are useful for assessing community-based support. SIPP primary guardians are asked questions about their neighborhoods including, "Are there people in this neighborhood/ community that you can count on?"; "Do people in this neighborhood help each other out?"; "Do people in this neighborhood watch each other's children?"; and "If something happened to your child, would there be someone who you would trust to help out." Each of these items is measured on a 1 to 5 scale, where 1=strongly agree, 4=strongly disagree, and 5=no opinion. We recoded this item so that "no opinion" was a neutral category (3) and so that higher values correspond with greater agreement (5=strongly agree). We also ran additional analyses utilizing a 4-item scale that omits the no-opinion category (10-13% of the sample for each item). In the SIPP adult wellbeing file, the reference person from each household is asked about access to help from family and friends. These items include, "If you had a problem with which you needed help, how much help could you expect from a family nearby?" and "If you had a problem with which you needed help, how much help could you expect from friends?" Both were measured on a 1 to 4 scale, where 1="all of the help I need" and 4="no help." We reverse-coded these items so that higher values refer to a greater expectation of help. While these latter measures are not direct assessments of neighborhood support resources, they provide information about access to social support that may be associated with residence in a public housing project. Additionally, by including the qualifier "nearby," the family support item may be a good indicator of geographically proximate support resources. We use 2 measures; of child and adult wellbeing in our analyses. From the child wellbeing file, we include measures of whether or not a child has ever repeated a grade (available for ages 5-17 years) or has ever been expelled or suspended from school (available for ages 12-17 years). Other studies have shown that aggregate measures of perceived neighborhood support are associated with reduced rates of expulsion, suspension, and grade repetition. 27 Such positive educational outcomes not only provide a measure of child wellbeing, but may also reflect a wellfunctioning household where elders are able to provide more support and supervision. From the adult wellbeing file, we use a measure of food insecurity, assessed on a 4-point scale (1="we have enough of the kinds of food we want" and 4="we often do not have enough to eat"). Through the pooling of risks and resources, 19,20 access to help from family and friends may protect individuals from food insecurity, which has been associated with poor health outcomes. 28 While the above measures are not direct assessments of health, they do capture wellbeing more broadly and are available in the SIPP waves that we utilize. The SIPP does include a measure of self-rated health in its disability file (wave 11 for 1996 and wave 7 for 2001). However, because this measure was not assessed simultaneously with either the adult or child wellbeing files, we did not include it in our analyses. --- Analyses In the first set of analyses, we use ordered logistic regression models to predict social support measures as a function of public housing residence among a sample of black adults who receive rent assistance. As described above, the community support measures are assessed on a 1-5 scale and the access to help measures are assessed on a 1-4 scale. Given that our entire sample qualifies for and receives rental assistance in some form, the public housing and non-public housing groups are inherently well matched. However, in all models we include controls for observable characteristics that differ slightly between these groups and may be related to social support including; age, gender, marital status, educational attainment, total monthly household income, and household size. We also include a control variable designating whether or not an individual resides in a Metropolitan Statistical Area, given that urbanicity may be related to both social support and housing type. Finally, we include a control variable for panel (1996 or 2001) to take into account the possibility that public housing conditions may differ between these 2 time periods. For those social support measures that are significantly related to housing type, we conduct a second set of analyses examining their relationship with measures of wellbeing. Firstly, we use logistic regression to predict grade repetition and expulsion or suspension (among children) as a function of community-based social support. These models contain controls for public housing residence, panel, child's age, child's sex, guardian's age, marital status, guardian's educational attainment, household income, household size and metropolitan status. Secondly, we use ordered logistic regression to predict food insecurity (assessed on a scale of 1-4) as a function of access to help. These models contain controls for public housing residence, marital status, education, age, gender, household income, household size, and metropolitan status. For all analyses, we use balanced repeated replication (BRR) with Fay's correction in order to account for the SIPP's complex sampling design. 26 In the case of the child outcomes, BRR also allows us to adjust for the non-independence of children in the same household. Additionally, for analyses utilizing ordered logistic regression, we test for violations of the proportional odds assumption confirming that the relationships between each pair of outcome groups do not differ significantly. 29 --- RESULTS Table 2 describes sample characteristics of the "public housing" and "other rentassisted" groups. There are few statistically significant (pG.05) differences between the 2 groups on observable demographic characteristics. However, in the adult wellbeing sample, public housing residents are significantly more likely to hold a high-school degree and have significantly smaller household sizes. This may be due to the fact that the adult wellbeing public housing sample contains some residents of senior complexes who are likely to be more socioeconomically advantaged and are less likely to have children living with them. For all measures of community support and access to help, public housing residents have higher mean values than other rent-assisted households and 3 of these relationships are statistically significant at pG.05. Table 3 reports proportional odds ratios from ordered logistic regression models that predict community-support measures as a function of rental assistance type. The odds ratios indicate that in comparison to other rent-assisted households, public housing residents are more likely to report access to social support. This effect is particularly strong for the items, "there are people I can count on in this neighborhood," "we watch each other's children," and access to "help from family nearby." For public housing residents (compared with other rent-assisted households), the odds of each higher level of agreement with the statement "we watch each other's children" are 1.54 times greater, holding all other variables in the model constant. Likewise, for public housing residents (compared with other rent-assisted households), the odds of reporting each higher level of help from family nearby are 1.30 times greater. These relationships are statistically significant at pG.05. Public housing residence is not a statistically significant predictor of the other 2 measures of social support although odds ratios are greater than 1. Table 4 presents results from the second set of analyses which seeks to determine the significance of the SIPP social support measures for wellbeing. The first 2 columns report educational outcomes as a function of the community-support measures that were found to be significant in Table 3. Both measures of social support are associated with significantly lower odds of being expelled from school, but are not significantly related to grade repetition. The last column reports food insecurity as a function of access to help from family nearby. For each level increase in reported access to help from family nearby, the odds of reporting greater food insecurity are reduced by 0.78, holding all other variables in the model constant. --- Sensitivity Analyses We also ran sensitivity analyses (results not shown) to evaluate the robustness of our findings. In these analyses, we omitted the "no-opinion" category for the community-based social support measures and utilized the resultant 4-item scale. For analyses predicting social support as a function of public housing residence, odds ratios were slightly larger than those we report in Table 3. Additionally, one measure, "people in this neighborhood help each other out" was significantly associated with the 4-item measure, but not with the 5-item measure that we use in this paper. The 4-item measure also produced slightly stronger relationships between community support and educational outcomes. Ultimately, we chose to use the more conservative 5-item measure which includes a larger portion of the SIPP sample and is thus less subject to non-response bias. --- DISCUSSION Using a sample of black rent-assisted households from the Survey of Income and Program Participation, we find that in comparison to other rent-assisted households, residents of federally owned public housing developments are more likely to report access to several measures of social support. These findings are consistent with several ethnographic studies of specific public housing developments that have documented the presence of community-based social resources in these settings. 8,11,12 We also find that some measures of social support are associated with significantly lower rates of expulsion or suspension among children and reduced odds of food insecurity among adults. Many questions remain with regards to the mechanisms underlying the associations between public housing residence and social support that are observed in this study. One possibility is that public housing residence provides greater residential stability than other forms of housing assistance and this stability in turn facilitates the development of social relationships. HUD data indicate nearly twice the length of residence for public housing residents compared with voucher users 15 and existing research suggests that residential stability may be protective against the deleterious effects of neighborhood disadvantage through increased access to social support. 30 Unfortunately, data limitations restrict our ability to accurately assess the potential mediating role of residential stability in this study. While the SIPP does collect information about length at current residence, this question was asked only in wave 2 (1 to 2 years prior to when the items we utilize were asked). A significant portion of individuals had moved during this lag time, making it difficult to obtain an accurate measure of residential tenure. Crosstabs of public housing residentsversus other rent-assisted individuals in the wave 2 sample do indicate a slightly longer average length of stay for public housing residents (4.81 years versus 4.05 years), supporting the HUD data and suggesting that residential stability may play a role in the relationships that we observe. However, more research is needed to better understand sources of social support, both in public housing communities and among other rent-assisted households. One limitation of this study is the self-reported nature of the rent assistance variables which have been shown in other studies to contain measurement error. 31 A more accurate way to measure participation in rental assistance programs is to match participants' addresses to HUD records. 7 However, to our knowledge there is no data set that includes such address matches as well as community-based social support measures. Additionally, classification error in the public housing measure will almost certainly bias the estimated effects towards the null. In this sense, our findings represent conservative estimates of the relationship between housing type and social support. Another limitation of this study is the fact that the heterogeneity of public housing in this country is unobservable in this national sample. It is possible that our findings are driven by subsamples of public housing residents, for example those living in large urban areas; or that average effects mask the diversity of social conditions within public housing projects. While we control for residence in a Metropolitan Statistical Area, other differences may be at play. Additionally, due to the limitations of our data, this study also masks heterogeneity in the alternatives to public housing that comprise the "other assisted households" category. Given HUD's current shift toward voucher-based assistance, it would have been useful to directly compare voucher users to public housing tenants. While we do not have accurate information about voucher use for our entire sample, based on subsample analyses and HUD records, we estimate that approximately three quarters of our "other assisted" category are voucher users. Additionally, given the particular emphasis that has been placed on the deleterious nature of federally owned public housing developments 32, the comparison between public housing and all other forms of assisted housing is still a useful one. 4 Finally, it would have been useful to have more direct measures of health, although child educational outcomes and food insecurity do provide some indication of overall wellbeing. As illustrated in Table 1, public housing residents and other rent-assisted households are well matched on observable demographic characteristics. However, to the extent that individuals can choose between rental assistance options, and to the extent to which those who choose public housing would have more access to social support regardless of housing type, such unobserved heterogeneity could introduce bias to our results. Nonetheless, we think that this is unlikely to be a significant source of bias because, in many cases, housing type is likely to be determined by exogenous factors related to availability. For example, individuals may place themselves on waitlists for both vouchers and public housing, and take what becomes available first. Furthermore, research indicates that tight rental markets often impose significant constraints on voucher use, relegating those who would otherwise choose vouchers to public housing. 33 The current study does not allow us to rule out the possibility that more socially integrated individuals are likely to remain in their current housing longer (and hence more likely to be captured in our sample) whereas those who have weaker ties to the community may move out when the option to do so arises, either as the result of increased material resources, the availability of another form of housing assistance, or the opportunity to move in with a family member, for example. Additionally, more frequent movers, who may be less socially integrated in their communities, are likely to be overrepresented among the relatively large proportion (30-34%) of respondents who have attritted by later SIPP waves. However, since these two issues apply to both public housing residents and the other assisted category, we do not believe that this introduces significant bias to our results. The observed associations between public housing and social support combined with the finding that measures of social support are correlated with indicators of wellbeing raises important questions that merit further inquiry and have been largely disregarded by those advocating a shift toward voucher-based assistance. The observed association between public housing residence and social support resources may also help to explain why programs that move residents out of distressed public housing have not produced universally positive health effects. 34 Even if these programs are successful in helping public housing residents access more advantaged neighborhoods, there may be health costs associated with a loss of social support resources. Indeed, existing research suggests that individuals who relocate from public housing often face barriers to establishing new social ties in their new communities. [35][36][37] For many individuals, relocation from public housing results in little to no improvement in housing and neighborhood conditions 33, and in such cases the loss of any social support may be particularly detrimental. Our findings do not imply that there is no need to improve the conditions that exist in US public housing developments. The material conditions in many public housing developments have suffered greatly after decades of disinvestment. Additionally, as a significant body of research has shown, public housing residents must contend with crime and violence in their communities. 2,8 However, the findings from this study suggest that these communities may also contain resources that are protective for their residents. To the extent that additional research supports these findings, the current study suggests a need for strategies of public housing revitalization that improve the physical conditions of federally owned projects, but also maintain the opportunity for current residents to remain in them. For example, recent congressional testimony recommends legislative proposals that protect the rights of original tenants to return to revitalized developments and a reinstatement of the federal one-for-one replacement statute that was repealed in 1995. 38 As public housing demolition continues to occur, housing authorities should be sensitive to the possible importance of social ties among their tenants and provide relocation assistance that facilitates the preservation of social networks. Additionally, the creation of post-relocation resident associations could provide important support and encourage the building and maintenance of social ties among voucher users. While the shift toward tenant-based rent assistance and the demolition of public housing has been justified in part by the presumed social pathologies of public housing developments, our findings suggest that these communities may in fact contain social resources that are less accessible to other low-income renters. For black public housing residents, such social resources likely play an important role in mitigating the health costs associated with both material disadvantage and racial exclusion. Given that existing research indicates extremely high rates of excess morbidity and premature mortality among black public housing residents, 39 it is critically important that future housing policies avoid further threats to the health of this population. Our findings suggest that consideration of social resources in public housing communities may be an important component of future policy conversations.

Recent shifts from federally owned public housing toward tenant-based housing assistance in the form of vouchers raise important questions about the health and wellbeing of rent-assisted households. In particular, little is known about how these shifts in housing policy will affect access to critical sources of community-based social support among those who receive rent assistance. Using the Survey of Income and Program Participation, we estimate the relationship between residence in a federally owned public housing project and the reported presence of social support among a nationally representative sample of blacks who receive rent assistance. We find that in comparison to other rent-assisted households, public housing residents are significantly more likely to report that people in their neighborhood count on each other, watch each other's children, and have access to help from a family nearby. We also find that these measures of community-situated social support are associated with reduced odds of school expulsion among children and food insecurity among adults. In conclusion, we find evidence suggesting that public housing communities contain social resources that are important to the wellbeing of their residents and are less accessible to other rentassisted households.

The Overlap of Youth Violence Among Aggressive Adolescents with Past-Year Alcohol Use-A Latent Class Analysis: Aggression and Victimization in Peer and Dating Violence in an Inner City Emergency Department Sample Y OUTH VIOLENCE IS A SERIOUS public health prob- lem. According to national school-based data, almost 1 in 3 high school students report having been in a physical fi ght in the last 12 months and nearly 1 in 10 students report being the victim of violence from a dating partner (Eaton et al., 2010). Violence rates are highest during adolescence, and homicide is the second leading cause of death among people ages 15-24 years. Both dating and peer violence can result in nonfatal injuries as well; in 2007 more than 600,000 youths ages 10-24 years were treated in the emergency department (ED) for injuries sustained from violence (Centers for Disease Control and Prevention, 2010). Although researchers have examined violence from the perspective of either victims or aggressors, a majority of adolescents involved in violence may be both aggressors and victims (Bossarte et al., 2008;Foshee et al., 2011;Rothman et al., 2010;Swahn et al., 2008). Foshee et al. (2011) investigated the overlap between adolescent peer and dating aggression and found that adolescent girls were more likely to engage in aggression in both types of relationships compared with boys, and boys used more frequent and severe aggression compared with girls. Similarly, Rothman and colleagues (2010) found a large degree of overlap between aggression against peers, siblings, and dating partners using a school-based sample. Both of these studies, however, were limited by a lack of assessment of violence victimization. Bossarte et al. (2008) used cluster analysis to identify patterns of victimization and perpetration of dating and peer physical violence among dating adolescents. The class with the highest levels of dating and peer violence also had higher involvement in delinquent behavior than other classes. Although this analysis accounted for both victimization and aggression, it did not assess risk and protective factors associated with these violent behaviors. Swahn et al. (2008) also demonstrated extensive overlap between dating and peer victimization and aggression but again did not examine factors associated with violence. Based on notions of resiliency theory (Fergus et al., 2005;Rutter, 1987), protective factors may reduce the negative effects of risk factors (Kraemer et al., 1997). Prior literature, which is limited by assessing aggressors or victims only, supports resiliency theory in that known risk factors for adolescent dating violence include alcohol use, depressed mood, harsh parenting, and lack of parental supervision (Foshee et al., 2007;Miller et al., 2009;Temple et al., 2011). Although less is known about protective factors specifi c to dating violence, theoretically, family relationship characteristics such as positive parental involvement and role modeling may be important. Similarly, risk factors for peer violence include alcohol use, marijuana use, exposure to violence, history of violence, and weapon carriage (DuRant et al., 1994;Resnick et al., 2004;Walton et al., 2009). Prior work has shown that parental involvement, pro-social peers, and school achievement are protective factors that help youths overcome the negative risk factors for peer violence (Borowsky et al., 2004;Resnick et al., 2004). A more thorough understanding of the patterns of overlap in violence across relationships (dating and peers), the overlap between victimization and aggression, and the risk and protective factors associated with these behaviors is necessary for effective prevention programs. Additionally, adolescents involved with violence are more likely to report other risk behaviors, including alcohol use, which is consistent with problem behavior theory (Jessor, 1991). The association between violence and alcohol use among adolescents has been clearly established (Ellickson et al., 1997;Silverman et al., 2001;Swahn et al., 2004;Walton et al., 2009). Given this strong association, more information is needed on the profi le of adolescents who engage in both violence and alcohol use to inform interventions that can address both of these risky behaviors. EDs represent a unique setting to study, screen, and intervene for high-risk behaviors among adolescents. Among adolescent males, injury is the most common reason to visit an ED (Melzer-Lange and Lye, 1996), and rates of dating aggression and victimization among adolescents in urban EDs are high regardless of the reason for the visit (Carroll et al., 2011;Whiteside et al., 2009). Approximately one in four teens ages 15-17 years does not have a primary care physician (McCormick et al., 2000) and thus seeks health care in the ED. To date, a single ED-based intervention study for youth violence and alcohol has shown sustained reductions in peer aggression 1 year after the ED visit (Cunningham et al., 2012;Walton et al., 2010). To inform future youth violence and alcohol interventions, more information is needed on the overlap of victim-ization and aggression among both peers and dating partners. The aims of this study are to identify overlap and violence types between peer and dating aggression and victimization using latent class analysis (LCA) among a sample of aggressive adolescents with a history of alcohol use and to identify risk and protective factors associated with each violence class. Based on theory and the literature described above, our hypotheses were that classes would vary based on the type of violence (aggression or victimization) as well as within relationship type (peer vs. dating), and there would be a class of adolescents with high levels of both types of violence across both relationship types. Those with the highest violence risk would have the highest risk factor profi le, including weapon carriage, alcohol misuse, marijuana use, and injury from fi ghting. Findings from this study will fi ll an important gap in the literature by including peer and dating aggression and victimization among a high-risk population with past-year aggression and alcohol use, which will provide critical information for future intervention development. --- Method In this article, we present cross-sectional data collected as part of the recruitment phase of a larger randomized controlled trial of an ED-based alcohol and violence intervention among adolescents (Cunningham et al., 2009;Walton et al., 2010). --- Participants and procedures Patients ages 14-18 years presenting to the ED for any reason (i.e., fever, headache, injury) were systematically approached by research assistants to complete a self-administered computerized screening survey. All surveys were completed after the research assistant obtained parental consent and participant assent (<unk>18 years) or participant consent for those 18 years old. Youths who completed the screen received a $1.00 gift. Patients were excluded if they had no parent or guardian available to provide consent, were actively suicidal, were in police custody, were being treated for sexual assault, or had abnormal vital signs. Participants were included in the baseline assessment if they separately endorsed both past-year aggression (defi ned as physical fi ghting with peers or with dating partners) and past-year alcohol consumption, which was defi ned as a positive answer to the question "In the past 12 months, have you had a drink of beer, wine, or liquor more than two to three times?" Eligible respondents then completed a selfadministered computerized questionnaire and received $20 in compensation. Recruitment occurred between September 2006 and September 2009, noon to 11 P.M., 7 days a week at the Hurley Medical Center, which is an urban Level 1 trauma center located in Flint, MI. All study procedures were approved by the Hurley Medical Center and University of Michigan institutional review boards, and a certifi cate of confi dentiality was obtained from the National Institutes of Health. --- Measures All measures were selected or adapted to ensure both the screening and baseline surveys were concise. Violence. Separate questions were asked regarding physical aggression and victimization with peers (excluding dating partners) and physical aggression and victimization with dating partners (excluding peers) over the past 12 months. Peer aggression items were drawn from the Confl ict Tactics Scale (CTS), which is a validated violence scale that has been used in adolescent samples to assess moderate and severe physical violence (Straus, 1979). Moderate aggression (pushed or shoved, hit or punched, slammed someone into wall, or slapped someone) (Cronbach's =.80) and severe aggression (serious physical fi ghts, class fi ghts, caused someone to need medical care, beat up, kicked, or used a knife or gun on someone) ( =.76) were both assessed separately. To assess peer victimization, similar validated items from the CTS (Straus et al., 1996), which mirrored the questions on peer aggression and used moderate and severe categories of victimization, were used ( =.86). To assess physical dating aggression, the original four-item Confl ict in Adolescent Dating Relationships Inventory (Wolfe et al., 2001) was collapsed in our survey measure into two items assessing frequency of moderate dating aggression (e.g., threw something that could hurt, twisted arm or hair, pushed, shoved, grabbed, or slapped) and severe dating aggression (e.g., punched or hit with something that could hurt, choked, slammed against a wall, beat up, burned or scalded on purpose, kicked, or used a knife or gun on) ( =.86). Two similar items were used to assess the frequency of dating victimization ( =.86). These two questions mirrored the questions on dating aggression and were separated into moderate and severe dating victimization. Response choices for all dating questions were modifi ed to be analogous to the choices offered by the CTS used to assess peer violence (Straus, 1979). When creating distinct variables for moderate and severe violence, participants who report both types of violence were coded as severe (Straus, 1999). The answers for these eight separate violence questions were dichotomized to past-year yes/no. Demographics. Demographic items, including receipt of public assistance and academic performance, were selected from the National Study of Adolescent Health (Harris et al., 2003). Risk factors. To assess injury from fi ghting, participants were asked if they had been injured in the past 12 months from involvement in a physical fi ght (Harris et al., 2003). To assess weapon carriage, participants were asked if they had carried a knife/razor or a gun in the past 12 months (Zun et al., 2005). Two questions ("How often do family members get so angry they throw things?" and "How often do family members hit each other in anger?") were used to assess family confl ict (Moos et al., 1974). Negative peer infl uences, or friend delinquency, was assessed using eight questions from the Flint Adolescent Study ( =.84), such as "How many of your friends drink beer, wine, or hard liquor at least once a month?" (Doljanac et al., 1998). Answers to all eight questions were summed to create a continuous variable from 0 to 32. Alcohol misuse (i.e., missing school, missing out on activities, being involved in a car crash after drinking, trouble getting along with friends secondary to alcohol use) was assessed using the Problem Oriented Screening Instrument for Teenagers (POSIT) (Rahdert, 1991), which is a 17-item scale. None of the items in the POSIT relate to violence during alcohol use. For the resultant composite alcohol misuse variable ( =.83), a cutoff of 2 was previously validated in adolescents to indicate alcohol misuse (Knight et al., 2002;Latimer et al., 1997). Subsequently, a categorical variable of a POSIT greater than or equal to 2 indicating alcohol misuse was created. The Alcohol Use Disorders Identifi cation Test-Consumption (AUDIT-C) (Bush et al., 1998;Saunders et al., 1993) assessed alcohol use frequency and quantity on a typical occasion and heavy episodic drinking, described as fi ve or more drinks per occasion (Chung et al., 2002). A composite alcohol consumption variable was calculated summing the total responses to the AUDIT-C ( =.81) (Chung et al., 2002). Participants were also asked about past-year marijuana use using a validated question from the Monitoring the Future study regarding frequency of use (Johnston et al., 2007). For analysis purposes, this question was dichotomously coded yes/no. Protective factors. The Parental Monitoring Scale, which is an eight-question tool that has previously been validated in adolescents ( =.80-.87) (Arthur et al., 2002), was also used. Participant academic performance and living situation were assessed using items obtained from the National Study of Adolescent Health (Harris et al., 2003). --- Statistical analysis To describe the demographic characteristics and frequency of violent behaviors within the entire study population, descriptive statistics and frequencies were generated using SAS Version 9.1.3 (SAS Institute Inc., Cary, NC). LCA was used to describe the violence (moderate and severe dating victimization and dating aggression and moderate and severe peer aggression and peer victimization) in this population with past-year alcohol use. LCA is a personcentered statistical technique that groups respondents based on a set of measured variables, such as survey items, that can be explained by a set of unmeasured, or latent, categorical variables (Collins and Lanza, 2010). In this analysis, eight distinct indicator variables were used: moderate peer aggres-sion, severe peer aggression, moderate peer victimization, severe peer victimization, moderate dating aggression, severe dating aggression, moderate dating victimization, and severe dating victimization. This analysis was carried out in an exploratory fashion using Mplus (Version 5.2) using both statistical and theoretical endpoints. A two-class model was examined fi rst. Next, classes were added to the model until no further statistical and theoretical improvements were observed. The empirical fi t of the model was based on the Bayesian information criterion (BIC), with lower values refl ecting an improved fi t (Nylund et al., 2007), and entropy, with an entropy value closer to 1.0 indicating better prediction. As per the LCA construct, conditional probabilities of all indicator variables within each latent class were then assessed to further characterize violence within each class. In addition, a graphical depiction of the subgroups was produced to evaluate the conceptual fi t of each model. After a model was chosen based on statistical endpoints and theory, the Vuong-Lo-Mendell-Rubin test and Lo-Mendell-Rubin Adjusted Likelihood Ratio test were both run to ensure that the model chosen was not statistically different from the model with one more class. A p value greater than.05 for the Vuong-Lo-Mendell-Rubin classes and the Lo-Mendell-Rubin Adjusted Likelihood Ratio test indicates that the two models are not statistically different, and thus it is reasonable to choose the simplest model with the fewest number of classes. Thus, the most parsimonious LCA model was retained. Analyses were then conducted to assess the associations between each violence class, demographics, and risk and protective factors described above. First, using chi-square tests for categorical variables and analysis of variance for continuous variables, bivariate comparisons were made to indicate general differences in the classes. Then, a post hoc chi-square test for categorical variables and Duncan's test for continuous variables were performed, examining the specifi c differences across classes for each variable. Next, a multinomial regression model was created using the demographics, risk, and protective factors found to be positively associated in the bivariate analysis. Class 1 was used initially as the reference group in the multinomial model compared with Class 2 and Class 3. To compare Class 2 and Class 3, a second logistic model was created predicting membership in Class 3 using Class 2 as the reference group. To evaluate for multicollinearity, diagnostics were calculated on all variables retained in the fi nal regression using SAS version 9.1.3 (SAS Institute Inc., Cary, NC). --- Results --- Descriptive fi ndings Of patients ages 14-18 years who were eligible for the screen (n = 4,296), approximately 88% were approached by the research assistant to participate, and 88% of those approached completed the screen (n = 3,338). Approximately one in four screened adolescents reported past-year aggression and alcohol use (n = 829; 24.8%); of these, 726 (87.6%) completed the baseline assessment. Of those who completed the baseline, 694 (95.6%) noted past-year aggression and had complete data for dating violence and thus comprise the sample used for this analysis. The mean age of the total sample was 16.8 years (SD 1.3), 55.6% (n = 388) were female, 55.2% (n = 383) were African American, and 57.3% (n = 396) received public assistance. The frequency of all four dating violence variables and all four peer violence variables along with the frequency of additional violence groupings are presented in Table 1 for the entire sample. Of note, 97% (n = 673) of the sample reported either moderate or severe peer aggression, whereas only 28.8% (n = 200) reported that they were involved solely in peer aggression, and 1.7% (n = 12) were solely involved in dating aggression. --- Latent class fi ndings Table 2 and Figure 1 report the conditional probabilities from the LCA examining violence. A three-class solution best fi t the data (BIC = 5450; entropy = 0.77) as compared with a two-class solution (BIC = 5535; entropy = 0.76) or a four-class solution (BIC = 5439; entropy = 0.76). The Vuong-Lo-Mendell-Rubin test (p =.09) and the Lo-Mendell-Rubin Adjusted Likelihood ratio test (p =.1008) indicated that a four-class solution was not statistically different from the three-class solution, and thus the three-class solution was selected for further analysis. Class 1, or the peer aggression (PA) class (n = 362, 53%), had a high probability of pastyear moderate and severe peer aggression but a very low probability of other violent behaviors. Nearly all of Class 2, timization within this class. Class 3, or the multiple domains of violence (MDV) class (n = 203, 29%), had high levels of all violence categories, with most members engaged in moderate dating aggression, moderate peer aggression, and severe peer aggression along with high levels of moderate and severe peer and dating victimization. The frequencies of demographics and violence risk and protective factors are presented in Table 3 for each class. Concerning demographics, post hoc chi-square tests done on categorical variables revealed that there are differences between gender, race, and public assistance across the three classes. There is no difference in the age of participants across classes (Table 3). Among the protective factors, only parental monitoring differed across classes, with the amount of parental monitoring being highest in the PA class (Class 1) and lowest in the MDV class (Class 3). Class 3 also reported the highest levels of risk factors, specifi cally being injured in a fi ght, weapon carriage, friend delinquency, increased family confl ict, marijuana use, and alcohol misuse. Of note, no differences exist in the rates of injury from a fi ght between Class 2 and Class 3, but the rates of injury differed between Class 1 and Class 2 and between Class 1 or the peer aggression + peer victimization (PAPV) class (n = 129, 19%), engaged in past-year severe peer aggression, and all members of the class had past-year moderate peer aggression. Additionally, most members of the PAPV class had past-year moderate and severe peer victimization; however, there were low levels of dating aggression and dating vicand Class 3. Additionally, no differences exist between the rates of alcohol misuse and marijuana use between Class 1 and Class 2, but differences in both alcohol misuse and marijuana use exist between Class 2 and Class 3 and between Class 1 and Class 3 (Table 3). In the multinomial regression (Table 4), those in the PAPV class were less likely to be female (odds ratio [OR] = 0.49, 95% CI [0.32, 0.76]) compared with the PA class. Also, members of the PAPV class had nearly two times greater odds of having been injured in a fi ght (OR = 1.94, 95% CI [1.21,3.11]) and were more likely to report friend delinquency (OR = 1.06, 95% CI [1.01, 1.12]) compared with the PA class. Members of the MDV class had approxi-mately three times greater odds of being female (OR = 3.01, 95% CI [1.95,4.64]) and more than two times greater odds of being African American (OR = 2.15, 95% CI [1.41, 3.27]) compared with the PA class. Additionally, those in the MDV class had higher odds of numerous violence risk factors, specifi cally previous injury from a fi ght (OR = 1.92, 95% CI [1.23, 2.99]), past-year weapon carriage (OR = 2.22, 95% CI [1.45,3.33]), family confl ict (OR = 1.37, 95% CI [1.08, 1.75]), friend delinquency (OR = 1.08, 95% CI [1.03, 1.13]) and misuse of alcohol (OR = 1.94, 95% CI [1.26,3.00]) compared with those in the PA class. Note that parental monitoring was no longer signifi cant once other risk factors were included in the multinomial regression. Further, members of the MDV class had more than six times increased odds of being female (OR = 6.34, 95% CI [3.57,11.28]), more than three times increased odds of identifying as African American (OR = 3.42, 95% CI [1.92, 6.08]), and almost two times increased odds of receiving public assistance (OR = 1.86, 95% CI [1.08,3.20]) compared with the PAPV class. Additionally, those in the MDV class had increased odds of multiple violence risk factors compared with members of the PAPV class, specifi cally weapon carriage (OR = 2.61, 95% CI [1.48,4.62]), alcohol misuse (OR = 2.02, 95% CI [1.11,3.69]), and marijuana use (OR = 2.01, 95% CI [1.10, 3.68]) (Table 4). --- Discussion Extensive overlap between peer and dating violence and between aggression and victimization was observed in this study of aggressive adolescents with past-year alcohol use. Almost all of the sample reported some type of peer aggression, yet only 28.8% reported exclusively peer aggression, and only 1.7% reported exclusively dating aggression. Extensive overlap was also noted between victims and aggressors. The LCA identifi ed three distinct classes of adolescents. Given the varying risk factor profi les across classes, adolescents may respond differently to prevention programs depending on their violence involvement. Within the LCA, almost one third (29%) of the sample was classifi ed in the MDV class. This degree of victimization across relationship types is similar to that reported in other studies (Bossarte et al., 2008;Ford et al., 2010), albeit at a higher baseline rate, which is likely related to the enriched nature of this sample of high-risk youths reporting past-year aggression and alcohol use. Nonetheless, we found differences across the three identifi ed classes of youths. The PA-only class was the least likely class to report the traditional correlates of violence involvement, such as marijuana use, alcohol misuse, and weapon carriage. This class was also the most broadly represented by each of the various demographic groups (age, race, gender, and socioeconomic status). Although the PA class expressed some peer aggression, it is possible that the relative absence of other risky behaviors such as substance use suggests that for some youths residing in urban communities, isolated peer aggression may be normative or necessary. Prior research has demonstrated an association among neighborhood disadvantage and youth violence (Chauhan et al., 2009;Resko et al., 2010), and adolescents who engage in limited forms of aggression may help to protect themselves from becoming victims of violence (Johnson et al., 2004;Molnar et al., 2005;Reese et al., 2001;Voisin et al., 2011). The PAPV class is most similar to that described by the popular press because this class is predominantly male, with high odds of injury and high odds of delinquent friends; yet, they were not more likely to report marijuana use, alcohol misuse, and weapon carriage than the PA class. The PAPV class may represent those involved in frequent fi ghts at school, reporting more peer victimization than the other classes of youths but without being involved in dating violence. Although this study did not address the power dynamic inherent in self-reported victimization and aggression, the PAPV class may use physical violence to cope with their own victimization or may be impulsive and/ or lack social skills to handle confl ict situations (Carbone-Lopez et al., 2010;Dukes et al., 2010;Nansel et al., 2003). It is notable that this class (PAPV) did report more frequent injuries from fi ghting compared with those in the PA class. It is known that, among assault-injured youths, the risk of future violence (as both a victim and perpetrator) is high in the period immediately following the injury (Wiebe et al., 2011). Among youths with a history of injury secondary to assault, attitudes regarding retaliation were shown to predict future fi ghting and aggression (Copeland-Linder et al., 2012). Although it is unknown if the injuries reported in this sample were secondary to aggression or victimization, retaliatory behavior can be either reactive or proactive to violence. Alternatively, it may be that these youths are exposed to settings/neighborhoods in which violence is more frequent or normative (DuRant et al., 1994). Neighborhood studies would be helpful to further elicit the effects of neighborhood composition on violence involvement. Those in the MDV class reported both victimization and aggression with dating partners and peers, and they also reported higher odds of other risky behaviors, particularly alcohol misuse and marijuana use, compared with the PA class and PAPV class, respectively. This class is most consistent with theories that explain and studies that document the clustering of risky behaviors across multiple domains, including alcohol use and violence among adolescents (Jessor, 1991;Walton et al., 2009). The association between alcohol use and youth violence with peers and dating partners can be explained by proximal effects models in which alcohol use impairs informationprocessing capacity, which can lead to an overreaction to perceived provocations and a decrease in a person's inhibition (Pihl and Hoaken, 2002). Chronic effects models, in which heavy alcohol use can result in impaired neuropsychological functioning and exacerbate psychopathological disorders and aggressive behavior, may also explain youths in this class (White et al., 2009). Alternatively, social contextual models suggest that alcohol misuse and youth violence may be associated as a function of shared risk and protective factors (Chermack and Giancola, 1997;Klostermann and Fals-Stewart, 2006). Our results support others who found that involvement in multiple forms of violence may create the highest risk of future injury, adult partner and peer violence, and ongoing drug and alcohol use and substance use disorders (Archer, 2000;Ford et al., 2010;Foshee et al., 2001;Miller et al., 2010). It is notable that the MDV class had increased alcohol misuse and marijuana use compared with the PAPV class, suggesting that substance use intervention is an important risk factor for youths engaging in both peer violence and dating violence and that substance use intervention may be well suited for populations of youths engaged in violence across multiple domains (Walton et al., 2010). Additionally, the MDV class was more likely to be female compared with the PA class and the PAPV class. Researchers have reported that female adolescents are more likely to engage in dating aggression compared with their male counterparts (Archer, 2000;Foshee et al., 2001Foshee et al.,, 2011;;Jain et al., 2010;Rothman et al., 2010). Others also report that high-risk adolescent females may be at equal or higher risk for both perpetrating and being injured by peer and dating violence compared with males (Miller et al., 2010;Ranney and Mello, 2011;Ranney et al., 2011). Yet, most violence prevention programs focus exclusively on males or ignore gender differences. The MDV class also reported more violence exposure (higher odds of weapon carriage, family confl ict, and friend delinquency) compared with the PA class and increased odds of weapon carriage compared with the PAPV class. The youths in the MDV class, like the PAPV class, may also be using violent behavior as a coping mechanism, and more research is needed to further elucidate the motives associated with violent behavior. Finally, because the various types of violence rarely occur in isolation, interventions may be most appropriately targeted at preventing both dating and peer violence, and both aggression and victimization, rather than attending to one subtype. Moreover, resources may be most appropriately directed at screening for those forms of violence that correspond to the highest behavioral risk-specifi cally involvement in both aggression and victimization-or violence across relationships (corresponding to the PAPV and MDV classes). Adolescents who present for ED care after an assault have a high rate of subsequent violence (Wiebe et al., 2011), and the ED may be an appropriate place to identify aggressive and violent youths and to intervene to prevent future violence. Targeting assault-injured youths may be a way to capture youths at particularly high risk for future violence, although programs would need to be available on weekends when alcohol-related violence has been shown to occur more frequently (Wells and Graham, 2003). Walton and colleagues (2010) targeted multiple behaviors using brief interventions to successfully reduce violence among adolescents engaged in aggression and alcohol use, but they did not report outcomes related to dating aggression or victimization. Given the high rates of injury seen in the PAPV and MDV classes, intervention efforts could also focus on impulse control, anger management, and confl ict resolution to decrease retaliatory violence. Additionally, neighborhood-level intervention efforts could focus on changing neighborhood collective effi cacy, improving community resources or programs, or increasing green space and parks (Jain et al., 2010;Molnar et al., 2008). Lastly, this analysis highlights the differences that exist between males and females in peer and dating violence. Again, given the overlap between domains of violence, dating violence interventions should not ignore peer violence or the high rates of aggression reported for female adolescents. Future studies that investigate the trajectory of violence among youths in this class can examine correlates of their risk for long-term negative consequences and continued violent behavior. --- Limitations Although there are several strengths of this study, including the large sample from a diverse urban ED, inclusion of victims and aggressors across multiple relationships, and the use of LCA to determine how violent behaviors cluster, several limitations require discussion. Whereas the use of LCA gives a person-centered approach, there was not adequate sample size to split the sample and replicate the analysis on a smaller piece of the sample. Replication is needed using similar methods. Our fi ndings are limited by the cross-sectional nature of the study, which limits causality and limits our ability to assess reciprocal infl uences of victimization and aggression. It is possible that the incident reported could have occurred in a group setting with someone fi ghting with a dating partner at the same time they were fi ghting with a peer. Future studies are needed using an event-based data collection methodology to tease apart the people involved in incidents of violence. Although participants needed to endorse both alcohol use and aggression to gain entry into the study, it is unknown how many youths engaged in these risk behaviors at the same time. Eventbased methods are needed to further elucidate the temporal relationship between alcohol use and aggression. Although the substance use variables were all drawn from validated surveys, these variables assessed use compared with nonuse; diagnostic assessments of substance use disorders were not feasible in this study. The fi ndings of this analysis also may not generalize to nonaggressive, non-alcohol-using populations, or nonurban populations. In addition, the data were all based on self-reports, which could introduce response bias, but researchers have demonstrated that self-reported data for sensitive information in this population-especially when using computerized assessment and when confi dentiality is assured-can be reliable (Brener et al., 2003;Turner et al., 1998;Webb et al., 1999). Additionally, for practical reasons it was not possible to staff the ED 24 hours a day; future studies should include youths presenting during midnight and morning shifts. Despite these limitations, our fi ndings offer useful insights regarding aggression and victimization among peers and dating partners among an aggressive, alcohol-using population. --- Conclusion Among adolescents with past-year aggression and alcohol use, the comorbidity of victimization and aggression among peer and dating relationships is high. This study contributes to our understanding of aggression and victimization in a high-risk sample and informs potential prevention and intervention strategies. These highest risk youths may benefi t from tailored interventions for both aggression and victimization across relationships, and future research should address co-occurring substance use.

The purpose of this study was to identify overlap and violence types between peer and dating aggression and victimization using latent class analysis (LCA) among a sample of aggressive adolescents with a history of alcohol use and to identify risk and protective factors associated with each violence class. Method: From September 2006 to September 2009, a systematic sample of patients (14-18 years old) seeking care in an urban emergency department were approached. Adolescents reporting any past-year alcohol use and aggression completed a survey using validated measures including types of violence (severe and moderate aggression, severe and moderate victimization with both peers and dating partners). Using LCA, violence classes were identifi ed; correlates of membership in each LCA class were determined. Results: Among this sample (n = 694), LCA identifi ed three classes described as (a) peer aggression (PA) (52.2%), (b) peer aggression + peer victimization (PAPV) (18.6%), and (c) multiple domains of violence (MDV) (29.3%). Compared with those in the PA class, those in the PAPV class were more likely to be male, report injury in a fi ght, and have delinquent peers. Compared with the PA class, those in the MDV class were more likely to be female, African American, report injury in a fi ght, carry a weapon, experience negative consequences from alcohol use, and have delinquent peers and more family confl ict. Compared with the PAPV class, those in the MDV class were likely to be female, African American, receive public assistance, carry a weapon, experience negative consequences from alcohol use, and use marijuana. Conclusions: There is extensive overlap of victimization and aggression in both peer and dating relationships. Also, those with high rates of violence across relationships have increased alcohol misuse and marijuana use. Thus, violence-prevention efforts should consider addressing concomitant substance use. (J.

peer and dating relationships is high. This study contributes to our understanding of aggression and victimization in a high-risk sample and informs potential prevention and intervention strategies. These highest risk youths may benefi t from tailored interventions for both aggression and victimization across relationships, and future research should address co-occurring substance use.

The purpose of this study was to identify overlap and violence types between peer and dating aggression and victimization using latent class analysis (LCA) among a sample of aggressive adolescents with a history of alcohol use and to identify risk and protective factors associated with each violence class. Method: From September 2006 to September 2009, a systematic sample of patients (14-18 years old) seeking care in an urban emergency department were approached. Adolescents reporting any past-year alcohol use and aggression completed a survey using validated measures including types of violence (severe and moderate aggression, severe and moderate victimization with both peers and dating partners). Using LCA, violence classes were identifi ed; correlates of membership in each LCA class were determined. Results: Among this sample (n = 694), LCA identifi ed three classes described as (a) peer aggression (PA) (52.2%), (b) peer aggression + peer victimization (PAPV) (18.6%), and (c) multiple domains of violence (MDV) (29.3%). Compared with those in the PA class, those in the PAPV class were more likely to be male, report injury in a fi ght, and have delinquent peers. Compared with the PA class, those in the MDV class were more likely to be female, African American, report injury in a fi ght, carry a weapon, experience negative consequences from alcohol use, and have delinquent peers and more family confl ict. Compared with the PAPV class, those in the MDV class were likely to be female, African American, receive public assistance, carry a weapon, experience negative consequences from alcohol use, and use marijuana. Conclusions: There is extensive overlap of victimization and aggression in both peer and dating relationships. Also, those with high rates of violence across relationships have increased alcohol misuse and marijuana use. Thus, violence-prevention efforts should consider addressing concomitant substance use. (J.

Introduction The issue of being NEET has remained a significant policy concern for over 25 years in the UK and across the Global North and South. Across the UK, the numbers of young people who occupy positions outside of education, employment, and training has remained in a state of flux, which has peaked during localised and international events, such as the Global financial crash of 2007-2008, the austerity policies of 2010-2012, Brexit, and now the ongoing COVID-19 global pandemic (Wrigley 2022). In England and Wales, this has occurred in the backdrop of loses to statutory careers guidance, youth services, and the introduction of policies based on heightened conditionality, including the Welfare Reform Act (2012) (cf. Holmes et al. 2021;Huegler and Kersh 2021;McPherson 2021). It is important to acknowledge that alongside these policy developments, there are several underlying risk factors that are associated with NEET (L<unk>rinc et al. 2019). In the literature, there is a plethora of complex and dynamic risk factors, such as Free School Meal Status (FSM), Special Education Needs and Disability (SEND), possession of an Education Health and Care Plan (EHCP), and a lack of basic attainment at Level 2 by aged 16 (i.e., 5 GCSEs grade 4-9 or A*-C) including English and Maths (known as 'Attainment 8') (Mirza-Davies 2014). Outside of these formal policy-related concerns, the everyday risk factors include fixed term or permanent exclusion from school, economic status, neighbourhood, early parenthood, mental health histories, and family breakdown (Maguire 2021). These risk factors have "the capability to increase the understanding of various vulnerabilities of young people by placing particular groups such as the low educated, early school dropouts, young mothers, or people with disabilities at the centre of policy debates" (Mascherini 2019:510). Despite recurrent periods of political and social crisis, NEET policy thinking has continued to be "a contentious issue for policy makers, youth services, academia and government alike" (Wrigley 2019). Considering recent developments regarding COVID-19, little is still known about the everyday experiences of young people who are NEET during this event. More so, there is a dearth of evidence considering how such rapid policy transformations have impacted on NEET experienced young people and their wider support networks, prior to and during the pandemic. Much of the existing research, instead, focuses separately on the individual experiences of NEET experienced young people, without an in-depth examination of their wider support networks and the stigmatising effects of recent policy-related environments and infrastructure (Guerra et al. 2022). To understand these issues-firstly, this article critically engages with the concept of 'NEET' and welfare reform policy transformations that has accompanied it. The article then critically assesses the impact of recent events regarding COVID-19 to understand the intersecting crisis of youth unemployment and education that has disproportionately impacted on NEET experienced young people. Thirdly, the article engages with the research methods that were adopted to understand conditionality and sanctioning for NEET young people prior and during the COVID-19 pandemic. Fourthly, the article discusses the findings and analysis, which discuss pre-existing sanctioning and welfare conditionality prior to the pandemic, alongside the changes to education, employment, and training provision for NEET experienced young people during the outbreak of COVID-19 and first national lockdown. Finally, the article outlines a concluding discussion of NEET experienced young people's experiences during the pandemic and the rapidly evolving policy environment associated with welfare reform and conditionality in relation to the COVID-19 crisis and beyond. --- Understanding 'NEET': Key Discourses of Education, Employment, Training and Welfare Reform 'NEET' as a policy discourse has been officially used in UK education and youth unemployment policy to understand the numbers of young people outside of education, training, or the labour market for over 25 years. The NEET population is aggregated by age (16-24 years old), gender, and geographical location (Simmons et al. 2014). According to the official definition in England and Wales, offered by Gov.UK (2019: Online), a young person is considered 'NEET' if all the following criteria applies: • They are not enrolled on a full-time education course and are still attending or waiting for term to start or restart • They are not doing an apprenticeship • They are not on a government-supported employment or training programme • They are not working or studying towards a qualification • They have not had job-related training or education in the last four weeks Office for National Statistics (ONS) data shows that at the end of 2021 689,000 UK young people between the ages of 18 and 24 years old were recorded as not in education, employment, or training (NEET). When compared to the same data from the previous quarter, the NEET rate had increased by 70,000 (Watson 2021). From this data, 368,000 men aged 16-24 defined as NEET in comparison to 322,000 of women. From an international perspective, 'NEET' has been applied to capture differing modes of participation and non-participation in education, employment, and training. The age boundaries differ for those who count as NEET, as across EU member states there is consensus on counting those up to aged 34 years old who are outside of education or unemployed (Mascherini 2019). It is important to note that NEET policy thinking remains controversial in its application. For instance, Anoop Nayak (2015) points out that NEET policy focuses on the so-called deficits of young people and has attracted critique from wider commentators. Indeed, there has been a suggestion that 'NEET' is a 'net widening' approach which promotes risk management and neoliberal agendas, within the very systems and structures that are designed to support young people (Owens and de St Croix 2020). This has also triggered controversies regarding the potential for pre-emptive criminalisation of young people who have experienced being 'NEET' (Day 2022). Over the last two and a half decades, there has been significant increase in attention by policy makers about young people who occupy this category, as "the growth of the NEET group is an even greater problem for society than overall unemployment, as it creates the risk of a lost generation" (Bruno et al. 2014: 594). Tyler (2013:161) points out that NEET policy developments focused on the "double axis of inclusion/ exclusion and work/ worklessness". For Tyler (2013) policies (including NEET) bolstered attention back onto to young people through a plethora of negative media outputs, the creation of punitive Anti-Social Behaviour laws, Dispersal orders, and Parental orders that had the legislative potential to criminalise young people for trivial or previously non-criminalised behaviours (Day 2022). Moreover, employment or education programmes became a 'bolton' to promote further welfare conditionality and punitive sanctioning of young unemployed people (Tyler 2013). Certainly, this has attracted criticism for problematising young people's lives and attempting to control the behaviour of young people living in economically marginalised localities and fuelling media myths and public anxieties of so-called workless communities (Jensen and Tyler 2015). In England and Wales, the introduction of the Welfare Reform Act (2012) produced a series of sweeping and systematic changes to the benefit system for young people under the age of 25, which enhanced the conditionality and eligibility of in-work and out-work benefit entitlements (Crisp and Powell 2017;Holmes et al. 2021). It has been well documented where NEET experienced young people have felt the sharp end of such policy reform, as several structural factors have influenced education and employment outcomes over the last decade, such as the reduction in youth support services, family support, and wider labour market precarity (Cook et al. 2022;Holliman et al. 2023;Szpakowicz 2023). More so, these structural influences have been compounded by a series of events inter alia the Global Financial Crash of 2007/8, centralised austerity measures to public services and subsequent policy reforms. The piloting of Universal Credit in January 2013 merged Job Seekers Allowance (JSA), housing benefits, and income support into one conditional single payment. Universal Credit (UC) is a set of conditional benefit payments offered by the Department for Work and Pensions (DWP) to those unemployed aged 18-65, who are deemed fit to work (Evans 2022). Claimants had to evidence up to 35 hours of job seeking activities per week to meet the conditions of the claim. Claimants had to engage in compulsory meetings at a DWP Jobcentre, monitored by a 'Work Coach'. If the claimant failed to meet such conditions, they were'sanctioned'. Sanctions operated on DWP discretion and a formal 'three strikes' approach, which can include a formal warning, deduction of financial remittances, or termination of claim. Evidence from Holmes et al. (2021) demonstrates how the sanctioning regime serves to push conditionality onto NEET experienced young people through 'threatening' to lose benefit entitlements. The introduction of these policy initiatives has been critiqued for the emphasis on conditionality and enforcing sanctioning regimes upon already socially and economically marginalised young people, including those who are NEET experienced (McPherson 2021;Roberts 2022). Moreover, critics of Universal Credit have argued "the intensity of conditionality has also increased for young people through the additional mandatory conditions imposed under UC [and] the enhanced sanctions regime" (Crisp andPowell 2017:1795). A plethora of research from the United Kingdom has found that Universal Credit claimants who are specifically NEET face a variety of structural and interpersonal barriers towards participation including: family breakdown (Maguire 2021), heightened welfare conditionality and sanctioning (Tyler 2020), inconsistency in welfare payment schedule (Russell 2016), domestic insecurity and homelessness (Scullion et al. 2022), digital exclusion (Szpakowicz 2023), and social isolation and loneliness (Wigfield et al. 2022). Despite these issues and concerns, the utilisation of Universal Credit as a flagship welfare package for NEET young people remains in operation (as of 2023), which was introduced under the Conservative government's Welfare Reform Act (2012). --- COVID-19 and NEET Experienced Young People: Welfare Reform and Reconfiguration The COVID-19 global pandemic has caused significant disruption to all aspects of everyday life, political systems, work, education, global democracy, and international relations (Reay 2020). Arguably, this crisis has overshadowed concerns relating to NEET policy and the lives of young people who have experienced being NEET. The changes in policy, however, have impacted upon these young people inter alia their education trajectories, future job seeking opportunities, and welfare entitlement (Wiggan and Grover 2022). As of late 2021, the pandemic resulted in 5.4 million deaths worldwide, with over 146,000 deaths occurring in the UK, which has the highest mortality rate within European countries (Our World in Data 2021). In March 2020, the UK entered the first period of national lockdown, which was contextualised by the health and social care sector reaching crisis point, compulsory education migrated online (with GCSE and A-Level examinations cancelled), the service sector having paused, and gig-economy work halted, consequently "bringing in its wake rising unemployment, poverty and possibly economic recession, which will, in turn, intensify the already existing pressures on the educational system" (Reay 2020:319). The reverberations of the first national lockdown and subsequent lockdowns are still being felt in terms of economic uncertainty in the UK and the Global North, with the youth unemployment rate having increased during July-September 2020 to 14.8 per cent compared to 11.7 per cent in the period prior to the pandemic lockdown (Powell et al. 2021). Indeed, Roberts (2022) acknowledges that as unemployment rose during 2020 for 16-24 years-olds, although NEET experienced young people in England and Wales have experienced forms of heightened and enhanced levels of precarity, due to service sector jobs, education funding opportunities, welfare support, and employability schemes being effectively shelved (albeit temporarily). By October 2021, pandemic-related Universal Credit uplifts of £20 were removed, leaving NEET experienced young people facing a cost-of-living crises and the additional social insecurities posed by the pandemic. This decision has not been without controversy, having attracted local, national, and international condemnation from bodies such as the UN and Amnesty International (Paliament.UK 2021). Others have also acknowledged that a wider range of young people outside of the NEET category have attempted to access support from overstretched welfare support services and occupied insecure labour market positions at a greater level since the COVID-19-related lockdowns (see Holliman et al. 2023;Scullion et al. 2022). Consequently, NEET experienced young people were, again, eclipsed by emergency social welfare and COVID-19-related labour market activation measures intended for those who were more likely to be able to re-engage in education, employment, or training destinations post-pandemic than their NEET counterparts (see also McPherson 2021;Szpakowicz 2023). The following section of the article discusses the methods for this research, followed by a comparative analysis prior to and during the COVID-19. As such, the article poses to understand how NEET young people were affected by the unfolding challenges of the COVID-19-related lockdowns and the synergies and parallels in-between such experiences beyond their education, employment, and training trajectories. In doing so, my argument emphasises the lack of safeguards for NEET experienced young people during the pandemic and the dangers of universal policy initiatives becoming a 'bolt-on' to a group that have been repeatedly denied dignity and tailored support. --- Method This section outlines the methods undertaken for the study which was carried out in the North of England between September 2019 and September 2020. The study adopted narrative interview methods with young people to elicit their understandings of how dominant societal structures and institutions (i.e., education, employment) shaped the young people's everyday experiences (Heath et al. 2009). Narrative interviews were able to assist the young people in narrativizing their experiences of the past, present, and future (Plummer 1995). The interviews were designed utilising a topic guide, which offered a certain degree of flexibility and opportunity for the participants to decide on the flow of the interview. In total, the sample consisted of 16 NEET experienced young people aged 18-25 years old-seven male and nine female. Eleven of the participants were of White British heritage, with five (1 male, 4 female) participants from ethnically minoritized backgrounds, including one young female of British Bengali heritage, one female of mixed Black British heritage, one female and male who had recently migrated to the UK and were Pakistani nationals, and, finally, a female from a Black British Caribbean background. Throughout September 2019-September 2020, 43 in-depth interviews were conducted-33 interviews with young people and 10 with key professionals. Follow-up interviews were undertaken in three waves; wave one consisted of 16 initial interviews. In wave two, ten young people continued to be re-interviewed and in the final wave (three) seven young people participated. Seven youth professionals participated in an initial interview, with three youth professionals taking part in a final follow-up interview. As can be seen from the 'Research Findings', gender and race/ethnicity had a significant effect on the young people's lives, with several female participants managing complex health and childcarerelated issues, which in part impacted on their welfare entitlement. More so, two participants from South Asian backgrounds (1 Pakistani national female and 1 Bengali British female) had significant intergenerational care responsibilities to siblings and extended family members. NEET experienced participants were selected utilising the assistance of two gatekeeping organisations from youth, community, and careers advice services in the North of England. Both organisations provided support for young people outside of education, employment, and training. One organisation offered a 13-week support programme that was specifically aimed at supporting NEET experienced young people (aged 16-25) back into education or the labour market. The second organisation provided careers advice, personal support, and fortnightly drop-in services for care leavers and NEET experienced young people. Snowball sampling from the organisations supported the recruitment of further young people and professionals of interest to this study (King and Horrocks 2010). Informed consent was obtained by all participants prior to research engagements. Anonymity was using pseudonyms, aliases were attached to organisations, and anonymisation of place and location names was utilised. The research was reviewed and reviewed in line with the University of Sheffield's Research Ethics Committee (UREC). An additional lay review person nominated by the University of Sheffield was appointed to ensure procedural transparency, in line with institutional ethical protocols and to satisfy Economic and Social Research Council (ESRC) ethical guidelines. The initial guiding research question asked, "What are the barriers and opportunities for NEET young people, in relation to Employment and Education/Training?" and explored the social connections and networks that may avail such opportunities (such as family, friends, youth professionals, and educators). The study utilises narrative interviews and narrative analysis to recognise and make sense of the multi-faceted barriers and opportunities faced by young people and supplementing or counter narratives from youth professionals (Elliott 2005). These interviews explored their professional expertise, social support offered, and professional concerns. The youth professionals also contextualised the operational issues across the organisation and wider youth support sector. The youth professional's expertise ranged from qualified youth workers, careers advisors, operational managers, and programme leaders on informal education programmes. Expertise ranged from 10 to 25 years of supporting young people in their respective youth support settings. Given the unprecedented circumstances of the COVID-19 pandemic and the first national lockdown (March-July 2020), the research methods were adapted to facilitate online and telephone interviews with participants. The research questions remained the same; however, the study began to ask additional questions, such as "What are the barriers and opportunities for NEET young people, in relation to Employment and Education/Training (during the COVID-19 related lockdown)?". In-depth interviews were continued via an online browser-based programme (Blackboard Collaborate). For those without internet access, the telephone interviews functioned as a tool to capture their narratives without the need for complex technical and potentially time-consuming interventions. This way, all participants had the ability to continue their involvement in the research and contribute their experiences of being NEET experienced throughout the COVID-19-related restrictions. Due to local lockdown restrictions and new research protocols introduced by the University of Sheffield during the outbreak of COVID-19, research continued either online or via telephone. The fieldwork ended in September 2020, prior to the UK entering a second period of national lockdown. --- Research Findings This part of the paper now explores the findings alongside a discussion of the in-depth interviews with NEET experienced young people and key professionals from the youth support sector. The data explores issues surrounding pre-existing welfare conditionality and sanctioning regimes by central government that have affected NEET experienced young people in this research. It is important to understand that interviews undertaken in the first set of research findings were undertaken in the several weeks leading up to the UK's entry into the first national lockdown on 23 March 2020. The second set of findings relate to the changes in welfare regimes, conditionality, and sanctioning whilst COVID-19 restrictions were temporarily lifted in quarter three of 2020. The data demonstrates a comparison regarding welfare conditionality for NEET experienced young people prior to and during the COVID-19 pandemic utilising the narratives of several different young people and key professional participants. --- Pre-existing Conditionality and Sanctioning Leading up to the COVID-19 Lockdowns The challenges of NEET experienced young people managing Universal Credit and legacy benefits, in a period of heightened welfare conditionality, are nothing new (see also : Tyler 2013;Whelan 2021). Yet, both key professionals from youth organisations and NEET experienced young people discussed in detail the ongoing issues of pre-existing Universal Credit sanctioning regimes as being inappropriate and unfit for purpose. It has been well documented, elsewhere, the complex, intersecting, and dynamic risk factors affecting NEET experienced young people, such as family breakdown, care-leaver status, lack of formal educational attainment, and socio-spatial marginalisation (Russell 2016). NEET experienced young people echoed the concerns from key professionals. Several young people had claimed state benefits once they had reached 18 years old and experienced benefit sanctioning. This was due to administration errors by the Department for Work and Pensions, discrepancies in their Universal Credit claim, or failure to comply with Jobcentre Plus processes and procedures. One key professional, a careers advisor with 25 years' experience, reflected on the interpersonal and structural risk factors facing NEET experienced young people: If you've got someone that's living a chaotic life, that's got problems with housing, family, maybe alcohol, drug-related activities, they're not going to be ready to settle down and engage in education and then that's a knock on effect [...] it costs more money in the long term if [we] don't invest at the early stages, you'll get more people drawing the DWP benefits when they hit eighteen (Jenny, Careers Advisor, January 2020). Due to changes introduced under the Welfare Reform Act (2012), NEET experienced benefit claimants were not entitled to full payments that could appropriately cover rent payments and the cost of living (Shildrick 2018). As a result, NEET experienced participants frequently felt unable to manage their finances and would have to 'trade off' between which shopping, or utility bills could be repaid each month prior to the COVID-19 pandemic. One young person (Jake, aged 19) recalled experiences of being a care leaver and living in a single occupancy residency, where he did not have adequate sustenance. He noted that his 'out of work' Universal Credit payments would be inconsistent each month and would have large financial gaps in upholding his cost of living. This meant he was unable to buy necessities such as food and toiletries. Jake explained that this occurred because of sanctioning due to missing Jobcentre appointments with a Work Coach. Jake cited his relationship with the Jobcentre as 'crap', due to the discrepancies in his payments and the high staff turnover of staff at the Jobcentre. At the time of interview, Jake discussed how his Universal Credit payment schedule had been frozen by the Jobcentre due to a change in his personal circumstances and gaining paid employment. Importantly, Jake noted that he had a poor relationship with family members, particularly with his mother as he subsequently entered a Local Authority care home at 15 years old. Therefore, he did not have many family members or friends who he could contact for emotional and financial support. Jake also noted frequent gaps in aftercare because of leaving local authority care post-16 years old. He discussed being left without access to finances for nearly four months in his independent living facility: --- When you get a job, it affects UC [Universal Credit] because they can't pay you the same payment. I used to get £251, I went onto my statement, and I got zero pounds. I was like, "Wait a minute, why do I have zero pound?" I went four months with no money. I would have starved for months and probably would have been dead by now (Jake, February 2020). A common theme from the data demonstrates that NEET experienced Universal Credit claimants had recurrent cycles of precarious and low paid across several sectors-most commonly care work, retail, and agency-based factory work. Certainly, this confirms similar findings from other pathbreaking scholarship, such as Shildrick et al. (2012) who postulate that young people living in economically disadvantaged towns and cities across the North East of England experienced recurrent shifts between low paid employment, unemployment, and underemployment. This type of work, which culminated from the legacies of de-industrialisation in the 1980s and the growth of unstable employment in such localities, ascribes to what Shildrick et al. (2012:18) coined as the 'low pay, no pay' cycle. In their words: "it refers to a longitudinal pattern of employment instability and movement between low-paid jobs and unemployment, usually accompanied by claiming of welfare benefits". Safaa (aged 21) had recently migrated to the UK from Pakistan. She had undertaken factory work with an employment agency on the suggestion of her Work Coach at the local Jobcentre. Her narrative highlights another dimension of the 'low pay, no pay' cycle and gained precarious work on the directive of the Department for Work and Pensions (see also Shildrick 2018;Shildrick et al. 2012). Safaa recalls how she had worked over the seasonal holidays of Christmas and New Year 2019-2020, which was supplemented by in-work Universal Credit payments. She details the exploitative workplace practices: I think, like by 5 o'clock if there wasn't much work to do, everybody knew that, you just grab a brush, grab like a broom and stuff, and just start sweeping the floors and stuff like that. I worked there like with Christmas and Boxing Day, [...] [by 3rd Jan] I had a text from the agency that I was working for "thank you for your service, but you don't have to come in tomorrow" So, it was basically like a huge crowd of all these people sacked (Safaa, February 2020). In addition to working in precarious circumstances, Safaa notes how she was expected to care for her sibling who was diagnosed with a learning disability and experiencing several developmental, psychological, and physical barriers in attempting to access appropriate support services. She had to manage the structural processes and procedures of the Jobcentre, along with her family's income and respective Universal Credit claims (see also McPherson 2021;Scullion et al. 2022). Safaa had the additional responsibility of managing the complexities of the welfare system in England and Wales for several close family members. Importantly, Safaa also spoke of a gendered and cultural dimension of her experiences managing Universal Credit, whereby she had to cope with feelings of judgment of what relatives from her middle-class surroundings in Pakistan would think about her working in a factory or being in receipt of social welfare (cf. Cook 2018;Shain 2021). She notes "[In Pakistan] -it's like a term where you call them 'la hasil' [Urdu -pointless / having no practical use/ no valuable purpose] and that's basically like -it's not like an insult, but it's not like the best thing for them". Here Safaa touches upon the intersectional nature of welfare related stigma and shame which transcends cultural/familial social ties (see also Tyler 2020). Allied to the themes raised by Safaa and Jake, Ayla (aged 20) who had been a Universal Credit claimant for several months, artfully summarises the issue with precarious and under employment faced by NEET experienced young people. At the time of interview, she had finished working for an employment agency in the local textile factory owned by a high street retailer, which was one of very few employment options presented to her by the Jobcentre. Comparable to Jake, Ayla had also managed growing-up within the care system and supporting her mother who had long-term experiences of ill-health. Despite this, Ayla had managed precarious and short-term agency work in a similar way to Safaa. Ayla points out that: They're all agency [...] They'll hire you from a certain point, like now there's nothing -till about Feb/ March time...'til whenever the peak period hits, then once that's over then they just lay you off. [...] the companies that are employing you because they know that you're agency, they treat you like shit basically. (Ayla, January 2020). NEET experienced young people noted how they had experienced recurrent shifts in under-paid and precarious employment. The accounts presented in this section have dismissed understandings of NEET young people that focuses on individual moral and individual deficits, which have been historically proliferated by successive government actors, policy makers, and media narratives (Shildrick 2018;Tyler 2020). This article has so far demonstrated how pre-existing and new forms of welfare conditionality have intensified in the backdrop of successive cuts to state benefits and services designed to support NEET experienced young people in managing adverse social conditions. More so, the barriers and opportunities faced by NEET experienced young people prior to the pandemic demonstrate that a plethora of familial remittances, cultural norms/expectations, and gender-based caring responsibilities also show a complex intersection with the precarities and discontinuities of welfare support in England and Wales and 'low play/no pay' cycles (cf. Scullion et al. 2022;Shildrick 2018). --- "With the Pandemic Everything Changes!": Experiences of Welfare and Benefit Conditionality During the Initial COVID-19 Lockdown The arrival of COVID-19 and subsequent public health measures and periods of lockdown had a significant impact on public and statutory services, alongside recurrent economic, social, and political crisis since the pandemic outbreak. For a period (30 March-July 2020), NEET experienced participants were not required to engage with Jobcentre appoints and formal work searching was suspended (Wrigley 2022). During this time, Universal Credit payments were temporarily uplifted by an additional £20 per week in England and Wales, to support with heightened costs of living during the COVID-19 initial lockdown (Wiggan and Grover 2022). Intervention programmes and careers support advice were put on hold during lockdown. In its place came a series of lockdown engagement activities, such as CV building, online taster courses with local educational providers to occupy the young people's time (fieldnote June 2020). Key professionals noted how there had been a relaxing of hard 'outcome' cultures that previously engulfed professional youth work practice and organisations working with NEET experienced young people (Howard 2022). One intervention programme manager noted how the pandemic inadvertently led to heightened engagement by some service users, but was reflexive of the rapidly changing support structures in their locality, stating: With the pandemic everything changes! and you don't know how people are going to respond to it. There were young people that responded really well to it and did accept offers of support. That was ranging from things like just updating their CVs, applications for college or applications for jobs or other training programmes (Jacqui, Intervention programme manager, June 2020). Despite this apparent engagement, young people were reflexive of the difficult realities of claiming Universal Credit during lockdown. It has been noted previously how sanctioning regimes were relaxed during the initial COVID-19 period of lockdown. However, some NEET experienced young people still experienced great difficulty in balancing the growing cost of living in addition to the added threat of illness and the breakdown of wider support services, institutions and structures. As Hall (2021:2) reminds us: "public services were hanging by a thread, institutions heavily neoliberalised, people and groups increasingly marginalised, and social inequalities widening". Caitlyn (aged 25) who was a longterm legacy benefit claimant and NEET experienced recalls the difficulties in managing a long-term health condition that had left her unable to work: I had an abscess and obviously I would have preferred to actually go back in see the surgeon but when obviously all this kicked off, they cancelled all the clinics, they were only speaking to people over the phone, so I don't yet know whether my surgery has worked [...] We're four months down now, so yeah, I feel better than I did, but my mental health hasn't been great (Caitlyn, July 2020). For the young people able to work during the pandemic, they were acutely aware of real potential for their Universal Credit and legacy benefits to be cut, despite the relaxing of sanctioning regimes during the first national lockdown and fractional lift in conditional payments. Caitlyn cited her family members as unhelpful in navigating welfare support and experiences of ill-health during the pandemic. Akin to Safaa and Ayla's narrative in the previous section, Caitlyn had long-term care responsibilities to her partner and various family members, which intensified the precarity and seeking of welfare assistance during the COVID-19 pandemic (cf. Holliman et al. 2023;Scullion et al. 2022). Jessie (aged 20), however, exemplifies an intensification of the 'low pay, no pay' cycle during the pandemic and the disposability of her labour as a young and precariously employed supermarket worker. She points out during an online interview: I got the job at Tesco at the end of March. I've only recently finished at Tesco early June.... It to an end because the contracts ended, and they couldn't really extend it anymore. So hopefully like I can find something else again (Jessie, July 2020). Jessie recalled how her extended family networks, such as her father's best friend and boyfriend's grandmother, provided additional advice and job seeking support, including searching for local vacancies, reading CVs/applications, and reassuring Jessie of the difficulties in trying to gain stable employment during times of global uncertainty. As MacDonald et al. ( 2023) reflects from their study of economically marginalised young people experiencing lockdown, the COVID-19 pandemic embolised the already pre-existing inequalities within the labour market and education. For many, however, the pandemic and subsequent lockdowns heightened anxieties and worries about finding work and elevated some concerns about financial security because of the continuously changing and conditional welfare reforms in England and Wales (cf. MacDonald et al. 2023;Shildrick 2018). Throughout the interview process, Jessie expressed her underlying anxieties about how finding work would alter her claim for Universal Credit. Jessie remained alarmed about financial discrepancies or capped/sanctioned payments, as the Department for Work and Pensions services were not easily accessible due to the lack of face-to-face consultations during this period. From an interview undertaken in the same timeframe, Leeroy (aged 19) reflects somewhat positively on claiming Universal Credit during the first national lockdown. He recalls how his payments increased slightly during lockdown. However, this was nothing to be celebrated as Leeroy posits how the payments were not enough to maintain his living standards. The narrative below points out how Leeroy did not think his Universal Credit claim stretched far enough during lockdown: INTERVIEWER: "Can you tell me more about your Universal Credit claim during lockdown?" LEEROY: "At first they was still doing the standard amount that I would get through Universal Credit but they increased it by I think about six, seven pounds or something like that, to help us through, but obviously it just feels like the normal pay, to be honest, 'cos it's not that sort of significant increase, really, so it's probably a couple of quid." Leeroy explained how, like several young people, he had struggled to maintain his Universal Credit claim during the

The purpose of this article is to critically explore pre-existing and continuing welfare conditionality of NEET (not in education, employment, or training) experienced young people in the UK. The article traces the policy history of NEET over the last 25 years, to demonstrate the enduring nature of benefit sanctioning that NEET experienced young people have faced throughout a decade of austerity, Brexit, and now the COVID-19 pandemic. The article engages with key narratives from 43 interviews of NEET experienced young people and youth work professionals, undertaken prior and during the pandemic. Overall, the article argues that government actors and policy makers alike have not gone far enough to support NEET experienced young people. The article found that more structural and institutional levels of support from central government are needed to meaningfully engage NEET experienced young people in their education, employment, and training trajectories throughout periods of crisis.

ed payments, as the Department for Work and Pensions services were not easily accessible due to the lack of face-to-face consultations during this period. From an interview undertaken in the same timeframe, Leeroy (aged 19) reflects somewhat positively on claiming Universal Credit during the first national lockdown. He recalls how his payments increased slightly during lockdown. However, this was nothing to be celebrated as Leeroy posits how the payments were not enough to maintain his living standards. The narrative below points out how Leeroy did not think his Universal Credit claim stretched far enough during lockdown: INTERVIEWER: "Can you tell me more about your Universal Credit claim during lockdown?" LEEROY: "At first they was still doing the standard amount that I would get through Universal Credit but they increased it by I think about six, seven pounds or something like that, to help us through, but obviously it just feels like the normal pay, to be honest, 'cos it's not that sort of significant increase, really, so it's probably a couple of quid." Leeroy explained how, like several young people, he had struggled to maintain his Universal Credit claim during the pandemic to support his living costs and the'misrepresentation' of welfare claimants during the pandemic. He also discussed how family members would frequently 'blame' him for issues within the household, as Leeroy was the only member of his household who was not in employment or education during the first national lockdown. He states: "There was a lot of arguments. There was always things that happened in my household that affected me because they was aimed at me, because which happened over the lockdown that I was blamed for, that I didn't do". Evans (2022:693), drawing on the work of Tyler, points towards the stigmatising effect and divisive logic around benefits, which unveils a system where "claimants are pitted against the 'hardworking' majority". Indeed, Leeroy perceives that he was on the receiving end of blame and stigma from family members due to him being out of work, whilst other family members were providing essential work during the pandemic. Leeroy also echoes this divisive logic when probed about common representations of young people who are in receipt of benefits: INTERVIEWER: "Do you feel like there is a misrepresentation or misunderstanding?" LEEROY: "In a sense of miscommunication between obviously parts of media and people and the public because I've seen posts on it on Facebook, a lot of people are saying how do people get this how come they're on x amount of Universal Credit, and it's just like, easy! [...] It's like we don't get that much! It's not that much that we actually get from Universal Credit. I only get £161 every two weeks [...]. So, obviously, most of my money goes there and I've got my food shop to do. I've got other shops to do [...] it's all gone, there's people who don't understand... maybe speak to people who are on Universal Credit and getting a better understanding of Universal Credit than just looking at how much to get?". Although uplifts in benefit payments have been welcomed, it is clear to see they did not go far enough to support NEET experienced young people during the pandemic. This is evident through the participants not being able to sustain stable employment or engage with educational trajectories throughout the pandemicrelated crisis and beyond. Given the recent direction of welfare policy in England and Wales, it remains doubtful if any further unprecedented additional structural or economic redistribution will be given to NEET experienced (Guerra et al. 2022). Especially those who are in receipt of conditional and means tested benefits throughout the ongoing cost-of-living crisis of 2022-2023. The narratives of NEET experienced young people during the COVID-19 lockdowns have signified a wider societal deficit in providing appropriate structural support, engagement, and understanding. This is despite such young people providing forms of essential work that presented real health and well-being risks and detriments during the pandemic. --- Concluding Discussion Through critically exploring the narratives of NEET experienced young people and key support professionals, this paper has allowed us to understand how welfare conditionality and sanctioning has continued to be utilised inauspiciously against NEET young people during recurrent political and social crisis. The empirical research which informed this paper has revealed how key professionals, such as youth work and educational professionals, are acutely aware of the ongoing challenges faced by NEET experienced young people and had to adapt to the changing policy and work environment, during periods of rapid structural, institutional, and economic challenge. Many of these challenges have been underpinned by changes to state benefits under the auspices of the Welfare Reform Act (2012) and the introduction of Universal Credit in 2013. Despite such reforms taking place over a decade ago, my argument has demonstrated the continuity of pervasive policy reforms that deny NEET experienced young people dignity and care from a variety of sources (including government, family, friends, and wider support networks) when experiencing the unprecedented nature of a global pandemic. By providing a snapshot of NEET experienced young people's lives prior to and during the pandemic, I have demonstrated a continuation and intensity of the barriers experienced by this demographic in England and Wales (see also Cook et al. 2022;McPherson 2021). It is also important to note that, NEET experienced young people have remained critical and conscious of the insecure social structures and precarities of education, employment, and training prior to and during the COVID-19 pandemic. The paper has also shown how NEET experienced young people have had the tenacity to challenge the inequalities associated with benefit sanctioning, recurrent periods of insecure work, and social abjection of this demographic. The paper has pointed towards the need for greater structural and fiscal reinvestment in NEET policy thinking that combat the 'low pay, no pay' status quo for NEET experienced young people (Shildrick et al. 2012). The COVID pandemic has exposed the insecurity of institutions and structures such as education and health care, alongside the potential for further austerity measures associated with the cost-of-living crisis. Fractional uplifts in state benefits during the initial COVID-19 pandemic have not gone far enough for claimants under the age of 25. The paper has suggested the need for bolstered support structures and meaningful financial remittances to manage the ongoing precarities and shortfalls in educational support and employment during times of national crisis, such as what has been demonstrated throughout the pandemic. --- Declarations Ethical Statement The project was approved by the University of Sheffield University Research Ethics Committee (UREC), Reference Number 028138. The project was additionally reviewed by a lay member of UREC, in accordance with funding requirements from the Economic Social Research Council (ESRC). All data was anonymised, and full informed consent was gained from all human participants. --- Conflict of Interest The authors declare no competing interests. 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://creativecommons.org/ licenses/by/4.0/.

The purpose of this article is to critically explore pre-existing and continuing welfare conditionality of NEET (not in education, employment, or training) experienced young people in the UK. The article traces the policy history of NEET over the last 25 years, to demonstrate the enduring nature of benefit sanctioning that NEET experienced young people have faced throughout a decade of austerity, Brexit, and now the COVID-19 pandemic. The article engages with key narratives from 43 interviews of NEET experienced young people and youth work professionals, undertaken prior and during the pandemic. Overall, the article argues that government actors and policy makers alike have not gone far enough to support NEET experienced young people. The article found that more structural and institutional levels of support from central government are needed to meaningfully engage NEET experienced young people in their education, employment, and training trajectories throughout periods of crisis.

Background Alcohol is a psychoactive substance with dependenceproducing properties. Alcohol use is one of the leading risk factors for disease, disability and death among young and middle-aged men and women in many countries, associated with more than 200 diseases and injury conditions and with 2.3 million deaths attributed to it globally in 2015 [1,2]. Asia is the fastest growing alcohol market, accounting for over 30% of global alcohol sales in 2014, with an estimated overall 176% growth from 2000 to 2019; China and India are leading the growth with rates of 382% and 1245% respectively [3]. Alcohol companies focus on youth drinking because they want to establish drinking habits that will be carried on and even expanded in middle age. Furthermore, binge drinking is more common among young people compared with older age groups [4,5], and young persons are being targeted by alcohol marketers through the development of new products and sophisticated marketing techniques [6]. Motivations to drink in young people, which have been extensively studied [7,8], commonly include to obtain social rewards such as camaraderie and approval, to enhance positive mood or wellbeing, to cope with negative emotions, and to avoid social rejection [9]. Nowadays, the internet and other social media have substantially extended the range of peer engagement, and gaining greater respect from peers is a major reason why youth is a risk period for alcohol use and abuse [10]. Although harmful use of alcohol among young people has been widely discussed in western countries [11], little attention has been paid in Asian countries. A recent World Health Organization (WHO) report highlighted the increasing adverse effects of alcohol use particularly on young people compared to older adults in still-developing Asian countries [8], pointing out that alcohol use among this group deserves special attention due to their biological and psychological vulnerability [8]. The present study reviews alcohol consumption patterns and related health and social issues among young people in Asian countries, defining young people as those aged 15-29. Strategies for prevention and control of alcohol-related harms are discussed and assessed in terms of their potential contribution to future policies to reduce harmful use of alcohol among young people in Asia. --- Search strategy We conducted a comprehensive thematic review of PubMed, Web of Science and Google Scholar for reports, reviews and journal articles published in English between 1st Jan 1990 and 31st August 2016, with search terms pertaining to "alcohol use or alcohol consumption or drinking", "current drinking or risky drinking or risk alcohol use or risky alcohol consumption" "young people or youth or adolescent or adolescence" "health outcome or social outcome or harm" and "Asia or Asian countries". The full search method of the review is elaborated in the Appendix. Only three WHO reports [8,12,13] on youth drinking in Asia were found in the initial search. We then narratively searched "youth drinking or drinking among young people" in eight selected Asian countries to identify country-specific studies, including China, India, Japan, South Korea, Malaysia, Mongolia, Thailand and Vietnam. Because Asia contains a variety of cultures and civilisations, with different traditions of drinking, these eight countries have been chosen as countries of substantial size for which there is available data that will give a sense of patterns and the extent of variation in the region. Forty-one reports, reviews and journal papers were identified and included in the final review (see Fig. 1). We also reviewed several major international sources of data and information regarding alcohol use in young people or youth: WHO (NFHS-3) in India were used in this review as sources of the prevalence of current drinking among young people in Hong Kong and India. The GSHS is a longitudinal survey conducted in many countries, and the results from the latest survey in selected Asian countries were abstracted. We also reported some results from the 2015 Global Burden of Disease Study's modelled estimates of number of deaths and percentage of total death attributable to alcohol use among young men and women aged 15-29 years in the eight Asian countries [1]. The measuresof current drinking (in the past 30 days) or risky or heavy episodic drinking (60 g or more of alcohol consumed in a single drinking occasion in the last 12 months) or alcohol's health or social harms among young people aged 15-29 yearswere abstracted from the reviewed studies. The Oxford 2011 Levels of evidence developed by the Oxford Centre for Evidence-Based Medicine [14] was used to assess the quality of studies in the thematic review. --- Prevalence and patterns of drinking among young people in Asian countries Prevalence of drinking and per capita alcohol consumption Among teenagers within Asia, there are big differences by country in the consumption of alcohol. Figure 2 shows alcohol per capita consumption among male and female youth aged 15-19 years in eight Asian countries in 2010 using data from the WHO's Global Information System on Alcohol and Health [15]. Alcohol per capita consumption for male adolescents was higher than for females in all eight countries, and males aged 15-19 years in South Korea consumed substantially more alcohol per capita than male adolescents in China, India, Japan, Malaysia and Thailand. The prevalence of current drinking among young people has been measured in a wide variety of surveys in Asia (shown in Table 3 in the Appendix). There are 9 surveys reporting results for an age spread in the range of 15-24 years, and 8 more surveys where the lowest age in the spread was under 12 or the highest was above 29. However, many samples were of parts rather than the whole of the country and the reported rates often varied substantially between different surveys in the same country, even when the same age group was interviewed. Because of the inconsistency of survey methods and samples across different Asian countries, only five Asian countries for which data was available in the same age group were selected to compare the prevalence of current drinking among young males and females aged 15-24 years in Fig. 3. The figure shows that the prevalence of current drinking among 15-24-year old males and females in cities in China, Taiwan, and Vietnam was higher than in India and Thailand. Higher prevalence of current drinking was found in the older age group (20-24 years) in India and Thailand, which is opposite to the pattern in the other three countries or regions. The studies from the GSHS mainly focused on youth aged 13-19, and were conducted in different years across selected Asian countries (see Fig. 4), suggesting more than 10% of youth aged 13-19 were current drinkers in a majority of Asian countries. --- Heavy drinking Heavy and risky drinking was common among young people, and those under age 35 had the highest levels of risky drinking practices in a study in Mongolia [16]. Among school students aged 12-17 in China, 11.4% of males and 5.1% of females had binge drinking at least once a month [17]. In South Korea, 7.9% of young males and 7. 3% of young females had drunk heavily on 1-2 days in the Fig. 2 Alcohol consumption among males and females aged 15-19 in eight Asian countries in 2010. Alcohol consumption per capita (litres) among male and female 15-19-year olds; countries include China, India, Japan, Malaysia, Mongolia, South Korea, Thailand and Vietnam; 95% Confidence Interval bars are shown; alcohol consumption data in eight Asian countries and elsewhere are available in the WHO's Global Information System on Alcohol and Health [15] past 30 days, while 1.6% of males and 0.9% of females had drunk heavily on more than 5 days in the past 30 days [18]. About 27% of teenagers aged 13-17 years and 26% of young adults aged 18-29 years had engaged in risky drinking in Malaysia [19]. In high schools in Japan, 3.0% of students were frequent drinkers (drank alcohol 10 days or more in the past month) [20]. In Thailand, very high-risk drinking (drinking more than 100 g for males and 60 g for females per day) was reported by 8.1% of boys and 1.8% of girls aged 12-19 years, and 16.6% of males and 4.6% of females aged 20-24 years. In a rural district in northern Vietnam, 35% of young people (18-24 years) were excessive drinkers, with 1. 9% binge drinkers and 11.8% problem drinkers as measured by their AUDIT score [21]. In India, 59% and 21% of males and females aged 18-34 years drank heavily (over 60 g alcohol) in a single drinking occasion in the last 12 months, while the heavy episodic drinking rate was still higher in Japan -76% among young males and 45% among young females [22]. --- Alcohol-related harm among young people in Asia Adolescents and young people are typically more vulnerable to alcohol-related harm from a given volume of alcohol than other age groups [23][24][25]. Drinking and heavy drinking are also associated with a variety of social and health harms among young people in Asia, and may be instrumental in the occurrence of the harm. A summary of detailed studies of the relation of drinking to health and social harms among young people from survey studies in eight Asian countries is presented in Tables 4 and5 in the Appendix. Heavy drinking was found to be significantly associated with suicidal ideation, suicidal attempts and, self-distress in many Asian countries [19]. HIV risk behaviours have been found to be strongly linked with binge drinking and its frequency among rural adolescents in Vietnam [26]. Effective measures to prevent binge Fig. 3 The prevalence of current drinking among males and females aged 12-24 years in five Asian regions. Prevalence of current alcohol consumption in the last 30 days (current drinking) among males and females 12-24-year olds; countries/regions include Shanghai (China), India, Taiwan (China), Thailand and Hanoi (Vietnam) Fig. 4 The prevalence of current drinking among youth aged 13-19 in selected Asian countries and districts. The prevalence of current drinking among youth both sexes 13-19-year olds in selected Asian countries and districts; the results were abstracted from Global School-based Student Health Surveys [66] drinking are thus essential to HIV prevention, especially among youth aged 18-20 years [26,27]. Students who started drinking at age 12 or younger, and at 13 or 14 years, were significantly more likely to be currently smoking, currently drinking, engaging in heavy smoking and heavy drinking than students who began drinking at age 15 or older. Studies from Western countries suggest that before 14 years of age, early onset of alcohol use was a predictor of impaired health status because it was associated with increased risk for alcohol dependence and abuse at later ages, alcohol-related motor vehicle crashes, and other unintentional injuries [27][28][29][30][31][32][33][34][35]. Adolescents who have used alcohol were more likely to have used other substances, and to have engaged in sexual behaviours and fights [36], while young people with current alcohol consumption were more likely to have poor academic performance, family conflict or social problems [37]. The projections in the recent Global Burden of Disease Study 2015 (Table 1) found that alcohol was ranked as the greatest risk factor for young and middle aged men in most Asian countries (but not in Malaysia), both in terms of attributable disability-adjusted life-years lost and mortality rates [1]. More than 15 % of total deaths among young men aged 15-29 years were attributable to alcohol use in China, Japan, South Korea, Thailand and Vietnam (see Table 1), amounting to a large number of deaths each year. The proportion of total deaths attributable to alcohol use was smaller in India and Malaysia. South Korea had the highest percentage of deaths attributed to alcohol use among both males and females. --- Strategies for prevention and control Despite the large health and social burden associated with harmful use of alcohol, it has remained a relatively low priority in public health policy in most Asian countries [38]. Harmful use of alcohol can have serious health, social and economic consequence both for the drinker and for others around the drinker, and for society at large. Population-based interventions have been considered as effective means to reduce alcohol consumption and alcohol-related harm. The WHO has recommended five "best buys"the most cost-effective policy interventions to tackle harmful use of alcohol in the national context, including restricting access to retail alcohol, raising taxes/prices on alcohol, imposing bans on alcohol advertising, enforcing drink driving laws, and offering brief advice for hazardous drinking [39]. We compared alcohol policies within these five "best buys" across the eight Asian countries, using policy data from the World Alcohol Strategy 2014 [40] (shown in Table 2). It should be recognised that some policies are set at subnational levels, and may vary within a country; this is particularly true for India. There is a wide range in Asia in terms of the extent of market and behavioural regulation around alcohol; it is apparent that "alcohol policy" has not yet really hit China in the era when a freer entrepreneurial market makes it a public health necessity. The majority of Indian states have set their minimum ages at 21 years or higher [41], resulting in relatively low prevalence of alcohol drinking among young people [42]. In contrast, there is a substantially higher prevalence of alcohol consumption among young people aged 16-29 years in China (see Table 3), which is the only country among the eight Asian countries in Table 1 without a law for a minimum legal drinking age. Compared with six other Asian countries, Mongolia is the only country which has a national alcohol monopoly and there are state level alcohol monopolies in some Indian states [40,43]. Government monopolies for the sale of alcohol could reduce alcohol consumption and related harm among young people, and such a system allows for more limits on the number of liquor stores and the trading hours and days than the private sale system [44,45]. Nevertheless, restricting availability may have much less effect in countries where one third of the alcohol drunk is informally produced and sold outside any government Increasing alcohol prices delays the start of drinking, slows young people's progression towards drinking large amounts, and reduces young people's heavy and risky drinking behaviour [46,47]. Table 2 shows that alcohol tax policies exist in all selected Asian countries. A study in Vietnam found increasing the price and reducing the availability of alcohol are potential means to reduce alcohol use among young people [48]. The taxation system in Thailand, 'Two-Chosen-One' (2C1), combines specific taxation (as a function of the alcohol content) and ad valorem taxation (as a function of the price); the higher one will be chosen when taxes are calculated according to the two alternatives, which it is argued results in a great potential to reduce simultaneously alcohol consumption and prevent drinking initiation among young people [49]. Alcohol is often supplied to adolescents and young adults by their parents, care-givers and peer friends. In China and South Korea, adolescents were often introduced to alcohol at home or friend's home via a taste from their parents' liquors during family gatherings or special celebration events [8,50]. Protective parenting practices and disapproving caregiver's attitudes towards youthful alcohol use can deter alcohol use among young people [51]. Social supply of alcohol to adolescents should be regulated via legislation, as early drinking leads to higher alcohol dependence in later life. Asian countries can learn from the social supply laws in Australia, which provide that supplying alcohol to a minor is illegal [52]. Evidence from longitudinal studies suggests that initiation of youth drinking and of riskier patterns of youth drinking are affected by exposure to alcohol advertising in social media, or in the form of movie content or of alcohol-branded merchandise [53], and similar associations were found in Taiwan, China [54]. The effects of exposure to alcohol advertising seem to be cumulative; young people are likely to continue increasing their consumption as they move into their mid-20s in markets with a greater amount of alcohol advertising [55]. Some Asian countries (such as China, Thailand and Vietnam) have implemented a partial ban of alcohol advertising in some media. Others have not had any alcohol advertising regulations (e.g. Japan and Laos). Alcohol companies are sponsors of major music and sports events where youth are heavily involved, sponsoring the International Music Summit in China, the Japanese team in the Olympics, Thai football teams and World Cup soccer [56]. In contrast, direct alcohol advertising is not permitted in the broadcast media or on billboards in Malaysia, except in the state of Sabah; this reduces exposure to alcohol advertisements and may <unk> <unk> <unk> <unk> <unk> <unk> <unk> <unk> Health warning labels on advertisements / container <unk> / <unk> <unk> / <unk> <unk> / <unk> <unk> / <unk> <unk> / <unk> <unk>/ <unk> <unk>/ <unk> <unk> / <unk> "<unk>" is no such policy and "<unk>" is yes. "Best buys" are WHO recommended the most cost-effective alcohol policy interventions to tackle harmful use of alcohol prevent alcohol-related harms among young people [57]. Bans or restrictions on alcohol advertising and sponsorship have been called for by public health researchers and bodies, because in some Asian countries (e.g., China and Japan), alcohol brands promote their products using sport and movie stars or successful business men, which shapes young people's drinking attitude and behaviour. School-, family-and community-based interventions have been found effective in reducing harmful use of alcohol among young people [58][59][60]. However, most of these interventions have been carried out in western developed countries. High quality interventions that target on youth drinking and other risky behaviours are recommended to be applied and evaluated in low-and middle-income countries, particularly in Asia. --- Limitations It is worth noting that a number of Asian studies on youth drinking, harms and alcohol policies were published in local (non-English) languages and were unable to be captured in this study. Another limit is that some of the findings used in the discussions of strategies for prevention come from non-Asian countries. --- Conclusion Harmful use of alcohol has been one of the global public health challenges among young people in the last decade, particularly in Asian countries. Over 70% of the total population of the earth lives in Asia, and Asian developing countries such as India, China, Thailand and Vietnam have been targeted by global alcohol corporations as emerging alcohol markets in recent decades. Alcohol imports in the developing Asian countries, such as Thailand and China, have been increasing significantly, facilitated by free trade agreements coming into effect in recent years [61,62]. The potential adverse public health effects from alcohol, tobacco and other drugs need to be taken into account in negotiating new international trading agreements involving Asian countries. More attention should be paid to the potential adverse effects of limiting governments' ability to control the alcohol market in increasing rates of alcohol problems, particularly among youth and young adults. To the best of our knowledge, there are as yet no formal studies of the social and economic costs of harmful use of alcohol among young people in Asian countries. This review suggest that more coherent and focused research efforts are urgently needed on youth drinking and its problems in Asia, where drinking is rising so rapidly. Public health research and policymaking needs to catch up with the alcohol industry's realisation that what happens in a youth cohort strongly affects their market for the next halfcentury. Studies on social and economic harm and cost of drinking among young people in Asia could be a good step forward, incorporating both population surveys and health, police and welfare register data. A recent collaborative project [63] (Alcohol's Harm to Other in five Asian countries) funded by the WHO and Thai Health Promotion Foundation may help to fill this research gap. Prevention of the health and social issues related to youth drinking will be a major goal for public health in Asian countries that follow WHO strategies to prevent non-communicable diseases and roadtraffic injuries by reducing harmful alcohol use within the national context [64,65]. Establishing or improving national monitoring and surveillance systems to inform alcohol policy in Asian countries could be the first step. But what is needed beyond this is a multi-level approach that integrates policy actions (e.g., sales, social supply and marketing), regulations (e.g., drinking age laws), health education (e. g., media campaigns and health warning labels), and effective health system responses (brief intervention, and alcohol abuse and dependence treatment). This is an urgent mission for public health action in all Asian nations. The review has particular policy implications for the Chinese government and health authorities in tackling the toll of death and disease among young people, given that China at present has almost no alcohol control policies. --- Appendix --- Search method of the systematic review We conducted a comprehensive thematic review of PubMed, Web of Science and Google Scholar for reports, reviews and journal articles published in English between 1st Jan 1990 and 31st August 2016, with search terms pertaining to "alcohol use or alcohol consumption or drinking", "current drinking or risky drinking or risk alcohol use or risky alcohol consumption" "young people or youth or adolescent or adolescence" "health outcome or social outcome or harm" and "Asia or Asian countries". Articles returned for those mentioned search terms were assessed for relevance. Studies were excluded if their abstracts or titles did not refer to the possibility of an association between alcohol or drinking and youth or young people or adolescent or adolescence and Asia or Asian countries. The final review was conducted on full texts of paper meeting this criterion. The initial search and article review were conducted in July 2016 by X.X., and the second search and review were conducted in September and October 2016 by H.J. In Google Scholar, the search terms gave more than 16,000 potential records, and the first 500 of these (sorted by relevance) were examined by title and abstract, and 60 items selected for further inspection. Studies were included in the final review if they included measures of current (past 30-day drinking) or risky or heavy episodic drinking (drink 60 g alcohol or more in a single drinking occasion in the last 12 months) or alcohol's health or social outcomes or harms among young people aged 15-29 years. In the initial search we did not find any journal articles discussed youth drinking or drinking among young people in Asia and only three WHO reports [12][13][14] were found related to the topic. We then decided to narrow our search scope to eight selected Asian countries, including China, India, Japan, South Korea, Malaysia, Mongolia, Thailand and Vietnam. Because Asia contains a variety of cultures and civilisations, with different traditions of drinking, these eight countries have been chosen as countries of substantial size for which there is available data that will give a sense of patterns and the extent of variation in the region. Forty-one reports, reviews and journal papers were identified and included in the final review. In the review process, we found many studies were conducted based on a small sample size without any justification of statistical power, response rates, random or non-random selection and sample representativeness. We found studies with sample size larger than 500 generally provided more reliable measurement on youth drinking behavior and related harms. Studies with sample sizes smaller than 500 were excluded. Studies that only measured age of initial drinking or frequency of heavy drinking or alcohol abuse or alcohol dependence or knowledge, attitudes, and practices related to alcohol use were excluded. Alcohol consumption data reported in the most recent country-level national survey reports were collected. We also reviewed several major international sources of data and information regarding alcohol use in young people or youth: The measuresof current drinking (in the past 30 days) or risky or heavy episodic drinking (60 g or more of alcohol consumed in a single drinking occasion in the last 12 months) or alcohol's health or social harms among young people aged 15-29 yearswere abstracted from the reviewed studies. The Oxford 2011 levels of evidence developed by the Oxford Centre for Evidence-Based Medicine [15] was used to assess the quality of studies in the thematic review. Identified published reports, reviews or journal papers were obtained and reviewed by X.X. and H.J. and data were extracted from these articles. Data were sought on countries and year of data collection. An example of search approach for alcohol con- --- Availability of data and materials All data generated or analysed during this study are included in this published article (and its supplementary information files). --- Ethics approval and consent to participate Not applicable. --- Consent for publication Not applicable. --- Competing interests The authors declare that they have no competing interests.

The paper reviews alcohol consumption patterns and alcohol-related social and health issues among 15-29-year old young people in Asian countries, and discusses strategies for preventing and controlling alcohol use and related harms. Methods: We searched Google Scholar, PubMed, and Web of Science for reports, reviews and journal articles published in English between 1st Jan 1990 and 31st August 2016. Results: Forty-one reports, reviews and journal papers were identified and included in the final review. The current drinking levels and prevalence among young people are markedly different between eight included Asian countries, ranging from 4.2% in Malaysia to 49.3% in China. In a majority of the selected Asian countries, over 15% of total deaths among young men and 6% among young women aged 15-29 years are attributable to alcohol use. Alcohol use among young people is associated with a number of harms, including stress, family violence, injuries, suicide, and sexual and other risky behaviours. Alcohol policies, such as controlling sales, social supply and marketing, setting up/raising a legal drinking age, adding health warning labels on alcohol containers, and developing a surveillance system to monitor drinking pattern and risky drinking behaviour, could be potential means to reduce harmful use of alcohol and related harm among young people in Asia.The review reveals that drinking patterns and behaviours vary across eight selected Asian countries due to culture, policies and regional variations. The research evidence holds substantial policy implications for harm reduction on alcohol drinking among young people in Asian countriesespecially for China, which has almost no alcohol control policies at present.

Background The burden of malaria is a major threat to developing countries, especially in sub-Saharan Africa. Studies showed that insecticide-treated bed nets (ITNs) are effective tools in the prevention of malaria. The use of ITNs alone significantly reduces morbidity and mortality due to malaria. In western Kenya, where intense perennial malaria transmission occurs, a randomized controlled trial confirmed that ITNs reduce all-cause child mortality in children aged less than five years by 16% [1]. ITN use was associated with a 44% reduction in mortality in Kenya [2]. This level of protection corresponds to about seven deaths averted for every 1000 ITNs distributed [2]. In 1998, the WHO launched the Roll Back Malaria movement. One of its primary objective is to increase ITN coverage among vulnerable groups to over 60%. The WHO later revised this ITN objective to reach 80% coverage by 2015 [3]. Under the new malaria strategy, high coverage of ITNs for vulnerable groups, particularly young children and pregnant women is the cornerstone of malaria prevention [4]. Recently, in addition to the conventional ITNs, the WHO Pesticide Testing Scheme recommends long-lasting insecticidal nets (LLINs) [5]. Insecticides are applied in LLINs in a factory, and they last for several years without requiring pesticide reapplication. Large increases in funding and attention to malaria have recently accelerated malaria control activities [3]. Rapid scaling up of ITNs coverage was reported in many African countries [6]. In 2006, the National Malaria Control Programmes distributed 7.1 million ITNs [3]. In Kenya, ITNs have been primarily distributed to pregnant women and children under five years of age, either free of charge or at subsidized prices, by the Kenya Ministry of Health and nongovernmental organization (NGOs). However some bed nets studies show that the incidence of use does not follow that of ownership [7][8][9][10]. A study in western Kenya found that 30% of bed net recipients did not adhere to net use [9]. Their attempt to use bed nets might be hampered by environmental, social and cultural reasons. Some studies reported that children under five years of age and pregnant women are more likely to use a bed net than children between five to 15 years of age [11][12][13][14][15]. Distribution of ITNs have been targeted to these age groups, because they are most vulnerable to malaria [3]. Consequently older children, mainly school-aged children are least protected by ITNs. However, other age groups also should be protected. Children older than five years and adults are also vulnerable to severe illness, death, and substantial economic costs from the disease. In addition, they can become a reservoir of Plasmodium falciparum [16]. Use of ITNs can extend protection to the surrounding community, providing protective effects beyond the individual. To have maximum effect within communities, ITN coverage should be as high as possible throughout all age groups [16]. In African countries, infants share the same bed space with their mothers to facilitate breast feeding [17]. However, older children sleep mainly in the living rooms without their mothers [17]. In living rooms, bed nets have to be removed and re-hung frequently. The inconvenience of frequent mountings is a problem for children, in particular [17,18]. It has been suggested that house structure and space arrangement make the problem more difficult [19]. However, this notion was mainly based on casual observations and stories from residents, and has not been studied in detail. This study explored the effects of sleeping arrangement and house structure on bed net use in villages along Lake Victoria in western Kenya. --- Methods --- Study area The study area (4.4 km 2 ) included three villages (Koguna, Nyachabe, and Tabla) along Lake Victoria in Mbita district, Western Kenya. The rainfall pattern in the area is bimodal, with the long rainy season occurring from March through May, and the short rainy season in November and December. Intense malaria transmission occurs throughout the year. Three species of vectors were known: Anopheles arabiensis, Anopheles gambiae, and Anopheles funestus [20]. The area had 455 households. Most houses are constructed of a stick framework plastered with a mixture of mud and cow dung, and a corrugated iron roof. A few houses have thatched roofs. The majority of residents belong to the Luo ethnic group. Although Luo is the main language spoken, many also speak English and Swahili. The major income sources are fishing and traditional small-scale farming. Some residents are temporary migrants who depend on fishing. --- Data collection One hundred houses were chosen randomly (31 houses in Koguna, 39 in Nyachabe and 25 in Tabla), using the latest data set obtained by the demographic surveillance system (DSS). Nagasaki University, Japan, and Kenya Medical Research Institute, Kenya, deployed the DSS in 2007. The houses were surveyed on six separate dates early in May 2009 (during the rainy season). During the early morning hours (4:30-6:00 hours), each house was visited jointly with a team that was sampling mosquitoes for a separate study. Residents in these houses paid attention to collecting mosquitoes and their usual usage of bed net was easily monitored. In the course of sampling mosquitoes, the sleeping arrangements of the residents were directly observed for (1) use of a bed net, (2) use of a bed, and (3) location. The ages of the residents were estimated and categorized in three classes: (1) under five years of age (infants), (2) between five and 15 years of age (children), and (3) over 15 years (adults). Sleeping arrangements of those residents who opened doors or had already left their sleeping sites were confirmed through an interview. Three local assistants were employed to undertake this task. The team sampling the mosquitoes informed the residents in advance of the dates of its visit. However, the residents were not informed of the dates of the bed net survey when they signed the consent form. This was to avoid any possible effects on bed net use by informing residents in advance. The procedure design was based on the method used in the study of Alaii et al [9]. A few hours after the morning survey, the houses were revisited. Family heads or mothers were interviewed to confirm sleepers' ages and sleeping arrangements, as recorded in the morning observation. If the interviewees' descriptions differed from those of the earlier survey, the information was verified by interviewing other family members. The bed nets hung during the daytime visit were counted, and their locations were noted. Residents were also asked about the number of nets not being used. Bed nets were categorized as LLINs and non-LLINs. The floor area (m 2 ) of each house was measured using a tape measure. The open floor area without furniture, and the sizes of the beds were also measured, and both measurements were used to estimate a potential area for hanging bed nets in each house. The potential area was divided by one bed net size (m 2 ) to estimate the potential number of bed nets that could be hung in each house. If any house included residents who had slept without nets the previ-ous night, the family heads or mothers of the houses were asked about the reasons for this. They were also asked about the purposes of using nets. --- Ethical consideration This study was approved by the Ethical Committee of Graduate School of International Health Development, Nagasaki University, Kenya Medical Research Institute (KEMRI) and Maseno University, Kenya. Informed consent was obtained from all heads of households after the study was explained in the local language. --- Data analyses A generalized linear mixed model (GLMM) using the binomial distribution was used to examine whether residents' ages and sleeping arrangements explained bed net use using the package lme4 in R [21]. Village was also included in the analysis as an explanatory variable (categorical), because bed net use might be different from one village to another. Bed net use was a binary response variable (slept with or without a net). Age was an explanatory variable categorized into three classes. Sleeping arrangement was categorized by four types: (1) slept on a bed in a bedroom, (2) slept on a bed in a non-bedroom, (3) did not sleep on a bed in a bedroom, and (4) did not sleep on a bed in a non-bedroom. Non-bedrooms included living rooms and combination rooms. A combination room was one used for a dual purpose in a house with only one room. When a mattress was used without a bed frame, and when a resident slept on a sofa, these sleeping arrangements were considered "not slept on a bed." Since most houses had multiple individuals, house was considered as a random intercept. A backward selection procedure was applied for modelling, and the selection was based on the log likelihood ratio test [22]. The same modeling procedure was used to explore whether any locations were more suitable for hanging nets, as the availability of suitable locations may affect bed net use. The response variable (binary) was whether a net used during the previous night was also hung or taken down in the course of the following day. The sleeping arrangements in the above modelling were used as probable locations for hanging. Some nets are taken down every morning, and hung or used the following night as necessary. The other nets hung throughout the day were more likely to remain at the same locations for a while, and the residents who sleep at the locations with nets likely use those nets because they are readily available. That is, the locations where nets were hung during the day were considered suitable locations. A GLMM was used to verify whether the nets hung during the day were more likely used during the night. Village was also included in the analysis as an explanatory variable. A GLMM with binomial distribution was also used to examine the relationships of four variables, net use with (1) bed availability, (2) bed net availability, (3) house size, (4) number of rooms, and (5) village. Bed net use was defined as the ratio of the number of residents who slept with nets to the number of those without nets in a house. The variable of bed availability was total bed area (m 2 ) in a house, and house size was total floor area (m 2 ). The values for these variables, excluding the number of rooms, were divided by the adjusted number of residents in each house. The adjusted number of residents was estimated based on body size: an infant was treated as 0.3 person, a child as 0.5 person, and an adult as one person. If the number of rooms in a house had been divided by the number of residents, the qualitative characteristics of the rooms that the data captured might have been lost. For example, in a house with two or three rooms, one was used as a living room, and the others were usually used as bedrooms. Using the raw number of rooms maintained both this characteristic and the quantitative characteristics. Sampling dates were considered as a random effect, and the modeling allowed for a random slope to find optimal random errors [23]. Collinearity between the variables was assessed using graphs, correlation coefficients, and variance inflation factors (VIF). The effects of bed availability, house size, and the number of rooms may be more profound in the case of houses that had enough bed nets, because the effects of net availability did not then exist, which excluded the age effect from the selective distribution to infants and pregnant women. In a separate GLMM, the data set from houses with enough nets was used to examine whether these variables were associated with net use. When a house had more than one net per two residents, the house was considered to have enough nets. This criterion was used because the Kenya Malaria Monitoring and Evaluation Plan had set this as a goal [24]. --- Results Of the 100 selected houses, 95 were surveyed. Five large concrete houses were excluded from the survey because concrete houses do not represent the ordinary houses in the area. The mean size of houses was 16.7 (SD = 6.0) m 2. The mean numbers of rooms and beds were 1.7 (SD = 0.8) and 0.9 (SD = 0.6) per house, respectively. In total, 388 residents and 289 nets were counted, and their means were 4.1 (SD = 1.9) and 3.0 (SD = 1.2) per house, respectively. Of the 289 nets, 132 (45.7%) nets were used, and 309 (79.6%) residents slept under nets. Over 80% (52 nets) of them were LLINs. The residents obtained the nets mainly from health centres, NGOs, shops or schools. None slept outside. That is, 0.7 nets were available per resident, and 2.3 residents slept per net. The mean poten-tial number of bed nets that could be hung was 2.6 (SD = 1.2) per house. A total of 86 family heads or mothers provided reasons for using nets. The most popular reason (n = 79) for using nets was to prevent mosquito bites (Table 1). Family heads or mothers of 25 houses that had non-bed net users were asked about not using nets. Nine of them could not provide a proper answer. The most frequent reason given (n = 5) was that there were no mosquitoes. Bed net use by children was lower than that among the other age classes (Table 2). However, when the explanatory variables, age, sleeping arrangement, and village were examined against an individual's bed net use, age, village and the interaction terms were dropped from the final model. Sleeping arrangement was statistically significant in relation to net use (n = 388, df = 3, deviance = 96.45, p <unk> 0.001). The net use of residents who slept on beds in bedrooms was greater than that in the other arrangements. The net use of residents on beds in nonbedrooms was greater than that of those without beds in non-bedrooms. Sleeping arrangement differed significantly among the age classes (n = 388, df = 6, chi-square = 100.13, p <unk> 0.001). Nearly 80% of children slept without beds in non-bedrooms, and only 10% of them slept in bedrooms (Table 3). The sleeping arrangements of infants and adults were similar, and over 50% of them slept in bedrooms. In the analysis of suitable location, the response variable whether nets were hung or taken down during the day was significantly associated with probable locations for hanging (n = 132, df = 3, deviance = 41.11, p <unk> 0.001), but village was dropped from the final model. More nets were hung on the beds in bedrooms during the day than in the other locations, and beds in non-bedrooms had more nets hung than non-bed sites in non-bedrooms (Table 4). Of 103 nets hung during the day, 94 (91.3%) nets were used during the night, and the association was statistically significant (n = 289, df = 1, chi-square = 142.20, p <unk> 0.001). Net use was examined using five variables, bed availability, bed net availability, house size, number of rooms, and village. An assessment of multicollinearity indicated that house size was highly correlated with net availability (r = 0.76). The VIF of house size was 2.8 and, therefore, house size was excluded from the modelling. The other reason for excluding this variable was that there was a greater interest in the relative importance of net availability. Bed availability, bed net availability and number of rooms remained in the final model, but village was dropped from the final model. Net availability, the number of rooms, and the interaction between bed availability and the number of rooms were statistically significant (Table 5). However, the variable of bed availability was not statistically significant. The coefficients suggest that the number of rooms and interactions were relatively more important than bed availability. Eighty (84.2%) houses had enough bed nets to cover all house residents. When the houses with insufficient nets were excluded from the modeling, bed availability, the number of rooms and their interaction remained in the final model (Table 5). --- Discussion Although bed net use differed among the age classes, removing the age variable from the model and using sleeping arrangement alone resulted in better prediction. In the study area, bed net use by children was less frequent than that of infants and adults. Infants usually sleep with their parents, and the usage patterns of these two age classes were similar. This finding is comparable to those of other studies [11][12][13][14][15]. Other studies claim that the difference in use is due to a strategy for distributing nets that prioritizes infants and their mothers. However, the results from this study suggest that the lower use by children is due to sleeping arrangements. More children slept without a bed in living rooms and combination rooms because infants with parents were given priority in using beds in bedrooms. Since nearly 85% of houses had enough nets to cover all residents, the low use by children was unlikely to have been due to an insufficiency of nets. Moreover, dropping the age variable suggests that low net use also occurred in the case of infants and adults who slept without beds in bedrooms and/or in the other rooms. The results from the daytime survey suggest that the most suitable location for hanging nets was over beds in bedrooms. Even in non-bedrooms, nets were hung over nearly 80% of beds. That is, most nets on beds were hung during the day, whereas over 50% of nets in non-bed sites in non-bedrooms were taken down. Nets in non-bed sites probably interfered with the daily activities (e.g., cooking) of humans and of animals such as chickens. In fact, over 40% of houses kept chickens in non-bedrooms, and most non-bedrooms had a sofa set. Residents had to rearrange furniture to create sleeping area in non-bedrooms everyday. Therefore, the nets were more likely to be taken down to increase space for various daily activities in nonbed rooms. This accounts for the lower number of nets hung in non-bedrooms during the day. In fact, the number of nets hung in non-bed sites in bedrooms was greater than that in non-bed sites in the other rooms. The instability of sleeping sites is another probable reason why more nets were taken down in non-bed sites. Non-bed sleeping sites were usually on an open floor space, and daily activities may force residents (mostly children) to shift their sleeping sites. For example, a guest sleeper reduces the sleeping space for residents in a living room or a combination room. Children must then shift their sleeping sites. Moreover, many children often shift their sleeping houses. Their frequent shifts of sleeping sites may reduce their attachment to bed nets. Nets are probably more easily hung over a bed using a frame. Bedrooms are usually narrower than the other rooms, and so nets are easily deployed on a bed by tying the strings to nearby objects. Consequently, residents can easily access the nets being hung with no extra effort, and then use in such sites increases. The variables bed availability, net availability, and number of rooms remained in the final model examining bed net use at household level. The importance of net availability indicates that some houses lacked a sufficient number of nets to cover all residents. Interestingly, the variable of bed availability alone was not statistically significant, despite other analyses that suggest the significance of beds for net use. However, bed availability became significant when it interacted with the number of rooms. The variable of the number of rooms was by itself statistically significant. A study in Burkina Faso reported the relationship between net use and the number of rooms based on a qualitative data set from observation [19]. The present study confirmed the relationship by analyzing a quantitative data set using direct observation. As the number of rooms increased, the role of each room became clearer: when a house had more than two rooms, one room was usually used as a living room, and the others as bedrooms. Consequently, having more bedrooms increases both privacy and the space available for beds, which in turn increases the number of sites that are suitable for hanging nets, thereby increasing net use. The analysis for houses with enough nets also confirmed this notion. --- Conclusion This study revealed that net use was affected by sleeping arrangement and availability of suitable locations for hanging nets, in addition to net availability. When residents were asked their reasons for not using nets, some responded that there were few mosquitoes, but none mentioned the sleeping arrangements. "Few mosquitoes" is also a popular response from residents in other study areas [8,19]. While the number of mosquitoes may affect use, most residents had probably not realized that sleeping arrangement and availability of suitable locations for nets were factors in net use, as the number of mosquitoes was expected to be high because this study was conducted during the rainy season [20]. --- Implications The numbers of rooms and beds could be increased to improve bed net use. However, such a practice would be unrealistic, because most residents cannot afford it. Moreover, it is difficult to have multiple beds in houses with an average size of 16.7 m 2. It is advisable to improve the tools for hanging nets. Hanging nets may become easier if girders or poles are installed, to which the strings of a net can be tied. As nearly 70% of residents slept in living rooms and combination rooms, it is practical to introduce methods that enable them to hang a net easily in these rooms. The ease of hanging a net is particularly important for children. Another implication of this study is that it is important to identify those houses without enough bed nets before nets are distributed. Most houses in the study area had enough bed nets, and in fact, several had more than enough. Despite this, NGOs continued to distribute nets without identifying which houses in the area lacked nets. Some residents asked NGOs or heath centers for extra nets because nets are used for various different purposes, such as storing crops or fishing [25]. However, this study found that some houses still lacked nets, and the distribution of bed nets should target those houses. --- Competing interests The authors declare that they have no competing interests. --- Authors' contributions HI and NM conceived and designed the study. HI organized the field work and collected data, with assistance from GD,GS, HK and YM. SK provided data from DSS. NM and MH performed the data analyses. HI drafted the first manuscript, and NM and YA finalized the manuscript. All authors have read and approved the final manuscript. --- Author

Background: Although insecticide-treated bed nets are effective tools, use often does not follow ownership. House structure and space arrangements may make the attempt to use bed nets difficult, especially for school age children. The objectives of this study were to explore whether an individual's sleeping arrangements and house structure affect bed net use in villages along Lake Victoria in western Kenya. Methods: Sleeping arrangements of residents were directly observed for use of a bed net, use of a bed, and location. House size, number and types of rooms, bed availability, and residents' ages were estimated. The family heads and mothers were asked about the reason for not using bed nets. Individual bed net use was examined against age and sleeping arrangement. Net use at the household level was examined against four variables: bed availability, bed net availability, house size, and number of rooms. Results: Bed net use by children between five and 15 years of age was lower than that among the other age classes. However, age was dropped from the final model, and sleeping arrangement was significantly associated with net use. Net use was significantly associated with bed availability, number of rooms and their interaction. Conclusion: Net use was affected by sleeping arrangement and availability of suitable locations for hanging nets, in addition to net availability. Most residents had likely not realized that sleeping arrangement was a factor in net use. The ease of hanging a net is particularly important for children.

Introduction The decrease in fertility rates accompanying the increase in wealth and well-being of societies, i.e. the demographic transition, has attracted a great deal of interest among scholars from both social and biological sciences [1,2,3]. While diverging in their approach, a common interest of those fields is to understand the role of individual vs. cultural factors in explaining reproductive decisions. Understanding how behaviours that appear a priori to be maladaptive at the individual level (i.e. reducing reproductive success [4], but see [5]) presents a particular challenge to evolutionary anthropologists, some of whom have argued that an increase in frequency of maladaptive behaviours can arise as a response to social transmission, i.e. the diffusion of ideas and behaviour through social interactions [6,7]. It is widely agreed that fertility decline is not simply an adjustment to changing socio-economic circumstances, and that additional understanding can be gained by taking into account the social transmission of fertility ideas and behaviours [8,9]. In particular, social diffusion has been invoked to explain why, among both preindustrial and industrial countries, fertility varies widely at any given level of development [10]. Social transmission has been suggested to explain the spread of low fertility norms during the European demographic transition: using provincial data (1870-1960), Coale & Watkins [11] showed that, once a region in a country has began to decline, neighbouring regions with the same language or culture follow after short delays, even if they were less developed. It has thus been argued that fertility decline reflects the spread of key attitudes (e.g. about the ideal family size) and behaviours (e.g. uptake of birth control technologies), a process partly independent from societal structural changes (e.g. decrease in mortality rate, availability of contraception), which can account for a unique portion of the variation in the timing and pace of change [10]. Diffusion refers to the process by which innovation spread among regions, social groups or individuals [12], and in particular, ''diffusion exists when the adoption of innovative ideas (and corresponding behaviour) by some individuals influences the likelihood of such adoption by others'' [13]. Individuals are embedded in a network of social relations, and social interactions can influence both access to information as well as the intensity of control exerted to enforce social norms. In particular, social interactions may provide a venue for payoff biased social learning and/or social influence (e.g. conformism; [10,14,15]). While social learning emphasizes the role of information in reducing uncertainty associated with the innovation [16], social influence refers to the process through which some individuals exert control over others, by virtue of their power or authority (although social influence may be hard to distinguish from prestige biased social learning [17]). Social effects (i.e. social learning and social influence) can accelerate or retard the process of fertility change. For instance, social influence is likely to be a critical factor in maintaining high fertility at early stage of fertility transition [18], and as such has been a topic of great interest to demographers. There is accumulating evidence that the deliberate control of fertility within couples may be an innovation that diffuses through social interactions [13,14,19,20,21,22,23,24]. However, most previous studies are cross-sectional, thus precluding ruling out the possibility that social interactions and fertility are jointly determined: unobserved factors might affect both behaviour and choice of social network partners [25]. For instance, as members of a social network are usually spatially aggregated, increase in the prevalence of contraceptive uptake in both individuals and their networks might result from extrinsic factors associated with local conditions (e.g. access). Additionally, women wanting to use modern contraception might be more inclined to choose networks partners who use family planning and indeed several studies specifically asked women to define their networks in terms of whom they talked to about contraception. Such family planning networks contain a high prevalence of individuals who can provide information (i.e. contraceptives users [26,27]). Therefore, any effect of social transmission is more likely to indicate information seeking, resulting from an individual decision to adopt contraception, rather than the imitation of others' choices. Because family planning networks underestimate the occurrence of social diffusion through copying relatively to information seeking, the possibility that fertility restriction can spread as a result of imitation cannot be adequately investigated. Rather, considering social transmission from and to networks of individuals with whom one normally interacts might prove more relevant, as those networks are not biased towards women a priori contemplating the adoption of modern contraception. Whilst macro-level studies have revealed evidence for social diffusion of contraceptive technologies, as well as for socioeconomic determinants (like education and low mortality; e.g. [11,13]), there has been surprisingly few micro-level studies on how this particular innovation spreads through communities at the local level, and even fewer have caught the first cases of the new innovation, when the nature of the spread should be most easily determined. This study investigates the extent to which considering social interactions improves our understanding of temporal and spatial patterns of first contraceptive uptake, using data from rural Ethiopia. The situation of Sub-Saharan countries is of particularly interest as their low prevalence of modern contraception is thought to result from social influence [8]. In Ethiopia for instance, contraceptive uptake is still low (15% and 10.9% in urban and rural areas, respectively; [28]) despite the government having a specific population policy to promote voluntary contraceptive since 1993. The objectives of the study, covering a period of 14 years, 4 villages and involving.900 women, are threefold: (i) to describe the temporal and spatial patterns of uptake of modern contraception, (ii) to identify the individual characteristics that predict the adoption of modern contraception (iii) to investigate whether and to what extent uptake of modern contraception is predicted by social effects (e.g. imitation and/or information seeking) once individual characteristics are taken into account. Our data have at least three strengths to understand the role of social diffusion for fertility decisions. First, network data contain information on both spatial relationships and friendships networks. In particular, women and their husbands were asked to name up to 5 other same-sex individuals with whom they talked most and perceived as their best friends (be they related, unrelated or living near or far away). Second, for each woman, the year of first use of contraceptives is informed along with network data. This allows to consider the timing of adoption events within a given network, and thus to infer the sequence of events. Finally, the study covers a period including when contraceptive use is just beginning, thus providing information on the role of social transmission at an early stage of the diffusion process when patterns of diffusion should be clearest. --- Materials and Methods --- Study site The study is based on a community of agro-pastoralists living in 4 villages of the Arsi Administrative zone, southern Ethiopia. In this rural area, the resources are limited, and the community suffers from periodic shortages of both water and food. Access to basic health service and school is restricted: the nearest health care services and high schools are over 20 km distance from the villages (see [29,30] for more information in the study site). Interestingly, although contraceptive prevalence is generally low among rural women (i.e.,3% in 2003), there is now evidence that contraceptive technology is gaining in popularity and demand for family planning is increasing. Informal focus groups on contraception conducted in 2005 conducted by RM and EG have revealed that the level of interest expressed in contraceptive use was far greater than anticipated given the low prevalence in 2003. --- Data Collection A total of 943 ever married women of reproductive age residing in the four villages were interviewed in 2008/9 about their birth and contraceptive histories. This includes all women living in the villages at the time of the survey as identified by a census of the four villages in 2008. The survey included questions on whether women had ever heard about modern contraception, and whether they had ever use it in the past (even though they might not be currently using it) and when (i.e. before their first birth, or after which birth). This allowed to identify the first year of contraceptive uptake and to reduce the uncertainty generally resulting from recall data. For those women who had ever used contraception, method and place of delivery were also informed. The quality of the data has been checked through comparisons with previous surveys conducted since 1999, date at which the process of contraceptive uptake was at an early stage. Only women for whom age and birth history record was known were included in the analysis. This reduced the sample to 936 women (among which.99% were married by 2008). For each woman, information on her demographic and socio-economic characteristics, her friendship social network, her husband's friendship social network, and her spatial location were collected (see next sections). Clearance was obtained from the UCL Research Ethics Committee and the Ethiopian Science and Technology Agency (ESTA). Signed consent was obtained from all participants. Those unable to read were read the forms before signing. The procedures were approved by the UCL and ESTA ethics committees. (a) Demographic and socio-economic variables. Each woman was asked about her age, marital and birth histories, education (binary variable: attended formal school or not), social status (2 variables to take into account variability in the extent to which individuals rely on crops or pastoralism: the first calculated based on the amount of crops in kg harvested the year before (teff, wheat, maize and barley), weighted by price given by the Food and Agriculture Organization of the United Nations (http://www. fao.org/), the second based on men's cattle possessions), religion (i.e. Muslim or Orthodox Christian), ethnic origin (i.e. Arsi or Shoa Oromo), and her use of a radio (i.e. never, sometimes, frequently). Women were assigned to different cohort depending on their year of birth (4 levels: # 1960; # 1967 &.1960; #1973 &.1967;.1973). (b) Friendships networks. To record data on friendship networks, women were asked the following question ''Name up to 5 other women with whom you talk most and perceive as among your best friends''. Similarly, men (N = 869, 79% of husbands found) were asked to name up to 5 such men. This allows us to draw a matrix of whom-to-whom communication, the elements of the matrix weighting the strength of the ties (1 if a contact was formed, whether or not it is reciprocated, or zero otherwise). It could be argued that social influence is stronger among reciprocated ties, yet studies on very large datasets did not find any significant differences in social influence between reciprocated and non-reciprocated ties [31,32]. Information was also collected on the relationship to each friend/relative named, and whether these friends lived in or outside the study area (See Table 1). Among women's friends,,9% are kin and,52% are affines, while among men's friends,,21% are kin and,41% are affines. Of those named, 19.9% of men's networks and 12.2% of women's networks were outside the study area and could not therefore be identified, leading to a ''quasi-complete'' social network. In total, 8.7% of women do not have a recorded social network and 31.7% do not have a network recorded for their husbands. Social networks provide information on both the structural properties of individuals (i.e. centrality or number of connection), as well as the content properties of their networks regarding reproductive behaviour (i.e. the proportion of ever-users) at time t-1. Since it is unlikely that adopting modern contraception at time t influence the proportion of ever-users in a network at time t-1, any effect is more likely to be interpreted as an influence of the network on the focal individual rather than the reverse. Structural properties. Two variables were used to describe the structural position of individuals within their networks. First, the number of nominations received (i.e. indegree) informed on how integrated an individual is in a network, and is usually referred to as a measure of opinion leadership or popularity. It is often argued that individuals who are highly interconnected are more likely to hear about innovations earlier and to have more opportunities for social comparisons and influence [12]. Second, the number of nominations sent (i.e. outdegree) allows to control for the size of the network, and thus for any unobserved characteristics that lead to differential efforts by women in building and maintaining social interactions. Each woman's in-degree and out-degree were derived at the community level (all villages included). Content properties. For each woman and at each time step, a variable describing her exposure to modern contraceptives through either her network or, if married, her husband's network (through wives of her husband's friends) was built. Note that at any given time, women were eligible to be part of a network only if they were aged at least 15. Specifically, at any given time t, the proportion of ever-users in a woman's network corresponds to the proportion of individuals in the network that had ever used contraceptives at time t-1. We created variables to inform on both unbiased and biased social influence. First, all network members were assumed to have the same influence (i.e. unbiased transmission or conformism, all ties between friends equal 1). Second, to take into account that ever-users in a network can have different influence depending on their prestige ( [17]; biased transmission based on popularity, social status and/or education), the ties linking two individuals have been weighted according to standardized coefficients describing the prestige of individuals (varying between 0 and 1, value divided by the maximum value in the population). (c) Spatial networks. A matrix was built that describe the spatial distance between each pair of points. Spatial coordinates associated with each household where individuals lived were recorded using a Global Positioning System (GPS type Garmin) using longitude and latitude coordinates (using degrees minutes and seconds (DMS) nomenclature). DMS were converted to Decimal degree to calculate distance between each pair of points using the great circle distance calculation (exact distance is calculated using spherical trigonometry, http://www.zipcodeworld.com/ docs/distance.pdf). For each woman at each time t, the minimum distance to an ever-user at time t-1 was inferred. --- Statistical analysis (a) Model. Since the data are right-censored (some women were non-ever-users at the last time period), contain a large amount of ties (many women had the same adoption time), and are recorded on an approximate time scale (years), data were converted into a person-period life table on which a discrete time hazard model was performed (i.e. a logistic regression including the main effect of period [33]). For each woman, the beginning of time (Period 1) corresponds to the first year of eligibility for the use of contraceptive: either the year of the first adoption event ever recorded (1995) if aged at least 15 at that time (75% of women), or, for younger women, the year at which they reach the age of 15. Once they have adopted modern contraceptives, individuals exit the dataset. The population value of discrete-time hazard for woman i in time period t is thus the probability that she will experience contraceptive uptake in that time period, conditional on no prior event occurrence and her particular values for the predictors in that time period. Variables included are both time-Table 1. Characteristics of friendship networks for women (female friends) and their husbands (male friends). Women are more likely to appoint affines as their friends (e.g. their husband's brother's wives (29.78%) and their husband's mother (16.24%)). Husbands appoint affines (spouse's brothers (37.10%)), friends (23.86%) and kin (e.g. their brothers (19.30%)). Women's friends are more likely to be in the same compound, while men's friends are more likely to be in the same village but outside the compound. In more than 70% of cases, women and men talk to their friends every day. doi:10.1371/journal.pone.0022515.t001 invariant (e.g. use of radio, village) and time varying (e.g. age, parity and proportion of ever-users in networks). The proportionality assumption (that the hazard risk of contraceptive uptake is independent of time for any given variable) has been checked for key variables (e.g. parity, proportion of ever-users in the social network). (b) Model Selection. A set of a priori candidate models is assumed (see next section), for which a measure of each model's fit scaling to its complexity is derived (e.g. Akaike information criterion [34]). The model for which AIC is minimized is selected as the best for the empirical data at hand. The evidence for each alternative model is done by rescaling AIC values relative to the model with the minimum AIC, which subsequently allows models to be ranked according to their ability to account for the data. In addition, a measure of weight of the evidence that a given model is the best in the set of models considered is calculated (Akaike weight (v)). Subsequently, rather than base inferences on a single selected best model, inferences are calculated using the entire set using model-averaged based estimators (estimates are balanced using Akaike weights and averaged across models; [35]). The use of model based average estimators allow better precision and reduced bias compared to the estimator of that parameter only for the best selected model. Following [36], we present only models that collectively account for 95% of the available model weight. All analyses were carried out using R software (version 2.11.0). (c) Candidate models.. Individual characteristics (set 1). If women plan the size/composition of their family so that they maximize their number of surviving offspring and/or surviving males, one can expect the adoption of modern contraception to be positively associated with the number of living children (Parity) and/or the proportion of living sons (Prop_LS), as well as negatively associated with the number of deceased offspring (Nb_DO). These possibilities are investigated with models controlling for the quadratic relationship between a woman's reproductive history and her age, her cohort, as well as for her marital status (MS): (i) Age + Age Additionally, contraceptive uptake is generally found to be associated with a woman's level of education [37], with educated women more likely to delay or reduce their reproduction in order to pursue their studies, or more informed on contraceptives. The variable describing women's level of education (Edu) is thus included to all 5 previous models. ( Finally, we investigated the relationship between wealth and the adoption of contraception uptake. A first scenario is that women from poor families experience a stronger trade-off between quantity and survival of offspring, and are thus expected to adopt modern contraception earlier. This has been found to be the case in rural Gambia [38]. Alternatively, in populations experiencing a decrease in child mortality as a result of modernization, it has been argued that the trade-off between fertility and parental investment increases with family socio-economic status. We investigated the relationship between socio-economic resources and contraceptive uptake in including material wealth variables (husband's cattle, and agricultural production) to all previous models (note that the set also contains a null model). ( Individual characteristics, social environment and social interactions (set 2). Individuals' decision to adopt modern contraception might be better understood if one considers not only socio-demographic determinants of fertility but also individual's social environment (e.g. group norms and media exposure). For instance, contraceptive uptake possibly differs among religious groups, as it has been shown to be the case in many countries (in Europe [11], in Ghana [39], in Malawi [37]). Note that variation in religious norms is observed in only 1 village, with all other 3 villages being characterized by a 100% Muslim obedience (See Table S1). Also, access to mass media and programs/adverts on modern contraception through the use of radio might exert a social pressure on women and/or provide them with more information hence reducing risk perception. In both cases, access to mass media is predicted to positively influence uptake of modern contraception. Models including social environment factors (SE) and/or individual factors (IF) were thus considered: (i) IF; (ii) SE; (iii) IF + SE, with SE referring to Religion + Radio + Village. Individual's decision to adopt modern contraception has also been suggested to partly result from social diffusion, i.e. to be related to social interactions (SI) or person to person contact, which lead to the inclusion of the following models in the set (iv) SI; (v) SE + SI; (vi) IF+ SI; (vii) IF + SE + SI. Several variables were considered to describe social interactions (SI), including spatial distance to contraceptive ever-users and both structural and content properties of friendships' networks. First, we investigated whether women are more likely to adopt contraception at time t if they are spatially close to individuals having already used contraception at time t-1. This was done by considering the minimum spatial distance to a contraceptive ever-user (SI1: Min_Distance). Second, we investigated the role of women's centrality, i.e. the number of nominations received through both women's and husband's network (SI2: Indegree_W NT, Indegree_H NT ). Indeed, central individuals are more likely to hear about innovations [40] and are in turn likely to adopt contraception earlier. Third, we investigated the role of the content of the friendship network. We considered the proportion of ever-users in women's and/or their husbands' social network at time t-1, with both unbiased and biased transmission according to characteristics of network partners (SI3: unbiased transmission: Prop. ever-users_W NT + Prop. ever-users_H NT ; SI4: biased transmission according to popularity; SI5: according to education; SI6: according to wealth). Indeed, some friends might be more influential than others [17]. Fourth, models assuming an interaction effect between social interactions and individual factors were also considered. Indeed, the role of social networks might depend on the ''readiness'' of individuals to adopt an innovation. For instance, women willing to adopt modern contraception as a result of individual circumstances might be more likely to do so if they can get information or receive positive attitude from other network members. Those models include an interaction effect between the number of living children (Parity) and the proportion of ever-users among network members at time t-1. A total of 32 models were included in the set. --- Results The risk of contraceptive uptake is best predicted by a combination of socio-demographic (i.e. the number of living offspring and education level) and social environment (i.e. religion and media exposure) characteristics. Social relationships with best friends and proximate households, however, do not improve the understanding of temporal and spatial patterns of contraceptive uptake. Interestingly, at the time of adoption, most women (.85%) are innovators relative to their friendship networks (e.g. all network partners have never used contraception in both women's and their husband's friendship networks, Fig. 1), and there is no evidence of a negative influence of non-adopters on contraceptive uptake. Rather, if relevant at all, the role of social interaction through friendships networks appears to be conditional of individual circumstances, some individuals being more sensitive to social transmission than others (i.e. women with the higher number of children). The study tells about a population in the early stages of contraceptive uptake when patterns of social diffusion are most tractable; results in populations where contraception is already widely used may differ. --- Contraceptive uptake: temporal and spatial patterns The earliest evidence of contraceptive uptake occurred in 1995. Contraceptive uptake increased and reached the level of 18.8% by 2008 among women of reproductive age (15-45 years). At that time, 96% of women had already heard about contraception, although it does not necessarily translate into behavioural change. The number of women having ever used contraception varies from 15.4% to 22.8% across the 4 villages considered (Table S1, Fig. 2), and the most frequent methods used are pills (30%) and injection (70%). Women generally use contraceptives for the first time after they have already reproduced (in 95.6% of cases). The mean number of children (6 s.d.) at the time of adoption is 3.762.1, which is consistent with the idea that women use contraceptives to either space births and or to end their reproductive career once they have achieved their desired family size. Note however, that 4.4% of the total number of ever-users reported having used contraception before their first birth. --- Decisions for contraceptive uptake Using data covering a period of 14 years (1995-2008), we investigated a blended model of fertility dynamics (e.g. an extended version of Cleland's model [8]), in which both individual and social factors matter. We used information theoretic methods (i.e. model comparison), providing a strength of evidence for an a priori set of alternative hypotheses [35]. A first set of models was considered to identify the most likely individual characteristics to account for patterns of contraceptive uptake. Second, these individual factors were combined with social environment variables (e.g. religion) and/or social interactions (e.g. centrality measures, proportion of ever-users among friendship networks at time t-1, minimum spatial distance to an ever-user at time t-1) in a second set (see Methods). This procedure limits the number of models considered, and thereby increases the probability that model selection reflects the genuine contribution of variables rather than spurious effects [35]. Figure 1. Thresholds for contraceptive uptake in women's networks at the time of adoption. A threshold corresponds to the proportion of adopters in an individual's network at the time of adoption of an innovation. Among women who have ever used contraception (N = 176), 86.3% are innovative relative to their network members, while 89.0% are innovative relative to their husband's networks. doi:10.1371/journal.pone.0022515.g001 (a) Individual characteristics. Model ranking reveals that the best model to account for contraceptive uptake (Akaike weight = 0.49, Table S2) includes the number of living children (parity: OR = 1.43; 95%CI [1.28; 1.62], Fig. 3a), the level of education (OR = 2.16; 95%CI [1.53; 3.03]), while controlling for age, age 2 and marital status (polygynous as compared to monogamous: OR = 1.22; 95%CI [0.85; 1.77]) and cohort effects (OR = 2.80; 95%CI [1.82; 4.34]). The number of children deceased and the amount of material wealth have no influence on contraceptive uptake while the number of living sons has a marginal positive effect (OR = 1.54; 95%CI [0.99; 2.41]), suggesting that sons are preferred over girls (Table S3). That material wealth is independent form contraceptive uptake is intriguing, as it has been shown to have effects, either positive [41] or negative [38] in other studies. (b) Additional role of social environment and social interactions. First, model ranking shows that individual factors and social environment should both be considered, as this combination provides the best account for the data at hand (sum of Akaike weight of models including these variables.0.95, Table 2). Furthermore, model comparison shows that models excluding either group of variables account for less than,1% of the total weight of the set. Including religious and village characteristics to a conventional socio-demographic model improves the understanding of the data. While controlling for individual factors, averaged estimates show that Orthodox Christians are less likely to adopt modern contraception than Muslims (OR = 0.22; 95%CI [0.10; 0.52], Fig. 3b, Fig. 4). Interestingly, shorter birth intervals have been reported for Orthodox Christians [30] in this population, indicating a higher emphasis on fertility in this religious group. Finally, women frequently listening to the radio are more likely to be ever-users (OR = 2.12; 95%CI [1.18; 3.78], Fig. 4), independently of individual wealth differences as they are controlled for. Note that radio use only informs on individual's behaviour in the year of interview, which precludes to conlude on any causality effect. Second, social interactions through friendships networks and geographical proximity do not improve the understanding of the timing of contraceptive uptake once individual factors and social environment are taken into account (Table 2). It could be argued that information on friendship network is biased, as composition might have changed across years or with migration. This possibility has been checked conducting an analysis restricted to the year of the interview and similar results have been obtained (Table S4). If the structure and the content of networks are not found to be critical, they are informative (Fig. 4). Interestingly, social effects appear to be conditional of both the type of network and individual characteristics.: women's social network matter more for those having a high number of living children (Parity 6 unbiased Prop. ever-users Wnt: OR = 1.30; 95%CI [1.14; 1.51]). Overall, the results support the idea that person-to-person effects on contraceptive uptake reflect a social learning process (rather than social influence), although the magnitude of the effect is weak and there is a high uncertainty among models including social interactions (Table 2). Finally, there is no effect of the number of individuals listing you as a friend (Indegree), so popular individuals, who may be among the more prestigious in the population, are not more likely to be ever-users than anyone else. Moreover, they are not more likely to influence others (no effect of prestige-biased friendship networks; Fig. 4). --- Discussion Social diffusion of fertility values and behaviours has been invoked to account for macro-level patterns of ''contagion'' observed during the demographic transition [11]. More generally, it has been suggested that social transmission through social interactions explains why cultural traits that do not enhance individual reproductive success may spread [6]. In this paper, we used data from a population entering the demographic transition to understand the role of social transmission for the early spread of modern contraception, a cultural variant a priori maladaptive (but see [5]). In particular, we investigated the extent to which a woman's decision to adopt modern contraception is the result of (i) the proportion of ever-users/non ever-users within both women and their husbands' friendships networks and (ii) the geographic distance to contraceptive ever-users. We found that decision to adopt modern contraception is strongly determined by individual demographic and socio-economic characteristics, and by the religious group. However, we show that the contribution of social transmission from either best friends or contraceptive ever-users in proximate households is minimal. Whether other sources of social transmission (e.g. from doctors [18], husbands [42], religious leaders [43], kin [24,44,45] or weak ties [46]) could affect the pace at which women adopt modern contraception is discussed. The study can only tell us about a population at the early stages of the demographic transition, and mechanisms at later stages or in populations characterized by higher economic development might differ. Yet, the results are important if one is to understand why women adopt modern contraception in the first place. The results show that the early rise in modern contraception is mainly predicted by individual demographic and socio-economic characteristics. First, contraceptive uptake increases with family size, and to a lower extent, with the number of surviving males. One plausible explanation is that contraceptive uptake is driven by competition for resources and need for higher level of investment per child as the society enters the market economy [47,48]. Interestingly, sibling competition for education, particularly between brothers, is argued to have recently increased in the population as a result of modernization [30] and in response to land shortages [49]. Women might also perceive higher rates of mortality with increasing parity, which is not inconsistent with a quantity/quality trade-off perspective since maternal mortality is a major cause of death in young children [50]. At a proximate level, women might grow tired of giving birth but also experience higher social status and autonomy with increasing parity, thereby facilitating contraceptive uptake. Alternatively, the link between parity and contraceptive uptake could result from social transmission, e.g. if high parity women interact more frequently with medical centres in which antenatal care is delivered. Whether this is the case, and whether such social transmission reflect individual social learning (i.e. information seeking) and/or social influence remains to be tested. Second, the results show that, as in modernized societies [51], educated women are more likely to start using contraception: among ever-users, 71% are educated. Note that no women in this population continue to study after marriage, so educated women do not adopt contraceptives to pursue education. Rather, the higher prevalence of contraceptive use among educated women might reflect higher knowledge about contraceptives and/ or social influence of teachers. Overall, the results suggest that birth control decisions are shaped by individual variation in both reproductive trade-offs and opportunities for social transmission. We found evidence that the early spread of modern contraception is best understood if both individual socio-demographic characteristics and the social environment are considered. In [52]. It is also possible that the effect of religion results not only (or not at all) from norm enforcement but from social transmission of attitudes and knowledge at religious gatherings. It is thus difficult to disentangle whether the effect of religion reflects an individual payoff assessment (balancing the cost of deviating from the norm with the benefit of contraceptive uptake) or social contagion among individuals. Contraceptive uptake does not result from imitation of prestigious ever-users within friendships networks. The study cannot exclude the possibility that a woman's decision is influenced by prestigious individuals outside of the friendships networks. But given the low prevalence of contraceptive uptake in the population, prestige-bias is more likely to account for the persistence of high fertility rather than the spread of modern contraception. In this population, fertility restriction is unlikely to be associated with the ability to achieve success since there are few opportunities for education and no non-agricultural employment. However, in populations characterized by higher economic development, if the reduction in the number of children allows women to pursue education and thereby compete for high achieving jobs, a positive link between prestige-bias and contraceptive uptake is expected [6]. Nevertheless, the link between education and status is likely to be weak in populations entering the demographic transition and generally characterized by poor economic development [53]. One might thus suggest that if prestige-bias is important for reproductive decisions, it will slow down rather than speed up the early spread of low fertility norms.. Averaged estimates (red squares) and 95% confidence intervals (black lines) for the effects of individual factors, social environment, and social interactions on the risk of first contraceptive use. Data cover a period of 14 years and involve.900 women (see Methods). Wnt: women's network; Hnt: husband's network; formal education is compared to the level ''no education''; villages are compared to the first level ''Village A''; Being polygynously married is compared to being ''monogamously married''. ''x'' indicates an interaction. doi:10.1371/

Socio-economic development has proven to be insufficient to explain the time and pace of the human demographic transition. Shifts to low fertility norms have thus been thought to result from social diffusion, yet to date, micro-level studies are limited and are often unable to disentangle the effect of social transmission from that of extrinsic factors. We used data which included the first ever use of modern contraception among a population of over 900 women in four villages in rural Ethiopia, where contraceptive prevalence is still low (,20%). We investigated whether the time of adoption of modern contraception is predicted by (i) the proportion of ever-users/non ever-users within both women and their husbands' friendships networks and (ii) the geographic distance to contraceptive ever-users. Using a model comparison approach, we found that individual socio-demographic characteristics (e.g. parity, education) and a religious norm are the most likely explanatory factors of temporal and spatial patterns of contraceptive uptake, while the role of person-to-person contact through either friendship or spatial networks remains marginal. Our study has broad implications for understanding the processes that initiate transitions to low fertility and the uptake of birth control technologies in the developing world.

the number of children allows women to pursue education and thereby compete for high achieving jobs, a positive link between prestige-bias and contraceptive uptake is expected [6]. Nevertheless, the link between education and status is likely to be weak in populations entering the demographic transition and generally characterized by poor economic development [53]. One might thus suggest that if prestige-bias is important for reproductive decisions, it will slow down rather than speed up the early spread of low fertility norms.. Averaged estimates (red squares) and 95% confidence intervals (black lines) for the effects of individual factors, social environment, and social interactions on the risk of first contraceptive use. Data cover a period of 14 years and involve.900 women (see Methods). Wnt: women's network; Hnt: husband's network; formal education is compared to the level ''no education''; villages are compared to the first level ''Village A''; Being polygynously married is compared to being ''monogamously married''. ''x'' indicates an interaction. doi:10.1371/journal.pone.0022515.g004 Although we didn't find evidence of social transmission through friendships or spatial networks regarding the adoption of modern contraception, it is possible that women copy, learn or receive social support from other actors. First, women with many weak ties (e.g. ties with socially distant individuals) are more likely to adopt contraception. Weak ties bring knowledge not available through friends, and are usually found to be critical for the spread of ideas [46]. It is important to note, however, that the simple exposition to information does not appear to be sufficient for a woman to adopt modern contraception. Indeed, the results show that central women (i.e. those having more connections) are not more likely to adopt contraception, nor are women spatially close to ever-users. Second, it is likely that a woman's fertility decision is not independent of her husband's attitude. A study in Cambodia shows that women who believe that their husbands have a positive attitude towards modern contraception are.3 times more likely to use it [42]. Studies conducted both among the Mpimbwe of Tanzania [24] and in Gambia [54] revealed that women are more likely to effectively limit their family size using contraception if they don't have a constant spouse. Third, it has been suggested that women decisions regarding fertility practices could be influenced by their kin [55]. Among the Mpimbwe where mortality and fertility rates are high, women with a large number of siblings are more likely to be ever-users of birth control methods [24]. In the Gambia, however, little evidence was found that kin directly influence contraceptive uptake, either by their presence/ absence or as models for social learning. Rather, contraceptive decisions in women were more directly related to sociodemographic variables such as age-specific parity and wealth rather than the presence or contraceptive behaviour of the extended family [54]. Overall, a woman's decision to adopt modern contraception will depend of potentially numerous sources of social transmission. Yet, whatever the source, one must identify the extent to which transmission refers to the behavioural imitation of others and/or information seeking. From an evolutionary perspective, these two mechanisms can reflect different selective pressures (i.e. cultural group selection and optimization of parental investment per child, respectively). Understanding which mechanism is at play at which stage of the transition will help to understand the underlying causes for the spread of low fertility practices. To conclude, the initial slow uptake of low fertility norms is likely to be associated with socio-ecological conditions in which the use of modern contraceptives is not associated with reproductive advantages in the short term i.e. high mortality rate and low sibling competition. Only when conditions are met that favour contraception (e.g. competition between offspring for parental resources, high incentive to pursue education), social interactions are likely to be used to obtain information on the cost and benefits associated with the innovation. There is some evidence that the relevance of social learning in family planning networks varies with the level of development, and is more likely to be an important mechanism in an advanced market economy [14]. This is consistent with the view that market economies instil higher demand for parental investment in terms of education. It is also likely that the relevance of social influence vs. social learning varies with the prevalence of the cultural trait in the population, and if pure social influence through networks does not appear to explain the initial diffusion of low fertility norms, it is possible that this mechanism plays a more important role in the later maintenance of the trait. Our understanding of the processes and motivations underlying shifts to modern low fertility will only be advanced by recognizing the multiple stages of the demographic transition and by testing competing theoretical models simultaneously. S3 Averaged estimates, standard errors and 95% confidence intervals based on models comparison (set 1, see methods section). Models in set 1 only consider individual socio-economic and demographic characteristics. For each model, a logistic discrete hazard model with no intercept and time period as a main effect has been ran on a person to period dataset. Nomenclature: P: time period; Parity: number of living children. NA: Not applicable. (DOC) Table S4 Best models for contraceptive uptake (analysis restricted to the last year of data) (DOC) --- Supporting Information --- Author Contributions Conceived and designed the experiments: RM. Performed the experiments: MAG EG. Analyzed the data: AA. Wrote the paper: AA RM.

Socio-economic development has proven to be insufficient to explain the time and pace of the human demographic transition. Shifts to low fertility norms have thus been thought to result from social diffusion, yet to date, micro-level studies are limited and are often unable to disentangle the effect of social transmission from that of extrinsic factors. We used data which included the first ever use of modern contraception among a population of over 900 women in four villages in rural Ethiopia, where contraceptive prevalence is still low (,20%). We investigated whether the time of adoption of modern contraception is predicted by (i) the proportion of ever-users/non ever-users within both women and their husbands' friendships networks and (ii) the geographic distance to contraceptive ever-users. Using a model comparison approach, we found that individual socio-demographic characteristics (e.g. parity, education) and a religious norm are the most likely explanatory factors of temporal and spatial patterns of contraceptive uptake, while the role of person-to-person contact through either friendship or spatial networks remains marginal. Our study has broad implications for understanding the processes that initiate transitions to low fertility and the uptake of birth control technologies in the developing world.

Introduction Studies show that a substantial proportion of transgender men (i.e., men assigned female at birth [AFAB]) and women (i.e., women assigned male at birth [AMAB]) and gender diverse (e.g., non-binary, genderqueer, gender fluid) individuals-including transmasculine people (i.e., transgender men and gender diverse AFAB people with masculine gender identities)-experience bias, prejudice, and discrimination based on their gender identity (i.e., cissexism) while obtaining health care [1][2][3][4][5][6]. For example, in the 2015 U.S. Transgender Survey (USTS), a large national survey of transgender and gender diverse individuals, one-third of participants who reported seeing a health care provider in the past year had at least one negative experience related to their gender identity and/or expression-including denial of services; verbal, physical, and sexual abuse; intrusive, non-respectful care; and having to educate their health care provider about transgender health [2]. Experiences of cissexism in health care settings have notable negative effects on health care access and utilization among transgender and gender diverse individuals [1,2,7,8]. Indeed, research shows that large numbers of transgender and gender diverse individuals avoid and postpone needed health care, including when sick or injured, as a result of past experiences and fears of cisexism [1,2,7,8]-which in turn contributes to poor health outcomes in these marginalized and underserved populations [1,2,9]. Intersectionality [10][11][12][13][14], an analytical framework rooted in Black feminist theory and practice [15][16][17][18], suggests that multiply marginalized transgender and gender diverse people, such as Black, Native, Latinx/e, Asian, and other transgender and gender diverse people of color, experience-and resist-not only cissexism but also other intersecting forms of discrimination, such as racism. Specifically, intersectionality postulates that multiply marginalized individuals' lived experiences are shaped by experiences of and resistance to mutually constitutive, unequal power relations (e.g., racism, (cis)sexism, classism, heterosexism)-which are rooted in reciprocal systems of exploitation and oppression (e.g., white supremacy, patriarchy, capitalism, colonialism) and result in experiences of discrimination that are both unique and more than the sum of their parts [10][11][12][13][14]. However, research on discrimination and health care among transgender and gender diverse people has largely focused on cissexism, to the exclusion of other reciprocally constructing forms of discrimination, among samples of predominately white individuals [1][2][3][4][5][6]. Nonetheless, a small body of research shows that transgender and gender diverse people of color have unique and compounding experiences of multiple forms of discrimination in health care settings [1,2,19]. First, studies indicate that transgender and gender diverse people of color experience higher levels of cissexism in health care settings, including emergency rooms, doctors' offices, hospitals, and ambulances, compared to their white counterparts [2,3]. For example, using data from the 2010 National Transgender Discrimination Survey, Kattari et al. found that 26.1% of transgender and gender diverse people of color experienced cissexism in a doctor's office or hospital, relative to 18.5% of white participants [3]. Moreover, 2015 USTS data show that, while 34% of white participants reported at least one negative experience with a health care provider in the past year as a result of their gender identity and/ or expression, 50% and 40% of Native and Middle Eastern participants, respectively, reported such an experience [2]. Second, research indicates that the health care experiences of transgender and gender diverse people of color are simultaneously impacted by not only cissexism but also racism [3,[19][20][21]. For example, in a qualitative study of transgender people of color in Chicago, IL, Howard et al. found that participants reported negative health care experiences as a result of both cissexist and racist stereotypes among health care providers and difficulty identifying providers who met their needs and preferences related to both gender identity and race/ ethnicity [19]. Compounding experiences of cissexism and racism in health care settings may in turn contribute to the higher levels of avoidance of care due to fear of mistreatment among transgender and gender diverse people of color relative to their white counterparts [2]. Research indicates that access to and utilization of health care is undermined by not only cissexism and racism but also classism, ableism, xenophobia, and weight-based discrimination, among others [2,[22][23][24][25][26]. However, studies examining the impact of these forms of discrimination on the health care experiences of multiply marginalized transgender and gender diverse people is extremely limited. Indeed, we could not identify any published study on discrimination and health care among transgender and gender diverse individuals explicitly focusing on classism, ableism, or xenophobia. Further, to our knowledge, only one published study has specifically investigated the negative effects of weight-based discrimination on the health care experiences of lesbian, gay, bisexual, transgender, and queer (LGBTQ) people in general [27]. Thus, we designed a qualitative research study to contribute to the literature on intersectionality, discrimination, and access to and use of health care among multiply marginalized transgender and gender diverse individuals-focusing on how transmasculine people of color, a particularly understudied and underserved subgroup, experience and resist cissexism, racism, and other forms of discrimination in health care settings. --- Methods --- Participant recruitment Using a purposive sampling strategy [28][29][30], we recruited individuals who met the following eligibility criteria: identified as a person of color, including but not limited to Black, Latinx/e, Native, and/or Asian; identified as transmasculine, including but not limited to a transgender man or a masculine gender diverse AFAB person; were between ages of 18 and 25 years; and resided in the greater Boston area. Using maximum variation sampling [28][29][30], we recruited participants from diverse gender identity and racial/ethnic backgrounds in order to capture the perspectives and experiences of a broad range of transmasculine people of color. We recruited participants between October 2018 and May 2019 by sharing study flyers with community-based organizations, community health centers, college student groups, email listservs, and Facebook groups that serve transmasculine young adults of color in the greater Boston area. Additionally, participants were asked to disseminate the study flyer to individuals in their social networks using a chain referral sampling strategy. Further, we shared information about our study with our personal and professional networks, who then shared this information with transmasculine individuals who may be eligible for and interested in participating in the study [28][29][30][31][32]. Lastly, drawing on the principles of communitybased participatory research, we convened and collaborated with a Youth Community Advisory Board (YCAB) composed of three transmasculine young adults of color who helped us identify potential recruitment sites and partners and disseminated the study flyer within their social networks [31,33,34]. --- Data collection We conducted mini focus group discussions (N = 5) with 3 to 5 transmasculine young adults of color each (n = 19) to elicit detailed and nuanced information on their sexual and reproductive health care experiences and their multilevel social determinants [35]. We chose to conduct mini focus groups to allow members of this multiply marginalized population-whose needs, concerns, and experiences are often ignored-ample time to share their perspectives on a variety of sensitive topics, which are often more easily discussed in smaller groups that facilitate rapport and comfort [35]. We determined our sample size a priori based on research indicating that thematic or meaning saturation is generally reached with 2-6 focus groups [36][37][38]. Indeed, after 5 mini-focus groups, we found no new theme pertaining to our research question and were able to generate a rich, comprehensive understanding of each of our themes and subthemes [36]. All focus group participants provided written informed consent at the start of each group. Focus groups were conducted between February and May 2019 in Boston, MA using a semi-structured focus group discussion guide (Appendix) [35]. The discussion guide included open-ended questions and probes pertaining to the following topics: sources of sexual and reproductive health information, sexual and reproductive health beliefs and risk perceptions, and sexual and reproductive health care attitudes, needs, preferences, and experiences. Focus group discussion guide questions included: "Tell me about a time when your transmasculine status, race/ethnicity, or other aspects of your identity affected your health care, " "Tell me about your experience discussing HIV and STIs with health care providers since identifying as transmasculine, " and "Tell me about your experience getting tested for HIV and STIs since identifying as transmasculine. " The guide was informed by the scientific literature on sexual and reproductive health among transmasculine individuals and reviewed by members of the YCAB, who provided oral and written input and feedback from their perspectives. The guide was also reviewed by members of a lesbian, gay, bisexual, transgender, and queer (LGBTQ) health research working group, which includes experts in transgender health, adolescent and young adult health, and sexual and reproductive health. Each focus group was conducted in person by an academic member of the research team with expertise in qualitative public health research or a trained member of the YCAB, both of whom were LGBTQ (i.e., queer cisgender woman, transmasculine individual) people of color (i.e., Latinx/e, Black). A trained member of the research team also took detailed notes during the focus groups. All focus groups were conducted at a transgender-inclusive social justice organization, LGBTQ youth community-based organization, or LGBTQ community health center, which helped facilitate participant comfort and promote group rapport and discussion. Focus groups were conducted in English and audio-recorded. Focus groups lasted between 93 and 111 min (mean: 99 min). At the end of each focus group, participants completed a brief demographic survey to help contextualize qualitative research findings. Participants received a $45 gift card for their time. All research activities were reviewed and approved by the Tufts University Social, Behavioral, and Educational Research Institutional Review Board. All methods were carried out in accordance with relevant guidelines and regulations. --- Data analysis Audio-recordings of the focus groups were transcribed verbatim by a professional transcription company and entered into Dedoose (version 8.3.19, Manhattan Beach, CA) for analysis. Focus group transcripts were analyzed using a template style approach to thematic analysis that involved both deductive and inductive coding using a codebook [39][40][41]. Data analysis began with immersion in the data, followed by codebook development, testing, and refinement. The codebook was developed collaboratively among research team and YCAB members and included both deductive codes based on the scientific literature and inductive codes based on the focus group transcripts. Two independent coders each applied the codebook to two focus group transcripts to test its fit to the data. Codes were then merged, refined, and discarded, and the revised codebook was applied independently by each coder to all five transcripts. Coding discrepancies were discussed and resolved by consensus, and the codebook was further refined and reapplied to the data based on these ongoing research team discussions [39][40][41][42][43]. For the present manuscript, coded text fragments pertaining to participants' experiences of health care discrimination were clustered into themes and sub-themes [39,42,[44][45][46]. Relevant quotes were organized according to the theme(s) and sub-theme(s) to which they pertained using a data analysis matrix, which allowed for further refinement and comparison of themes and subthemes across and within focus groups and participants by gender identity and race/ethnicity [47]. Memo writing and regular research team meetings were also used to facilitate the identification and refinement of themes and sub-themes [48]. Focus group transcripts were then reviewed to ensure that all relevant coded excerpts were included in the analysis, study findings accurately represented the data, and all relevant themes had been identified [49]. All research team and YCAB members provided feedback on the themes and sub-themes, which were also reviewed by members of a LGBTQ health research working group composed of experts in transgender health, adolescent and young adult health, and sexual and reproductive health. --- Reflexivity Throughout the research process, members of the research team engaged in reflexivity, which was facilitated by writing memos and engaging in team discussions. Memos and discussions focused on examining the effects of research team members' professional background, social positions, and values as well as the impact of social, economic, and political contexts on both data collection and analysis. In particular, data collection and analysis were conducted by academic researchers with training in qualitative public health research and in the structural and social determinants of health inequities. Research team members had diverse sexual orientation (e.g., queer, bisexual), gender (e.g., cisgender woman, transmasculine individual), and/or racial/ethnic (e.g., Black, Latinx/e, white) identities and had strong commitments to racial, social, and economic justice. The research team engaged with study participants and YCAB members as cocreators of knowledge and meaning with expertise in the research question of interest. To that end, YCAB members provided input and feedback on all data collection procedures and on the themes and sub-themes resulting from data analysis and were included as coauthors of the present manuscript. In particular, one trained YCAB member took on a more in-depth role in data collection and analysis by serving as a focus group discussion moderator and coding transcripts. Additionally, in light of the social, economic, and political marginalization and oppression experienced by transmasculine people of color in U.S. society in general and the health care system in particular, all focus groups were conducted in partnership with community-based organizations and community health centers that serve individuals with minoritized gender and racial/ethnic backgrounds. --- Results --- Participant sociodemographic characteristics Table 1 shows that study participants ranged in age from 18-25 years, with a mean age of 22 years. Most participants identified as non-binary (37%; n = 7) in terms of gender identity, queer (42%; n = 8) in terms of sexual orientation identity, and Black (58%; n = 11) in terms of race/ethnicity. Further, most participants were working full-time (47%; n = 9), and the majority had some college education or more (84%; n = 16) and were enrolled in a private health insurance plan (63%; n = 12). Additionally, the majority of participants received care at a community health center (63%; n = 12) and from a Nurse Practitioner or Registered Nurse (74%; n = 14). --- Research findings We identified four major themes across the focus group transcripts: 1) structural barriers to accessing health care as transmasculine people of color; 2) anticipating and experiencing multiple intersecting forms of interpersonal discrimination in health care settings; 3) consequences of multiple discrimination in health care settings; and 4) strategies for challenging and resisting multiple discrimination in health care settings (Table 2, Fig. 1). --- Theme 1. Structural barriers to accessing health care as transmasculine people of color Most study participants described experiencing notable challenges accessing physical and mental health care as a result of structural barriers to identifying health care providers with expertise in transgender health, finding health care providers who share one or more of their social positions and lived experiences, and accessing financial resources to cover high health care costs. --- Lack of access to health care providers with expertise in transgender health The majority of participants discussed the challenges they faced identifying health care providers with expertise in transgender health, which in turn undermined their access to and use of both mental and physical health care. For example, an Arab and multiracial transmasculine participant noted: "[I] disclosed [my gender identity] to my therapist and then 2 months later he said he didn't feel qualified to take care of someone with a non-binary gender because he felt like there was something exotic about it. He was very clear that he felt like he was going to misstep and then hurt me, and it would really stress him out. I felt like I was being released into the ocean, no support at all. And it was literally because of my identity. " Further, explaining his avoidance of sexual and reproductive health care, a Latinx/e transgender man explained: "I've never been to the OB/GYN. And the reason I haven't gone at all is because I'm very afraid of it being awkward and having to explain things or what T [testosterone] does. And I'm not looking forward to that, because it's very frustrating, because it makes me feel like I don't exist. It leaves me feeling really pessimistic. There's so few of us, why ever would doctors be trained? They just don't think it's important. " Limited access to health care providers with one or more shared marginalized social positions Most transmasculine people of color in our study, including those who reported finding health care providers with expertise in transgender health, reported difficulty identifying health care providers who shared one or more of their marginalized social positions and related lived experiences. Many participants reported experiencing barriers to identifying and receiving care from health care providers of color, for whom they expressed a preference. For example, a Black non-binary participant stated: "I would prefer to see people of color. It's nice when I don't feel a cultural barrier between myself and the provider. Or just seeing someone who looks like me, so that I know they're not denying me care because of the color of my skin or anything like that. " Additionally, several participants also described the challenges they faced identifying and receiving care from providers who shared more than one of their social positions as transmasculine people of color, for which they expressed a preference. For example, a Black, Native, and multiracial agender participant noted: "I'm trans, I'm poly[amorous], I'm into kink. I am Brown/Black and AFAB [assigned female at birth] and transmasculine even though I identify as agender. I don't want a therapist that's white. And so, that's a very narrow pool. Finding niche doctors is really hard. And then all the actual ones that do fit that are already taken up because they're already so limited. " A few participants discussed the conflicts they experienced among their different social positions and compromises they had to make in selecting a health care provider who met their needs and preferences as transmasculine people of color. For example, an Asian transmasculine participant noted: "[My therapist] was trying to figure out who to transition me to when she left, and she was like, 'Well, there's this person who'll understand your culture. She has a South Asian heritage,'or, 'There's this person who understands the queer side.'You've got to pick. " Similarly, a Black agender participant mentioned: "It's scary to try to find these doctors. Sometimes I have to compromise one box they don't tick off, as long as they tick off the rest. I have to think about, 'What's more important for me right now?' [rather] than think about ticking off all the boxes, because no one's going to check off all the boxes, usually. For example, I have a therapist that's nonbinary and trauma-informed, but they're white. I want a therapist of color, but that's okay, because they ticked off at least two of the boxes. " Lack of access to affordable health care and financial resources Some participants reported facing pronounced structural economic barriers to accessing health care due to the high cost of health care and a lack of access to financial resources. For example, a Black Caribbean transgender man explained: "I think the main thing is how serious the situation is, and if I can afford it. So, if I feel like I really need to be seen for something that's kind of worrying me to the point where I'm stressing out, then I'll find a way and try to pay it and make an appointment. But if I think, 'I can deal with this,'then I'm usually try-ing to save my money. " Further, an Arab and multiracial transmasculine participant noted: "Seeing a doctor is kind of an ordeal financially. And also, just feeling like navigating the whole thing [health care system] and not knowing how much it costs ever. " Similarly, a Black, white, and multiracial demi-girl stated: "I'm hesitant to go, but I'll say 'Well, if I need to.'But the bigger problem is just finances. And also the fact that I'm unemployed. It's not always directly, 'Oh I won't go to the doctor because they're going to discriminate against me there.'It's like I can't afford to pay because I don't have a job because anywhere I want to work doesn't want to hire someone like me. " --- Theme 2. Anticipating and experiencing multiple intersecting forms of interpersonal discrimination in health care settings Participants discussed anticipating and experiencing multiple, intersecting forms of interpersonal discrimination as transmasculine people of color navigating various health care settings. Cissexism Most participants reported anticipating cissexism in the context of health care. For example, a Black non-binary participant noted: "It's also nerve-racking because you never know how a clinician is going to treat you and if they're going to change after you come out to them, like, 'Oh, is this person secretly anti-LGBT? And now I told them, and now they're not a safe health care provider for me.'Or are they going to think I'm crazy and not listen to me? Or invalidate my experiences?" Similarly, a Black, white, and multiracial demi-girl explained: "The worst part is just not knowing if they're going to regard me the right way. Like acknowledge me how I want to be acknowledged. Whether it's my pronouns and my name or just the way they're looking at me or are asking questions. That's always something I have to worry about and anticipate or prepare myself for. It's usually not to the extent of feeling mocked or ridiculed but sometimes it is, and I just kind of have to prepare myself for like, 'Oh these people are judging me when I walk in the door. '". Further, the majority of participants reported either personally experiencing or hearing about peers experiencing cissexism-including intrusive, disrespectful, and inappropriate care as a result of their transgender or gender diverse status-during clinical encounters. For example, a Black, Latinx/e, and white non-binary participant mentioned: "I have scoliosis and fibromyalgia so I will have to go see a back doctor, and then they're just like, 'Oh so I see you're like gender...' and I was like, 'I don't want to talk about that! I want to talk about my back.'And then they keep asking me questions about my gender when it has nothing to do with my back. " Moreover, referring to their peers' experiences of cissexism in sexual and reproductive health care settings, a Latinx/e and Native transmasculine participant noted: "I'm really nervous to get a Pap smear. [I've] just heard some horror stories from friends who have doctors who are very confused by the genitals of people who went on T [testosterone]. Also, one of my friends got referred to a psych person because they thought they were a man who thought he needed a Pap smear. They thought they were a cis[gender] dude. " In contrast, several participants described feeling affirmed and validated when receiving care from health care providers with knowledge of and experience in transgender health who used gender-inclusive language. For example, a Latinx/e and Native transmasculine participant explained: "My PCP [primary care provider] was really good. She used this awesome language where she was like, 'Have you been with any sperm-producing people?' And I loved that, because I used to identify as a lesbian, and I only had sex with people who identified as women. And since then, that's changed a lot and the bodies of the people that I sleep with are much more diverse now. And so that was really helpful language for me personally and felt validating not only of me but of my partners. " Similarly, an Asian non-binary participant mentioned: "She doesn't ever gender any body parts or myself. And I was kind of nervous going to her as a non-binary person who wanted to start T [testosterone], because I wasn't sure if I would have to pretend that I was a trans man or something like that. She was very understanding and said she has a lot of other patients like that, so I just think she has a lot of experience. " Racism Many participants in our study-notably, all of the Black participants-reported experiencing racism in health care settings, including erroneous racist health care provider beliefs about their sexual behavior and level of pain tolerance, which they described as being further compounded by (cis)sexism. For example, a Black, white, and multiracial demi-girl explained: "When I had a different psychiatrist before, he would always make these comments regarding me as aggressive. He'd hypersexualize me and just make me more mature in his head than I actually was because of my racial identity. " Moreover, a Black agender participant observed: "There's this common misconception that Black folks, especially Black people who are assigned female at birth, are less likely to feel pain. [That] is a consistent thing that I do notice [when seeking care]. " Further, a Black gender non-conforming participant stated: "I specifically only ask other people of color about health care. Because I feel like the people who generally tend to have negative experiences, specifically at [LGBTQ health clinic], are always people of color, especially the Black people. If doctors are, you know, hypersexualizing you because you're Black, white people won't notice that. " This participant continued: "But I think that Black, especially Black transgender people, should be able to go into a health space and be able to ask for sexual health services and testing without the 'Oh, so you been [having sex.]' That always seems to happen. " Moreover, several participants mentioned that they experienced less or no racism relative to their peers with darker skin tones as a result of their lighter skin color and their proximity to whiteness. For example, a Black gender non-conforming participant observed: "I know that I'm lucky in that, as a light-skinned Black person, I don't deal as much with hyper-sexualization in health spaces. " Similarly, referring to their darker-skinned partner, a Black, white, and multiracial demi-girl observed: "And so sometimes, I notice that at similar places that we may go for certain care, they would acknowledge us differently because they feel more favoritism towards me because of my lighter skin and whatever else. " Moreover, referring to being perceived as white despite not identifying as such, a Latinx/e transgender man mentioned: "Because I'm white-passing, I haven't had experiences where doctors are outwardly rude or anything. " Further, with regard to their experiences of racism, which were shaped by not only their skin color but also their parent's race/ethnicity, both their own and their parent's social class, and their gender expression, a Black, white, and multiracial nonbinary individual explained: "I feel like I've had a very different experience. I have parents that are both white. And my mom would always [...] come with me to the doctor when I was growing up. So, I definitely had that, 'this is the child of this middle-class, white woman. And so, I think that was a good, pretty strong barrier [against racism]. " Referring to their current experiences of racism and other discrimination in health care settings, they continued: "I think it's easy for me to go in and be like, 'Yeah, I'm a well-educated, maybe light skinned, maybe Italian, woman.'I can have people read me that way. And then know that people [...] are going to listen to me and respect me, and do whatever I want them to do. " Weight-based discrimination Several, mostly Black participants also reported experiencing weight-based discrimination in health care settings, including health care providers dismissing their health concerns and needs. For example, a Black non-binary participant described interacting with health care providers who attributed their health concerns to their weight and prioritized addressing their weight over their health concerns. They noted: "A lot of the time, [it's] like, 'Oh, I'm in pain.'And they go like, 'Did you try losing weight first?' They continued: "Or if I have cramps, 'You should lose weight, it will get better.'I'm like, 'What if you just gave me a solution that would work? What if I didn't want to lose weight? What if I'm fine the way I am?'" Similarly, a Black gender non-conforming participant explained: "I have chronic joint pain literally all the time. I get random dizzy spells. I have all these symptoms that I don't know what the cause of them are. And I've tried bringing it up with my PCP [primary care provider], and she would send me to 10 different specialists. All of them would be like, 'Hm. Looks good to me. You're fine.'I'm like, 'No, it's not. No.'So finding a doctor that would actually take my symptoms seriously and wouldn't, just chalk it up to me being fat... I still haven't really found any competent doctors who take chronic illness seriously in general, never mind for folks who are fat. " Moreover, a few participants described how anticipating and experiencing weight-based discrimination in health care settings was a deterrent to seeking care and a barrier to obtaining high-quality care. For example, a Black agender participant explained how weight-based stigma and discrimination were a deterrent to seeking care and could also promote poor health: "But the fatphobia definitely has been very...I have been scared to see doctors before, at a certain weight. I have lost a lot of weight. And because of being on T [testosterone] and working with children, I've lost 70 pounds. And it's kind of good, because yeah, I lost 70 pounds through mostly healthy means. But sometimes, I lose weight rapidly, and it's because I'm too depressed to eat. And it's hard to find doctors that can understand that two things can exist. That weight loss can exist because you're working out a lot and you're eating healthier, but it can also exist because you're sick. " Lastly, some participants described how health care providers use their weight as an excuse to deny them gender-affirming surgery. For example, a Black and Latinx/e non-binary participant noted: "The best doctor to go to is [doctor's name], but he doesn't take you if you're over a certain BMI. And if you... even if you express to him, you know,'Actually, we probably shouldn't have conversations about my weight. I am recovering from an eating disorder. We really can't talk about this.'He'll still tell you, 'Well, you need to lose weight if you want me to do the surgery for you. '" In contrast, a Black, Native, and multiracial agender participant described receiving care that was affirming of both their gender and weight and respectful of their bodily goals. They explained: "I went swimming for the first time in February shirtless. It was great, it was really nice. And it's like they're the right size. I'm a fat person, I shouldn't have a flat chest. I should have something because that's how fat works on bodies. I'm really glad that the doctors and the people I interacted with were knowledgeable enough for what I needed to help me achieve what I wanted. " Ableism A few participants reported experiencing disability-related discrimination in health care settings. For example, a Black, white, and multiracial demi-girl mentioned: "I am autistic and so something that I do to regulate myself is I do tactile stims. And so it's been a big thing where I've gotten medical abuse where they've tried to limit that and not allow me to do stuff like that, which would lead to panic attacks and stuff for me. " Additionally, a Black and Latinx/e genderfluid participant noted: "I'm young and [health care providers] don't really think young people have chronic pain. So every time when they ask me [about] my pain, and I tell them about my issue with my feet or anything else, they're kind of just like, 'Well, I don't know what to do' or they send me to [another medical center]. " Further, referring to the compounding negative effects of ableism, weight-based discrimination, (cis)sexism, and anti-Black racism in particular on the health care experiences, a Black gender non-conforming participant explained: "I feel like every part of my identity just kind of stacks on top and having this cute little brick wall that means that I won't get the care that I need when I go to the doctor. Being fat usually means that my doctors are going to either attempt to chalk up whatever is wrong with me [to me] being fat. " They continued: "I'm technically diagnosed with ADHD, but that's the only thing I can get a diagnosis for. Being a Black AFAB person who is an adult, my chances of even being able to get in for autism testing are slim to none. " --- Theme 3. Consequences of multiple discrimination in health care settings Participants described the negative impact of anticipating and experiencing multiple, intersecting forms of interpersonal discrimination in health care settings on their health care utilization, the quality of care they received, and their mental and physical health. Delaying and avoiding care Many participants described delaying or avoiding seeking health care in response to prior and fears of

Background: Research shows that transmasculine people experience discrimination based on their gender identity and/or expression (i.e., cissexism) while obtaining health care. However, studies examining the experience of other forms of discrimination in health care settings among diverse subgroups of transmasculine individuals, including those from minoritized racial/ethnic backgrounds, are very limited.Guided by intersectionality, we designed a qualitative research study to explore how transmasculine people of color experience-and resist-multiple, intersecting forms of discrimination in health care settings. Guided by a purposive sampling strategy, we selected 19 transmasculine young adults of color aged 18-25 years to participate in 5 mini-focus groups conducted between February and May 2019 in Boston, MA. Focus group transcripts were analyzed using a template style approach to thematic analysis that involved both deductive and inductive coding using a codebook. Coded text fragments pertaining to participants' experiences of health care discrimination were clustered into themes and sub-themes. Results: Transmasculine people of color described experiencing notable challenges accessing physical and mental health care as a result of structural barriers to identifying health care providers with expertise in transgender health, finding providers who share one or more of their social positions and lived experiences, and accessing financial resources to cover high health care costs. Further, participants discussed anticipating and experiencing multiple forms of interpersonal discrimination-both independently and simultaneously-in health care settings, including cissexism, racism, weight-based discrimination, and ableism. Moreover, participants described the negative impact of anticipating and experiencing multiple interpersonal health care discrimination on their health care utilization, quality of care, and mental and physical health. Lastly, participants discussed using various strategies to resist the multiple, intersecting forms of discrimination they encounter in health care settings, including setting boundaries with health care providers, seeking care from competent providers with shared social positions, engaging in self-advocacy, drawing on peer support during health care visits, and obtaining health information through their social networks. Discussion: Efforts are needed to address cissexism, racism, weight-based discrimination, ableism, and other intersecting forms of discrimination in clinical encounters, health care institutions and systems, and society in general to advance the health of transmasculine people of color and other multiply marginalized groups.

m, weight-based discrimination, (cis)sexism, and anti-Black racism in particular on the health care experiences, a Black gender non-conforming participant explained: "I feel like every part of my identity just kind of stacks on top and having this cute little brick wall that means that I won't get the care that I need when I go to the doctor. Being fat usually means that my doctors are going to either attempt to chalk up whatever is wrong with me [to me] being fat. " They continued: "I'm technically diagnosed with ADHD, but that's the only thing I can get a diagnosis for. Being a Black AFAB person who is an adult, my chances of even being able to get in for autism testing are slim to none. " --- Theme 3. Consequences of multiple discrimination in health care settings Participants described the negative impact of anticipating and experiencing multiple, intersecting forms of interpersonal discrimination in health care settings on their health care utilization, the quality of care they received, and their mental and physical health. Delaying and avoiding care Many participants described delaying or avoiding seeking health care in response to prior and fears of future experiences of multiple and intersectional discrimination in health care settings. For example, referring to the negative impact of weight-based discrimination on seeking care, a Black gender nonconforming participant stated: "And it got to the point where I literally, for a span of about 8 months, I literally just refused to go to the doctor for anything. Because I couldn't handle the stress and disappointment. I would cry if someone told me to go to the doctor because I couldn't handle it. Because the sheer amount of fatphobia that I would face from doctors, would just be too much. " Further, with regard to the negative effects of experiencing cissexism in health care settings, a Latinx/e and Native transmasculine participant mentioned: "Last year I got in a car accident, and I had to go through the ER alone and it was one, super scary because I was in a car accident, and I broke my leg. But two, it was super invalidating and felt really hard because everyone was misgendering me and talking about my body in ways that didn't feel good. I was wearing a chest binder and they wanted to cut it off of me. And I was like, 'No, I can't, I won't. I can't afford to replace it, so I will pull it off myself.'And luckily, one nurse had a trans son, and she intervened and was like, 'No, let them take it off.'But just, stuff like that makes me really hesitant to go to the doctor if I don't absolutely need to. " Similarly, a Black gender non-conforming participant described discontinuing their care in response to a provider's refusal to respect their gender identity: "I just stopped going to see her because she was a cis[gender] white woman, and she didn't really get the whole trans thing. Even when I went to see her while I was on my hormones, she always misgendered me, she always used the wrong name. I had told her what the correct name was, and she didn't listen to me. " Moreover, a Black, Latinx/e, and white non-binary participant stated: "If it doesn't kill me then why put myself through having to correct someone on my body and my gender? Because if they're like, 'You've got to get your teeth cleaned', I'm just going to get my teeth cleaned and you're going to call me a man the whole time and make me uncomfortable. So why put myself through that just for a cleaning?". Erasure of social identities and lived experiences Several participants described how experiencing multiple, intersecting forms of discrimination in health care settings led to the erasure of aspects of their social identity and lived experience-which in turn undermined the quality of care they received, including patient-provider communication and the recommendation and delivery of relevant and needed health services. For example, referring to how they negotiate their gender identity in the context of cisnormative health care settings, a Black, white, and multiracial non-binary participant explained: "I've been nervous lately. Like when my PCP [primary care provider] asked for my pronouns, I almost lied. Because I was like I don't know how this is going to affect the care that I get. I don't know, I just feel weird because I think that I feel concerned that if I tell people I'm non-binary, they're going to think that's weird and then think that I'm dumb and not want to...so, I've hidden it a lot. " Similarly, with regard to how health care providers interact with their multiple, intersecting social identities and lived experiences, a Black, white, and multiracial demi-girl noted: "It's just like people pick the pieces that they can find comfort in. For example, like my privilege of being light skinned, they try to find comfort in that. But the things that seem exotic to them and that they don't want to educate themselves on or that they don't understand, they try to keep away from it as much as they can-even if that means risking my health care or risking my needs and not acknowledging them. " Negative mental and physical health effects Participants reported that accessing health care as a transmasculine young adult of color presented mental health risks that often outweighed the benefits of receiving care. For example, a Black gender non-conforming participant mentioned: "I wanted to perish, frankly. I wanted to, you know, take a nap and not wake up. It wasn't great. It made my mental health not feel good. And it was just really frustrating. Because that -on top of all the other things that were going on with me -that she didn't really listen to me about [this] was the straw that broke the camel's back. " Further, referring to the negative mental health impact of experiencing cissexism in the especially vulnerable setting of gynecological care, an Asian non-binary participant noted: "She would misgender me every time I went in for surgery stuff or like check-up stuff. And I never felt comfortable correcting her because I was always half naked with my foot in the stirrups. And I felt super vulnerable because I'm also a survivor, so I had a lot of trauma around there. " Moreover, describing the deleterious mental health effects of having to educate their health care providers about transgender health, an Asian non-binary participant stated: "The overwhelming feeling is exhaustion. So the onus is on trans people to educate their providers a lot of the time, and not the other way around. And it shouldn't be that way. " A few participants also described physical risks associated with stigmatizing and discriminatory health care experiences. For example, referring to the negative effects of cissexism on their reproductive health, a Black, Latinx/e, and white non-binary participant stated: "A lot of things slipped by because I didn't have the confidence or the knowledge or couldn't get past the anxiety to explain to them that's not what I wanted, this is not how I identify... I'm anemic, so I was losing blood a lot with this IUD [intrauterine device]. At one point I passed out and I had to go to [a clinic] to get it emergency removed. " --- Theme 4. Strategies for challenging and resisting multiple discrimination in health care settings Participants discussed using various strategies to challenge and resist multiple, intersecting forms of discrimination and their negative effects in health care settings. Setting boundaries with health care providers Some participants described setting clear boundaries to protect their mental health and well-being in the context of patient-provider interactions. For example, with regard to preempting any negative impact of potential weight-based discrimination, a Black, Native, and multiracial agender participant explained: "I appreciated that she wouldn't tell me my weight. I would be like, 'I don't want to know my weight. I don't have any intention of exercising or doing anything to modify my body weight because I'm pretty happy with how I am.'[She was] like, 'Okay, I can respect that. But we will keep an [eye] on things if they become concerning.'And I was like, 'That's fair. '" Further, a Black, Latinx/e, and white non-binary participant mentioned: "I'd gone to this physical therapy place. [The health care providers] were like, 'We have to do this, we have to do that.'I was like, 'Oh, I'm actually not comfortable doing this, because I don't want you touching me there.'And they were like, 'Yeah, but all the guys do it,'and I was like 'But I'm not a guy,'and she was like, 'What do you mean?' I had to briefly explain that I was trans and that I wasn't comfortable doing that because my chest is not the same as cis males. " Seeking care from competent health care providers with shared marginalized social positions Most participants mentioned seeking out health care providers who were knowledgeable about transgender health and shared one or more of their marginalized social positions and related lived experiences in order to avoid discrimination and promote their comfort and well-being during clinical encounters. For example, with regard to avoiding experiencing cissexism while obtaining mental health care by seeking care from a non-binary provider, a Black agender participant noted: "I got lucky with my therapist that I see. What made me comfortable with this therapist was that we had a shared experience, we're both non-binary people. And they actually were one of the first people to affirm that it was okay if I wanted top surgery [in a] different [way] than a lot of people, because eventually, I do want to get top surgery. But I want a reduction; I don't want to say goodbye completely to everything. But also knowing that my therapist was sharing their experiences as well made me feel comfortable. " Further, referring to avoiding experiencing racism and xenophobia in health care settings by receiving care from a provider of color, a Black, Latinx/e, and white non-binary participant mentioned: "I specifically wanted a doctor of color because I had a really bad experience with a white doctor. I specifically wanted to go to a place that was more diverse because there's been two times where I've been asked for my Green Card. So, I specifically wanted a doctor of color, which I did get. I'm very lucky. I love her so much. " In contrast, a few participants mentioned being concerned about receiving care from a health care provider of color due to fears that they might not be affirming or accepting of their gender identity. For example, an Asian non-binary participant observed: "I think there's this perception that people who are white American are more LGBTQ-friendly, and whoever you are, you kind of internalize that. And so, I think if a doctor is someone who isn't white American, I'm like,'Are you going to be queer-friendly?' And it's probably not fair. That's a stereotype, just totally a stereotype and a bias I have. " Engaging in self-advocacy Many transmasculine young adults of color in our study mentioned having to advocate for themselves in order to receive competent care, including by asking questions about their care, requiring that their health care experiences be documented, and requesting to change health care providers. For example, with regard to asking questions about their care, a Black non-binary participant explained: "I am someone where I really take my health care seriously. And so when I don't understand something, I would like to ask a doctor. Like, 'Oh, we're going to test you for this,'and if I don't know what that means, I'm like, 'Okay, what is that?' And they tell me. " Moreover, referring to ensuring that their health care experiences and care decisions are documented, a Black and Latinx/e non-binary participant noted: "I walk into every room and ask for a scribe to be there because I do not trust my health care providers. I don't talk to any health care provider without someone in the room who is transcribing exactly what is happening, who will answer me when I ask them if they noted something in my chart, who will read things back to me before I leave. " Similarly, a Black gender non-conforming participant explained: "Before I knew that I could [ask], 'Oh, can you please note on my chart that you refused to give me treatment for my nausea that's seriously affecting my health?' Before I knew that was an option, I just wouldn't go [to the doctor]. Now that I know that there's a way to keep medical professionals that I see accountable, I might go to the doctor. And I feel like I finally have a tool to really help me get the care that I need. " Lastly, referring to requesting a different health care provider after experiencing cissexism, a Black, Latinx/e, and white non-binary participant mentioned: "This is the person who tried to change my name in the system back to my deadname, and I was like, 'Have you ever heard of a trans person?' And she was like, 'You're trans?' And I was like, 'Have you ever heard of a trans person?' And she was like, 'Not'til you, I guess.'And I was like, 'Who in your office has?' She said, 'I guess soand-so.'I was like, 'You need to transfer me to them.'So I did get transferred to this person. She changed my name back to what it's supposed to be and helped me get back on my insurance. " Drawing on peer support during health care visits Some participants mentioned having partners or friends accompany them to health care visits to provide emotional support and advocate on their behalf. For example, a Black, Latinx/e, and white non-binary participant noted: "So I'm really scared of the doctors -most providers, so I usually have someone come with me. And if they [partner] see that I am not going to bring it up, because I'm too nervous, they will bring it up. So, my partner has been really good about that because usually we'll start talking and all of a sudden, they [provider] will slip a 'he' pronoun and my partner is like,'Actually it's 'they'.'And that will initiate the conversation of me being more comfortable to tell them that I'm non-binary. " Moreover, a Black and Latinx/e non-binary participant stated: "Having someone in the room while my doctor tried to force an IUD [intrauterine device] on me, that was great for me because it just made me realize that I didn't dissociate and hallucinate the whole experience. " Lastly, a few participants expressed that, when they were unable to find someone to accompany them to a health care visit, they delayed or avoided care. For example, a Black, Latinx/e, and white non-binary participant mentioned: "That's why I cancelled my last two dentist appointments. Because my partner couldn't go, and I was too scared to [go alone]. " Obtaining health information through social networks Many participants mentioned that, in the context of stigmatizing and discriminatory health care experiences, they instead turned to other transgender and gender diverse people for health information that meets their needs by accessing either in-person or online social networks. For example, a Black gender non-conforming participant explained: "That's probably the reason why I don't go for preventative care stuff. Because various aspects of my identity form a barrier to receiving a specific type of care that I would need. So, I just don't talk about it, and I just don't go. I know enough people that have similar experiences that we all just kind of form a little community network of like, 'Okay, I'm sick, what do I do?' 'Oh, I do this.''Okay, I'm going to try that.'And then it works. " Further, an Asian non-binary participant noted: "I feel like the queer community at large, at least the ones that I've been a part of, are very vocal about the importance of [STI testing]. And that's primarily where my education's come from, from the community, not from a doctor, not from online, regarding STIs. " They continued: "I mean, for a lot of queer and trans people, it's like, if we don't protect each other, who will?" Recommending critical health care provider training Several participants recommended that, in order to address how multiple, intersecting forms of discrimination simul-taneously undermine the health care experiences of transmasculine people of color, health care providers receive critical training in recognizing and addressing cissexism, racism, and other forms of discrimination in health care settings. For example, an Arab and multiracial transmasculine participant suggested: "It's critical teaching physicians about the racialized history of STI stigma and research. There's the Tuskegee trials and all these [awful things] that doctors don't know about. And so, trying to mitigate that by actually giving explicit and race critical and gender critical education to physicians. " Moreover, a Black, white, and multiracial demi-girl recommended: "For the health care providers, I think it's important that they get effective training and regular training, not just like, 'Oh I took a 30-min little class that a cisgender straight person taught me about cultural competence with LGBT people,'and also the teacher was white and talked a little bit about racism but that they didn't experience [it]. I just hope that health care providers can get more effective training and direct knowledge from people that actually have experiences of it and include our voices. " --- Discussion Using thematic analysis, we found that transmasculine people of color experience pronounced barriers to accessing physical and mental health care, all of which can be linked to structural cissexism, structural racism, and capitalism. Specifically, the participants in our study reported having trouble identifying health care providers, including obstetrician/gynecologists, with expertise in transgender health, which is linked to pervasive structural and institutional cissexism in society in general and the health care system in particular [50][51][52][53][54]; challenges obtaining care from providers who shared their gender identity, race/ethnicity, and/or other marginalized social positions, which is linked to structural and institutional cissexism, racism, and other forms of discrimination [55,56]; and difficulty meeting the high financial costs of health services, which is linked to the market-based nature of health care in the U.S [57][58][59]. Additionally, study participants reported anticipating and experiencing multiple, intersecting forms of interpersonal discrimination-including cissexism, racism, weight-based discrimination, and ableism-in various health care settings. While most participants discussed these fears and experiences of discrimination separately, many also described how they simultaneously impacted their health care experiences in compounding ways, in line with intersectionality [10][11][12][13][14]. Our findings align with and build on those of Howard et al., who found that transmasculine people of color experienced discrimination in relation to both gender identity and race/ethnicity in health care settings [19]. Similarly, the authors also found that, although participants tended to describe these two forms of discrimination separately and mentioned that their dominance varied across clinical encounters, the health care experiences of transmasculine people of color were simultaneously and uniquely impacted by both cissexism and racism, among other forms of discrimination, as shown in our study [19]. Of note, our study elucidates the unique and specific impact of anti-Black racism on the health care experiences of Black transmasculine people in particular, as well as the mutually constitutive and compounding ways in which anti-Black racism intersects with cissexism and weight-based discrimination in the health care system. Specifically, we found that all Black participants experienced racism during clinical encounters, which underscores the persistent and pervasive nature of anti-Blackness in U.S. society in general and in the health care system in particular. Indeed, critical race theorists explain that racism, especially anti-Black racism, underpins all U.S. systems and institutions, including but not limited to the education, employment, housing, criminal legal, and health care systems [60,61]. Moreover, Washington, Roberts, and others have demonstrated how U.S. medicine, which espoused and propagated eugenics, was developed through the exploitation of and experimentation on Black individuals, from slavery to the present [62][63][64]. Lastly, scholars have also shown the mutually constitutive nature of anti-Black racism and other forms of oppression, including transphobia, anti-fatness, and ableism, among others, which subjugate and disproportionately harm those who experience them simultaneously [65,66]. Thus, our study provides an empirical illustration of how these historical and contemporary processes undermine the health care-and in turn, the health-of Black transmasculine people in particular, whose experiences in the health care system are shaped by intersections of anti-Black racism, cissexism, weightbased discrimination, and ableism. Similarly to other quantitative [8,67] and qualitative [19,68] research studies, we also found that experiences of discrimination in health care settings were linked to the denial of, delays in, or avoidance of care and the receipt of low-quality care among transmasculine people of color. Further, in line with other research conducted among predominately cisgender populations, we also identified negative effects of health care discrimination on participants' mental and physical health [9,69,70]. Lastly, in line with other studies conducted among predominately white transmasculine individuals [50,71], our findings indicate that transmasculine people of color actively use a range of strategies to challenge and resist the multiple forms of discrimination they face in health care settings. Specifically, study participants reported establishing boundaries with health care providers, seeking care from providers with expertise in transgender health and who share at least one of their social marginalized positions, self-advocacy during clinical encounters (including asking questions and requiring documentation of the visit), ensuring peer support during health care visits, and obtaining health information through social networks of transgender and gender diverse peers [71].Additionally, participants recommended that health care providers receive critical, historically-informed training in recognizing and addressing cissexism, racism, and other forms of discrimination in health care settings. Our findings should be interpreted in the context of several limitations. First, our sample primarily consisted of individuals who had received at least some college education and were enrolled in a private health plan; thus, findings may not reflect the experiences of transgender and non-binary AFAB people with less than a college-level education or those enrolled in a public health plan or lacking health insurance. Second, our study was limited to young adults aged 18-25 years; as such, our findings may not be applicable to younger or older transmasculine people of color. Third, focus groups took place in the greater Boston area, thus findings may be less applicable or transferable to those who live in geographic areas with other social (e.g., more conservative gender norms and sexual attitudes), economic (e.g., lower levels of educational attainment), political (e.g., no legal prohibition of gender identity-related discrimination), and health policy (e.g., located in a state with no Medicaid expansion) climates. Fourth, focus groups were not stratified by race/ethnicity or gender identity, so findings may have masked differences among racial/ ethnic and gender identity subgroups of transmasculine young adults of color. Fifth, our findings pertain to experiences of interpersonal discrimination in health care settings and do not examine the influence of institutional discrimination in the health care system or of structural discrimination in society more broadly, which shapes individuals' health care experiences as well as the nature, occurrence, and impact of interpersonal health care discrimination. Lastly, we were not able to examine transmasculine people of color's experiences of heterosexism, xenophobia, and other forms of discrimination in our study. Thus, future quantitative, qualitative, and mixedmethods research studies that investigate how various multiple and intersectional forms of discrimination at multiple levels and in multiple settings differentially and simultaneously affect the health care experiences of specific subgroups of transmasculine people of color from diverse gender identity and racial/ethnic as well as socioeconomic, age, geographic sexual orientation, and nativity backgrounds, among others, are needed. Our study on the experiences of multiple, intersecting forms of discrimination in health care settings has important implications for practice and policy. First, as underscored by many participants in our study, there is a pressing need for health care facilities to hire, promote, and retain transgender and gender diverse health care providers and health care providers of color, including providers with both marginalized gender identity and racial/ethnic positions, at all levels of the institution. Indeed, research shows that receiving care from a provider who shares one or more marginalized social positions with multiply marginalized patients can promote patient comfort during clinical encounters, as well as the delivery of high-quality care [21,[72][73][74][75]. However, health care institutions should ensure that marginalized health care providers and leaders are supported in their work and that robust mechanisms are in place to identify and meaningfully address bias, prejudice, and discrimination directed toward them when they occur. Second, some participants called for health care providers to receive critical, historically-grounded training on the impact of cissexism, racism, and other intersecting forms of discrimination on health care. It is possible that these trainings may decrease the burden transmasculine people of color face in having to educate providers about their gender-specific health concerns and health care needs [2]. However, research shows that provider training has limited and mixed results on improving provider knowledge and delivery of clinical services to marginalized populations, including transgender and gender diverse individuals [76]. For example, in a 2019 study, Stroumsa et al. found that providers' knowledge of transgender health was associated with transphobia but not with formal or informal education on the topic [77]. Thus, efforts are needed to address cissexism, racism, weight-based discrimination, ableism, and other intersecting forms of discrimination in clinical encounters, health care institutions and systems, and society in general. At the interpersonal level, research suggests that using a shared-decision making approach rooted in the provision of person-centered [78], structurally competent [79], and culturally humble [80] care may be beneficial to improving the health care experiences and promoting the health of transmasculine individuals of color [81]. Such an approach would ensure that providers listen to and center transmasculine patients of color's health and health care concerns, needs, and experiences at the intersection of multiple dimensions of discrimination and in the context of other societal factors that shape their health and lives, including housing, employment, and food security [81]. Moreover, this approach would also involve providers avoiding making assumptions about transmasculine people of color's behaviors, concerns, and needs, using accurate language to refer to patients and their bodies, ensuring that only information that participants would like to document is included in the visit notes, and that supportive individuals of patients' choice are allowed to attend clinical visits [50,71,[81][82][83]. At the institutional level, efforts are needed to dismantle practices, rules, regulations, systems, and norms that perpetuate and reinforce cissexism, racism, weight-based discrimination, ableism, and other forms of discrimination and implement systems that promote equity and respect towards transmasculine individuals of color and other multiply marginalized populations [84]. Of note, research suggests that applying a shared decision-making framework that centers the lived experiences and health care experiences of transmasculine people of color to the organizational context of health care institutions, including their workflows, health information technology, organizational structure and culture, resources and clinic environment, training and education, and incentives and disincentives, may help improve health care experiences and health outcomes in this and other marginalized populations [84]. Further, health care institutions can create searchable directories of health care providers with lived experiences of and competence in providing care at the intersections of gender identity and expression, race/ethnicity, and other dimensions of social position and ensuring the inclusion of transmasculine people of color and other marginalized groups in health education and other materials [73]. Moreover, health care institutions can partner with community-based organizations that serve transmasculine individuals of color to deliver health services in trusted community-based settings, which may facilitate access to and utilization of high-quality health care in these communities [21,71]. Even still, addressing multiple, intersecting forms of discrimination in health care settings will require the creation of new health care institutions and community-based organizations that center the lived experiences of transmasculine people of color from the beginning and provide tailored, person-centered, and structurally competent care that challenges structural and interpersonal cissexism, racism, and other forms of discrimination as well as capitalism in health care [85]. Lastly, ensuring access to high-quality health care among transmasculine people of color will necessitate repealing discriminatory laws, policies, and regulations and challenging social norms that promote and reinforce cissexism, racism, weight-based discrimination, ableism, and other social inequities at all levels of society [86][87][88]. Further, efforts to establish and promote structures, systems, practices, and norms that foster equity and social justice at the intersection of multiple dimensions of social inequality in all sectors of society through advocacy, community organizing, and participatory social movements that center the most marginalized are urgently needed to ensure access to high-quality care and foster health and well-being among transmasculine people of color and other multiply marginalized populations [86,88]. --- Availability of data and materials The data used in the present study are not available per our IRB research protocol. For additional information, please contact Dr. Madina Agénor at [email protected]. --- Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12913-022-07729-5. --- Additional file 1. Transmasculine People of Color Sexual Health Care Study: Focus Group Discussion Guide. --- Authors' contributions MA initiated and conceptualized the study, led and supervised data collection and analysis, and wrote and revised the manuscript. SRG analyzed the data and contributed to writing the manuscript. DZ contributed to data analysis and writing the manuscript. RJ and SG were all major contributors in writing the manuscript. AM was involved in data collection and revising the manuscript. MC analyzed the data and contributed to revising the manuscript. ARG contributed to revising the manuscript. All authors read and approved the final manuscript. --- Declarations Ethics approval and consent to participate All research activities were reviewed and approved by the Tufts University Social, Behavioral, and Educational Research Institutional Review Board (IRB). All participants provided written informed consent, including consent to publish the study's research findings, prior to participating in the study. --- Consent for publication All participants provided written informed consent, including consent to publish the study's research findings, prior to participating in the study. --- Competing interests None of the authors have any competing financial or non-financial competing interest. • 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: Research shows that transmasculine people experience discrimination based on their gender identity and/or expression (i.e., cissexism) while obtaining health care. However, studies examining the experience of other forms of discrimination in health care settings among diverse subgroups of transmasculine individuals, including those from minoritized racial/ethnic backgrounds, are very limited.Guided by intersectionality, we designed a qualitative research study to explore how transmasculine people of color experience-and resist-multiple, intersecting forms of discrimination in health care settings. Guided by a purposive sampling strategy, we selected 19 transmasculine young adults of color aged 18-25 years to participate in 5 mini-focus groups conducted between February and May 2019 in Boston, MA. Focus group transcripts were analyzed using a template style approach to thematic analysis that involved both deductive and inductive coding using a codebook. Coded text fragments pertaining to participants' experiences of health care discrimination were clustered into themes and sub-themes. Results: Transmasculine people of color described experiencing notable challenges accessing physical and mental health care as a result of structural barriers to identifying health care providers with expertise in transgender health, finding providers who share one or more of their social positions and lived experiences, and accessing financial resources to cover high health care costs. Further, participants discussed anticipating and experiencing multiple forms of interpersonal discrimination-both independently and simultaneously-in health care settings, including cissexism, racism, weight-based discrimination, and ableism. Moreover, participants described the negative impact of anticipating and experiencing multiple interpersonal health care discrimination on their health care utilization, quality of care, and mental and physical health. Lastly, participants discussed using various strategies to resist the multiple, intersecting forms of discrimination they encounter in health care settings, including setting boundaries with health care providers, seeking care from competent providers with shared social positions, engaging in self-advocacy, drawing on peer support during health care visits, and obtaining health information through their social networks. Discussion: Efforts are needed to address cissexism, racism, weight-based discrimination, ableism, and other intersecting forms of discrimination in clinical encounters, health care institutions and systems, and society in general to advance the health of transmasculine people of color and other multiply marginalized groups.

Introduction In a manifesto published almost seventy years ago in 1972, UNESCO called for educational systems to provide opportunities that empower each and every individual to reach their full potential (Faure 1972). This treatise, BLearning to Be′′, created a global vision for the future of learning and technology. Since then, the UN has offered versions of the Millennial Goals in the 90's (Annan and Unies 2000) and 2015 (Nations 2015), eventually leading to the 2040 goals, which remarkably, have been met and in some cases surpassed. This achievement is due in no small part to advances in cyberlearning paradigms and implementations that have now been broadly adopted (Woolf 2010). In 2050, we will announce a new Vision for 22nd Century Millennial Goals, focusing on the remaining (known) Bwicked problems,<unk> (Rittel and Webber 1974)-complex and large-scale challenges and opportunities likely to have an enduring influence on our societal transformations. These challenges range from climate change, to nuclear proliferation, to nanotechnology, synthetic biology, regional and global pandemics, the AI singularity, and many more (Levin et al. 2012). Today's cyberlearning-the tight coupling of cyber-technology with learning experiences offering deeply integrated and personally attentive artificial intelligence-is critical to addressing these global, seemingly intractable, challenges. Cyberlearning provides us (1) access to information and (2) the capacity to experience this information's implications in diverse and visceral ways. It helps us understand, communicate, and engage productively with multiple perspectives, promoting inclusivity, collaborative decision-making, domain and transdisciplinary expertise, self actualization, creativity, and innovation (Burleson 2005) that has transformative societal impact. Cyberlearning has expanded from primarily attending to individual learners through a sequence of isolated problem solving activities, to embrace a rich array of collaborative experiential learning contexts, made possible by sophisticated and interconnected artificial intelligences. These include diverse and blended formal/informal learning environments, centers, resource networks, teams, communities, and ultimately global societies. Cyberlearning strives to ensure that each stakeholder is empowered to reach her or his full potential. To achieve this goal, AIED brings together diverse resources, virtual and physical instruments, simulations and models, and communities of practice to foster flow (and mitigate Stuck) (Burleson 2005), creativity, and wicked-problem deliberation. In the context of increasingly complex wicked challenges, whose solutions continue to evade even the most capable of experts, society and technology have co-evolved to embrace cyberlearning as an essential tool to envision, iteratively explore, and refine the evolution of our society, towards utopia. Since 2015, Artificial Intelligence in Education (AIED) has transitioned from what was primarily an applied research endeavour operating with limited educational impact (effecting only a few million user/learners), to become a core contributor to our new paradigm of learning and living, made possible by the expansive experiential super computing cyberlearning environmentknown as the Holodeck. Holdecks, over the past 25 years, have been instrumental to an important shift in the siloed nature of diverse societal engagements, resulting in broad adoption of an integrative approach to education, research, policy, and citizen engagement. Today, due in no small part to the collaborative and engaging nature of the Holodeck (See Fig. 1), we have achieved universal literacy and STEM literacy has quadrupled. Lifelong and life-wide passionbased learning have become global, high priority, all-hands-on-deck endeavours-enabling our entire global population to be involved, as diverse and key expert stakeholder participants, in advancing solutions to the grand challenges of our time. Evolving Utopia: Learning to Live and Learning to Be Today's longer life expectancies and increased access to integrated formal and informal learning opportunities (See Fig. 2) have expanded from 2005 categories (0-5, K, GR 1-12, UG, Grad, Work, and Retirement) to encompass a continuum, spanning the entire spectrum of life (Stevens and Bransford 2007). Blended formal and informal learning environments now provide as much as 75-100 % life-wide learning through experiences that leverage real-world contexts and authentic settings. Supporting increased opportunities for passion-based pursuits, there is universal access for individuals, teams, and communities, to a broad array of virtual and hands-on learning and innovation resources, e.g., high-end tools and Fig. 1 The NYU-X Holodeck, the first Experiential Super Computer effort, integrated virtual, acoustic, physical, robotic, physiological, co-located, and distributed individual and team experiences into an advanced education, research, and innovation instrument expert mentors. Learning from peer and expert mentors and, reciprocally, being a mentor to peers and others, and becoming increasingly expert in one's own right are quintessential elements of today's learning and core elements of active citizenship. This eco-system provides low thresholds (lower barriers to entry), high ceilings (growth and impact potential), and wide walls (broad explorations and broad participation) (Resnick et al. 2005). Commensurately, there is no longer an emphasis on traditional retirement (Hiemstra 1999). Instead, we channel our energies into multiple lifelong and passion-based learning pursuits engagements in and contributions to integrated education, research, and innovations that have broad societal impact (Foundation 2014). This lowering of institutional, programmatic, and life-stage boundaries, along with a concerted confluence of learning, career and leisure activity have convened to create rich and robust lifelong and lifewide growth experiences and actualizing opportunities. Both lifelong and lifewide learning underpin the concept of BLearning to Live<unk>, referring to both learning how to thrive in a new and evolving range of contexts and circumstances, as well as providing the modus operandi for living as learning. Living has come to be embraced and appreciated as a rich experience of learning and growing, becoming, connecting, engaging energetically, exercising, teaching, mentoring, aspiring, discovering, exploring, fantasizing, daydreaming, and simply, in all its nuanced facets, Bbeing<unk>and learning to be! Learning to live is essential to the journey towards evolving utopia. (Stevens and Bransford 2007) As novice and expert learners engage with the Holodeck, they explore and create multifaceted experiences on multiple levels (fear, hate, love, insight, inspiration, flow and stuck, etc.) and learn to adopt and develop diverse and flexible perspectives (the obvious and the nuanced, the favoured and the marginalized) as they navigate possible worlds1 (Lewis 1977). Living in and creating these possible worlds, engages individuals in deep exploration of diverse utopias (i.e. non-existent societies described in considerable detail2 (Wikipedia. Utopia 2015)). Our overarching goal is to understand the past and present as a foundation to help us imagine and evolve the future. Sophisticated imagining of the future can be an act of Bliving the future today( Kelley 1997, Personal Communication https://www.ideo.com/people/david-kelley) that helps us understand, re-solve, and begin to iteratively implement our collective aspirations for our 2041 world and its future. Living within the fascinating, multitudinous, and consternating, Holodeck simulations (diverse possible utopias) require reflective metacognition. This experience is purposely perplexing. It is perplexing in that there are so many challenges, so many opportunities, and so many seeming unresolvable wicked challenges. Nonetheless, we embrace this perplexity as desirable. We have evolved a broad consensus that the best way to handle wicked challenges is to develop a series of incremental iterative solutions, a process known as the re-solving (Lewis 1977) of ongoing challenges. We achieve this via sophisticated scenario development and committed engagement in the rich and diverse stories (simulated and real) of living in utopia. In this context, exploration and deliberation within the Holodeck is not only a hallmark of cyberlearning, but also enhances the capacity of our global community to collaboratively create and implement the iterative re-solutions required to solve our wicked challenges. To reach our full potential and to succeed at re-solving wicked challenges, we need to be exploratory, creative, and to develop our diverse, individual and collective expertise. Schank posited that when the walls can answer questions, those that learn the most are the ones with the best series of questions (Brockman 2007). Expanding on this, in the context of the Holodeck, we have found that when individuals and teams of learners actively engage in hands-on collaborative activities, they begin to understand things from multiple perspectives-they begin to become experts (Burleson 2005;Kay 1991). In these environments, key elements of Amabile's componential model of creativity: intrinsic motivation; domain expertise; creative style (Creativity Support Tools (Resnick et al. 2005) and tools for reflective engagement); and actualizing resources, coalesce to advance individual and team creative processes and outcomes (Amabile 1983). By definition, creativityanything new, non-obvious, and usefulis responsible for all societal advancement (Burleson 2005). Thus, with creative exploration and ever more sophisticated expertise, the goals of cyberlearning, AIED, and the Holodeck are to facilitate learning to live, learning to be, and living in and evolving utopia. --- Today's Cyberlearning Features, Utopia and Wicked Challenges Evolving utopia and iteratively re-solving wicked challenges are critical to cyberlearning and advancing society. The primary qualities of the brave new cyberlearning environments of today, include: Personal stories and interactive experiences that make it rich -The magic of humanity has been our dreams, our exploration and fulfilment of dreams, and our complex story telling (Sagan 1985). These dreams are core to our ethical and philosophical understanding and to our appreciation of our historical heritage. Learning has evolved from ancient toys and board games, to embedded cyberlearning phenomena (Moher 2006) such as Real World Games (Waern et al. 2009;Rashid et al. 2006;Burak et al. 2005;McGonigal 2011) and personalized environments (Lahey et al. 2008;Mahoney et al. 2014); the ability for individual (Papert 1980) and communal (Resnick et al. 2009) appropriation of these is appreciated as being core to the reflection (Shneiderman 2003) and feedback loops that help people learn and help creative societies evolve. Open streaming content that make it real and compelling -Multi-modal modeling simulation and real world prediction provide visceral qualities that empower learners to feel experiences, as they react to immersive worlds and understand (on multiple levels) the implications. In the context of simulation, it is possible to Bturn on<unk>and Bturn off<unk>complexity to access the diverse array of realworld and Bopen world<unk>data sources in real-time and asynchronously. We can fly drones over Antarctica, and under the ice into ancient lakes (Berenfeld 1996) or obtain data from the LEGO robots on the moon and international instruments on Mars and beyond the solar system (Burleigh et al. 2003). Contributions that make it yours, together -All participants take active ownership of their learning, and living experiences. Learners, peer tutors, and mentors (learners and teachers of all ages and stages) are empowered to creatively embark on their own learning trajectories, to reflect on these, and to share their insights and contributions broadly. This empowering ecosystem is fundamental to developing: (1) robust expertise; (2) deep collaborations; and (3) strong communication skills, both within and across domains. Core to today's cyberlearning is the ability to actively learn and teach effectively, within and across individual and global communities. Wicked challenges that can be iteratively Bre-solved<unk>-Rittel introduces the notion of solving again and again, of re-solving wicked challenges, as being the iterative and collaborative attempt to inch ever closer towards addressing the complexity intrinsic to these challenges (Rittel and Webber 1974). Since this inherently requires multi-generational understanding, our advancement of utopia requires levels of engagement, dedication, and persistent, life-long hard work, coupled with the richness and actualization of deep play (Ackerman 2011). Making progress in addressing and overcoming the complex wicked challenges that face our society, e.g., climate change, disease/bio-resilience, unintended consequences (economic stability, volatility, Bprogress<unk>) etc., is highly rewarding and truly significant. As we embrace the wisdom of our elders, we are compelled to equip our next generation with the best of our understanding, abilities, and tools, to help them take a long perspective and to equip them with the most effective tools that we can provide, to Bleave the future with a free hand<unk> (Feynman 1955). We strive to achieve these goals in the midst of an on-going range of wicked challenges and their own inherent interconnectedness. Much work is still needed to solidify, scale, penetrate, and adopt the evolving re-solutions; though there are great risks, there is substantial support, and great potential reward. --- Recognizing the Merits of Advanced Cyberlearning Twenty-five years ago, American educators and learning scientists experienced a critical moment in their history, as their nation's preparedness and leadership in STEM innovation faced a range of internal and external challenges. U.S. high school students ranked lower on math and science scores than peers in 46 % and 34 % of OECD countries, respectively ((PISA), P.f.I.S.A. 2012); and China had overtaken the U.S. in the number of patents filed (Gurry et al. 2014). At the same time, the structure and economic models underpinning American higher education were undergoing a massive transformation (Hirsch and Weber 2002). Grade inflation and market forces were threatening the quality of higher education in America and her role in leading the globe in advanced education was being called into question (Arum and Roksa 2011). Supposed experts, graduating with bachelors, masters, and doctoral degrees from even the most acclaimed institutions were increasingly incapable of: (1) comprehensively understanding and solving meaningful problems in their own domains; (2) working with colleagues across disciplines and across cultures; and (3) effectively communicating the value of their fields and engaging a broad public audiencea public, comprised of diverse stakeholders, in dire need of comprehending a wide range of increasingly complex matters. Compounding this situation was an evolving, though not yet universal, appreciation that dramatic advancements in technology, increasing complexity of society, and the disastrous effects of unintended consequences presented a context in which Bwicked challenges<unk> (Rittel and Webber 1974) were becoming ever more complex (Levin et al. 2012). The increased access and capacity offered by these emerging technologies, coupled with the motivating influence of pressing wicked challenges led to increased recognition of the importance of integrated transdisciplinary education and research, as fertile ground for discovery, creativity, and innovation. These activities are now seen as critical to realizing the full potential of each and every individual; a means of enhancing national capacities; and as having the power to foster global, democratic, access to universal lifelong learning opportunities. Researchers and practitioners developed translational learning science innovation centers (Duderstadt 2010) to ensure that society would be equipped with cyberlearning strategies and tools with the capacity to overcome the siloed cultures of the academy and education sector, that could bridge gaps with industry and the public, and empower dreams that begin to realize our collective true potential. This served as both a fundamental investment and a societal commitment to building an open and participatory utopia. For the first decade of the millennium, the AIED community generally held that the gold standard of advanced cyberlearning technology was an Intelligent Tutoring System (ITS) capable of achieving comparable results to those from one-on-one interaction with a human tutor. Today, a new gold standard has emerged. It is based on the broad appreciation of the transformative potential and transdisciplinary depth and breadth of both individuals and teams, working in dynamic, co-located, and distributed configurations with the common goal of empowering lifelong learning and achievement. Two Computing Research Association Grand Challenges for Information Science-Providing a Teacher for Every Learner and A Team (team of human, agent, and robotic collaborators) of One's Own (Association, C.R. 2003) -were merged to create a multifaceted initiative to advance human development through enquiry, exploration, discovery, and innovation. This initiative has facilitated a new generation of cyberlearning technologies that fuses hybrid (physical and digital) experiences with advanced understanding of the psychology of individual and team learning, affect, social interaction, motivation, and creativity. Hybrid experiences are made possible by rich media, content, and advanced tools. Psychology has advanced over this period, using multimodal sensors and machine-learning techniques to create a sophisticated fusion of theory and practice to provide just-in-time, individualized, and team support. During the early 2000s, large-scale learning research was generally limited to indepth observation of a few learners or coarse-grained measures of learning outcomes for larger groups. The state-of-the-art cyberlearning tools that have emerged can now augment learning research with capabilities, such as: multi-modal formative and summative assessments to iteratively determine the zone of proximal development; sensing of cognitive load and affect; integrated real-time feedback that fosters metacognition; and utilization of attribution, cognitive aids, and stress inoculation, to personalize support that improves individual, collaborative, and collective decisionmaking processes, learning, and creativity. For example, mid-21st-century cyberlearning environments are fusing immersive environments with peer learning companions (including both virtual and robotic social agents). This blending of multimedia and physical agents encourage embodied actions and gestural interactions, and empower learners and active citizens to explore and manage complex environments (Hodges 2012), adopt systems thinking strategies, and engage in team collaboration to address societal challenges. --- Holodecks: Experiential Super Computers for Cyberlearning In the early 2000s, workshops sponsored by the Computing Community Consortium (CCC), Computing Research Association (CRA), and National Science Foundation (NSF) Global Resources for Online Education (GROE) program advanced a Roadmap for Education Technology. This strategic plan included a research strategy for rich interfaces (Woolf 2010) (see Table 1). Appreciating GROE's vision of rich interfaces, the NYU-X initiative (NYU-X 2015) and its consortium of public and private institutional partners advanced first and second-generation experiential super computers-BHolodecks<unk>(see Fig. 1). For the past 20 years, NYU-X has iteratively created a sophisticated suite of rich interfaces. Today, our global network of experiential super computers, broadly accessible through common low-end consumer electronic devices, provides a democratic foundation for integrative approaches to cyberlearning, grand challenge innovation, and wicked problem solving. The Holodeck is the foundation of today's cyberlearning experience, offering a software/hardware instrument that seamlessly integrates visual, audio, and physical (haptics, objects, real-time fabrication) components with novel technologies. This system enhances social interactions (human-human, human-agent, and human-robot) by creating a powerful, unified education and research environment and network. Capabilities support capture of comprehensive behavioural, physiological, affective, and cognitive data; visualization; real time analysis of the data; and sophisticated scenario modeling and engagement. The initial NYU Holodeck balanced opportunities for small group, cross-site collaboration and research with incremental equipment costs. Included were Bfield kits<unk>capable of global distributed support for single users or specialized interaction by multiple participants. The NYU Holodeck (NYU-X 2015) infrastructure linked many other facilities, like the BeingThere Lab (BeingThere Center 2015; Raskar et al. 1998), ASU Decision Theater (Theater 2015), UCSB AlloSphere (Kuchera-Morin et al. 2014), and Stony Brook Reality Deck (Papadopoulos et al. 2015) to advance what was at the time, state-ofthe-art rendering of complex real-time scenarios and contingencies. By 2030, this project architecture had paved the way for infrastructure improvements that supported thousands of simultaneous users. Today's Holodeck thrives upon the evolution of the internet, creating a global network that is fundamentally accessible as a human right (Nations 2011) to the entire global population (<unk>10 billion people). The network connects approximately a trillion devices-the internet of things, each with their own embedded intelligence and autonomy, spanning all sectors of enterprise and society and extending initially throughout, and now beyond the solar system (CISCO 2011). Fundamentally, the Holodeck's well-integrated multimodal capabilities serve as a dynamic engine for the core tenants of BLearning to Be′′; functionality includes: Physical -Smart objects, digital-manipulatives, and robotic interfaces are some of the rich interfaces the Holodeck has evolved. These expand upon Tangible User Interfaces (TUIs) such as Sandscape (Ishii et al. 2004) and malleable interfaces such as programmable matter (Gilpin and Rus 2013) and digital clay (Rossignac et al. 2003). Simulation tools, customized user interfaces (e.g., aviation yolks, steering wheels, command centers, and glass cockpits), and a range of robotic platforms have become available for collocated and/or distributed remote interaction (5Ds of robotics e.g., for dirty, dull, dangerous, domestic and dexterous engagement). Likewise, haptic interfaces (data gloves) and 3D fabrication tools have been combined to enhance creative generative experiences and exploration. These tools provide added reality dimension to virtual experiences, and have made us aware of previously unknown or underappreciated aspects of our environment. Human Dynamics: Biometric -Sophisticated multimodal sensing capabilities include eye-tracking (wearable/mobile, at a distance, and multi-person), multi-touch pressure sensors, Brain Computer Interaction (BCI), and affective and sociometric sensors and algorithms (Burleson 2005;Arroyo et al. 2009;Tripathi and Burleson 2012). A high quality camera array-based motion capture system synchronously and asynchronously acquires, analyses, classifies, and streams spatio-temporal data from a wide variety of kinematic sources (individual or groups of human bodies/faces, robotic mechanisms, rigid object Bprops<unk>, etc.). These rich data sets drive customizable animations and other displays and extrapolate data from nonverbal expressions. Research locations are linked with seamless and instantaneous (within our latest understanding of the Blaws of physics<unk>) transmission of data and visualizations. Human Dynamics: Social Collaboration -The Holodeck offers enhanced social collaboration, co-located and distributed human-human, human-agent, and/or human-robot interaction capabilities. Customizable virtual agents and social robots equipped with advanced technology interact using natural language, mirror rich emotive facial gestures, and reflect social characteristics that synchronize speech and gesture production. Integrated agents and surrounding hardware/software create rich multimodal environments with the capacity for real-time data modelling of individual and team behaviours, interactions, team creativity, and collocated and distributed knowledge (wisdom of crowds and expert systems, e.g., IBM's Watson (Ferrucci et al. 2013)). These are coupled with lifelong and lifewide personal, team, and community learning portfolios that provide rich and open learner models and data resources for understanding effective collaboration, teamwork, and communal deliberation. Infrastructure: Network, Communication and Collaboration -A Bdata as servicem odel has created a multi-site, node-based, hybrid, maximally transparent AR/VR space that features high quality, multimodal tracking and collaboration. High-bandwidth connections between local and central nodes are supplemented with low latency networks that seamlessly and reliably scale on demand. The open source platform of real-time APIs supports real-time sharing and data control. Field kits link remote sites with select functionality to provide data, interactivity, and share resources with the networked instrument and Holodeck infrastructure, while reducing their own computational requirements, complexity, and cost. --- Element Description Visual Multimodal mesh networks provide peer-to-peer and peer-to-network connectivity creating the framework for globally-distributed visual communication and engagement. --- Acoustic Audio capabilities include distributed technologies that can create almost any auditory environment using captured, generated, or pre-recorded sounds. --- Physical Smart objects, digital-manipulatives, and robotic interfaces enable rich interactions an imaginative explorations. Human Dynamics Aggregates biometric, social interaction, crowd source wisdom and expert systems along with rich learning portfolios and models of collaborative understanding. --- Infrastructure Provides a robust modular system that can evolve and adapt to technological advances and refinement. Cyberlearning research afforded by experiential supercomputing has scaled through mobile, hand-held, and distributed devices to broadly impact education and daily living. As robust, consumer-grade VR hardware, digital manipulatives, and low-cost robotic and fabrication platforms emerged, cyberlearning research and infrastructure was revolutionized. The result was findings with transformative impact on formal and informal learning environments (classrooms, museums, homes, communities, nations, and our international community) across the entire socioeconomic spectrum. --- Conclusion We are proud of what we have achieved, and are cautiously optimistic for what our future holds. We have made tremendous progress since the early days of the ideal cyberlearning environment that began with individual intelligent tutoring systems and built on existing classroom-based activities. Today's interfaces provide ubiquitous connectivity and universal access to comprehensive experiential learning, discovery and innovation that can support all manners of inquiry and endeavors. In 2040, learning is unlimited -each individual can create a teacher, team, country, world, galaxy or universe of their own. We have created an environment where we can imagine possible worlds and experiences to help us re-solve the wicked challenges whose solutions will shape our continuing evolution. There is no question that we must learn a great deal more as we continue to champion optimism and democratic exploration. The future belongs to us all and we are motivated by our responsibility to continue our evolution toward utopia.

This essay imagines the role that artificial intelligence innovations play in the integrated living, learning and research environments of 2041. Here, in 2041, in the context of increasingly complex wicked challenges, whose solutions by their very nature continue to evade even the most capable experts, society and technology have co-evolved to embrace cyberlearning as an essential tool for envisioning and refining utopias-non-existent societies described in considerable detail. Our society appreciates that evolving these utopias is critical to creating and resolving wicked challenges and to better understanding how to create a world in which we are actively Blearning to be^deeply engaged in intrinsically motivating experiences that empower each of us to reach our full potential. Since 2015, Artificial Intelligence in Education (AIED) has transitioned from what was primarily a research endeavour, with educational impact involving millions of user/learners, to serving, now, as a core contributor to democratizing learning (Dewey 2004) and active citizenship for all (billions of learners throughout their lives). An expansive experiential super computing cyberlearning environment, we affectionately call the BHolodeck,^supports transdisciplinary collaboration and integrated education, research, and innovation, providing a networked software/hardware infrastructure that synthesizes visual, audio, physical, social, and societal components. The Holodeck's large-scale integration of learning, research, and innovation, through real-world problem solving and teaching others what you have learned, effectively creates a global meritocratic network with the potential to resolve society's wicked challenges while empowering every citizen to realize her or his full potential.

Introduction The growing homeless population in the U.S.A. [1] is disproportionately impacted by poor mental and physical health status [2][3][4][5], including a higher incidence of acute and chronic health problems, increased hospitalizations, and premature mortality compared to the general population [6][7][8][9][10][11][12][13] as well as higher healthcare costs [14,15]. Further, studies have shown that past experiences of trauma are highly prevalent among the homeless [16,17], resulting in a higher prevalence of post-traumatic stress disorder (PTSD) compared to the population at large [18]. Thus, people experiencing homelessness face major vulnerabilities likely to adversely impact their health and well-being, including physical and sexual violence and other traumas [19]. Recent policy research has elucidated stark differences between people who are unsheltered and people who are sheltered [20]. Findings indicate that those who are unsheltered are more likely to stay homeless longer and have more significant health challenges [20]. Further, research points to gender differences in exposure to violence and trauma, levels of social support, diagnoses of chronic illnesses, and past month illicit drug use among persons who are experiencing unsheltered homelessness with serious mental illness [20,21]. Further, the more significant health issues and vulnerabilities in this population have been shown to be present prior to housing loss as well as during the early experiences of homelessness [20]. Additionally, poor mental health status among homeless women in particular has been associated with lower selfreported social support, physical or sexual violence in the previous year, more chronic health conditions, and illicit drug use during the previous month [21]. Furthermore, a lack of social connectedness among the homeless, including repeated social exclusion, social isolation [22,23], and low levels of social support and social functioning, have been shown to contribute to poor health [23]. Relationships with family have also been shown to be significant predictors of lower self-reported health status among those experiencing homelessness [24], and one study found family support to be a key contributor to positive views of recovery from mental health illness among homeless youth [25]. Together, these findings point to the possibility of increased needs and vulnerabilities among people experiencing homelessness. Yet, few studies have examined self-reported risk factors for perceptions of low health status among the homeless population, especially those with serious mental illness. Accordingly, the purpose of this study was to examine the association between demographic, social, and clinical factors and perceptions of general health status among a sample of people experiencing homelessness with serious mental illness during admission to an integrated behavioral health treatment program in a large urban area. --- Methods --- Participants The study sample included 331 adults (18 years and older) experiencing homelessness with serious mental illness (SMI) or a coexisting SMI and substance use disorder (COD) who were continuously admitted to an integrated behavioral health treatment program. All persons enrolled in the treatment program were included in this analysis. Enrollment at the time of this study ran from January 2019 to October 2021. The Mini-International Neuropsychiatric Interview (M.I.N.I.) was utilized to identify individuals with SMI. The M.I.N.I. was administered by licensed masterslevel therapists who participated in an orientation to the structure of the M.I.N.I and observed a clinical supervisor administer the M.I.N.I with 5 patients. The masters-level therapists were then observed by their clinical supervisor administering the M.I.N.I. with three or more patients. All M.I.N.I results were reviewed by the principal investigator who served as the clinical supervisor to interpret results and compare M.I.N.I findings with the findings from other clinical assessments collected routinely as part of the intake process. These included the Patient Health Questionnaire-9 (PHQ9), PTSD Checklist for DSMV (PCL-5), Generalized Anxiety Disorder 7-item (GAD-7), Young Mania Rating Scale (YMRS), and Brief Psychiatric Rating Scale (BPRS). Services were provided at multiple homeless services locations and patients were self-referred or referred by other services providers at these programs and no patients were turned away if they met enrollment criteria. Accordingly, patients were not approached specifically for participation in this data analysis as this study was an analysis of data collected during program intake. Recruitment sites included a day program for unsheltered homeless, a residential substance use treatment program for males experiencing homelessness, a psychiatric step-down respite program for those experiencing homelessness following psychiatric hospitalization, permanent supportive housing for formerly chronically homeless adults, a faith-based food distribution program, and homeless encampment sites in a large urban area. All participants were homeless as detailed by federal definitions [26]. Structured clinical interviews by trained staff were used to collect data from participants. This study was reviewed by the University of Texas Health Science Center at Houston Institutional Review Board. --- Measures The Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Mental Health Services (CMHS) National Outcome Measures (NOMs) Client-Level Measures for Discretionary Programs Providing Direct Services: Services Tool for Adult Programs; SAMHSA's Performance Accountability and Reporting System (SPARS) November 2021 [27] was utilized to obtain patient self-reported information across the following eight domains: demographics, military history, drug and alcohol use, family and living conditions, education, employment and income, crime and criminal justice status, mental and physical health problems and treatment/recovery/functioning, violence and trauma, and social connectedness. The NOMS Government Performance and Results Act (GPRA) interview tool is required by SAMHSA CMHS funded programs to be administered at program intake, every 6 months and at discharge in order to collect outcome data that "embody meaningful, reallife outcomes for people who are striving to attain and sustain recovery, build resilience, and work, learn, live, and participate fully in their communities'' [28,29]. As such, NOMS/GPRA data provide an important source of patient-reported information to inform patient-centered, recovery-oriented treatment for vulnerable populations served by SAMHSA-funded programs. Items from all patient self-report domains, 63 items in total, were included in the analysis. --- Outcome measure The 36-Item Short Form Survey (SF-36) is a set of generic, coherent, and easily administered health-related quality of life (HR-QOL) measures tool drawn from the RAND Corporation's Medical Outcomes Study that provides a broad measure of health status rather than focusing on specific groups (such as age, disease, or treatment) [30]. The SF-36 is free for use as long as RAND's terms and conditions for use are adhered to [30]. Accordingly, this tool has been widely used in health research to obtain patient-reported information on physical and mental health status, with more than ten thousand publications using the SF-36 to date [30][31][32][33][34] and assess the impact of various diseases, interventions, and characteristics on quality of life (QOL) outcomes in various populations [31,34]. The SF-36 tool comprises scales of eight separate health domains: physical functioning, role limitations due to physical health, emotional well-being, role limitations due to emotional problems, energy/fatigue, social functioning, bodily pain, and general health. The SF-36 Scoring Manual and tool developers do not provide support to calculate a single measure of health-related quality of life, such as a "SF-36 Total/Global/Overall Score." Additionally, the tool developers do not recommend combining SF-36 summary measures to produce an overall score of healthrelated quality of life [32]. Because the focus of this study is on the examination of patient perspectives on health status [34], this study utilized the general health domain (benchmark reliability <unk> = 0.78, mean = 56.99, standard deviation = 21.11) derived from the RAND Corporation's Medical Outcomes Study [30], as its primary outcome variable, which consisted of five items: (1) "In general, would you say your health is:" (2) "I seem to get sick a little easier than others." (3) "I am as healthy as anybody I know." (4) "I expect my health to get worse." (5) "My health is excellent." Each item has a five-point Likert scale response range. The first is scored from "Excellent" to "Poor," while the last four are scored from "Very True" to "Very False." The scale drew from equally weighted survey questions scored from 0 to 100, with lower scores indicating poorer outcomes [30]. --- Data analysis Elastic net regression modeled the SF-36 domain general health a function of a large set of dichotomous and continuous predictors; after one-hot encoding (i.e., converting categorical predictors into a set of binary 0/1 indicators), 63 predictors were included in the current analysis. Of these, 51 predictors were treated as continuous, including a set of variables with a native ordinal scale (e.g., Likert-type items using a 5-point scale from "strongly disagree" to "strongly agree") and the remainder were treated as dichotomous. The full set of predictors is described in Table 1. All analyses were conducted using the R Statistical Computing Environment [35] using tidymodels [36], and glmnet [37]. Prior to analyses, the sample was assessed for data entry mistakes and missing data. Missing data (i.e., participants responded "refused," "don't know," or "not applicable" in response to a question or certain questions/ sections were deferred) comprised less than 10% of all variables. All missing observations were imputed via the bagImpute function from the tidymodels package in R [38]. Elastic net regression [39] was used to model the general health domain outcome as a function of all 63 predictors at the same time [40]. The elastic net penalizes (i.e., shrinks) regression coefficients to prevent inflated estimates that may arise due to multicollinearity; further, the method may reduce coefficients all the way to zero, providing de facto variable selection. The model utilized tenfold crossvalidation across a Latin hypercube grid search to identify optimized values of two tuning parameters, lambda and alpha, where the former describes the magnitude of the penalty placed on model coefficients and the latter describes the blend of the penalty between two related methods (ridge regression; LASSO). Optimized values for alpha and lambda were chosen by root mean squared error (RMSE). The elastic net model provided penalized coefficients that may be interpreted in the traditional way as relating the magnitude and direction of the effect of a predictor on the outcome variable. Model assumptions (e.g., homogeneity of variance; normality of residuals) were tested via visual examination of graphical plots. --- Results --- Sample characteristics Measures of central tendency, dispersion, and frequency are described in Table 1. Of the n = 331 person sample, 81% were male and 91% were heterosexual. The population was predominantly African American (55%) or White (37%) and about 17% were Hispanic/Latino. The average age of the sample was 45.4 (sd = 12.2), with a range of 19 to 73 years old. Forty-seven percent of the sample was recruited from a homeless day program serving the unsheltered population or homeless encampment site, indicating they were unsheltered. Overall, 93% of the sample indicated they had a past experience of trauma or violence against them, 10% had served in the military at some point in their life, and 96% were currently unemployed. In the 30 days prior to enrollment, 35% had spent at least one night in a hospital for mental health reasons, 6% had spent at least one night in jail, and 41% had used illicit drugs. The average score for the SF-36 domain general health was 51.3 (sd = 26.1). category). Further, some of these higher-magnitude coefficients may reflect overfitting, despite the use of cross-validation in the training data set and a held-out test data set. For example, only 2% of the sample reported inhalant use greater than the lowest NOMS response option. Findings should be considered preliminary until generalizability may be evaluated with additional data from disparate sources. --- Elastic net --- Discussion This study had a large sample of participants experiencing homelessness with SMI or COD and examined the effects of various demographic, social, and clinical factors on the general health status domain in the SF-36. Even though those experiencing homelessness are a diverse population with various demographic, housing, financial, and social characteristics, this study identified multiple significant predictors of both lower and higher self-reported general health status. Inhalant use, transgender status, and number of times arrested were identified as the strongest predictors of lower self-reported general health status. Chronic exposure to inhalants can produce significant damage to the heart, lungs, liver, and kidneys [41]. While the impact of inhalant use on health status has been established, it has historically been the least studied form of substance abuse [42]. A higher prevalence of inhalant use has been found among homeless youth [43] and individuals reporting a sexual minority status [44]. A recent international study examining health status among a homeless population linked inhalant use of glue in particular with higher rates of negative states of health and disability, worse than those observed in other socially excluded groups [45]. Accordingly, this finding warrants further exploration to better understand the impacts of inhalant use among homeless populations to inform interventional research. The finding that persons reporting transgender status were more likely to self-report lower general health status is consistent with prior research [46]. Because transgender men experiencing homelessness have been found to be particularly at risk for physical health problems [46], this study finding provides more evidence of the need to explore this understudied area. The inverse relationship between number of times arrested and self-reported general health status is consistent with prior research on health and interactions with the criminal justice system. For example, history of imprisonment has been found to be associated with greater levels of health risks (including infection with HIV, heroin and cocaine use, and mental illness) within the homeless population [47]. Several predictors including male gender, "other" sexual identity, stimulant use, and Asian race were identified as the strongest predictors of higher self-reported general health status. Our finding that homeless cisgender females having poorer health than homeless males is supported by previous findings showing females to be more vulnerable to the health effects of homelessness compared to males [48]. Further, research has revealed a greater number of chronic physical conditions among females experiencing homelessness [48], with reports of females being frailer and having more physical health problems than homeless men [49,50]. The finding that persons reporting "other" sexual identify is a strong predictor of greater self-reported general health status should be explored in future research. Sexual minorities who are also homeless have been found to be at greater risk for physical health problems [46]; however, current research on sexual identity and homelessness has been limited to persons who report lesbian, gay, bisexual, or heterosexual identity [46]. Additionally, the finding that higher levels of stimulant use was associated with a higher self-reported general health status should be interpreted with caution. Within the NOMS data, certain stimulant use including methamphetamine and cocaine were assessed separately and both associated with lower self-reported general health status. While a common cause of mortality among homeless and unstably housed women is acute intoxication where cocaine is present [51], research examining prescription stimulant misuse among people experiencing homelessness is needed. Further, prescription stimulants act on the central nervous system to increase alertness, attention, and energy and are prescribed off-label among older adults to treat depression, poststroke recovery, motor function, and fatigue [52]. Additionally, research has shown that the most fundamental perceived benefits of the alertness resulting from methamphetamine use is the ability to cope with a multiplicity of vulnerabilities directly tied to homelessness or housing insecurity [53]. Accordingly, self-reports of improved general health status with stimulants other than methamphetamine and cocaine may point to a perceived beneficial impact of prescription stimulants among persons who are experiencing homelessness. Finally, the finding that Asian homeless individuals are more likely to endorse higher general health status also needs further examination in future studies. Although prior research has demonstrated that Asian individuals were more likely to self-report positive health status (excellent, very good, or good) than their Hispanic, White, and Black counterparts in the general population, we are not aware of any studies examining this question in homeless individuals [54]. Further, because they account for a relatively small percentage of the population in the U.S.A. and other western nations, Asians are often included in an "other" racial category in studies, making comparison of self-reported health status with other racial groups challenging [54]. The limitations of this study include the use of a self-reported measure administered with an interviewer present. While the interviewers received extensive training with the homeless population, the possibility of some degree of response bias from participants either underor over-reporting answers should be considered. This research was also conducted solely in a large urban center in the southern U.S.A., which limits the generalizability of the study to other geographic regions in the U.S.A. and internationally. Furthermore, one residential recruitment site in this study served an exclusively male homeless population, which could have biased the sample away from other genders in the homeless population. A potential source of sampling bias also stemmed from the recruitment process as the social workers tasked with enrolling the participants may have been less likely to interact with or locate those with more significant mental illness (as they may have been less approachable), biasing the sample toward those with less severe symptoms. In addition, as previously noted, many categorical variable levels demonstrated low representation, and several continuous variables reflected means closer to their lowest potential value; as such, results should be considered preliminary until replicated to provide evidence supporting generalizability. Finally, much of the recruitment period coincided with the COVID-19 pandemic, which at times resulted in services, recruitment sites, and staff being unavailable. One of the strengths of this study is the sample, which was relatively large and diverse and drew from a variety of different recruitment sites across a large urban area. All of these characteristics might help generalize the findings to the homeless population at large. Further, very few of the individuals approached by staff refused to participate, which reduces the non-response bias in the study. Finally, this study used the SF-36 general health score as the outcome, which helps give a more global perspective on how participant demographics, social interactions, and clinical factors contribute to overall QOL as it pertains to health. Future research can draw and expand on these findings to determine specific interactions of these characteristics with various aspects of health. --- Conclusion People experiencing homelessness face considerable physical, mental, social, and financial challenges that adversely affect their health. This study found that characteristics and patient-reported factors such as male gender, "other" sexual identity, stimulant use, and Asian race were associated with positive perceptions of general health status, while transgender status, inhalant use, and number of times arrested were associated with negative perceptions of general health status. These findings suggest potential areas to target for screening within the homeless population; however, further studies are necessary to demonstrate generalizability of these results. --- Data availability The data that support the findings of this study are available from the corresponding author, LP, upon reasonable request. --- Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1007/ s11136-023-03370-9. Author contributions Each of the authors made contributions to the study design and preparation of the manuscript. Material and data collection were performed by JH's staff, including LP and GH. Data analysis for the revised draft was performed by RS. The first draft was written by LP, GH, and JH, and all authors (including Robert Suchting, who was hired to assist with methodology and analysis revisions) collaborated with each other in making revisions for future versions. The final manuscript was read and approved by each of the authors. --- Declarations Competing interests The authors have no competing interests (financial or otherwise) to disclose that are relevant to this research. --- Ethical approval This study was reviewed and approved by the University of Texas Health Science Center at Houston Institutional Review Board. --- Consent to participate All participants enrolled in this study gave written informed consent and verbally acknowledged understanding and willingness to participate. Consent to publish There were no identifiable figures, data, or descriptions of the participants in this study. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

The growing homeless population in the U.S.A. is disproportionately impacted by poor mental and physical health status, including a higher incidence of acute and chronic health problems, increased hospitalizations, and premature mortality compared to the general population. This study examined the association between demographic, social, and clinical factors and perceptions of general health status among the homeless population during admission to an integrated behavioral health treatment program. Methods The study sample included 331 adults experiencing homelessness with a serious mental illness or co-occurring disorder. Participants were enrolled in services at a day program for unsheltered homeless adults, a residential substance use treatment program for males experiencing homelessness, a psychiatric step-down respite program for those experiencing homelessness following psychiatric hospitalization, permanent supportive housing for formerly chronically homeless adults, a faith-based food distribution program, and homeless encampment sites in a large urban area. Participants were interviewed using The Substance Abuse and Mental Health Services Administration's National Outcome Measures tool and a validated health-related quality of life measurement tool, SF-36. Data were examined using in elastic net regression.The study found seven factors to be particularly strong predictors of SF-36 general health scores. Male gender, "other" sexual identity, stimulant use, and Asian race were all associated with better perceptions of health status, while transgender status, inhalant use, and number of times arrested were associated with poorer perceptions. Conclusion This study suggests targeted areas for health screening within the homeless population; however, more studies are necessary to demonstrate generalizability of the results.

INTRODUCTION Women are inevitable important being in every human society. Any society or organisation that lack women are found not interesting and have limited achievements. Women are the Joy-givers, Peace-giver, Organizers, Coordinators, Supporters of child(ren) and spouse, Joy of the family, Am<unk> <unk>d<unk> <unk>d<unk> <unk>-lárinrin, alát<unk>l<unk>y<unk>n, <unk>tùnù-olólùf<unk> <unk>, and so on. Women hold a very strong position on child's life, particularly in the well-being of the family and society at large. Society even believes that "behind every successful man there's a good woman". This confirmed how important women are in the life of every human. Women serve as lubrication in the wheel of life of all humans. When we are talking about women power, we are not referring to the strength needed to dismantle hill or tree, it is mainly spiritual power that matters here. Women may appear weak physically, but they possess orphic, paranormal and spiritual powers than men. Spiritually, sacred women are healers, diviners, care-givers, fertility provider, motherhood, overseeing bodies of water and, also serve as lieutenants to the supreme. Women exhibits their endowed and gifted power by the Supreme being during worship, spiritual festivals/ceremony, sacrifices and other activities at the temple or shrines. The above submission buttresses [9] view where he pointed that, all Yoruba shrines are decorated with female symbols or signs. Also, that women are divinity's wife, priestess,... awo àj<unk> <unk> (witch cult), awo abiyam<unk> (fertility cult). He added that, the these show how important and relevant women are in traditional religion and in society at large. Among the <unk>gù (<unk>gùn) people of Badagry traditional worships and festival comprise of different activities and stages like other ethnic groups. Thùth<unk>à and Y<unk>h<unk> deities selected for this study are not exempted, and with several activities involved in their worship and spiritual festivals. These deities are goddess and found among the <unk>gù people in <unk>jàrá and V<unk> th<unk> <unk> town in Badagry. According to the devotees Thùth<unk>à was a kind-hearted woman who loves and lives in <unk>járá with her husband but was not blessed with the fruits of the womb (barren). It was further revealed that; it is origin that is called Y<unk>h<unk> in <unk>gù Language. The shrine was created by the first generation of <unk>járá Vetho town. The oldest woman among the settlers was a very kind and caring woman. She stood in position of care-giver and healer to everyone in the community. After several years of living in peace and harmony with people, this oldest woman died, and her corpse disappeared mysteriously from where she was laying. The settlers deliberated and concluded that would continue to be consulting her spirit at that spot of disappearance for help and turned the spot to a shrine (<unk>zá<unk>n). Moreso, all items they found there were chosen as ritual rites. As the community was expanding, different families decided to create Y<unk>h<unk> shrine in their compounds, that brought about Y<unk>h<unk> temples like Y<unk>h<unk> <unk>gbón<unk>gàm<unk>, Y<unk>h<unk> Thaom<unk>, Y<unk>h<unk> S<unk>ngbom<unk>, Y<unk>h<unk> S<unk> th<unk> <unk> and Y<unk>h<unk> V<unk> th<unk>gb<unk> all in Vethod. The target of this study was to examine the position <unk>gù women engaged in during ritual and sacrifices among <unk>gù people of Badagry. It was also set create awareness about Thùth<unk>à and Y<unk>h<unk> deities, although they have suffered a serious setback in encounters with foreign religious (Islam and Christianity) and western education, it is still much alive and actively worshipped. This study also presents the position of women in the worship and festival rituals of Thùth<unk>à and Y<unk>h<unk> deities among <unk>gù (<unk>gùn) people of Badagry, Lagos State, Nigeria. <unk>gù (<unk>gùn) people of Badagry are endowed with very rich cultural activities, traditional or ritual festivals, shrines and deities. There are several deities among these people as we have in Yorùbá communities. Several research works have been carried out on many of deity's symbols and poetries, but it was observed that little or none was done on the position of women in worshiping goddesses. However, the impact of women in making sacrifices and worshiping of these deities among the <unk>gù (<unk>gùn) people of Badagry, Lagos State, Nigeria needs to be given attention. Therefore, this study sought to research into the efforts, duties and responsibilities of women in successful ritual festivals and worship of these selected goddesses among the <unk>gù people. --- LITERATURE REVIEW The need to research into the position and activities of women in ritual, particularly female deities has become inevitable. Many scholars have worked on rituals, gods, goddesses, and deities generally, some of these scholar works are reviewed and this stands as background upon which this research work rest on. [14] examined the <unk>j<unk>gàba <unk>kùnrin lór<unk> Ob<unk>nrin n<unk>n<unk> awo àti <unk>d<unk>n <unk>b<unk>l<unk> <unk> Yorùbá (Dominance of Male Offer Female in Cults and Yorùbá Traditional Festivals). She explained that female contributions are not well recognized or pronounced in Yorùbá traditional festivals, but obvious and relevant and cannot be ignored or erased. [2] in <unk>un in the Verbal and Visual Metaphors, reveals the position and impact of <unk>şun goddess in Yorùbá society and, also explored on the faith of <unk>şun devotees. <unk>şun as the personification of Yorùbá womanhood; as a model mother; a pediatrician;... beauty and the elegance of <unk>şun was also examined. [2] propound emphatically on position of women in traditional religion that "there is no Yoruba native cult without women as its backbone" while [4] explained that "Women play key roles in religious ceremonies as priestesses and prophetesses. Some important deities are female...". These scholars made it clear that women have huge duties in Yoruba traditional religious and festivals. [10] stressed that female deities are not given power or recognition like the male deities, also female deities act only under the male image of the Supreme Being. The female worshipers are subordinate, and they were given peripheral roles in religious spheres. They stated clearly that, African Traditional Religion players relegates females and female worshipers. This position is clearly different from the practice of the devotees of Thùth<unk>à and Y<unk>h<unk> deities selected for this research work. [12] in her research into the role of women in African Traditional Religion, was not in conformity with the submission of [10] when she pointed out that women play the role of mother and caregivers in African religion. Also, that women are described mythologically as "mother of mankind, from whom all people originated. One could deduce from her submission that women are actively relevant and ascribed with different responsibilities both socially and spiritually. --- The <unk>gù People of Badagry, Lagos State The history of the <unk>gù (<unk>gùn) people of Badagry could not be left out in scholarly research works available. Some of these scholars are [13], [1], [5], [3], [15] to mention but few. The Ogus popularly mistaken referred to as <unk>gùn are originally settlers in Dahomey now known as Republic of Benin. Their forefather migrated from Dahomey to Ipokia Local Government in Ogun State while some settled in Badagry in Lagos State. <unk>gù is a dialect of Gun-be. The <unk>gù speaking people are descendants of those who migrated from Whidah, Allada, Weme which are now part of the Republic of Benin... [5]. From this author's view, one can deduce that <unk>gù (<unk>gùn) of Lagos State moved from Republic of Benin to settle in Ogun where they later moved to Lagos of Nigeria. [15] the Akran of Badagry town speaks on this in an online interview that: The only link we have with the people of Republic of Benin is that we speak the same language, but we are not from there. We are originally from the present days Ghana, from a place called Aneho and settled in our present abode in the 13 th century. That is over 800 years ago. Agbede was the first of our ancestors to settle here. It was from him that the town got its name, Agbadagreme, which the white-man adjusted to Badagry to suit his tongue'...The Kingdom of Badagry starts from Seme border right through to Ajegunle. [15] submission above shows that, <unk>gù (<unk>gùn) people of Badagry are not from Republic of Benin, that its only local dialect that connects the <unk>gù (<unk>gùn) people of Badagry in Lagos State with the ones in Republic of Benin. It is obvious that <unk>gù (<unk>gùn) people of Badagry migrated to where they found them in Lagos and Ogun State today. <unk>gù (<unk>gùn) people can be found in towns and villages like Badagry, Igbobele, Rópoj<unk>, Agbojetho, Kweme, Aivoji, Iweseme, <unk>járá, <unk>járá Vetho, <unk>k<unk> <unk>ga and <unk>j<unk>d<unk> under Badagry Local Government of Lagos State, Nigeria. There are several deities among these community as we have in Yoruba communities. --- RESEARCH METHODS The researcher carefully selected two female deities that is Thùth<unk>à deity in <unk>járá and Y<unk>h<unk> deity in Vetho community of Badagry Local Government Area of Lagos State, Nigeria to focused on. The study made use of both primary and secondary sources of data. The primary source comprised in-depth oral interviews with six purposively selected informants; one priestess and two devotees from each of the two selected goddesses in Badagry area of Lagos State, Nigeria. This was complemented with a participant-observation of the proceedings during the worship of the deities. There were also audio and video recordings as well as a photographic documentation of the symbolic elements of the selected deities at their temples. The secondary source included books, journal articles, magazines and the Internet. The data collected were transcribed and analysed within an eclectic framework of Hermeneutic Theories of literature. --- RESEARCH FINDING AND DISCUSSION --- Duties and Responsibilities of <unk>gù Women in Ritual Space The results of this study shown that women play an important and a weighty role in the lives of family, religious settings and in the society. Research reveals that there are several roles and action carried out by women during sacrifices and worships of the selected goddesses. Using hermeneutics theory and physical attendance as our tools, we identified the following responsibilities carried out by female devotees: --- Women as the Chief Priestess (Ab<unk>r<unk> ) It is obvious that the chief priestess of the two goddesses (Thùth<unk>à and Y<unk>h<unk>) are women, and they are called Hùn<unk> <unk> in <unk>gù language. The oldest woman among the devotees, and in the community is made the chief priestess. She anchors all activities in the shrines. In preparation for Thùth<unk>à worships, the chief priestess (Hùn<unk> <unk>) leaves home very early in the morning of the sacrifices day to fetch well water with sacred clay-pot. The chief priestess put the sacred clay-pot on her head while going to fetch the water. Once she's in this position, she has turned to representative of the goddesses on earth and can only communicate with the goddess spirits so there shouldn't be any communication with an ordinary person till she dropped the sacred pot. --- Picture 1. Thùthùá sacred pot It is a taboo for her to talk to anyone because it is disrespectful to spirits. She must not greet nor answer any greetings to and from the well side. This well water is used as cleanser by sprinkling it on everyone that will enter the temple with ak<unk>ko leaves by the chief priestess. Their belief is that anyone that this water touches is clean from any kind of dirty that he or she might have gotten in touched with on his/her way to the temple. Research also reveals that, Y<unk>h<unk> chief priestess also sprinkles water with ak<unk>ko leaves on everyone that will enter Y<unk>h<unk> temple. This serves as cleanser for everyone that will partake in any rites that will take place at the temple. The below pictures are the cleanser water of the two deities in the buckets. Picture 2. Y<unk>h<unk> Cleanser Picture 3. Thùth<unk>à Cleanser All activities at the temples are performed by the chief priestess (Hùn<unk> <unk>) of each goddess. Their actions indicate the relationship between goddesses (Thùth<unk>à and Y<unk>h<unk>) and the devotees. This shows that there is communication between the past (the origin of the goddess), the present (the devotees) and what is expected by the devotees in the future. This alien with the assertion of [6] which pointed that, "hermeneutics sees history as a living dialogue between present and future and seeks pertinent to remove obstacle to this endless mutual community communication." From this scholar's view, one can use occurrence and the history of the society to have deep knowledge about the responsibilities ascribed to chief priestesses of Thùth<unk>à and Y<unk>h<unk> in the worships and festival rituals of these deities. --- Women as Prayer Warriors As we have discussed earlier that the Chief Priestess (Hùn<unk> <unk>) is the one in charge of all activities in the shine. Research reveals that, prayers is one of the major activities that will take place on sacrifice day. The Chief Priestess also the covenant woman stands as spirit and pray directly to god on behalf of her family, the devotees and the community at large. She offered prayer request on good health, security of life and property, good sales, peaceful environment and so on with eatable deposited on the shrine. Devotees responded to prayers with Nishe (amen) as it is done generally in African and particularly among the Yorùbá community. Example of prayers offered at Thùth<unk>à shrine is as follows: Mi mà ná thin k<unk>é gb<unk>, àk<unk>é màná yin k<unk>nt<unk> ná mi May we will not lack money in our lifes, wealth will not be our enemy The above are prayers that chief priestess used to appease to Thùth<unk>à deity after she presented the devotees to Thùth<unk>à deity. She requested prayed for sound health, protection and guidance from evil doers, blessing for their heart desires. It was shown that men are also among the devotees, but they are not permitted to offer prayers, they only join other women to say amen (Nishe) to prayers. Y<unk>h<unk> devotees on the other hand also work together for successful prayer session, sacrifices and ceremony. <unk>gù women devotees shoulder all activities at the temple, prayed together, responded to prayers where necessary and, also eat left over of ritual rites. They held deity in high esteem and requested for what they lack during prayers, sacrifices and ritual festivals. The position and interaction of <unk>gù women devotees with deity is in conformity with the assertion of [6] that pointed out that, "hermeneutics sees history as a living dialogue between present and future and seeks patiently to remove obstacle to this endless mutual communication". Researcher physical presence at Y<unk>h<unk> shrine makes her to see the barriers that are likely to affect total control of the shrine by <unk>gù women and smooth communication between past, present and future of Y<unk>h<unk> devotees has been reduced to minimum occurrence. Going by this scholar's view, it is obvious that Y<unk>h<unk> devotees' actions were guided by the history their past generation passed onto them. This shows that devotees followed the steps of their past generations and teaching their children what they need to know about Y<unk>h<unk> deity. --- Women as Deity Feeders Presenting ritual rites to the deities is one of the main responsibilities that devotees or the priestess takes very seriously. Yorùbá believes in a proverb that says "ik<unk> k<unk> <unk> j<unk>un <unk>ni kó t<unk>n pani" meaning death cannot insist on taking one's life, after eating one's meal. They also believe in another proverb that says "bi <unk>nu bá j<unk>, oj<unk> a t<unk>" meaning one becomes harmless after accepting gift. These two proverbs are part of what encouraged Yorùbá to continue given ritual rites to deities even when their requests are yet to receive positive responses. <unk>gù people of Badagry, Lagos, Nigeria share the same view with the Yorùbá. In most cases, the custodian of the deities is the one to give deity food. This decision may be as a result of trying to do things orderly, to prevent given deity wrong food or the divinity chooses who to give him/her food (present sacrifices). In the case of Thùth<unk>à and Y<unk>h<unk>, only the chief priestess (Hùn<unk> <unk>) presented the ritual rites to the deity, other women assisted and responded to prayers/poetry accordingly. Some of the items use as ritual rites for the two deities are: Thùth<unk>à -kolanut, alligator pepper, biter kola, honey, dry gin (<unk>gógóró), Shinarp, soft drink (7up or sprit), clean water, palm-oil, snail, banana and shea butter; Y<unk>h<unk> -Shinarp, palm-oil, soft drink (7up, soda water, limca, schweppes or sprit), corn powder (athan), kolanut (aláw<unk> <unk> m<unk> <unk>rin), biter kola, water, alligator pepper, goat or pig. Below pictures show how ritual rites are been offered to the deities. The chief priestess offered these items one after the other and give the rest of the items to devotees to share among themselves. It was revealed that sharing and eating of the ritual rites' leftover symbolizes cooperation and unity among the devotees. It also indicates that they have covenant and they must not betray each other. If women could carry out all these activities at the Thùth<unk>à and Y<unk>h<unk> shrine without taking any instruction or guide from any man, one can say <unk>gù women of Badagry held an important spiritual space in worship of female deities. --- Women as Deity Eulogizer/Singers and Dancers Society of today sees songs and dance as just a form of exercise and entertainment but it goes beyond this. Song and dance are a way of communicating with the deities. They are kind of activities that connect body, mind and souls with spiritual realms. Women are the major sacred singers and dancers and the activities are very common with female deities. These shows that impact of women singing and dancing during ritual and traditional festivals are very germane. Dance is one of many human ways of expressing art. Sometimes it is very cultural and has spiritual significant embedded in its moves. In African, dance is one of many ways of worship, performed as offerings to the gods of the land... [11]. Position of this scholar indicated that dance at the shrine or during sacrifices is an important part of ritual rites. Traditional Yorùbá society values songs and hardly will you see any aspect in their life that does not have songs. Yorùbá people generally and <unk>gù people of Badagry, Lagos State use different songs, clapping and dancing during rituals. It was revealed that everything existing in the Thùth<unk>à and Y<unk>h<unk> shrines are with human being. This is line with assertion of hermeneutics theorist that says, everything existing in the world is not independent of human being. It is no doubt that Thùth<unk>à and Y<unk>h<unk> deities falls into the category of traditional worship where sacred songs and dance are the integral part of the religious ritual and ceremonial expression. The devotees offer dance and songs as a supplication to Thùth<unk>à and Y<unk>h<unk>. Below It was revealed that dancing and singing during ritual rites go a long way in making deities accept their sacrifices and answer their prayers. The deity songs and dance have spiritual impact on the dancers, devotees and the deities. This also brings joy, happiness and promotes unity among the women. Every activity carried out by women at the shrine confirmed [1] position on hermeneutic theory that says, "the issue of religion has to do with human being in the society and religion cannot exist without the adherents". --- Women as Peace Maker Women has always been active advocators of peace and harmony in the community. They often understand the important of been in harmony with each other and aware of the distress and problem that follows crisis, dispute or war. The devotees (women) of the two deities are not left out in this peace keeping mission. The chief priestesses and other devotees are mindful of quarrels and dispute among members because they are aware of what this can lead. Yati<unk> Hungbo one of the Thùth<unk>à devotees informed us that, the chief priest constitute delegate that will visit members that has issues with each other for settling before sacrifice day. These delegates will dig into the causes of the crisis and resolve accordingly before festival day. It was also revealed that the devotees have no option than to let go and whoever refuses will be banned from joining the congregations. They understand that if this type of person(s) join them in worship, their prayers will not be answered so they don't joke with it at all. Doing this regularly on yearly bases has made their society to be peaceful. Research revealed that Thùth<unk>à and Y<unk>h<unk> women devotees are agents in the peace process, and an important agents and actors in peace keeping process within <unk>gù community and larger society. The chief priestess of Thùth<unk>à and Y<unk>h<unk> always include request for peace and harmony among the devotees and for the society in the prayers during festivals and sacrifices. They believed that their prayers at the shrine goes directly to God (gods). Therefore, they don't allow disputes, misunderstanding or dirtiness debars their prayers. We identify the ritual items used in praying for peace and harmony are as thus: In Thùth<unk>à shrine, they used snail, snail water, water and palm-oil; while in Y<unk>h<unk> shrine corn powder, water, palm-oil and soft drink are used. The below pictures showed how these items are being offered to the deities: They appease the deities with prayers as they offer the ritual rites. Prayers is another important weapon that women believe in and they used it in keeping peaceful community. They prays with ritual rites the way Yorùbá and other Africa people does during ritual festival or worships. All activities carried out at the shrines are in accordance with the culture and norms of the community. We found it necessary to get details information about the deities because the hermeneutic literary chosen for this research stated clearly that, a critic must research deeply and comprehensibly into all aspect of his/her work. He added that, it will be difficult to give details information about events without making enquiries [7].

This research investigated the role of women in rituals among the Ogù people of Badagry. It also analysed various ritual space women engaged in and their impact on poetries of the selected goddesses. The data for this study was generated from field investigation during visitations to the selected deities' shrines. Interviews were conducted with six selected devotees and physical observation of activities at Thuthuá̀ and Yọhọ deity shrines. There were audio/video recordings and a photographic documentation at grooves. The data collected were transcribed and analysed from the lens of hermeneutics of religion. The study authenticated Ogù women as the sustaining forces in the indigenous religious aethetic practice. Ogù women play leadership roles in indigenous religion, especially as it concerns rituals, in contrary to the opinion of many that women occupy subservient position in the society. It also revealed that Ogù women played the role of prayer warriors, deity feeders, deity eulogizer/singers and dancers during sacrifices. The study concluded that although worship of the selected goddesses has suffered setback in encounters with foreign religious and western education, it is still actively worshipped in Ogù Community. Also, the goddesses and their poetries are repertoire of cultural practices of Ogù people of Badagry.

INTRODUCTION This article examines intersectional praxis as an approach to institutional transformation, arguing that intersectionality is both a catalyst for and outcome of gender equity efforts in the social sciences and other academic STEM fields. As such, approaching gender equity intersectionally can be understood as a way that theory and practice are co-constitutive in social science and hence an important aspect of transforming academic institutions. Through a case study of the US National Science Foundation (NSF) ADVANCE program for gender equity in STEM, I look at the development of ADVANCE from an effort to support women in scientific fields to becoming a program for institutional transformation grounded in an intersectional understanding of women's inequity in the academic labor force. I ask two related questions in the efforts to address gender inequities in STEM. First, what is the relationship between academic institutions (which are simultaneously sites for the discovery of knowledge and gender inequality), and the National Science foundation, as the premier American academic institutional funding agency? Second, how has this relationship, through those working on ADVANCE, fundamentally shifted the understanding of the social scientific tools and strategies necessary to advance equity for women in academia? In answering these questions, I argue that, beyond women's representation in social sciences and academia broadly, intersectionality is an important scholarly advance that offers a dialectical tool for change. More than just a buzzword (Davis, 2008) an intersectional approach simultaneously calls attention to multiple sites and processes of institutional oppression and privilege while still being attentive to the individuals that occupy disadvantaged structural locations (Cho et al., 2013). For social scientists, therefore, intersectionality offers a praxis or practice that attends to structural inequality as well as the representation of individuals in addressing social change. Indeed, faculty who have taken on much of the work of institutional transformation are, themselves, also the targets of the structural reform that ADVANCE seeks to achieve. Social science fields including psychology, sociology, political science, anthropology and economics are classified as sciences by NSF definitions (Congressional Research Service, 2012). Social scientists involved in ADVANCE thus seek to solve inequities on a structural level, but also reflexively understand these issues as reflected in their own experiences (see Laube, 2021;McQuillan and Hernandez, 2021). Because of this focus on gender representation, in most ADVANCE programs, gender is generally treated as binary, and equity efforts entail adopting programs for inclusivity and women's access to academic STEM fields. While there has long been attention to women's representation in the natural and physical sciences, women's access in the social sciences is also unequal. Economics and political science are also dominated by white men, with women representing 32% of political scientists and 24% of economists (Hur et al., 2017). While sociology and psychology have achieved overall gender parity (National Science Foundation [NSF], 2019), both fields have fewer women full professors (American Psychological Association, 2014;American Sociological Association, 2016) giving rise to concerns over a leaky pipeline (National Science Foundation [NSF], 2019). Moreover, BIPOC (black, indigenous, people of color) women are significantly underrepresented in academic sociology and psychology (American Sociological Association, 2016;Hur et al., 2017;Stewart and Vailan, 2018;National Science Foundation [NSF], 2019). Adopting intersectionality as part of the ADVANCE program, therefore, had implications for the social sciences as STEM disciplines, as these fields developed strategies of structural change to address the ways that gender inequality is intersectionally defined, and in particular, the ongoing underrepresentation of BIPOC women in the academy (DeAro et al., 2019;Fox Tree and Vaid, 2022;Gregory, 2001). Through the ADVANCE program, intersectional approaches to inequality recognize the contributions of underrepresented women, while also calling upon the social sciences to devise institutionally based strategies to increase the representation of all women throughout the academy (Carbado et al., 2013). Because strategies for gender equity are designed by each individual NSF ADVANCE institutional awardee, this case study of ADVANCE draws on the websites, proposals, reports and publications of a random sample of institutional transformation programs, examining the strategies adopted by these institutions. Looking at ADVANCE historically, I also consider the changes in the calls for ADVANCE proposals that guided these programs. I discuss the feedback loop among social scientists who are working toward gender equity, the funding agency and academic institutions in advancing intersectional change to facilitate women's representation. Approaching gender equity intersectionally engages theory and practice as co-constitutive in the process of transforming academic institutions. This defines intersectionality interactively, or as the interplay between and among social actors and social institutions as they give meanings to categories such as "race, " "gender" and "class" (Ferree, 2009). Rather than something inherent in social structures, intersectionality emerges through a dynamic process that ensures that the role of social actors is not overlooked (Ferree, 2009). Intersectional analysis thus involves looking at the processes by which configurations of intersectional social relations and institutional sites arise (Choo and Ferree, 2010). By adopting intersectionality in programs to address equity in the academy, I argue that social sciences helped design strategies and inform notions of their own representation and overall mechanisms of institutional change (see Patton and Haynes, 2018). I begin with a brief overview of NSF ADVANCE goals for gender equity through systemic change in academic STEM fields. I then discuss the evolution of the ADVANCE program in dialogue with institutional grantees, and the initiatives to address institutional inequity that the grantees implement. Next, I consider the explicit introduction of intersectionality into ADVANCE as an important discursive moment for fostering equity for women with intersectional identities, particularly BIPOC women. As social scientists adopted an intersectional lens, they furthered the possibilities of transformation through the intersectional production of knowledge and continue to move the academy to structural changes to generate a culture of equity through the recognition of minoritized women of color (Patton and Haynes, 2018). --- CASE STUDY: NSF ADVANCE Gender equity in Science, Technology, Engineering and Mathematics (STEM) fields is a primary policy and higher education goal in the US and across many countries (Kodate et al., 2010;Smith, 2011;Morimoto and Zajicek, 2014;Rimmer and Sawer, 2016). The National Science Foundation (NSF) began the ADVANCE program as an effort to foster gender equity by facilitating STEM women faculty's access to and advancement in US academic institutions (DeAro et al., 2019). In the United States, gender equity is often couched in this binary, and specifically to ensure the talent and participation of the full workforce in order to maintain a leadership position in innovation and technology (Zippel and Ferree, 2017). As STEM fields are historically dominated by men, facilitating opportunities for women in STEM is critical to building the talent pool in technological fields and hence an important policy goal. The ADVANCE program was designed with the understanding that-for women to gain equity in the STEM workforce-they must also be teachers, mentors and leaders in scientific fields. The US NSF ADVANCE program provides an important case study because the National Science Foundation is the primary funder of basic research and education in the social sciences in the US (Congressional Research Service., 2021) With one of NSF's primary goals being to "promote the progress of science, " this independent federal funding agency is governed by a director and a National Science Board that also serves in an advisory capacity to the US Congress and President (Congressional Research Service, 2012). Accordingly, the NSF's approach to creating equity in STEM fields influences and enables the how US universities understand and tackle this issue. Moreover, demands for greater inclusion informs policy-not just in the United States, but also in the United Kingdom and the European Union (Elomäki, 2015;Ferree and Zippel, 2015). To achieve more inclusive STEM fields, in the early days of ADVANCE, research on gender equity came from studies that showed that organizations were inherently gendered and unequal (Ferguson, 1984;Acker, 1990). These concepts were applied to academia in an 1999 MIT report (MIT Report, 1999) that stated that gender inequity is embedded in the broad environment of academic culture and reinforced through microlevel institutional processes (National Academy of Sciences (US), 2006). Therefore, as programs for equity developed, efforts shifted from enabling individual women to successfully navigate academia and defining gender equity in terms of the number of women in academic positions, to finding ways to transform educational institutions into more equitable environments. In the discussion that follows, this article considers how social scientific theory about gender equity developed alongside these programs for institutional change. Accordingly, social science STEM disciplines-particularly psychology and sociologyengaged in the practice of dismantling gender inequality within their institutions and disciplines through designing and implementing ADVANCE equity strategies. Accordingly, social scientists argued that transformation requires attending to intersectionality, or the complex ways that multiple axes of ability and constraint-including race, class, sexuality and physical ability, among others-limit women's access to academic careers and success (Browne and Misra, 2003;Ong, 2011;Wu and Jing, 2011;Morimoto and Zajicek, 2014;Armstrong and Jovanovich, 2017). --- DATA AND METHODS Because ADVANCE programs are designed and implemented by individual institutions, I conducted content analysis of ADVANCE documents from two randomly selected institutions in each of the ADVANCE Institutional Transformation cohorts 1-7 (2001-2014), and all of the social science projects in cohorts 8 and 9 (2016 and 2019), as these most recent cohorts represent the period for which NSF required intersectionality as an additional criteria in ADVANCE proposals. Project analysis included a review of all of the documents and websites associated with the NSF ADVANCE grant, including research proposals, reports, publications and white papers. This study included analysis of all of the social science supplemental projects, where available. Alongside the analysis of proposals, I reviewed the ADVANCE calls for proposals for the years from 2005 to 2016 (n = 5) to document changes in the call and conceptualization of the ADVANCE project (see also Laursen and De Welde, 2019). Content analysis was performed on documents, deriving codes related to intersectionality and generating themes (Boyatzis, 1998). Initial categories were developed according to the intervention or social science phenomenon that was the subject of the study. Subsequent codes examined the ways that intersectionality was implicated or studied in the research, according to identities that modified gender such as URM, BIPOC or LGBTQ (Armstrong and Jovanovich, 2017), as well as the theory or social phenomenon that the social science project was engaging. Documents were then reexamined with codes in mind to understand what type of intersectional approach the projects were taking. Specifically, we noted whether intersectionality was treated as counting the number of women in various categories (i.e., BIPOC women, Latinas, etc.) and/or if intersectionality was emergent (i.e., social phenomena of inclusion or exclusion arose within organizational contexts, or if those contexts gave meanings to penalties and privileges). To the extent that a specific category of women were being studied, we noted this as well, along with the level of analysis of the ADVANCE project, and how or whether the study included structural change. Coding was conducted by the author and a research assistant, to allow for a check on the quality of coding and reconcile differences in document analysis. In reviewing these documents, I sought to gain insight into how issues of gender equity were framed and what the theories or strategies social scientists relied on in seeking gender equity in academic institutions. In contextualizing the documentation in terms of the literature on ADVANCE and the projects coming out of ADVANCE, I seek to understand how changing concepts of addressing equity are reflected in the social scientific discovery that has come out of NSF ADVANCE. In addition, I assess the extent to which the evolution of the social science coming out of ADVANCE paves the way for women's representation and success in the academy and continues to impact how social scientists understand strategies to increase equity. It is important to note that the content analysis does not provide a rigorous overview or assessment of ADVANCE projects or their accomplishments and relies on data that is self-reported through project websites and materials. Moreover, I do not assess BIPOC women's outcomes quantitively. Instead, my goal is to understand how social science continues to evolve in seeking equity, arguing that an intersectional framework is an emergent and central component of change for the social scientists working on these grants, as well as for the disciplinary contexts in which they pursued institutional transformation. --- THE FIRST GENERATION OF ADVANCE: FROM A PROGRAM FOR WOMEN TO INSTITUTIONAL TRANSFORMATION At its inception, NSF ADVANCE offered competitive opportunities for women scientists to advance in academic institutions through fellowships, grant funding, and similar opportunities that targeted individual scientists (Armstrong and Jovanovich, 2017;DeAro et al., 2019). With an approach that focused on representation, early ADVANCE programming sought to provide funding for STEM women and thereby offer a path to their success. While this strategy allowed for an impact on a handful of women, it also implied that navigating the academy was an individual pursuit, and that, with assistance, women could and would become successful within the constraints of the institution. More pejoratively referred to as a strategy of "fixing women, " (Dalton, 2001;Stewart and Vailan, 2018) social science critics argued that the problems of inequity could not be resolved by supporting the careers of token experts, but instead the key to a more equitable scientific workforce entailed addressing the ways that academic institutions constrained and enabled faculty (Rosser and Lane, 2002;Rosser, 2017;DeAro et al., 2019). Accordingly, to address inequality inherent in academic culture (MIT Report, 2010), ADVANCE also called for an institutional transformation (IT) track, which supported transforming the institutional contexts in which scientific and engineering knowledge is produced. Spurred by social science research indicating that institutional barriers can only be addressed by institutional-level solutions, the ADVANCE IT program was designed to effect change at the institutional level, rather than focusing on supporting careers of individual women (Rosser, 2006). The decision to engage gender equity as a problem of transforming institutions derived from a long line of feminist thinking showing how gender-defined as a social relation, institution, and/or structure-is deeply embedded in the everyday operations of modern bureaucracies. Stemming from sociology, this scholarship showed the complexity of discriminatory structures, as well as the contradictory processes and the multiplicity of meanings and symbols permeating gendered organizations (Alvesson and Billing, 1992;Britton, 2000;Reskin, 2003;Ridgeway, 2009). Indeed, Acker's (1990) groundbreaking work on gendered organizations prompted the rapid development of scholarship on the organizational processes, practices, and mechanisms that create and reproduce gender inequalities. Consequently, feminist scholars replaced the notion that equity requires the abolition of bureaucracy (Firestone, 1970;Ferguson, 1984;Acker, 1990) with a sociological research that asserted that greater equity required the transformation of the bureaucratic institution (Britton, 2000;Britton and Logan, 2008;McQuillan and Hernandez, 2021). Thus, moving from an initial focus on women scientists and STEM disciplines, the ADVANCE IT program called for strategies to transform systematically the day-to-day operations of institutions of higher education in pursuit of gender equity (Rosser and Lane, 2002;DeAro et al., 2019) and ultimately, create a better workplace for all faculty (Stewart et al., 2007;Bilmoria and Liang, 2012;Laursen and Austin, 2020). Recognizing that structural barriers to gender equity are specific to institutional contexts, therefore, ADVANCE solicits grant proposals seeking to implement activities that will lead to greater gender equity in STEM fields by transforming those institutions. Targeting these institutional barriers was thus borne from social science research, and a way for social scientists to address inequality in their own fields. As Valian and Stewart note, much of their ADVANCE work was informed by their experiences as academic psychologists (Stewart and Vailan, 2018; see also McQuillan and Hernandez, 2021). Accordingly, early ADVANCE grantees focused on social science research that corresponded with barriers to women's STEM equity such as lack of transparency and clarity in tenure and promotion and the absence of effective mentoring structures. For example, in the first IT cohort in 2001, Georgia Tech examined how gender affects mentoring and mentoring networks. Fox and Fonesca (2006) found that both women and men of higher rank are more likely to mentor, but men are more likely to mentor men only, while women are likely to mentor both men and women (Fox and Fonesca, 2006). Moreover, Fox and Fonesca (2006) show that mentoring is variable by institutional climate, but importantly, institutional climate varies by gender composition. Also in an early cohort (2005), UNC Charlotte sought to address "the interplay between structural and social psychological factors that generate gender inequality" (University of North Carolina Charlotte, 2005). Through a number of initiatives aimed at recruitment, mentoring, leadership and salary equity, UNC Charlotte's ADVANCE team reported better climate and more women STEM faculty at the end of their granting period. At the same time, however, the number of underrepresented minority faculty declined during this time (Lorden et al., 2013). Consistent with NSF proposal requirements of this cohort, the initial Charlotte project used a social science framing that addressed gender inequity, and included analysis of underrepresented minority (URM) faculty. Importantly, their approach centered on identifying and solving inequities through institutional research rather than developing an underlying understanding of the mechanisms that created that inequality (Devine et al., 2017;Laursen and Austin, 2020). In developing attention to multiple sites of inequality, ADVANCE social science researchers at University of Nebraska-Lincoln (cohort 2008) examined the networks of faculty in STEM to understand how faculty were connected and what these connections meant for long-term faculty success. Networks analysis provided insight into individual and departmental connections and isolation, as well as access to collaborative, mentorship and social networks for faculty members, finding that women and non-white faculty are more likely to be peripheral network actors (Falci, 2009;Falci and Watanabe, 2020). Over time, the National Science Foundation became increasingly explicit about the social science aspect of the projects, and the use of social science theory and methods to investigate persistent inequalities (Laursen and De Welde, 2019). In addition to articulating the planned activities for structural equity within institutions, starting in 2010, NSF called for a research project to accompany the main activities of the grant, indicating "IT projects must include a 5-page research component designed to study the effectiveness of the proposed innovations in order to contribute to the knowledge base informing academic institutional transformation" (National Science Foundation [NSF], 2010). In doing so, NSF incorporated social science into the ADVANCE program for institutional transformation. These criteria became more explicit in their connection to social science research, when, in 2014, the solicitation was revised to indicate: "the supplemental document must include information relevant to the proposed study, such as: (1) the disciplinary and conceptual framework for the project; (2) a discussion of the theory or theories grounding the research and the testable hypotheses; (3) the proposed methods to test the hypotheses; (4) the expected findings; and ( 5) to what extent the results and data will be disaggregated for multiple characteristics such as race, ethnicity, sexual orientation and disability, in addition to gender" (National Science Foundation [NSF], 2014). In addition to requiring a disciplinary framework for the research project associated with the proposed grant supplement, the project had to include a theory of change, a testable hypothesis and, in foreshadowing the move toward intersectionality, the extent to which the project would address "multiple characteristics... in addition to gender" (National Science Foundation [NSF], 2014). In an example of how institutions adapted to the changing requirements of the solicitation, Montana State examined barriers to women's careers and structured their ADVANCE project on self-determination theory, which is rooted in psychology and holds that meeting the psychological needs of autonomy, relatedness and competence provide motivation and lead to success (Deci and Ryan, 2012). Montana State structured the interventions at their institution to address these needs by focusing on building women's research capacity, creating supportive interactions and relationships and integrating worklife balance. Their projects showed improvements for women faculty and increased hiring of women on campus. The social science project supported self-determination theory as improving inclusivity on campus and garnering more participation for women in STEM (Smith, 2012). Despite these successes, with ADVANCE projects primarily focused on theoretical frameworks to address gender equity, early ADVANCE projects were criticized for implicitly or de facto targeting and thus benefiting white women (Hunt et al., 2012;Armstrong and Jovanovich, 2017;Fox Tree and Vaid, 2022). Indeed, studies showed that while white women were beginning to make equity gains in academic STEM fields, women of color lagged behind (Hirshfield and Tiffany, 2012;McQuillan and Hernandez, 2021), particularly black women (Snyder et al., 2016;Buchanan, 2020;Fox Tree and Vaid, 2022). In the social sciences, this is quite noteworthy, with less racial and ethnic diversity in these fields than in men dominated fields of engineering and biomedicine (Hur et al., 2017). Attentive to these issues, however, through their reliance on self-determination theory, programs like Montana State learned that structurally addressing the inequality of (white) women lead to improved outcomes for faculty of color and other marginalized faculty members. Likewise, Oregon State relied on systems oppression theory with the goal of "disrupting systems of oppression, " addressing inequality intersectionally by encouraging administrators and faculty to develop a "critical consciousness" that would generate more inclusive interpersonal interactions and a more positive atmosphere. Importantly, the researchers at Oregon State argued that a critical consciousness is particularly important at predominantly white institutions, hence adding an intersectional element to shifting the climate in the study of structural gender inequality. As these earlier projects demonstrated, even without an explicit call for intersectional research or an intersectional framework, intersectional concerns emerged in research that seeks to address structural inequalities. Indeed, an intersectional framework coincides with the multiple goals of ADVANCE to address systemic inequality while also being attentive to individuals that occupy locations of opportunity and constraint. With an approach that entails addressing empowerment of those at the margins through community engagement, social critique, coalition building and establishing resistance (Rosenthal, 2016) intersectionality also crosses social scientific disciplinary boundaries by considering both the individual and their context as paramount to changing outcomes and social transformation. Accordingly, intersectional concerns emerged in ADVANCE projects because they reflected reality. Such reality is consistent with intersectionality as the ways that the on-going renegotiation and reconceptualization of individual identities exposed how "systems of inequality grant or prohibit access to power" (Warner et al., 2018a, p. 526). --- THE SECOND GENERATION OF ADVANCE: GENDER EQUITY AND INTERSECTIONALITY Thus, supported by findings at ADVANCE schools such as Oregon State and Montana State, social scientists argued noted that gender inequity could not be addressed independent of addressing other penalties and privileges associated with identity (Hunt et al., 2012;Armstrong and Jovanovich, 2017;DeAro et al., 2019). Accordingly, in 2016, NSF revised the ADVANCE solicitation to indicate that intersectionality was an additional merit review criteria for addressing gender inequality in academic STEM fields and all proposals for ADVANCE grants were required to conceptualize their projects accordingly (National Science Foundation [NSF], 2016;DeAro et al., 2019). With its roots in black feminist thought that was critical of second wave (white) feminism as exclusively concerned with the plight of white women (Davis, 1981;Lourde, 1984;Crenshaw, 1989) intersectionality as a framework for ADVANCE projects resonated with what some ADVANCE scholars were already advocating by showing that that oppression is linked-or intersects-on axes of race, class, gender, sexuality and other sites of social hierarchy (King, 1988;Crenshaw, 1989). Intersectional theorists examined this "matrix of domination" (Collins, 1990), showing ways that systems of oppression "mutually construct one another" (Collins, 1998), while social scientists began unpacking how to operationalize and apply intersectionality in efforts for social change (McCall, 2005;Ferree, 2009;Cho et al., 2013). The National Science Foundation's requirement of an intersectional component importantly signaled the NSF's endorsement of this orientation as pivotal to questions of equity. In doing so, intersectionality, as a critical concept, also became central to the way ADVANCE social science scholarship approached change and equity. With a focus on the academy, ADVANCE scholars revealed the complexity and the many dimensions of inequity in academic intersectional practices, policies, and authority structures, through the development of an intersectional approach to transformation of academic institutions. Illuminating how gender inequities were not independent of or simply additive to other barriers to success in the academy, research shows that BIPOC women are chronically underrepresented in academia generally, and particularly in STEM fields (Li and Koedel, 2017;National Science Foundation [NSF], 2019). Indeed, psychology has the highest proportion of White faculty of the social sciences (Fox Tree and Vaid, 2022). The change in the ADVANCE program to include intersectionality in the call for proposals was therefore arguably inevitable because multiple dimensions of inequality emerged when ADVANCE programs addressed "gender only" equity in STEM. Moreover, scholars critiqued sublimating non-white identities in intersectional projects and thus voiced support for the revision of the ADVANCE solicitation guidelines to include a call for intersectionality (Hunt et al., 2012;Armstrong and Jovanovich, 2017). Doing so resulted in the development of a social science coming out of ADVANCE that was more multidimensional, allowing for more expansive insight into the workings of subtle power relationships in the day-today operations of academic institutions. In operationalizing intersectionality, therefore, ADVANCE scholars focused on "how things work, rather than who people are" (Cho et al., 2013;Warner et al., 2018b). Accordingly, in addition to giving voice to the marginalized, incorporating intersectionality into ADVANCE ensured attention was paid to how those in the dominant group access power (Warner et al., 2018a, p. 527). ADVANCE projects and related research thus identified social science phenomena such as cognitive and implicit biases, bystander impact and intervention, cumulative disadvantage and microaggressions as significant factors in gender inequality. Further, by focusing on equity in STEM, NSF ADVANCE became a locus for intersectional thinking among non-social science STEM fields (see Nielsen et al., 2017Nielsen et al.,, 2018)). Florida International University (FIU), for example, implemented a project on bystander awareness, as a behavioral intervention aiming to make faculty more appreciative of diversity and less likely to harbor prejudicial attitudes as part of their early ADVANCE funding. FIU also sought to increase the affirmation of diversity by teaching the social skills necessary to intervene when confronted with bias and discrimination (Florida International University, 2021). Combining this approach with their social science project on microclimates and developing a network of other institutions in Florida, FIU's project explicitly targeted broad issues of diversity, equity and inclusion as a way to understand and address gender inequity intersectionally. By considering climate issues and educating and empowering all faculty about their role in creating more diverse and inclusive environments, FIU's program focuses on social phenomena that arise in microclimates and contribute to inequality on multiple levels. Similarly, UMass Lowell addressed microaggressions in their social science project. This project sought to gain insight into how microaggressions constrained all faculty, with a particular focus on how faculty of color experience gendered microaggressions and the attitudes that study participants developed toward microaggressions. In addition, the UMass Lowell team sought to understand how identity (for both majority and underrepresented groups) affects barriers to intervening in microaggressions. Thus, at both UMass Lowell and FIU, social scientists examined the responsibility of both dominate and marginalized groups in bringing about social change. In other recent ADVANCE cohorts, institutions seek to understand how inequities are embedded and emergent in the structure and development of the academy and academic careers. For example, Arizona State University takes a life course perspective in examining the structure of pathways to leadership at an interdisciplinary institution. Their approach allows them to see how gender, race, ethnicity, foreign-born status, sexual orientation and disability shape faculty career pathways and leadership opportunities. Approaching the problem holistically and structurally allows the researchers to highlight how categorical markers of inequality constrain and enable faculty throughout their scientific careers. UMass Amherst ADVANCE, conversely, takes an approach that emphasizes on-going data collection and development of plans and progress across the institution. The ADVANCE team then leverages these largescale data to structure and inform change targeting the "relationships, resources and recognition" that create and promote successful faculty members. With both a baseline climate survey and the continual collection and examination of institutional data, the ADVANCE team is able to understand how faculty access to resources and development of inclusive communities emerge based on gender, race, sexuality, nationality, rank and other factors. Data collection such as this points the ADVANCE team in directions to help them understand problems as they emerge-and hence enabled the team to address, for example, the COVID crisis and its intersectional impact (University of Massachusetts Amherst, 2021). By examining data from the ground up, this ADVANCE team can see how intersectional concerns structurally emerge and tackle those concerns alongside their planned areas of intervention. --- DISCUSSION AND CONCLUSIONS: OPERATIONALIZING INTERSECTIONALITY AND INSTITUTIONAL TRANSFORMATION By operating at multiple levels of analysis, therefore, intersectionality addresses the complexity of both the barriers to equity and the ways to address inequity. Feminist scholars have long held that reflexivity about knowledge-intensive institutions and academic institutions in particular, is critical because-so long as academic institutions remain inequitable-the project of science and discovery of knowledge remain hegemonically masculine (Harding, 1986(Harding,, 1991)), white (Collins, 1990) and heterosexist (Foucault, 1978). Although the ideology of some academic disciplines, such as engineering, is more tightly coupled with the image of disembodied white heterosexual hegemonic masculinity (Bix, 2004;Leonard and Nicholls, 2013), the image of a scientist, scientific excellence, and hegemonic masculinity undergirds the broader organization of science and the discovery of knowledge (Harding, 1986(Harding,, 1991(Harding,, 2008;;Ong, 2005;Allison, 2007;Wilcox, 2009). Importantly, STEM researchers, particularly but not exclusively, those in sociology and psychology social sciences, became instrumental in designing and implementing the strategies to seek gender equity in their fields. Both from their own experiences of bias in the academy and drawing on findings of inequalities within institutions and organizations, social scientists-as STEM researchers, practitioners and women navigating their own academic careers-became key players in strategies for dismantling gender bias in academic settings (see McQuillan and Hernandez, 2021). When putting ADVANCE projects with an intersectional component into practice, social science scholars demonstrate that IT is not an abstraction, but also intimately tied to real embodied workers. Thus, equating organizational successboth practically and symbolically-with real, embodied workers rather than a disembodied ideal can generate more equitable organizational practices in the academy as well as other organizations. Importantly, since transforming organizations involves being attentive to the ebb and flow of crossconstitutive organizational structures and practices (Holvino, 2010). Interactive intersectionality asks us to continually and actively be on guard to the ways that inequalities arise and must be addressed. Moreover, it forces us to continually consider the context and assumptions that give rise to those inequalities (Ferree, 2009;Choo and Ferree, 2010;Cho et al., 2013). According to Ferree, "it is an empirical matter in any given context to see what concepts are important to the configuration of inequalities in discourse and in practices by people in many different social positions, and locational studies of intersectionality can contribute to this discovery process" (Ferree, 2009, p. 89). Therefore, by operationalizing intersectionality with the understanding that the meanings of gender, race, class and any number of other social categories are produced and reinforced in and through social organization, we can see how confronting and dismantling these structures in the academy necessarily leads to new knowledge and experiences. As a theory or framework for action, therefore, intersectionality is less precise than other models of change. Concepts with clearer and more measurable outcomes are likely to be counted as more successful in garnering calculable progress (Britton, 2010;Springer, 2020). In particular, representation is the easiest way to identify success; if more women are in working and getting promoted in US academic institutions, then the NSF ADVANCE program is working (Bilmoria and Liang, 2012;McQuillan and Hernandez, 2021). Likewise, if more BIPOC women are in STEM, then including a call for intersectionality as a requirement for ADVANCE programs is also a success. As Nelson and Zippel (2021) point out, social science theoretical concepts that can be demonstrated and provide measurable remedies for change are likely to gain high traction in addressing inequalities, particularly if those inequalities are intersectionally located. Yet intersectionality, in and of itself, is not measurable in such a clear way. Nor does it guarantee a quick-or perhaps even long term-change or turnaround in representation of BIPOC women on university faculties. But easy measurement, particularly of representation, has its limitations as well. As Ray (2019) explains, for change, we have to continually look at the organizational context and changes within those structures to see shifts. With this in mind, and as the expansion of the research on institutional change continues to make progress, current research looks toward institutional transformation as a process involving non-predominantly white institutions (PWI), since the majority of ADVANCE grants have gone to PWIs (Bird and Kowalski, 2022), which necessarily inhibits the ability to change either representation or organizational structure. Further, questions about equity and inclusion force a rethinking about inclusionary and exclusionary categories, as women-as-binary approaches exclude women identifying and trans faculty (t philosopher, 2019). The success of social sciences to bring about change is harder to quantify but easier to see in the shifts in institutional culture (McQuillan and Hernandez, 2021). Laube (2021) finds that feminist sociologists have the field of vision and analytic tools to work toward institutional transformation, and the ability to adapt and expand those tools to continually promote change. Likewise, Settles

This article examines intersectional praxis as an approach to institutional transformation, arguing that intersectionality is both a catalyst for and outcome of gender equity efforts in the social sciences and other academic STEM fields. As such, approaching gender equity intersectionally can be understood as a way that theory and practice are co-constitutive in social science and hence an important aspect of transforming academic institutions. Through a case study of the US National Science Foundation (NSF) ADVANCE program for gender equity in STEM, I look at the development of ADVANCE from an effort to support women in scientific fields to becoming a program for institutional transformation grounded in an intersectional understanding of women's inequity in the academic labor force. I ask two related questions in the efforts to address gender inequities in STEM. First, what is the relationship between academic institutions (which are simultaneously sites for the discovery of knowledge and gender inequality) and the National Science foundation, as the premier American academic institutional funding agency? Second, how has this relationship, through those working on ADVANCE, fundamentally shifted the understanding of the social scientific tools and strategies necessary to advance equity for women in academia? In looking at these questions, I argue that, beyond women's representation in social sciences and academia broadly, intersectionality is an important scholarly advance in social science that offers a dialectical tool for change.

measurement, particularly of representation, has its limitations as well. As Ray (2019) explains, for change, we have to continually look at the organizational context and changes within those structures to see shifts. With this in mind, and as the expansion of the research on institutional change continues to make progress, current research looks toward institutional transformation as a process involving non-predominantly white institutions (PWI), since the majority of ADVANCE grants have gone to PWIs (Bird and Kowalski, 2022), which necessarily inhibits the ability to change either representation or organizational structure. Further, questions about equity and inclusion force a rethinking about inclusionary and exclusionary categories, as women-as-binary approaches exclude women identifying and trans faculty (t philosopher, 2019). The success of social sciences to bring about change is harder to quantify but easier to see in the shifts in institutional culture (McQuillan and Hernandez, 2021). Laube (2021) finds that feminist sociologists have the field of vision and analytic tools to work toward institutional transformation, and the ability to adapt and expand those tools to continually promote change. Likewise, Settles et al. (2020) argue for structural changes in the field of psychology that allow for epistemic inclusion of intersectional scholarship and scholars. Embedding of practices and concepts that enable equity is also important to creating change, and likely more enduring (McQuillan and Hernandez, 2021). Moreover, when equity practices become "the way we do things around here" those practices are less likely to encounter resistance and concern (Bird and Lattimer, 2019). Adopting intersectionality as a cornerstone of the ADVANCE program is part of the praxis of such a cultural shift in academic institutions. The NSF ADVANCE IT program began with the premise that the production of knowledge is rooted in an inequitable organizational structure. In conjunction with the funding agency, award grantees and social science discovery, the inception of an intersectional framework entails the production of knowledge that allows for academic institutions as a space for resistance and an opportunity for transformation. Accordingly, as an intersectional stance becomes part of the everyday business of equity within academics, it both facilitates equity efforts in the academy, and is a cultural outcome of those efforts. While academic institutions often seem stuck in maintaining conventional paths to institutional power, an intersectional approach to equity forces a rethinking of social science knowledge. And it is through the diversity of knowledge that comes with intersectionality that new knowledge is most likely to emerge (Patton and Haynes, 2018;Laursen and De Welde, 2019;Hofstra et al., 2020). --- AUTHOR CONTRIBUTIONS The author confirms being the sole contributor of this work and has approved it for publication. --- Conflict of Interest: The author declares 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.

This article examines intersectional praxis as an approach to institutional transformation, arguing that intersectionality is both a catalyst for and outcome of gender equity efforts in the social sciences and other academic STEM fields. As such, approaching gender equity intersectionally can be understood as a way that theory and practice are co-constitutive in social science and hence an important aspect of transforming academic institutions. Through a case study of the US National Science Foundation (NSF) ADVANCE program for gender equity in STEM, I look at the development of ADVANCE from an effort to support women in scientific fields to becoming a program for institutional transformation grounded in an intersectional understanding of women's inequity in the academic labor force. I ask two related questions in the efforts to address gender inequities in STEM. First, what is the relationship between academic institutions (which are simultaneously sites for the discovery of knowledge and gender inequality) and the National Science foundation, as the premier American academic institutional funding agency? Second, how has this relationship, through those working on ADVANCE, fundamentally shifted the understanding of the social scientific tools and strategies necessary to advance equity for women in academia? In looking at these questions, I argue that, beyond women's representation in social sciences and academia broadly, intersectionality is an important scholarly advance in social science that offers a dialectical tool for change.

INTRODUCTION The Internet has enabled the spread of various forms of digital information for communication purposes. This digital information can be in images, text, videos, memes, and more (Rogers, 2021). Currently, memes have attracted more attention and become a subject of many researchers across the globe. Memes have also become a new media to facilitate the distribution of messages among Internet users. Studies found that more and more internet users search for memes on Google for various purposes, such as marketing, information sharing, and propaganda (Beskow, Kumar, & Carley, 2020). Memes have been widely used to spread information through various social media platforms, either just for notification purposes or for campaign purposes on various social, political, and educational issues, and even the dissemination of religious-related information (Ratkiewicz et al., 2011). Previous studies found that most of the young Muslim generation no longer rely on conventional teachers or educational institutions, such as Ulama, madrasah, or Islamic boarding schools, to learn Islam (C.-M. Hefner, 2016). A survey conducted by the State Islamic University of Jakarta, which involved 1214 young generations from 34 provinces in Indonesia, also found similar results in which Muslim millennials have intensive access to online resources to increase their knowledge of Islamic teachings (Halimatusa' diyah, 2021). The changing paradigm in learning Islam reflects the changing behavior of the young generation in utilizing new media. The young Muslim age uses digital media not only for fun but also for educational purposes. As such, the role of digital media in religious studies has also become pivotal for the acquisition and dissemination of religious knowledge (Hjarvard, 2008). This caused the emergence of various digital platforms and digital media that interfere with knowledge authorities. As a result of the phenomenon of using the Internet for communication purposes through various platforms, Islamic da'wah activities are also increasingly prevalent in multiple digital formats through social media and the form of digital memes. More than ten years ago, using digital images to distribute online messages and content caused the emergence of memes as a new digital media to facilitate digital information and knowledge exchange among virtual communities (Wood, 2020). Likewise, the spread of religious texts that were previously shared and communicated through manual leaflets has been transformed into digital memes, such as the dissemination of hadiths and Quranic verses (Syahridawaty & Qudsy, 2019). Even the religious memes of the Internet are considered to represent the humanist and spiritual ideas of certain people, which is called Sufistic memes. Currently, the young generation tends to distance themselves from conventional religious institutions, such as Mosques and churches, to obtain religious-related knowledge because they are busy or attached to new media. Thus, creating and circulating aesthetically pleasing short-form videos such as memes has become a new media of religious dissemination that is considered meaningful for conveying more touching religious messages (Haden Church & Feller, 2020). The rampant use of memes has triggered the dissemination of religious teaching in online spaces. The memes support the virilizing of information at a low cost and minimum effort. In addition, Internet users can see the memes repeatedly because they are funny and attractive, which causes them to keep them in mind for an extended period and circulate them across Internet platforms. The memorable characteristics of memes have caused them to be a practical tool for delivering Islamic teaching to online communities. Individual Muslim scholars or organizations can utilize memes to deliver various religious messages to change Muslim communities' knowledge and behavior. Islamic education and religious messages can be designed and modified with exciting characteristics and disseminated with memes. For example, hadith related to Islamic praying, fiqh, sadaqah, zakat, etc., can be delivered with interesting digital memes through images, videos, and texts. The memes can also be distributed and exchanged using various social media sites that connect Muslims across regions and the globe. Previous studies (e.g: Obadă & Dabija, 2022;Zulli & Zulli, 2022) argue that most online communication modes have used memes on the Internet to distribute information and to persuade virtual communities to adopt particular behavior and knowledge. As such, various memes are growing in online space to shape communities and opinions. The memes also deliver various messages based on the creators of the memes' mission (Latchem, 2014). For example, business actors might create memes for their product marketing. In contrast, religious actors, such as preachers and Ulama, might create and use memes to deliver religious teachings and messages to their followers. This helps Muslim communities access knowledge by distributing religious memes, such as hadith and Qur'an verses memes, faster and more conveniently. Likewise, popular Ulama such as Abdul Somad, Adi Hidayat, Felix Siauw, and others have carried out da'wah communication activities through various platforms on the Internet. The use of short memes in text, images, and videos is also increasingly widespread by individuals and religious organizations. Experts such as Bellar et al. (2013) said that religion-related Internet memes can shed more light concepts on religious concepts about religious messages in society. The distribution of religious memes, such as hadith memes, has been found to be able to instill divine experiences of internet users even while transcending the constraints of mobile media that circulates them (Haden Church & Feller, 2020). Similarly, the use and distribution of hadith memes across internet platforms are considered to increase the Muslim community's spiritual experience and knowledge of various Islamic teachings. However, studies on the distribution of hadith memes and their topics shared in online space are scarce. Meanwhile, such studies are critical to providing deep insight into the distribution of various types of hadith memes across online platforms to increase digital hadith meme distribution effectiveness among Muslim communities. Therefore, this study aims to examine and discuss the distribution of the types of hadith memes spread on the Internet. This study also intends to classify or categorize what sorts of hadith memes are spread on the Internet. In doing this study, we used Rajan's theory (2015) of faith meme types to examine the types of hadith memes shared in the social media groups of millennial Ulama in Central Sulawesi, both on Facebook and WhatsApp groups. This research is expected to provide understanding to academics and practitioners regarding the spread of hadith meme types in increasing public Muslim knowledge and spirituality. --- NETNOGRAPHY APPROACH TO RESEARCH This research used a netnography methodology to study community and social interaction in a virtual world (Bowle, 2010). The term ethnography comes from ethnography which is a research method to study communities' social interaction within a conventional context, and when the community interactions are practiced in a virtual world, then the ethnography becomes ethnography (Morais, Santos & Gonçalves, 2020;O'Donohoe, 2010). In this study, we examined millennial ulama social interaction on the Internet and social media platforms when they disseminate and exchange information in a virtual world. Communication in this study was related to the spread of hadith memes on the social media platforms of millennial Ulama. The observation and examination of millennial ulama interaction on social media sites such as WhatsApp groups and Facebook were conducted for three months. Such observation and reflection resemble the ethnography method where the researchers and online communities (millennial Ulama) engage with the millennial Ulama and other online communities as practiced by Jeacle (2021). Through the use of netnograpgy method, we were able to understand deeply the interaction of millenial Ulama as virtual communities in sharing and transferring hadith memes. Then, we collected types of hadith Furthermore, the analysis of hadith memes on the Internet was carried out by identifying and classifying the types of memes spread by referring to the theory of faith memes by Rajan (2015), which includes prayer memes, sacrifice memes, and end-of-day memes. We used the concepts from the theory to observe and categorize the hadith memes shared by millennial Ulama in Central Sulawesi on their social media groups. However, in this study, we are also open to new themes of hadith memes. In other words, Rajan's theory did not preclude our analysis of new themes of hadith memes shared by millennial Ulama. The data from social media content analysis related to the spread of hadith memes was analyzed using an online content analysis approach (Su et al., 2017). This allowed researchers to understand the cultural context of human action in the context of online communities related to the spread of hadith memes. The content analysis results were categorized through a coding process by following the categories and themes of the memes (Seiffert-Brockmann, Diehl, & Dobusch, 2018) communicated in the social media groups of the millennial Ulama. --- UNDERSTANDING THE CONCEPT OF MEMES The concept of'meme' was first mentioned by Richard Dawkins. It refers to the transmission of small units of culture analogous to genes that spread from person to person as genes spread themselves from one pool to another by moving from one body to another. Dawkins gives instances of memes such as slogans, fashions, and musical songs. As such, the term Memes has been transformed into Internet Memes when they are used and transmitted across internet platforms in the forms of digital messages and images, and they are quickly designed and transformed into new tools for online communication (Mielczarek, 2018). The term of Meme has been simplified from the word mimeme, which relates to the concept of memory with genes. Memes can be defined as cultural units that duplicate themselves in a process of copying and imitating. In a broad sense, the concept of Meme includes repeated lines, phrases, images, behaviors, ideas, or fragments of ideas that are perceived to quickly stick to the minds of users and also spread quickly (Susan Blackmore & Blackmore, 2000). Then, memes are widely used as a new metaphor to distribute digital content in online space. The memes are considered to fit new media in online communication, and they are also fitted with other digital media species. The memes also support delivering various types of messages produced by different individuals and organizations to be disseminated across online environments (Zhang & Pinto, 2021). Internet memes support the production and the creation of online content in a new format to be distributed online across communication environments by adjusting messages to give them subjectivity and generating new ways of communication (Wiggins & Bowers, 2015). Memes can be in the form of images, content, and videos while at the same time adding other language elements to them that are able to adapt to the internet media environment (Rajan, 2015). Memes present a participatory notion in the context of online communication that leads to the production and utilization of content that often takes the form of humor. Memes often take the form of digital photos or images that are humorous and ironic and sometimes aim to provoke humorous and critical ideas in society (Brantner, Lobinger, & Stehling, 2020). Internet memes are also considered to be highly visual and emotive online communications media that use images of popular culture with short messages to communicate. Internet users use the word Meme to describe a medium of absorption and dissemination of certain ideas presented in the form of written text, images, language, or other cultural units (Truszkowski, Rouff, Akhavannik, & Tunstel, 2020). These characteristics of Internet Memes' rapid dissemination and modification characteristics have provided insights into how culture is produced and transmitted in the context of new media. This process describes the participatory culture involving internet users modifying memes to distribute their digital messages. Scholars found that the successful engagement of communities in online media space should be supported by the communities' literacy on digital media. Social media literacy aims to address the negative effects of social media use (Schreurs & Vandenbosch, 2021). Within religious message distribution, media literacy can help Muslim communities participate actively and exchange meaningful content to deliver Islamic teachings. In other words, the Muslim community must have better technological proficiency in being involved in pop culture discourses to make and design digital media content to enable the spreading of Islamic messages virally. Such viral distribution of Islamic information can lead to Live Religion (Silvestri, 2015), in which the Islamic information and teachings are circulated and manifested by literate Muslim society. Thus, Muslim society's ability to understand Internet memes as a construction created in the form of images and texts with various themes, such as religious culture or religious traditions, can be combined with our ability to understand elements of popular culture. --- MEMES IN RELIGIOUS CONTEXT Previously, memes belonged to political and business institutions to promote their interest and business. In context, the memes were mainly adopted and used by religious believers. However, currently, the memetic culture is consumed by religious believers. Their religious institutions also utilize it by creating memes in particular formats, such as a short movie to be distributed online (Campbell & Sheldon, 2021). Such short films may consist of religious preaching that mimics the style and the form of a popular culture meme. It often does not explicitly list the identity of the author of the religious memes. Some research shows that posting photos generates more likes, and people will post repeatedly, making it more effective in spreading the message (Campbell & Sheldon, 2021). Religious institutions use this to their benefit by posting meme-image-based religious messages in the hope that they will spread effectively. The distribution of religious memes is particularly important on more fully structured social media sites such as Instagram, Pinterest, Google+, and so on (Brubaker, Boyle, & Stephan, 2017). Such used memes are a way of being metonyms for themes preached by religious institutions and thus become more easily disseminated. By attaching images in the dissemination of religious beliefs, the attention of social media users can be attracted and religious materials can spread quickly digitally (Burroughs & Feller, 2015). The messages of religious institutions online usually aim to instill divine experiences in their followers and must even transcend the boundaries of the mobile media that circulates them. In response to this urgency, religious institutions' messages can overcome communication barriers by using synecdoche or language that represents multiple meanings to create a more complete interaction with God (Haden Church & Feller, 2020). Internet religious memes can simplify the dissemination of religious beliefs in a more effective way. The use of Internet memes in spreading religion has made religious content more accessible and possibly more relevant in the lives of religious people on social media networks. Internet memes can also help promote religious allegiance, but they can also criticize religious beliefs (Burroughs & Feller, 2015). Religious individuals and institutions can act as a creator of religious memes by continually producing and distributing religious memetics on their social sites. Religious memetics can be incorporated with various religious teachings and messages to increase believers' knowledge and spirituality. The religious memetic can also be used for worship to make the believers more attached to their religion in online space. For example, Muslim society often shares memes related to praying, hadith, and Al-Quran verses for worship. Even though society does not attend conventional religious learning, such as in schools, mosques, or churches, they still can learn religious teaching and practice it in daily life. This reflects that religious practices have jumped from the pages of scripture into a virtual reality, which is called a new home by millennial individuals, both religious and non-religious. Related to memes in the context of religion, there are three types of memes, according to Rajan (Rajan, 2015), namely: 1. Faith Memes or Prayer Memes are the format of memes that are used to encourage societies to build a prayer habit by attracting and persuading the society to read the prayer meme texts or images. The prayer memes also encourage people to interact and communicate with God. The content of prayer memes is often based on values embedded in scripture, compassion, and forgiveness. The prayer memes can influence people to practice their praying even though they interact online. The prayer memes also want to depict that society does not need to spend longer time and get bored doing rituals, but the ritual can be made shorter, understandable, and still with a sincere conversation with God. The prayer memes can also facilitate the practice of prayer and popular religious culture among people who may need to be more religiously literate. 2. Sacrifice Memesevoke a sense of gratitude that obligates people to follow a particular way of life. These memes reaffirm beliefs through visualizations of sacrifices God encourages people to make. For example, images around us show a selfless lifestyle and encourage others to live the same way. The potency of such imagery creates respect in the minds of people who do not belong to a religious tradition. The messages of such memes are simple and, therefore, appeal to those outside the tradition who are accustomed to the value of sacrifice. The depiction of sacrifice aims to reaffirm the belief in the love of God. 3. End of Days memes are formats of memes that use narratives and images to communicate about the coming of doomsday and its signs. These memes also present images of the destruction of the world and stories of life in heaven and hell. End times memes are also used to evoke fear in the mind of the viewer. Fear not only works as a threat that affects individuals, but it also requires an understanding of the scriptures that provide references for the separation of good from evil in relation to the day of judgment or the afterlife. Allah frees those who do good deeds by admitting them to heaven and punishes those who do evil. These end-times memes, therefore, show the glory and holiness of God only to users who have knowledge of the apocalypse and thus will be motivated by the fear portrayed in the Meme. --- THE DISTRIBUTION OF HADITH MEMES ON SOCIAL MEDIA The utilization of hadith knowledge acquired online in daily activities shows a high significance level. The use of hadith in everyday life is related to answering fiqh questions asked by the people in the daily lives of millennial Ulama, such as issues of worship and muamalah. Our study found that millennial Ulama uses the hadith knowledge acquired from online sources by sharing them on social media for the public to read. Transmitting hadith online has been done using previously popular memes in other fields, such as business, politics, and social affairs. Millennial Ulama is using memes to spread hadith that can increase the knowledge of Islamic society. We found that the use of hadith memes in distributing Islamic teachings among millennial Ulama is considered an effective way to create participative religious messages and living hadith understanding among Muslim communities, as said by a millennial ulama as follows: "I think the reason to use hadith memes in circulating Islamic teachings among Muslim communities is to increase the participation of Muslim communities in creating digital media to ease the distribution of Islamic teachings because such memes are easy to make and can be distributed quickly across regions. Besides, by using memes in sharing hadith, we can create a live religious experience because religious messages can be created and shared by someone self " (Partcipant ANW) The participant statement above shows reasons for the use of hadith memes in the distribution of Islamic teachings among Muslim communities. The arguments are consistent with research conducted by Aguilar et al. (2017) and (Campbell, 2017), who found that the use of memes in religious message distribution can create lived religious experiences and digital culture, which become essential resources for presenting popular beliefs about religions. The hadith memes shared include thematic hadiths such as hadith related to prayer, hadiths related to the Day of Judgment, and related to making sacrifices, and related to tolerance. Here are some examples of traditions based on these themes: --- HADITH MEMES ABOUT PRAYER The hadith memes shared by informants are related to prayers that are often used in everyday life. The prayer hadith memes shared by millennial Ulama are prayers that are commonly used by the community. For example, memes of hadith prayers easily accepted by Allah swt are shown in picture 1 below. Source: https://www.islamquote.com/2020/04/13/dua-supplication-for-protection-against-evil-diseases/ The two Meme hadiths above show prayer for protection from lousy characters and from evils and black magic, commonly practiced by Muslim communities. The hadith memes reflect several prayers often shared among Muslims and used in their daily lives. Millennial Ulama even shares hadith prayer memes from their own organization, namely MajelisUlama Indonesia, and also takes hadith prayer memes from other social media, such as Mutiara Islam.net, which are then shared in their social media groups. --- HADITH MEMES ABOUT SACRIFICE The second type of hadith memes that millennial Ulama often share are those that narrate the theme of sacrifice. The sacrifice hadith memes depict the willingness to do good deeds, sacrifice on Hajj, and give alms. Some examples of hadith memes with the theme of sacrifice shared by millennial Ulama on social media include the hadith depicted in picture 2. Source: https://www.nubontang.or.id/2020/06/berqurban-1-unta-atau-sapiuntuk-7-orang.html The two examples of hadith memes with a sacrifice theme encourage Muslims to make charity related to kind words and sacrificial prayers to slaughter animals. Such hadith memes can encourage the Muslim community to be aware and make charity, such as zakah and infaq, which potentially contribute to the welfare of the Muslim community. The distribution of hadith memes about the charity can increase the Muslim community's willingness to make infaq, sadaqah, and waqaf. This could help the government and improve Muslim society's economic welfare (Ascarya, 2022). As such, the distribution of hadith memes about charity and sacrificial animals can play significant roles in Islamic economic development. --- HADITH MEMES ABOUT DOOMSDAY The third category of hadith memes shared online by millennial Ulama are end-of-life hadith memes in which a hadith tells about the end of the world, the end of life, and lives in heaven and hell. These hadith memes are mostly intended to raise Muslims' awareness about the future of life and to prepare themselves by doing good deeds. Examples of these hadith memes include those shown in picture 3 below: Source: https://kumparan.com/berita-terkini/dalil-tentang-hari-akhir-jangan-diabaikan-1v5tRi1aWQL Such hadith memes narrating the story of hell and doomsday can prevent people from doing evil deeds. Such stories about hell and doomdays can function as moral apocalyptic instruments (Cook, 1997) which can be used as a guidance that prevents them from doing evil things. Such hadith memes are commonly shared through millennial Ulama's social media site, Facebook. The content of the hadith memes narrated about living in the grave and hell can also be used as material for dakwah by other Muslims. --- HADITH MEMES ABOUT TOLERANCE The millennial ulama generation also shared several hadith memes related to tolerance on their social media. Some of these hadith memes discuss the need to live well with neighbors, namely by loving neighbors as part of a Muslim's faith. Tolerance has become an important issue among millennial Ulama since they were trained with religious moderation topics in their Ulama cadet program. The religious material given during their ulama cadet program training were implemented daily by distributing hadith memes about tolerance with a neighbor and different race, as depicted in figure 5 above. The roles of religious authorities in promoting tolerance among societies have been found to be significantly important, in particular in reducing inter-race and religious conflict in Pakistan (Kalin & Siddiqui, 2014). Given tolerance is an important issue in Indonesia (R. W. Hefner, 2021;Widayati & Maulidiyah, 2018), millennial Ulama shows their concern regarding the problems by stressing the importance of tolerance behavior and the importance of treating non-Muslims in a good manner. The concerns were reflected in the meme hadith they shared on social media as depicted in picture 6 below. Source: https://www.fly-cards.com/en/cards/108 The distribution of hadith memes about tolerance is expected to grow a sense of tolerance and respect in the Muslim community to the non-Muslim minority. The sense of tolerance has become a critical psychological variable in raising mutual respect and forming positive feelings towards other minority groups (Dangubi<unk>, Verkuyten, & Stark, 2021). In some memes, tolerance also contains an invitation to love and respect fellow human beings, both fellow Muslims and other humans of different religions. The Prophet's words, "I will complain (to God) on the day of judgment," reflect the essential of respecting non-Muslim minorities. Sharing memes and hadith could potentially provoke the Muslim community to love other religious believers. Memes tolerance has been discussed in the previous study, but it is limited to social and political context (Tawadros, 2020) rather than religious context. https://doi.org/10.24260/alalbab.v12i2.2778 In this study, religious meme tolerance was found to be shared in the form of hadith memes, which is a new theme. The memes hadith about religious tolerance in this study is different from Rajan's (2015) theory, which focuses on three themes: prayer, sacrifice, and the day after memes. Therefore, memes about tolerance are the new finding of this study. The finding of hadith memes about tolerance contributes to the development of theory in the context of hadith memes study. The new finding as the result of our netnography method we used in this study allows us to explore online phenomenon of virtual communities (Caliandro, 2014;Kulavuz-Onal, 2015;Lizzo & Liechty, 2022) of ulama millenial interaction in creating and distributing of hadith memes. --- CONCLUSION The results of our study show that various hadith memes shared by millennial Ulama on their social media can be categorized into four themes. Three of the themes are following Rajan's (2015) theory. However, in this study, the themes of hadith memes have been adapted to the context of hadith memes so that they are in accordance with the Islamic context, namely hadith memes about prayers, hadith memes about the last days such as the grave, and the day of judgment, and hadith memes related to pleasing sacrifices such as selfless sacrifice and sacrifice by giving alms. In this study, we also found a new theme of hadith memes, namely hadith memes about tolerance, which is an important theme in the context of the Indonesian state, especially in the context of the department of religion as the spearhead of maintaining moderation among Muslims. This research only focused on the themes of hadith shared by the millennial ulama generation through the social media Facebook and WhatsApp. This research has not studied whether the individuals who share them have an excellent or superficial understanding of hadith. In the future, there is a need for further research that also focuses on in-depth interviews with individuals who often share hadith on social media to find out their level of knowledge about hadith. Although some researchers argue that people who learn hadith through Internet memes have a superficial understanding of the meaning of hadith, the spread of hadith in the form of various memes can increase people's knowledge of different types of hadith. For example, hadiths related to prayers can increase the piety of people's understanding of multiple prayers derived from hadith. Then, the hadiths about sacrifices, such as sacrificing for charity, can increase the willingness of Muslims to make charity.

Instead, the use of hadith memes among Muslim communities is rampant, and the study of hadith memes is scarce. This study, therefore, aims to examine the use of hadith memes by millennial Ulama and the types and content of hadith memes disseminated and exchanged in the virtual world by millennial Ulama. This study built thematic hadith memes based on their contents and formats on social media platforms using Rajan's (2015) theory of religious memes. This study employed a netnography method, collecting data from the social media sites Facebook and WhatsApp of Islamic millennial Ulama. We used a thematic approach in analyzing the data. Our results show that hadith memes disseminated on social media sites fall into four themes. The first theme is prayer hadith memes that present the traditions of prayers in Islam. The second theme is hadith memes related to sacrifice, which depict messages of Muslims' willingness to practice gratitude and to sacrifice to do things according to Allah's will. The third theme of the hadith memes is that they present messages about the afterlife, which tells about the end of life, such as life in the grave, hell, and heaven. The last theme is hadith memes about tolerance, which tell about the importance of living in tolerance and respecting each other. We conclude that our study contributed to understanding the distribution of hadith meme themes in the virtual world to enhance the sharing and exchange of Islamic teachings.

Introduction The internet has become a major source of health information for laypersons (Sun et al., 2019). Because information online can be published without adhering to verification standards (Braasch et al., 2014), the internet has also become a platform for spreading misinformation, including issues concerning health (Ecker et al., 2022). This requires a level of criticality that can challenge laypersons, especially when their prior knowledge about the issue at hand is limited (Andreassen & Str<unk>ms<unk>, 2012;Braasch et al., 2014). The challenge of credibility evaluation is even more pronounced when people encounter health-related issues on social networking sites. Social media messages are often very short and informal and may use improper syntax or spelling (Addawood & Bashir, 2016). On social networking sites, such as Twitter, short texts can contain arguments with accurate, inaccurate, inappropriate, or missing justifications, especially when these texts involve controversial topics. Although modern societies are portrayed by the division of cognitive labor wherein individuals defer to relevant experts to ground their understanding of less familiar topics (Scharrer et al., 2017), on social networking sites anyone can share their knowledge, views, or opinions, regardless of their expertise. --- Theoretical Model for First-and Second-Hand Evaluation Our study was primarily informed by a bidirectional model of first-and second-hand evaluation strategies (Barzilai et al., 2020) while also considering one additional feature of the Critical Online Resource Evaluation (CORE) framework (Forzani et al., 2022). The bidirectional model of first-and second-hand evaluation strategies is based on the content-source-integration model (Stadtler & Bromme, 2014) that suggests that readers employ two levels of strategies to resolve scientific conflicts. Readers can evaluate information validity to determine whether the presented claims are accurate (i.e., using first-hand evaluation). However, readers do not always have sufficient knowledge to make the appropriate judgment. In this case, they can resolve the conflict by turning to second-hand evaluation to determine whether the source of information is trustworthy. In their bidirectional model of first-and second-hand evaluation strategies, (Barzilai et al., 2020) specify three firsthand evaluation strategies to judge the validity of scientific claims (i.e., distinguish accurate claims from inaccurate ones). These strategies are knowledge-based validation, discourse-based validation, and corroboration. When using knowledge-based validation, readers rely on their prior knowledge and beliefs about the topic, whereas when using discourse-based validation, readers use various discourse features, such as argument structure and quality to make judgements about the credibility of content. Corroboration, a third strategy for validating content, is when readers compare text content to what other resources state about a given issue. The term second-hand evaluation (Barzilai et al., 2020;Stadtler & Bromme, 2014) refers to sourcing strategies that readers employ to judge a source's trustworthiness. Readers can make inferences and evaluate a source's expertise, benevolence, and integrity (Hendriks et al., 2015) by relying on available information about the source. According to the model, readers use first-and second-hand evaluation strategies reciprocally. That is, content quality judgments inform source trustworthiness judgments and vice versa. In addition to the first and second-hand evaluation strategies, readers can also evaluate context as part of the credibility evaluation process, which Forzani et al. (2022) refers to as tertiary evaluation. According to Forzani et al. (2022), context refers to the temporal, social, and political setting of the text (e.g., social media texts read in specific crowdsourcing platforms). In this study, we considered the effects of platform context, while also incorporating a slightly broader interpretation of context by considering contextual attributes of the readers evaluating the texts (i.e., adult readers representing different nationalities). --- First-Hand Evaluation In this study, we focused on credibility judgments of health-related social media posts to determine the extent to which readers rely on their prior beliefs (i.e., knowledge-based validation) and information presented in the posts (i.e., discourse-based validation) and sourcing. Next, we define relevant concepts and outline previous research associated with first-and second-hand evaluation; first-hand evaluation involves knowledge-based and discourse-based validation while second-hand evaluation focuses on sourcing. We also present research suggesting contextual attributes, such as a reader's cultural background, can affect adults' credibility evaluations in social media contexts. --- Knowledge-Based Validation Prior knowledge and beliefs are internal resources that readers can use to quickly evaluate the accuracy of information (Richter & Maier, 2017). When readers evaluate information using their prior beliefs, they seem to favor belief-consistent information over belief-inconsistent information (Abendroth & Richter, 2021;McCrudden & Barnes, 2016;van Strien et al., 2016). As such, readers attend to evidence that is consistent with their beliefs and resist evidence that contradicts their beliefs. This text-belief consistency effect is similar to confirmation bias (Karimi & Richter, 2023) -the term used in the psychological literature to refer to seeking or interpreting evidence in accordance with a person's existing beliefs, expectations, or hypotheses (Nickerson, 1998). However, a confirmation bias occurs when a reader starts with a particular view of a particular issue and then actively searches for additional information that upholds that view. In contrast, the text-belief consistency effect occurs during the comprehension process (Karimi & Richter, 2023), when a reader encounters information and, often unconsciously, attends to text that is consistent with their beliefs while also passing by text that contradicts their beliefs. The text-belief consistency effect in credibility evaluation has been shown in different contexts, including isolated arguments with no indicators of context (McCrudden & Barnes, 2016), and arguments presented in the context of social media posts (Wertgen & Richter, 2023). For example, McCrudden and Barnes (2016) asked 72 high school students to evaluate eight isolated arguments about climate change. Four arguments claimed that humans affect climate change, and four other arguments claimed the opposite. Half of the arguments were strong, and half were weak. It was found that students evaluated belief-consistent arguments more favorably than belief-inconsistent arguments. However, arguments were not evaluated solely based on their belief-consistency. Namely, students evaluated strong arguments more favorably than weak arguments. Importantly, further analysis showed that students' evaluations of strong beliefinconsistent arguments and weak belief-consistent arguments did not differ. In a second study, Wertgen and Richter (2023) examined the text-belief consistency effect when asking university students to evaluate short messages, resembling Twitter posts, on four socio-scientific controversial topics (see Experiment 1). For each topic, the messages represented opposing positions. In addition to the position, Wertgen and Richter (2023) also manipulated the source-message consistency. In the consistent source-message condition, the source (e.g., World Wildlife Fund) presented the expected position (humans cause climate change). In the inconsistent source-message condition, the source presented an unexpected position (natural causes for climate change). Participants read belief-consistent messages faster and judged them more plausible than belief-inconsistent messages. The same pattern was found for source-message consistency. When the sources presented expected positions in the social media messages, the messages were read faster and rated slightly more plausible (or more likely to be acceptable in a certain situation); when the sources presented unexpected positions, the messages were read more slowly and rated slightly less plausible. Overall, the use of prior beliefs as a resource could be especially applicable when people initially browse short social media messages using quick, superficial processing (Metzger & Flanagin, 2013) before they stop to evaluate the information more strategically. --- Discourse-Based Validation According to Barzilai et al. (2020), evaluating arguments presented in a text is an essential component of discoursebased validation. Discursive elements include the argument's structure and coherence as well as the quality of evidence provided. Arguments may have a rhetorical structure or a dialogic structure. A rhetorical argument includes a claim (or assertion) with an accompanying justification, which differs from a dialogic argument or debate, which includes an opposition between two or more assertions (D. Kuhn, 1991). A simple rhetorical argument contains one claim with only one instance of justifying support, which is called evidence (Zarefsky, 2019) or data (Toulmin, 2003). According to Toulmin (2003), an argument can also include other components, such as a warrant, which is an often unstated but implicit inference that connects the evidence to the claim. For example, empirical research (used as evidence) entitles us to conclude that vaccines are safe (the claim) because we trust that the research has followed scientific standards (the warrant). Social media posts with restricted lengths, such as those found on Twitter, are typically structured as simple rhetorical arguments, making them a relevant context for examining how adults attend to the coherence of a single claim, evidence, and warrant to evaluate the credibility of a simple argument. In addition to judging the coherence of the parts of an argument, readers can also attend to the quality of evidence in an argument. There are several different types of evidence (Hornikx, 2005;D. Kuhn, 1991;Zarefsky, 2019); these types reflect how the evidence was produced and they vary in terms of their quality (C. A. Chinn et al., 2014). Four types of evidence include evidence produced from research, testimonies, anecdotes, and social consensus (Zarefsky, 2019). Evidence resulting from rigorous research processes, such as experiments, statistical analyses, and meta-analyses, can offer causal and statistical evidence. A second type of evidence is testimonial evidence (Zarefsky, 2019) or expert evidence (Hornikx, 2005). Testimony, which can consist of either a fact or an opinion, is a statement made by some source. It is reasonable for an author to rely on testimonial evidence from a qualified source to support one's claim when an author does not have direct knowledge of the topic but can trust the expertise of others. Anecdotal evidence, such as personal experience, relies on a narrative way of knowing (Hinyard & Kreuter, 2007) while social consensus refers to widely agreed-upon facts, shared value judgments, shared historical understandings, and previously established claims (Zarefsky, 2019). Anecdotal evidence and social consensus, two types of evidence that are not necessarily supported by accurate information (e.g., research evidence or expert testimony), are common in health communication, especially in social media contexts (Suarez-Lledo & Alvarez-Galvez, 2021). Thus, social media posts are an authentic context for determining if adults can evaluate the extent to which evidence supporting certain claims provides accurate and inaccurate information. Because social media contain an enormous number of short messages competing for readers' attention, the persuasiveness of evidence is crucial for authors to craft their arguments in ways that are both efficient and effective. When examining the relative persuasiveness of different evidence types (e.g., anecdotal versus statistical evidence), results have been contradictory. In one narrative literature review, Hornikx (2005) reviewed twelve studies that compared the persuasiveness of anecdotal evidence and statistical evidence. Six of those studies showed that statistical evidence was more persuasive than anecdotal evidence, one study showed that anecdotal evidence was more persuasive, and five studies showed no difference between the two types of evidence. Elsewhere, a meta-analysis of 15 studies concerning health communication campaigns (Zebregs et al., 2015) showed that statistical evidence had a stronger influence on beliefs and attitudes than anecdotal evidence, but that anecdotal evidence had a stronger influence on intention, which relates more closely to affective responses. Notably, a recent review found that presenting anecdotal evidence and personal experiences was one of the 12 identified persuasive techniques used in communicating online health misinformation (Peng et al., 2022). When evaluating evidence, readers may struggle to differentiate evidence in terms of quality, especially when judging the quality of different types of research evidence. For example, List et al. (2021) found that even though undergraduate students (N = 82) considered anecdotal evidence considerably less convincing than other types of evidence, they struggled to differentiate between certain type of research evidence that imply causation and observational and correlational evidence (that do not imply causation). This is especially concerning because, on social media, discussions of health issues often include causal claims or generalizations that may or may not be supported by appropriate causal evidence. --- Second-Hand Evaluation The trustworthiness of a source refers to readers' perceptions of positive characteristics on the part of that source; these perceptions, allow them to accept the source's message (Fogg, 2002;Ohanian, 1990). Evaluation of source trustworthiness is essential, particularly when readers evaluate scientific information, including health information, about which they do not have specialized knowledge (Hendriks et al., 2015). Hendriks et al. (2015) found three dimensions that laypersons rely on when deciding whether they trust an expert. These dimensions are expertise, integrity, and benevolence. A source's expertise can be evaluated by exploring that source's credentials, such as degrees, professional achievements, affiliations, and other indicators of competence, such as awards and publications (Br<unk>ten et al., 2018;Rolin, 2020). Furthermore, integrity refers to honesty, objectivity, and acting according to scientific and professional standards, whereas benevolence refers to goodwill and intentions toward others and society (Hendriks et al., 2015). It is widely acknowledged that information about a source's expertise plays a pivotal role in credibility evaluation of social media messages and beyond (Lin et al., 2016;Meinert & Krämer, 2022;Stadtler & Bromme, 2014). For example, Hirvonen et al. (2019) have studied cognitive authority in online health-related information-sharing processes. They found that authority-related cues, such as user information, the authority's own experience, education, and background, were important when girls and young women evaluated the information credibility of their peers in an online forum related to health topics. However, evaluation of the source's trustworthiness can also be based on symbols of authority and fruits of success rather than on perceived expertise (Shieber, 2015). For example, in one interview study, all 18 interviewed participants (ages 18 to 30) viewed celebrities as trustworthy sources of online information (Djafarova & Rushworth, 2017). In other research, Lin et al. (2016) studied the credibility evaluation of mock Twitter posts that discussed health risks. In the study, 696 undergraduates participated in a quasi-experiment in which the following aspects of Twitter posts were manipulated: author information, originality of the tweets (original or retweeted), and bandwagon cues (i.e., replies or not). The authors were manipulated by authority and whether the identifying information was provided. The Twitter pages were owned by either the Center for Disease Control and Preventions (CDC), a college student, or a stranger without any identifying information. After viewing the pages, students were asked to evaluate the source's credibility according to three criteria: competence, goodwill, and trustworthiness. The researchers determined that participants viewed authority cues as the most credible compared to the other cues (i.e., identity, original or retweeted, bandwagon cues). The CDC was evaluated as more credible than the student and the stranger. The bandwagon cues also had an effect, such that the student and the stranger were evaluated as more credible when they retweeted each other. Interestingly, the CDC twitter page without any retweets was perceived as the most credible in all evaluated aspects. Some studies have examined other features of the source, such as gender and ethnicity. Spence et al. ( 2013) investigated intercultural differences in responding to health messages specifically in the context of Facebook. In their study, participants from the Caucasian and African American communities (N = 200) were evaluated to determine their response efficacy and behavioral intentions after being exposed to a social media page with an avatar. The African American page owner communicated either high or low ethnic identity (that is, including a greater or lesser number of cues on their page to promote their ethnic identity) while encouraging participants to read a story about heart disease. African American participants perceived both ethnic authors as more competent, caring, and trustworthy than Caucasian participants did. While the perceived credibility of the author was not measured, African American participants indicated stronger intention to change their dietary behavior after seeing a health message delivered by an African American avatar with high ethnic identification as compared to one with low ethnic identification. Armstrong and McAdams (2009) examined the role of gender in credibility evaluation of blogs. They found that gender influenced how undergraduates at a large university in southeastern United States perceived credibility. The blog posts with male authors were seen as more credible than posts with female authors. Similar results regarding credibility and gender have also been attained with newscasters (Weibel et al., 2008). More recently, Groggel et al. (2019) investigated how people perceived both gender and ethnicity as well as physical attractiveness as a cue indicating trustworthiness when evaluating Twitter accounts. In the study, Amazon Mechanical Turk workers evaluated the trustworthiness of 816 Twitter profiles. Results indicated that attractiveness was positively associated with trust. Furthermore, Twitter accounts belonging to white individuals were evaluated as more trustworthy than accounts belonging to Black individuals. Also, accounts belonging to Black males and both Black and White females were viewed as less trustworthy than accounts belonging to White males. White crowdsourcing workers also evaluated accounts belonging to White individuals as more trustworthy. --- Contextual Attributes of Readers At least two studies have found that cultural context or a reader's membership in a particular social media network influenced adults' credibility perceptions of social media posts. Yang et al. (2013) compared credibility perceptions of microblog posts among U.S. and Chinese participants in two social media networks; the posts varied in terms of author's gender, name style, profile image, location, and degree of network overlap with the reader. They identified several key differences in how users from each country critically consumed microblog content in the two networks, including the observation that Chinese respondents considered information from microblogs to be more credible than U.S. respondents. However, the researchers explained "it wasn't clear whether this difference was due to inherent differences in credibility quality of microblog information in the two cultural contexts, or to the different way that people perceive the credibility of microblog information and/or other information sources. " (p. 581) In another study of 746 adults from 76 countries, S. Shariff et al. (2016) used chi-square analyses to correlate tweet credibility evaluations and demographic attributes (gender, age, education, and location) partitioned into three different settings. That is, location data were partitioned into original setting (Asia, Europe, South America, North America, The author of the social media post. A) Professor of medicine B) Nurse education practitioner C) Professional lifestyle blogger D) Parent Source's Gender3 Self-identified gender of the author A) Female presented in the profile picture. B) Male Source's Ethnicity 3 Self-identified ethnicity of the author A) Asian presented in the profile picture. --- B) Black C) White Platform 4 Crowdsourcing platform on which A) Prolific participants completed the set of credibility evaluation tasks. --- B) Toloka --- Control Variable: Topic The topic of the health-related social A) Fish oil media post. B) Food healthiness C) Processed red meat D) Vaccine safety E) Vitamin D and Africa), binary setting (Eastern hemisphere, Western hemisphere) and categorical setting (Asia-Pacific, Americas, Europe, Africa). They found a combination of readers' education background and their geo-location had a significant correlation with credibility judgments, but gender and age did not. Further, only location was significantly correlated at all levels of data partitioning. Finally, S. M. Shariff (2020) conducted a literature review of credibility perceptions of online information and concluded that most studies have not paid sufficient attention to how and why readers carry out their credibility judgements of social media posts. Shariff called for more research in credibility perceptions that attends to demographic attributes and other participant characteristics (e.g., membership in particular groups or social media platforms). Considering all of these findings, in this study, we focused on credibility judgements of health-related social media posts to determine to what extent adult readers relied on their prior beliefs (i.e., knowledge-based validation), evidence types presented in the posts (i.e., discourse-based evaluation) and source characteristics (expertise, gender, and ethnicity) after controlling for the topic of health-related posts. We also examined whether crowdsourcing platform membership played a role in readers' credibility evaluations given that the nationalities of members across the two platforms did not overlap. --- Methodology The present study was intended to understand how adults evaluate short social media posts on health issues. We created accurate (i.e., in line with current scientific knowledge) and inaccurate (i.e., not in line with current scientific knowledge) social media posts on five health topics. Then, we used a computerized algorithm that systematically manipulated evidence type in the posts and source characteristics (the author's expertise, gender, and ethnicity) to generate 840 unique combinations of the posts. Each unique post was copied 10 times to generate a pool of 8400 posts. The participants, recruited from two crowdsourcing platforms, were asked to evaluate the credibility of ten different posts selected from the larger sample and delivered to each participant via the platform. We examined how evidence type, participants' prior beliefs, source characteristics of the post and crowdsourcing platform membership were associated with participants' credibility judgments on the posts after controlling for the topic of the posts. Based on theoretical assumptions supported by previous empirical evidence ( Barzilai et al., 2020;Richter & Maier, 2017;Stadtler & Bromme, 2014), we assumed that the quality of evidence, participants' prior beliefs, and expertise of the source would be associated with participants' credibility judgments. First, we expected that the more that participants' prior beliefs were consistent with the content in the post, the higher the participants would evaluate the credibility of the post (McCrudden & Barnes, 2016;Wertgen & Richter, 2023). Second, we expected that posts with claims supported by research-based evidence would be evaluated as more credible than posts that contained evidence from testimony, personal experience, or consensus (Hornikx, 2005;List et al., 2021). Third, we expected that posts by sources with relevant domain expertise would be evaluated more credible than posts by sources without domain expertise (Br<unk>ten et al., 2018;Lin et al., 2016). In addition, we were interested in testing the effect of the source's gender and ethnicity on credibility judgements as well as exploring whether membership in a certain crowdsourcing platform would be associated with participants' credibility judgments. In our analyses, we controlled for the topic of the posts because topic has been shown to play a role in the credibility evaluation of texts (Br<unk>ten et al., 2018;Hämäläinen et al., 2021). To study these associations, we ran an online quasi-experiment with an incomplete repeated measures design (Shaughnessy et al., 2012). That is, there was no control group, and a single rater rated a maximum of 10 posts out of the 840 unique generated posts. The factors were controlled independently, with practice effects controlled with a completely random order in the Toloka platform, and with balancing in the Prolific platform. The final dataset (8380 posts) consisted of 10 ratings of the 820 unique posts from different raters, and 9 ratings for 20 of the unique posts. All the variables included in this study are presented in Table 1. --- Participants We used crowdsourcing to recruit participants for our study. The popularity of crowdsourcing has increased steadily, and it has been used in a variety of fields (Hossain & Kauranen, 2015). A total of 844 participants were recruited from two crowdsourcing platforms: Prolific and Toloka. According to Chapkovski (2023), Toloka provides access to some populations that can be hard to access through Prolific or MTurk. While the MTurk population is mostly based in the US and India (Difallah et al., 2018), and Prolific users reside mostly in the UK and US (Peer et al., 2017), Toloka's users mostly reside in Russia and other former Soviet countries. Thus, we used the Prolific and Toloka platforms to obtain a geographically and culturally broad sample. The Prolific platform is available for participants who are at least 18 years old from most OECD countries, except for Turkey, Lithuania, Colombia and Costa Rica where Prolific is not available ( (Prolific, 2023b)). Prolific is also available to participants in South Africa and other participants who are not from OECD supported countries can still participate if they live in a supported country. In September 2023, according to Prolific's audience checker tool (Prolific, 2023a), approximately 58% of its users identified as female, while 42% identified as male. Regarding age, 47% reported being under 30 years old, 48% were between the ages of 30 and 59, and 5% were 60 or older. Prolific crowdworkers are primarily recruited by word-of-mouth through social media (e.g., Facebook, Twitter, Reddit) and flyers distributed on university campuses. All participants are paid rewards when their submissions are approved. According to its website, the Toloka platform collects data from crowdworkers who live in more than 100 different countries, with a "large concentration of participants coming from Pakistan, Kenya, Brazil, Turkey, India, Egypt, the Philippines, and the United States," and "about half of Tolokers are native speakers of English, Urdu, Arabic, Russian, or Spanish" (Toloka, 2023). The majority of Toloka workers are between 20-30 years of age; they are equally divided between members of the middle class and working class, and 62% of its members identify as male. Toloka acquires its users at least through social media presence and advertising. Participants were required to complete a demographic survey at the beginning of the study. We used Pew Research's Demographics Questionnaire (PewResearchCenter, 2015), as the basis for our survey. As shown in Table 2, the mean age of respondents was higher in the Prolific platform (M = 43) compared to Toloka (M = 33) and there were more male respondents in Toloka (56%) than in Prolific (49%). In terms of ethnicity, a large percentage of respondents in both platforms identified as White (73% in Toloka and 85% in Prolific), fewer identified as Asian (11% in Toloka and 5% in Prolific) or as individuals representing multiple ethnicities (10% in Toloka and 7% in Prolific) while the smallest number of respondents in either platform identified as Black (6% in Toloka and 2% in Prolific). Education levels were similar across the two platforms, but notably, there was no apparent overlap in the nationalities of respondents across the two platforms. In Toloka, more than half (56%) of respondents identified as Russian, while the remaining respondents lived in regions in Eastern Europe, the Middle East, Kenya, or India. In contrast, more than three-quarters (77%) of respondents in Prolific were from either the United Kingdom (65%) or the United States (12%), and the remaining respondents were from either Canada or other countries in Western and Southern Europe. --- Generation of Credibility Evaluation Items for Social Media Posts --- Designing Posts We designed short social media posts regarding five health topics on which contradictory information, including accurate and inaccurate claims, had been spread on the internet. In designing the social media posts, we consulted a current Finnish book written by Knuuti (2020), a professor and director of the Turku PET Centre, University of Turku. For this book, Knuuti collected 250 common health-related knowledge claims spreading on the internet and analyzed them in light of current scientific knowledge. The chosen topics were the safety of vaccines, Vitamin D, processed red meat, fish oil, and food healthiness. There are several false claims about vaccines on the internet, one of which is that the aluminum in vaccines is dangerous. Also, excessive claims about the benefits of Vitamin D, such as preventing cancer, have been presented. Furthermore, research on the health effects of red processed meat has been misinterpreted by neglecting the potential harms. Finally, there are contradictory claims about the benefits of fish oil and food healthiness. We used research presented in the book to design the research-based social media posts. The sources provided in the book are presented in Table 7 of Appendix. Each post comprised three main components which were systematically manipulated with a computer algorithm: the knowledge claim, supporting evidence, and author of the post (see Figure 1). Knowledge claims were either accurate, that is, in correspondence with the current scientific knowledge (e.g., Vitamin D does not prevent cancer), or inaccurate (e.g., Vitamin D prevents cancer). The knowledge claims were paired with supporting evidence that represented one of the following evidence types: research evidence, testimony, personal experience, and social consensus (Jacobsen et al., 2018;Zarefsky, 2019). Because we used authentic findings as research evidence, we only presented these findings with accurate claims. Examples of the knowledge claims and evidence types related to processed red meat are presented in Table 3. We created four types of authors (or sources) and varied their expertise. Two sources, a professor of medicine and a nurse education practitioner for undergraduate students, were experts in the health domain. The other two sources, a professional lifestyle blogger and a parent, did not have domain expertise. In addition to this information, the author's profile included a short description, such as 'passion for running', to make the social media messages seem more authentic. Because some prior work has suggested that an author's ethnic background and gender may be associated with readers' responses to social media health information (Armstrong & McAdams, 2009;Spence et al., 2013), we also varied the author gender and ethnicity. To do this, we used the Chicago face database (Ma et al., 2015), which provides facial pictures along with the self-identified ethnicity and gender, as well as a subjective attractiveness score based on ratings from US-based raters. Using this data, we selected pictures of people with average attractiveness who were between 35 and 45 years of age. We included males and females, as well as those who self-identified as Asian, Black, and White. The age and attractiveness selection were performed to create a uniform set of facial pictures and thus rule out very unlikely combinations, such as 20 year old professors. The selected profile pictures are shown in Appendix (Figure 5). --- Full Factorial Design Next, unique combinations of sourcing features (author expertise, gender, ethnicity, and profile picture) and content features (topic, claim type, and evidence type) were generated by applying mathematical principles of combinatorics (R. Kuhn et al., 2009) to a full factorial design to study all possible combinations of the different levels of factors being considered. Traditional experimental designs in credibility evaluation often avoid full factorial design because the total number of all combinations can escalate quickly, surpassing what is feasible to study -hence, the complexities we touch upon in the paper title. For instance, an experiment may examine two factors: source expertise of a post and evidence backing the post. If each factor has two levels (e.g., source expertise includes 1) Professor and 2) Blogger, and evidence type comprises 1) Research and 2) Personal experience), this results in four unique combinations (2x2). If --- Table 3 Arguments of the evaluated social media posts concerning processed red meat. --- Argument with the accurate claim Evidence type Red processed meat is a major health hazard. The study review found that red processed meat was associated with a higher incidence and mortality of arterial disease. --- Research Red processed meat is a major health hazard. The WHO places processed meat into the highest risk category of carcinogens.. --- Testimony Red processed meat is a major health hazard. Humans with a balanced diet without red processed meat feel better. --- Consensus Red processed meat is a major health hazard. I eat red meat regularly and at my physical, some of my important indicators are alarming. --- Personal Experience Argument with the inaccurate claim Red processed meat is not a significant health hazard. My personal trainer appreciates red processed meat as a part of a balanced diet. --- Testimony Red processed meat is not a significant health hazard. Humans are carnivores and this is how we have survived. --- Consensus Red processed meat is not a significant health hazard. I eat red meat regularly and at my physical, all of my important indicators are great. --- Personal Experience there are three levels for each factor, then nine (3x3) combinations arise. Introducing a third factor with three potential values, such as source ethnicity, balloons the number of combinations to 27 (3x3x3). The number of factors and levels renders full factorial design seemingly unfeasible in studies of credibility evaluation. In our study, we implemented a full factorial design that tested 840 unique combinations. With such a vast number of combinations, we encountered two main challenges. The first was the effort of creating 840 distinct social media posts and ensuring that each combination was created just once. The second challenge was how to conduct an experiment with this multitude of posts. We addressed the first issue using an algorithm and software that automatically generated the required 840 social media posts, ensuring all combinations were produced. This resulted in 480 unique posts with accurate knowledge claims and 360 unique posts with inaccurate knowledge claims. For the second challenge, we employed two crowdsourcing platforms, from which large numbers of participants could easily be recruited. To conduct the experiment, we used an incomplete repeated measures design since expecting one person to evaluate all 840 posts would be unrealistic. As a result, each participant only assessed 10 unique posts. Figure 2 illustrates how social media posts were generated with this computerized procedure by using the credibility evaluation task item presented in Figure 1 as an example. A combination of ethnicity, gender, and profession was used to select the profile picture (i.e., Black female professor) associated with the social media post, which was generated using a combination of the topic (Vitamin D), accuracy of claim (accurate), and evidence type (research). Although we conceptualized perceived credibility as a multidimensional construct, reflecting the idea of firstand second hand evaluation (Barzilai et al., 2020;Stadtler & Bromme, 2014), we measured participants' credibility judgments with a single item (cf. Hanimann et al., 2023). Participants were assigned to evaluate the credibility of ten posts on a single item scale from 1 to 7 (1 = not at all credible; 7 = extremely credible). The single item was used because we sought to understand how different content-and source-related issues affected participants' overall evaluations of the social media posts' credibility. Single-item scale may be advantageous because participants may resent being asked questions that

The internet, including social networking sites, has become a major source of health information for laypersons. Yet, the internet has also become a platform for spreading misinformation that challenges adults' ability to critically evaluate the credibility of health messages. To better understand the factors affecting credibility judgements, the present study investigates the role of source characteristics, evidence quality, crowdsourcing platform, and prior beliefs of the topic in adult readers' credibility evaluations of short health-related social media posts. Researchers designed content for the posts concerning five health topics by manipulating source characteristics (source's expertise, gender, and ethnicity), accuracy of the claims, and evidence quality (research evidence, testimony, consensus, and personal experience) in the posts. Then, accurate and inaccurate posts varying in these other manipulated aspects were computergenerated. Crowdworkers (N = 844) recruited from two platforms were asked to evaluate the credibility of ten social media posts, resulting in 8380 evaluations. Before credibility evaluation, participants' prior beliefs on the topics of the posts were assessed. Results showed that prior belief consistency and source expertise most affected the perceived credibility of accurate and inaccurate social media posts after controlling for the topic of the post. In contrast, the quality of evidence supporting the health claim mattered relatively little. In addition, the data collection platform had a notable impact, such that posts containing inaccurate claims were much more likely to be rated higher on one platform compared to the other. Implications for credibility evaluation theory and research are discussed.

. Figure 2 illustrates how social media posts were generated with this computerized procedure by using the credibility evaluation task item presented in Figure 1 as an example. A combination of ethnicity, gender, and profession was used to select the profile picture (i.e., Black female professor) associated with the social media post, which was generated using a combination of the topic (Vitamin D), accuracy of claim (accurate), and evidence type (research). Although we conceptualized perceived credibility as a multidimensional construct, reflecting the idea of firstand second hand evaluation (Barzilai et al., 2020;Stadtler & Bromme, 2014), we measured participants' credibility judgments with a single item (cf. Hanimann et al., 2023). Participants were assigned to evaluate the credibility of ten posts on a single item scale from 1 to 7 (1 = not at all credible; 7 = extremely credible). The single item was used because we sought to understand how different content-and source-related issues affected participants' overall evaluations of the social media posts' credibility. Single-item scale may be advantageous because participants may resent being asked questions that appear to be repetitive (Fuchs & Diamantopoulos, 2009). In this study, the unit of analysis was the credibility evaluation of one post. --- Prior Belief Measure Before gaining access to the credibility evaluation task, participants' prior beliefs on the topic were measured using one statement for each topic at hand and a 7-point scale. The statements were worded, for example, 'Vaccines are safe', and 'Red meat is healthy'. We coded the responses to prior belief items in relation to how consistent they were with the : Note: 1 Rows 1-3 represent steps in the computerized process of selecting a unique combination of source features (source, gender, and ethnicity [i.e., Professor who is female and Black] paired with a profile picture matching those features. Rows 4-6 represent steps in generating content of the social media post associated with that source by selecting a topic (Vitamin D), claim type (accurate), and evidence type (research). 2 The Research type of evidence was only available for accurate claims. claim. For accurate claims, a prior belief score of 7 corresponded to a prior belief consistency score of 3, and a prior belief score of 1 corresponded to a consistency score of -3. For inaccurate claims, this was done in reverse, with a prior belief score of 1 corresponding to consistency score of 3 and a prior belief score of 7 corresponding to a consistency score of -3. For example, if the participant responded with 1 on the item "Vaccines are safe,", it was coded as -3 for the accurate claim. In the case of an inaccurate claim, the participant's response 1 was coded as 3. The variable was labeled as prior belief consistency, with a scale from -3 to 3. --- Data Collection Procedure Prior work has established cultural differences in credibility evaluation of online reviews (Brandt, 2022), as well as how people use and trust health information in online contexts (Khosrowjerdi, 2020;Song et al., 2016). Because we opted for two crowdsourcing platforms, with a wide variety of nationalities in the userbase, crowdworkers on Toloka and Prolific were offered an opportunity to take part in our study. Participants were first asked to fill out a questionnaire on demographic information and the prior belief measure. After completing the questionnaire successfully, the participants proceeded to the credibility evaluation task, in which they were asked to evaluate the credibility of ten social media posts. We assigned only ten credibility evaluation items to each participant to ensure that they could focus sufficiently on each item. In addition, with this procedure, we could recruit a considerable number of participants which assured that they represented diverse backgrounds. On the two platforms, somewhat different methodologies were used to deliver the set of credibility evaluation items to raters because of how these platforms worked. On the Prolific platform, we gave the tasks to participants in predetermined batches of ten, with minimized repetition of the manipulated aspects. In principle, ten posts could have some repetitive elements. The same topic, evidence type, source, and profile picture could have been shown to the participant in a maximum of three posts. However, the exact same post was not shown twice to the same participant. On the Toloka platform, each participant had an opportunity to make ten evaluations that were assigned to them at random. This was done by randomizing the order of posts that were given to the crowdworkers on a first-come firstserve basis. However, like Prolific, the exact same post was not shown twice to the same participant. Thus, the items were manipulated independently of each other. Only the top 20 % performing crowdworkers on the Toloka platform were offered the chance to participate in the study. Crowdworkers' performance was calculated by their success in completing tasks on the platform (i.e., the acceptance rate of their previous work at the platform). All evaluations made on the Toloka platform were accepted. Of the Toloka participants, 99% completed the maximum of ten evaluations. The task used on the Prolific platform is shown in Figure 1. --- Statistical Analysis In the statistical analysis, the unit of analysis was the credibility evaluation of one social media post. Analyses were conducted separately for posts including accurate and inaccurate knowledge claims, which are later referred to as accurate and inaccurate posts below. Data consisted of 4787 credibility evaluations of accurate posts and 3593 evaluations of inaccurate posts. Twenty credibility evaluations were excluded from the analysis due to technical problems. All statistical analyses were conducted using R. To examine how independent variables (see Table 1) were associated with the credibility evaluations of social media posts, we used a cumulative link mixed model. The cumulative link mixed model (CLMM), also known as ordered regression model (Christensen, 2015), has been advocated for use with ordered outcome measures (Fullerton & Anderson, 2023). To provide a CLMM model and odds ratios, we used the ordinal package created by Christensen (2015) for the R programming language. The specific formula used is follows: "Credibility<unk>Accuracy + ClaimEvidence + Topic + Author + Platform + Gender + Ethnicity + (1|ID)". The control variable ID corresponds to each individual evaluator who performed a maximum of ten evaluations in the sample. For the reference category, that is, the category other categories are compared to in the model (see reference categories in Tables 5 and6), we chose the category that one would assume to produce the highest credibility rating. For all other variables, we used the category that was first in alphabetical order. Thus, for evidence type, we chose research; for prior beliefs, we chose highest consistency, and for source expertise, we chose professor. For gender, ethnicity, platform, and topic, we used alphabetic order. We also present odds ratios (ORs), which are calculated with the ordinal package (Christensen, 2015), to highlight the association between the independent variable and the dependent variable. Odds ratios have been advocated for use as an effect size measure with cumulative link mixed models and ordered regression models (Fleiss, 1994;Fullerton & Xu, 2016). Moreover, odds ratios have been used with CLMM models in a variety of fields (Oehm et al., 2022;Rezapour & Ksaibati, 2021). An OR greater than 1 indicates how many times greater the expected credibility evaluation value of the category of interest is compared to the reference category. In contrast, an OR smaller than 1 indicates that the expected evaluation value in the reference category is greater than that in the category of interest. The ORs were transformed to another popular effect size measure, Cohen's d, with the effectsize R package created by Ben-Shachar et al. (2020). The Cohen's d effect sizes were interpreted as follows: small (d = 0.2), medium (d = 0.5), and large (d = 0.8) (Cohen, 2013). To calculate the goodness-of-fit statistics, we used the anova.clmm function of the RVAideMemoire package (Hervé & Hervé, 2020) to perform a likelihood-ratio test (Crainiceanu & Ruppert, 2004). --- Results In this study, we were interested in how content-related issues (i.e., prior belief consistency and evidence type), source characteristics (i.e., source expertise, ethnicity and gender), and crowdsourcing platform (i.e. Toloka or Prolific) were associated with reader's credibility evaluations of short social media posts when the posts' topic were controlled for. Specifically, we were interested in the relative impact of the identified factors on the perceived credibility of social media posts containing accurate or inaccurate health claims. Descriptive statistics are shown in Table 4. We ran the CLMM analyses separately for credibility evaluations of the posts with accurate and inaccurate knowledge claims. A Likelihood-ratio test between full models and their null model counterparts, that is, models without predictors, showed a good fit, with both being statistically significant at the p <unk>.001 level. Results of the CLMM analysis are presented in Table 5 for the posts with accurate claims and in Table 6 for the posts with inaccurate claims. As assumed, the content-related issues (i.e., prior belief consistency and evidence type) affected readers' credibility evaluations of the posts regardless of whether the claims were accurate or inaccurate. As shown in Tables 5 and6, participants' prior beliefs significantly affected their credibility evaluations. The more consistent participants' prior beliefs were with the claim of the post, the more the message was evaluated as being credible. Effect sizes (Cohen's d) between evaluations of the very high consistency posts and the very low consistency posts were -0.71 for posts with accurate claims and -1.17 for posts with inaccurate claims. The role of evidence type in credibility evaluation was small. When other evidence types were compared to research evidence (posts with accurate claims), the effect sizes ranged from 0.11 to -0.18, and when compared to testimony (posts with inaccurate claims), the effect sizes ranged from 0.01 to -0.18. Notably, for the posts with accurate claims, the posts with testimony were evaluated the most credible, testimony being 1.21 times more likely to be evaluated credible than research evidence. When evaluating posts with inaccurate claims, readers evaluated the posts with testimony and consensus similar in credibility. In terms of the source characteristics, the expertise of the source affected credibility evaluations, whereas source gender and ethnicity did not have any effect. The posts written by the expert sources, that is professor of medicine or nurse education practitioner, were evaluated to be more credible than posts by non-expert sources. Cohen's d varied from -0.43 to -0.62 when the expert sources were compared to the parent and from -0.39 to -0.49 when the expert sources were compared to the professional lifestyle blogger. In terms of contextual attributes of the crowdworkers themselves, the choice of data collection platform had a notable impact on our results. Participants from the Toloka platform tended to perceive both kinds of posts as more credible, whether they contained accurate or inaccurate claims. This disparity between the platforms was even more pronounced for posts containing inaccurate claims (d = 0.57), with a post of this nature being 2.83 times more likely to be rated higher on the Toloka platform compared to Prolific platform. To sum up, our results suggest that adults' prior beliefs play a considerable role in the credibility evaluation of short social media posts across different sources (See Figure 3). This is particularly significant when adults face inaccurate information on social media. Furthermore, adult readers seem to pay more attention to source features indicating the source's expertise than to the quality of the evidence (See Figure 4). For example, regardless of evidence type used in the arguments, participants trusted the posts by the professor of medicine more than those by the parent. Finally, adults' credibility evaluations differed significantly across the two crowdsourcing platforms, such that crowdworkers in the Toloka platform tended to evaluate the credibility of the inaccurate posts, in particular, higher than crowdworkers in the Prolific platform. --- Discussion This study sought to understand how adult readers evaluate the credibility of short health-related social media posts that vary in source characteristics and argument quality. Our design of the social media posts included some unique features. First, we chose topics on which contradictory claims, including accurate and inaccurate information, spread on the internet, by relying on the thorough investigation of a medical professor who has collected scientific evidence to combat the common misinformation on health issues (Knuuti, 2020). Second, this study was the first to manipulate evidence type (i.e., research evidence, testimony, consensus, and personal experience) in social media posts showing that the quality of evidence had a minor effect on adult readers' credibility evaluations. Another unique feature of this study was that we recruited participants from two different crowdsourcing platforms to have a culturally broad sample, which had interesting results. First, we discuss the findings in terms of first-and second-hand evaluation (i.e., content and source evaluation), after which we discuss effects of the crowdsourcing platform as a context for evaluating social media posts. Finally, we discuss how these findings provide important contributions to theoretical models and methodologies for studying credibility evaluation and consider limitations of the study. In terms of first-hand evaluation strategies, participants' prior beliefs mattered more regarding their credibility judgments than the quality of the evidence presented in the post. The more consistent the participants' prior beliefs were with the claim of the post, the more credible the post was evaluated as being. This association was found in credibility judgments of both accurate and inaccurate posts, and it is in line with previous research (Abendroth & Richter, 2021;McCrudden & Barnes, 2016). Relying on one's prior beliefs in credibility evaluation is, however, a double-edged sword. When a person has accurate prior beliefs, they can be effectively used to disregard misinformation. In contrast, when a person has false prior beliefs, relying on them in credibility evaluation is unwise, as this strategy may do nothing but strengthen one's false beliefs. Therefore, it is essential that, in our increasingly complex knowledge society, laypeople acknowledge the limits of their prior knowledge and beliefs when consuming online information (Osborne & Pimentel, 2022). This becomes even more important when comprehending health information in social media contexts, given the level of domain knowledge required to understand complicated medical terminology and evidence that misinformation on major public health issues is very common on social media platforms (Suarez-Lledo and Alvarez-Galvez, 2021; see also Vosoughi et al., 2018). Readers' prior beliefs are a quick internal resource that they can easily access and use in their credibility evaluations. In contrast, using discourse-based validation strategies, such as evaluating the strength of the argument, may require more processing effort. However, it is still somewhat surprising that the evidence type had relatively small effect (ds 0.02-0.28) on participants' evaluation of accurate social media posts in which all four evidence types (i.e., research, testimony, consensus, and personal experience) were represented. It is understandable that research and testimony had a similar effect on credibility evaluation because the testimonies used in our posts relied on authorities (e.g., European Food Safety) or experts (e.g., a doctor), but it is surprising that the posts relying on consensus or personal experience were valued rather similarly to the posts that included research evidence or expert testimony. It is true that findings in previous studies by List et al. (2021) and Hornikx (2005) indicate that research-based evidence is highly valued among readers. However, in these studies participants evaluated evidence in more traditional contexts, such as newspaper stories (List et al., 2021), not social media. Our study uniquely examined evidence as part of social media posts, suggesting that research-based evidence may be less valued in the social media context. One reason may be that narrative ways of knowing, such as personal experience, are more persuasive in social media. Instead of seeking research-based evidence for decision-making, people may turn to other consumers' or influencers' experiences that they can relate to (Feng et al., 2021). Such behavior may also be reflected in the credibility evaluation of the social media posts. Another explanation is that many students leave high school unable to understand, evaluate, or write arguments, and especially scientific arguments (Duschl & Osborne, 2002;Larson et al., 2009;Takao & Kelly, 2003) Strategies for comprehending and evaluating arguments are not explicitly taught in school and are rarely emphasized in university curricula (Osborne, 2010) and deficits in aspects of scientific reasoning are pervasive among university students (Britt et al., 2014). Thus, more research is needed to understand if increased exposure to arguments, and explicit instruction and practice in the skills of argumentation, influence adults' discourse-based credibility evaluation skills, particularly in social media contexts. In terms of second-hand evaluation strategies, we manipulated the source's expertise, gender, and ethnicity. Our results suggest that participants focused primarily on a source's expertise when evaluating the credibility of social media posts. In fact, a source's gender and ethnicity were not associated at all with participants' credibility judgments. Our findings about the role of source expertise in credibility evaluation are in line with previous research (e.g., Lin et al. (2016)). Participants evaluated the expert sources (i.e., the professor of medicine and nurse education practitioner) as being more credible than the laypersons (i.e., the lifestyle blogger and parent) almost regardless of the presented evidence (Figure 4). This could be explained based on default trust: the default trust occurs when there is no reason to doubt the argument of the source. This kind of trust is typically based on inductive reasoning (Shieber, 2015). For example, trust in the professor's argument is based on the experience that professors typically provide accurate information. Trust in epistemic authority can also be based on monitoring for the trappings of competence, such as professional titles. This kind of monitoring is more about the symbols of authority than substance (Shieber, 2015). In our study, a source's gender and ethnicity did not predict participants' credibility judgments. This is in contradiction to some previous work (Armstrong & McAdams, 2009;Groggel et al., 2019). In these previous studies, the focus was more on the source's gender and/or ethnicity as such. For example, when examining the gender effects on perceived credibility of blog authors, the content of the blog was kept constant (Armstrong & McAdams, 2009). In our study, the expertise of the source and content of the post were varied, which might explain why gender and ethnicity of the source did not predict participants' credibility judgments. Thus, it is possible that this variation overrode the effect of the source's gender and ethnicity. It is worth noting that the credibility evaluation of social media posts is cognitively demanding as readers must keep several content and source features in their minds when processing and judging the posts. In this light, our results align with the limited capacity model of mediated message processing (Lang, 2000). The model suggests that due to limited cognitive capacity, people cannot process all aspects of messages they receive, and thus, readers select and process only some features of messages. Furthermore, building on this assumption, the dual processing model of credibility assessment emphasizes that readers' motivation and ability determine whether and to what degree readers will evaluate the credibility of online information (Metzger & Flanagin, 2015). Our credibility evaluation task did not have high personal relevance for the participants, crowdworkers. Thus, crowdworkers' motivation to deeply consider a broader range of source and content features may have been low, leading to using cognitively and temporally costeffective evaluation strategies. For example, crowdworkers may have based their credibility evaluations mainly on their prior beliefs and source expertise, neglecting the evaluation of the quality of evidence. We assume that readers' behavior would likely be somewhat different if they were engaged in seeking information needed to make important health-related decisions (cf. Sperber et al., 2010). Thus, the results of this study should be interpreted carefully. Regarding contextual attributes of the crowdworkers themselves, because there appeared to be no overlap between the self-reported nationalities of study participants in the Prolific and Toloka platforms, we explored the possibility that cultural background (i.e., groups of individuals with nationalities associated with each platform) played a role in predicting the quality of adults' credibility evaluation practices. Notably, we found that the crowdsourcing platform in which participants completed the credibility evaluation tasks had a significant effect on their performance. Toloka crowdworkers, representing nationalities including Russia, Eastern Europe, the Middle East, Keyna, and India, tended to evaluate the credibility of the inaccurate posts, in particular, higher than Prolific crowdworkers, most of whom lived in the United Kingdom, United States, Canada, and Western and Southern Europe. One reason behind these results might be that adults living in open Westernized countries, like the participants in Prolific, may be exposed to more opportunities to critically question the quality of information sources while participants in Toloka were living in countries like Russia and Turkey with governments that are more likely to repress public forms of criticism and adopt greater restrictions targeting social media use (cf. Tufekci, 2014).Thus, Toloka participants may have less practice in negotiating alternative viewpoints and distinguishing between accurate and inaccurate information in social media posts. --- Implications for Credibility Evaluation Theory and Research Findings from this study have implications for theory and research involving the study of credibility evaluation. First, our results affirm the bi-directional model of first-and second-hand evaluation strategies (Barzilai et al., 2020) by showing that both content and source related issues were associated with reader's credibility judgments of social media posts. In addition, by accounting for multiple factors (i.e., variations in content and evidence type, variations in the source's expertise, gender and ethnicity, and differences in crowdsourcing platform membership) at the same time, rather than assigning participants to predefined conditions involving fewer factors, this study provides a richer and more complex understanding of the order of importance each factor can play in adults' overall credibility evaluations of social media posts. For example, while we learned that adults' rely on their prior beliefs and source expertise more than other source features, such as gender and ethnicity, to evaluate overall credibility, we found that evidence quality doesn't matter as much as we would hope when adult readers consume information about controversial health issues on social media. Our study also provides more conceptual clarity in how variations in these factors can be operationalized and incorporated into the design of authentic, critical online reading tasks for adults. These findings also complexify bi-directional theories of credibility evaluation (Barzilai et al., 2020;Richter & Maier, 2017;Stadtler & Bromme, 2014) by hinting at how readers may attend to contextual attributes of the text as a third tier of credibility evaluation (Forzani et al., 2022). That is, as readers are expected to make inferences about the social and political contexts of health-related social media posts (e.g., unvetted information often paired with testimonials and endorsements by strangers), it is possible that their reasoning may need to extend beyond the use of explicit content and source features to evaluate the quality of unstated warrants in these contexts. Of course, the design of our study does not allow us to explore this possibility. To understand how participants employ first-or second-hand evaluation strategies or if there is a need for additional tiers of strategy use, methods (e.g., think-aloud, open-ended questions) allowing participants to explain their reasoning behind their credibility judgments are needed. Furthermore, more controlled experiments could clarify the nature of the reciprocal relationship between content and source evaluation, or explore the role of additional reader attributes needed to make inferences about information in complicated globally networked social media contexts. Finally, by broadening our conceptualization of context beyond text and source attributes to explore the effect of one contextual attribute of the participating readers (i.e., crowdsourcing platform membership), we considered the idea that significant differences in credibility evaluations may potentially reflect the different demographic compositions of the participants in the Prolific and Toloka platforms. Unfortunately, because many different nationalities were represented within each platform, it is impossible to know more about how geographic location or nationality might have affected the credibility evaluations of participating crowdworkers in our study. However, the idea of including nationality, and other demographic attributes of readers (i.e., such as gender, ethnicity, and level of education) in future conceptualizations of credibility frameworks seems worthy of additional study. Findings from this study also have methodological implications for research in credibility evaluation. Our full factorial design with five independent variables, each having multiple levels, allowed us to study numerous factors within the same experiment, constrained only by the number of unique variations that can be generated. Our methodology also enabled a comprehensive comparison of the influence that each considered factor had on the dependent variable. By employing a cumulative link mixed model (special form of multiple regression) to assess the impact of individual categories within each factor, the resulting coefficients and calculated effect sizes offer a means to rank these factors based on their relative impact. Our study also underscores the potential of applying software to generate and ensure that all unique combinations of social media posts have been created. Key to this approach was the well-established research in combinatorial software testing (R. Kuhn et al., 2009), which involves the automatic generation of unique test cases from a model of all factors and their levels. Crowdsourcing has emerged as a natural methodological choice in modern online combinatorial experiments that demand scalable and on-demand human subject participation. In our study, this approach enables the rapid testing of hundreds of unique variations. Additionally, leveraging multiple platforms promotes cultural and global diversity in samples, as different online human subject pools have distinct participant bases (Douglas et al., 2023). Achieving full cultural representativeness in study samples will require further efforts of course, and one must recognize the self-selection bias inherent in these subject pools. Nevertheless, platforms like Prolific, Panels & Samples (by Qualtrics), and Google Surveys are now widely recognized for capturing high-quality human opinions. They are widely adopted by multinational corporations like Meta, institutions such as The World Bank, and behavioral researchers from prestigious institutions, including Stanford and the University of Oxford. --- Limitations As with all studies, this study has limitations that must be considered when interpreting the results. First, we only investigated two first-hand evaluation strategies (i.e., discourse-based validation and knowledge-based validation), excluding corroboration from our inspection. As corroboration is a vital strategy to understand the consensus in the scientific community (Osborne & Pimentel, 2022), future studies could seek to understand how and in what conditions readers corroborate information when they encounter health information in social media. Furthermore, we did not manipulate the bandwagon features typical of social media messages, such as likes and shares, even though they have been shown to affect the credibility evaluation of such messages (Lin et al., 2016). However, we would like to note that the current design already resulted in a large number of different messages (480 unique combinations for accurate posts and 360 unique combinations for inaccurate posts). Second, we used well-known organizations (e.g., WHO) and non-named experts (e.g., doctor, personal trainer) in the testimonial evidence. Consequently, the strength of the evidence in the testimony and research categories was partly overlapping. In future studies, the second-hand sources referred to in testimonial evidence should be better aligned. Third, due to the platforms' functionalities, the posts were delivered to the different crowdsourcing platforms slightly differently. However, we attempted to minimize the potential effects by controlling for the platform used in our analysis. However, using two crowdsourcing platforms resulted in a more diverse sample compared to using only one platform. It is worth mentioning that the crowdsourcing platform had an effect on perceived credibility. The crowdworkers of Toloka tended to evaluate the credibility of the inaccurate posts, in particular, higher than the crowdworkers of Prolific. Future studies should consider potential effects when using different crowdsourcing platforms, especially when generalizing findings. Fourth, using crowd-sourcing platforms for data collection has some downsides. For example, workers may complete the tasks as quickly as possible to maximize their income which is a potential threat to the validity of all studies performed using crowd-sourcing (Gadiraju et al., 2015). We combated this threat by using filters in both crowdsourcing platforms, that is, recruiting only the top-performing workers for our study. Fifth, we used a single item to measure the perceived credibility of the social media posts, limiting the estimation of instrument reliability. However, according to Fuchs and Diamantopoulos (2009), single-item scale may be advantageous to avoid participants resenting their being asked to respond to similar items, especially when items are administered multiple times. --- Conclusions Our study sheds light on how variations of multiple factors of social media posts (i.e., content, evidence type, source expertise, gender, and ethnicity) can influence credibility evaluation performance. When evaluating the credibility of social media posts, readers can pay attention to the quality of content and trustworthiness of the source of the post. This study shows that readers tend to judge belief-consistent information as more credible than belief-inconsistent information. At worst, this tendency, accompanied by algorithm bias, may strengthen some readers' false beliefs. This, in turn, may accelerate the spread of misinformation in social media. Alarmingly, readers tend to ignore, to some extent, the quality of evidence in their credibility evaluation. This may be due to reluctance to revise one's beliefs, inability to differentiate the quality of different types of evidence, or not valuing research or expert evidence. However, regardless of whether the post was accurate or inaccurate, content posted by an expert was evaluated as more credible than content posted by a layperson. Thus, readers can be more vulnerable to misinformation posted by someone considered an expert. Moreover, our study revealed that different demographic backgrounds of the readers may significantly affect credibility evaluation performance. Overall, our study suggests a need for further developing the credibility evaluation skills of readers across all ages, not only of children and young people who have typically been the target group of critical reading interventions. An inclusive education system should equip all citizens with adequate credibility evaluation skills. Further, the design and findings of our study answers calls to capture more of the complexities of digital reading tasks associated with texts, readers, and contexts (Coiro, 2021) in addition to calls for more credibility evaluation research that considers the demographic attributes of readers (see S. M. Shariff, 2020). Last, our study bridges theory and research efforts in psychology, communication, and media studies with those that explore critical online resource evaluation (Forzani, 2020;Forzani et al., 2022) in educational contexts.

The internet, including social networking sites, has become a major source of health information for laypersons. Yet, the internet has also become a platform for spreading misinformation that challenges adults' ability to critically evaluate the credibility of health messages. To better understand the factors affecting credibility judgements, the present study investigates the role of source characteristics, evidence quality, crowdsourcing platform, and prior beliefs of the topic in adult readers' credibility evaluations of short health-related social media posts. Researchers designed content for the posts concerning five health topics by manipulating source characteristics (source's expertise, gender, and ethnicity), accuracy of the claims, and evidence quality (research evidence, testimony, consensus, and personal experience) in the posts. Then, accurate and inaccurate posts varying in these other manipulated aspects were computergenerated. Crowdworkers (N = 844) recruited from two platforms were asked to evaluate the credibility of ten social media posts, resulting in 8380 evaluations. Before credibility evaluation, participants' prior beliefs on the topics of the posts were assessed. Results showed that prior belief consistency and source expertise most affected the perceived credibility of accurate and inaccurate social media posts after controlling for the topic of the post. In contrast, the quality of evidence supporting the health claim mattered relatively little. In addition, the data collection platform had a notable impact, such that posts containing inaccurate claims were much more likely to be rated higher on one platform compared to the other. Implications for credibility evaluation theory and research are discussed.

Introduction It has long been understood, or at least assumed, that child maltreatment is a risk factor for antisocial behavior and crime among adolescents and adults (Maxfield & Widom, 1996;Widom & Maxfield, 2001). A number of studies have been published on the topic. For example, a study by Widom and Maxfield (2001) of more than 900 individuals with officially recorded histories of child maltreatment found that, relative to those of a comparison group, previously maltreated individuals were at higher risk for violent crime as juveniles and as adults, and for being arrested at least once by the time they reached adulthood. Frequency of arrests was also higher for those who had been maltreated at some point earlier. In another study of more than 1,400 participants followed from kindergarten to adulthood, Topitzes, Mersky, and Reynolds (2011) found that child abuse and neglect, based on official records, predicted violent crime convictions in adulthood for both males and females. However, maltreatment was associated with adult violent crime arrest only for females in that study. Elsewhere, Smith and Thornberry (1995) found that official child maltreatment was associated with moderate and more serious forms of self-reported adolescent crime. English, Widom, and Brandford (2002) found higher rates of criminal arrests at age 24 for participants of their study who had been previously abused or neglected. Although these and other studies do in fact provide evidence of a link between maltreatment and crime, methodological weaknesses in these and other studies limit the extent to which definitive conclusions can at this point be drawn (English et al., 2002). In fact, some have argued that research on the consequences of child maltreatment generally has failed to meet a basic threshold of methodological rigor, in part because there is too heavy a reliance on cross-sectional data and retrospective measures of child maltreatment (English et al., 2002;Thornberry, Knight, & Lovegrove, 2012). A related concern is that too many studies rely exclusively on official record measures of crime (e.g., arrests and court dispositions) which may underestimate crime involvement (English et al., 2002;Widom, Raphael, & Dumont, 2004). Yet another problem with some studies on these topics is that far too little attention has been paid to correlated risk factors (English et al., 2002), which, when not attended to in analyses, can lead to inaccurate estimates and faulty conclusions about child maltreatment effects on adult crime. Even as researchers move to strengthen the designs of their studies by analyzing risk factors comprehensively and by investigating predictors and outcomes longitudinally, knowledge of whether and how child maltreatment serves to catalyze crime involvement remains incomplete (T. I. Herrenkohl, 2011a;Thornberry et al., 2012). In that child abuse and neglect are themselves risk factors that are correlated with other forms of adversity, including poverty and low socioeconomic status (SES; T. I. Herrenkohl & Herrenkohl, 2007), it is important to account for this covariation when analyzing crime as an outcome. Few studies have systematically accounted for socioeconomic differences that can be hidden from view when child maltreatment is examined as a stand-alone predictor (Maxfield & Widom, 1996). A study by Smith, Ireland, and Thornberry (2005) on young adult crime in a cohort study of about 1,000 males showed that, after accounting for SES factors that include individual's level of education and poverty, officially recorded (substantiated) reports of abuse and neglect did, in fact, predict later arrests and self-reported general and violent offending. Odds ratios (ORs) for these outcomes were around 2, indicating a doubling of the risk for later crime associated with a youth's having been maltreated, after controlling for SES. Their study suggests that child maltreatment effects may persist when SES is taken into account, although it is noteworthy that this particular study focused on maltreatment in adolescence, not in childhood, which has more often been the focus of other studies on the topic. In the current investigation, we revisit the question of whether child maltreatment predicts adult crime, but we do so using data from an extended longitudinal study that began when participants were children. We investigate child maltreatment in bivariate and in multivariate models to account for SES and other covariates. We examine bivariate associations between child maltreatment and crime for our full analysis sample and for males and females of the sample separately so as to examine possible gender differences (Howell, 2003;Johansson & Kempf-Leonard, 2009;Topitzes et al., 2011). Although some research has investigated subtype differences in child maltreatment (e.g., physical abuse vs. neglect) and its effects on crime, we analyze abuse and neglect together as a single construct because the findings of several studies similar to ours point to subtype effects of a very similar magnitude when crime serves as an outcome (Mersky & Reynolds, 2007;Widom & Maxfield, 2001). Results of the current investigation follow others from our longitudinal data set in a line of inquiry focused on adult outcomes of various sorts (substance use, physical and mental health, and mental well-being; for example, T. I. Herrenkohl et al., 2013). Thus, results of the analyses reported in this article can be compared with those of our earlier studies on outcomes of substance use and physical and mental health, offering an opportunity to compare etiological and developmental processes related to child maltreatment across a range of indicators of adult functioning. --- Method --- Data and Procedure As noted in other manuscripts (most recently, T. I. Herrenkohl et al., 2013;T. I. Herrenkohl, Klika, Herrenkohl, Russo, & Dee, 2012), data are from the Lehigh Longitudinal Study, which began in 1973 to 1974 as the evaluation portion of a child abuse and neglect treatment and prevention program in two counties of eastern Pennsylvania (R. C. Herrenkohl, Herrenkohl, Egolf, & Wu, 1991). Selection of the sample was accomplished over a 2-year period by referrals, from two county child welfare agencies, of all new and some ongoing cases in which there was at least one abused or neglected child 18 months to 6 years of age present in the home. The children served by child welfare agencies participated in one of several group settings (e.g., day care, Head Start). It was from these other settings, also located in the same two-county area, that children outside of child welfare were enrolled in the study. The study design allows for comparisons of those children involved with child welfare for abuse and neglect reports to others in the sample who had no history of child welfare involvement, but whose families differed on other key variables, such as SES. The original sample contains five groups and totals 457 children: child welfare abuse (n = 144), child welfare neglect (n = 105), Head Start (n = 70), day care (n = 64), and middle-income nursery (n = 74), and is composed of near equal numbers of males (n = 248) and females (n = 209) and families from diverse socioeconomic backgrounds. The racial and ethnic composition of the sample is consistent with the makeup of the twocounty area from which participants were drawn: 1.3% (n = 6) American Indian/Alaska Native, 0.2% (n = 1) Native Hawaiian or Other Pacific Islander, 5.3% (n = 24) Black or African American, 80.7% (n = 369) White, 11.2% (n = 51) more than 1 race, and 1.3% (n = 6) unknown. Just more than 7% (n = 33) self-identified as Hispanic or Latino and 91.5% (n = 418) as Not Hispanic or Latino. For a very small percentage, 1.3% (n = 6), the ethnicity of the child was unknown. Eighty-six percent of children were from two-parent households. The income level of 63% of families at the time was below US$700 per month. Other families had incomes that ranged to more than US$3,000 per month. The first "preschool" wave of the study took place in 1976 to 1977 when children recruited to the study were 18 months to 6 years of age. A second "school age" assessment was conducted in 1980 to 1982. A third "adolescent" assessment of all youth participants (91% of the original sample) was conducted in 1990 to 1992. When they were assessed in adolescence, participants were 18 years of age on average. An adult wave of the study was completed in 2010, after intensive locating and interviewing efforts. Approximately 80% of the original sample still living (n = 357) was located and assessed via a comprehensive, interviewer-administered survey. In the adult assessment, participants were 36 years of age (range = 31-41) on average. The sample remains gender balanced: 171 (47.9%) females and 186 (52.1%) males. Analyses of the currently retained sample showed that, although more of the original child welfare abuse group was lost to attrition, there were no significant group differences in gender, age, childhood SES, or ratings of neglect or parent-reported physically abusive discipline. Study procedures were approved by the Human Subjects Division at the University of Washington and the Office of Research and Sponsored Programs at Lehigh University. --- Variables Child maltreatment-Officially recorded child abuse and neglect was modeled as a dichotomous variable that distinguishes individuals originally recruited to the study from child welfare caseloads for abuse or neglect from those who were recruited from other group settings in the same two-county area (Head Start, day care, and middle-income nursery programs). The child welfare/maltreatment group (coded 1; n = 181) consists of 98 males and 83 females. The comparison group (coded 0; n = 175) consists of 88 males and 87 females. These numbers differ slightly from those reported in other reports because they account for missing data on the outcome variables under consideration. Adult crime-Various measures of adult crime were scaled from 29 survey items on lifetime and past-year criminal offenses (see Appendix.). These survey items include a wide range of law-violating behaviors, and they were categorized according to crime types used by the National Incident-Based Reporting System (NIBRS; Federal Bureau of Investigation, 2013). NIBRS refers to several categories of offenses: crimes against persons, property, and society. In the current investigation, we scaled our variables to reflect these NIBRS categories as follows: Lifetime crimes against property summed affirmative (0 = no crime, 1 = crime committed) responses to 17 survey items. Example items include "ever broken or tried to break into a building or vehicle," "ever stolen or tried to steal a motor vehicle," and "ever tried to cheat someone by selling them something that was worthless." The scaled variable has a range from 0 to 13 and a mean of 2.0 (SD = 2.84). For the maltreatment group, scores on the variables range from 0 to 13 and the average is 2.4 (SD = 3.10). Scores for those who were not involved with child welfare for abuse and neglect (i.e., comparison group) also range from 0 to 13 and the average is 1.58 (SD = 2.48). Overall, 189 individuals (53.1% of the analysis sample) reported having committed one or more property crimes in their lifetime. Lifetime crimes against persons summed 5 survey items coded to indicate the presence or absence of person crimes (0 = no crime, 1 = crime committed). These include "ever been involved in a gang fight," "ever had or tried to have sexual relations with someone against their will," and "ever hit anyone." This scaled variable has a range of 0 to 6 with a mean of 1.17 (SD = 1.27) for the full analysis sample. Scores for those in the maltreatment and comparison groups range from 0 to 6. The mean for the child maltreatment group is 1.4 (SD = 1.36) and that of the comparison group is 0.94 (SD = 1.12). Overall, 211 individuals (59.3%) reported having committed one or more crimes against persons in their lifetime. Lifetime crimes against society summed 5 survey items, also coded 0 = no crime and 1 = crime committed. These include "ever paid someone for having sexual relations with you" and "ever sold hard drugs." For the full analysis sample, this variable has a range of 0 to 5 with a mean of 0.58 (SD = 0.99). For both the maltreatment and comparison groups, scores range from 0 to 5. The average for the maltreatment group is 0.77 (SD = 1.18) and for the comparison group 0.39 (SD = 0.69). In all, 121 (34.0%) individuals across both groups reported having committed at least one crime against society in their lifetime. We also assessed overall crimes (lifetime) by summing the three categories of crimes (persons, property, and society). Although the possible range on this combined variable is 0 to 29, actual scores for the analysis sample fall between 0 and 23 and the mean is 3.76 (SD = 4.46). The range of scores on this variable for the maltreatment group is 0 to 23 and the mean is 4.58 (SD = 4.98). For the comparison group, the range is 0 to 18 and the mean is 2.91 (SD = 3.68). A total of 258 participants (72.5% of the analysis sample) reported having perpetrated at least one crime in their lifetime. Crimes committed in the past year were also analyzed. Low prevalence prohibited the investigation of individual crime categories (i.e., crimes against property, persons, and society), but it was possible to study overall crimes by combining the three categories. Ninety (25.3%) participants committed at least one crime of some sort in the past year. To address the skewed nature of score distribution for this variable, scores were inverse transformed. Scores of the transformed variable range from 0.1 to 1.0, with a mean of 0.85 and a SD of 0.26. The range for the maltreatment group is 0.09 to 1.0 and the group mean is 0.83 (SD = 0.28). For the comparison group, the range is 0.14 to 1.0 and the mean is 0.88 (SD = 0.25). The comparison group has a higher mean than the maltreatment group because the variable was inverse transformed so variable values became reverse ordered. Additional variables of crime history included measures of arrest, convictions, and incarceration. One hundred thirty-four participants (38.0%) reported having ever been arrested. Eighty-two had ever been convicted (23.2%), and 56 (15.9%) had at some point been incarcerated. Measures of the number of arrests and convictions were also examined after having been inverse transformed. The variable for arrests, after transformation, ranges from 0 to 1 with a mean of 0.74 (SD = 0.35). For the maltreatment and comparison groups respectively, the range is 0 to 1 and 0.01 to 1, and the group mean is 0.69 (SD = 0.37) versus 0.80 (SD = 0.32). For convictions, the range for the full sample is 0 to 1 with a mean of 0.85 (SD = 0.29). For the maltreatment and comparison groups separately, the range is 0 to 1 versus 0.01 to 1, and the mean is 0.81 (SD = 0.32) versus 0.89 (SD = 0.25). The means of the comparison group are higher similarly because of inverse transformation. --- Covariates Covariates in the multivariate analyses include childhood SES, gender, race, education level, marital status, and age. SES is a standardized composite measure of parents' occupational status, educational level, family income, and total rooms in the family's home. The SES variable has a mean of 0 and a SD of 3.29, ranging from -5.43 to 9.18. Gender was coded males = 1 (n = 186) and females = 0 (n = 170). Race was coded White = 0 (n = 280) and "other" coded 1 (n = 74). For education level, high school graduate or GED equivalent was coded 1 (n = 251) and no high school degree was coded 0 (n = 67). Marital status was coded married = 1 (n = 164) and not married (single, divorced, separated, and widowed) = 0 (n = 192). Participant age was left a continuous variable. Marital status, education, and age were added as covariates given their relation to crime in other studies (Farrington, 1986;King, Massoglia, & MacMillan, 2007;Sampson, Laub, & Wimer, 2006) and our having included these variable in analyses of two previously published articles on other adult outcomes. Age was included for analyses of past-year, but not lifetime, crime. --- Analysis Analyses consist of group-based comparisons in which the child maltreatment group was compared with the comparison group on the specified outcomes without and then with covariates (SES, gender, race, education level, marital status, and age) added to the analysis. Tests of group differences used chi-square tests for dichotomous crime variables and independent samples t tests for counts. T tests of the count variables were conducted only among those who had at least one lifetime criminal offense (n = 313) to investigate the extent of criminal involvement among those who had offended at least once. Each comparison was conducted using the total analysis sample and then repeated for males and females separately to illustrate how results compare across the two gender groups (Topitzes et al., 2011;Widom & White, 1997). Normality of count variables was checked using measures of skewness and kurtosis. Variables with elevated skewness and kurtosis were sensitivity tested by comparing models with original versus transformed scales. Original scales were maintained for ease of interpretation if no meaningful differences in results of the two model tests were observed. Multivariate logistic and ordinary least squares (OLS) regressions were conducted to examine the conditional effects of child maltreatment on adult crimes after accounting for covariates. In multivariate OLS regressions, data for the full sample were analyzed. We also investigated the interaction of child maltreatment and gender to test for differences in the relationships for males and females. However, no statistically significant interaction effects were observed. --- Results Tables 1 and2 show percentage breakdowns and mean levels of each crime outcome for the full analysis sample and for males and females separately by group (maltreated vs. comparison). As shown in Table 1, analyses of adult lifetime and past-year crime for the full analysis sample show that, overall, individuals who had been maltreated engaged in more crime than did those in the comparison group. For example, 78.5% of maltreated adults reported having committed at least one criminal offense in their lifetime, compared with 66.3% of those in the comparison group (<unk> 2 = 6.60, p <unk>.05). The mean number of lifetime criminal offenses reported by those with child maltreatment histories is also significantly higher: 5.27 versus 3.26 for the comparison group (t = -4.03, p <unk>.01). A similar pattern was observed for past-year offenses. Nearly 30% of those who had been maltreated reported having committed at least one offense in the year leading up to the adult assessment, compared with 20.6% of the comparison group (<unk> 2 = 4.04, p <unk>.05). The mean number of past-year criminal offenses also registered higher for the child maltreatment group (t = 2.04, p <unk>.05). Participants with maltreatment histories were found to have had more involvement with law enforcement over their lifetime (i.e., arrest, conviction, and incarceration; Tables 1 and2). About 46% of those who were maltreated reported having been arrested, compared with just under 30% of those in the comparison group (<unk> 2 = 9.83, p <unk>.01). Conviction and incarceration histories were similarly elevated for maltreated adults (28.2% and 20.4% vs. 18% and 11%, respectively). Chi-square tests were in both cases statistically significant (conviction: <unk> 2 = 5.10, p <unk>.05; incarceration: <unk> 2 = 5.83, p <unk>.05). Numbers of arrests and convictions, too, were higher on average among those who had been maltreated (arrest: t = 3.37, p <unk>.01; conviction: t = 2.79, p <unk>.001). Analyses of crimes by category-property, person, and society-provided further evidence of a link at the bivariate level between child maltreatment (child welfare involvement) and later crime. For example, 65.7% of adults from the child maltreatment group reported having committed a crime against another person at some point in their lifetime, compared with 52.6% of those from the comparison group (<unk> 2 = 6.40, p <unk>.05). The group difference was marginally significant for crimes against property (<unk> 2 = 2.82, p <unk>.10) and society (<unk> 2 = 3.60, p <unk>.10). The mean numbers of lifetime property, person, and society crimes were consistently higher among those in the child maltreatment group compared with the comparison group (2.77 vs. 1.78 [t = -3.05, p <unk>.01], 1.62 vs. 1.05 [t = -4.04, p <unk>.001], and 0.89 vs. 0.44 [t = -3.95, p <unk>.001], respectively). Findings reported in Tables 1 and2 show that the above pattern in maltreatment and crime is generally consistent for both males and females of the sample. For example, although crime generally is more prevalent among males in both groups (maltreatment and comparison), females who had been maltreated were more likely than those not maltreated to report having had some prior involvement in crime (68.7% vs. 50.6%; <unk> 2 = 5.77, p <unk>.05). A similar pattern among females was observed for past-year crimes, although the chi-square test was in this case only marginally significant (<unk> 2 = 2.76, p <unk>.10). Further evidence of this pattern among females is shown in other categories. For example, about 54% of maltreated females perpetrated a crime against another person, compared with only 36% of those in the comparison group (<unk> 2 = 5.94, p <unk>.05). Interestingly, there is no statistically significant difference in person crimes for males with a history of maltreatment and those without. With respect to conviction and incarceration history, males in the child maltreatment group were more likely than those in the comparison group to report prior convictions (<unk> 2 = 2.86, p <unk>.10) and incarcerations (<unk> 2 = 5.55, p <unk>.05), whereas females of the two groups did not differ statistically on these outcomes. 3 and4 are for the multivariate analyses in which crime outcomes were regressed on a variable that distinguished the child maltreatment group from the comparison group, as well as variables for (male) gender, childhood SES, minority racial status, marital status, and education level. In the tables, results are shown for outcome variables modeled as both dichotomous and count outcomes. As shown, with one exception (crimes against society), the significant association between child maltreatment and crime observed in bivariate tests was lost in these conditional tests, indicating that what appeared a significant main effect of maltreatment, shown in Tables 1 and2, may possibly be due to variable confounding. --- Results of Tables An examination of covariates in the model suggests persistent main effects for male gender. As expected, males were generally at higher risk for crime than females. The odds of lifetime crime overall for males was 4.6 times the odds for females (OR = 4.57, p <unk>.001). The odds of crimes against society for males were 5.16 times (p <unk>.001) greater than those for females. Childhood SES was also a significant predictor of overall lifetime crime, incarceration, and person crimes. Minority racial status predicted several outcomes, including past-year crime and crimes against society. Marital status was also predictive of (inversely related to) most crime outcomes. For example, overall (lifetime) crimes, convictions, incarceration, and person and property crimes were significantly related to being married (p <unk>.05). Past-year crime and arrests were marginally significantly related to being married. Finally, education level (having earned a high school degree) predicted less involvement with criminal justice, fewer arrests, fewer convictions, and fewer incarcerations. --- Discussion Findings of this study suggest that, although child maltreatment is related to adult crime at the bivariate level, the association of that variable with the outcomes under consideration appears to be reduced (rendered nonsignificant) after other demographic variables are taken into account. Indeed, nearly all the previously shown significant effects of child maltreatment on adult crime outcomes were lost when covariates were included in the analysis. In this regard, findings of the current investigation appear to stand in some contrast to earlier published studies on these topics, including the prospective investigation of Widom and Maxfield (2001), which concluded that child maltreatment and crime are causally linked. In that study, adults who had been abused and neglected as children were more likely to have been arrested for a violent crime when compared with matched controls. Results of bivariate tests were replicated in multivariate regressions that controlled only for age, race, and gender. In another study by English and colleagues (2002) of 877 individuals who, as children, had been under state supervision for substantiated abuse and neglect were at significantly higher risk for adult crime arrests than were matched controls. In that study, males and females who had been abused and neglected were more than twice as likely to be arrested for both nonviolent and violent crimes by the age of 24, according to data obtained from local, state, and federal sources. The risk of arrest for violent crime as an adult was particularly high for abused and neglected females compared with controls of the same gender. Similar to the approach of Maxfield and Widom (1996), analyses accounted for race and gender, but did not incorporate data on SES, education level, or marital status, all of which appeared to be important covariates of the models tested here. Moreover, data of both prior studies on child maltreatment and crime relied on official records, which underestimate the true occurrence of offenses that are committed. Also of note, the findings of the current investigation differ from those of a previous investigation based on the same data set, where childhood SES did not account for the association between child maltreatment and other adults outcomes: adult substance use, mental health, and physical health (T. I. Herrenkohl et al., 2013;T. I. Herrenkohl et al., 2012). Similar, however, to the current investigation, education level and marital status were shown to be uniquely predictive of the outcomes in question, providing evidence of their potential role as protective factors. Bivariate-level analyses that accounted for gender showed that maltreatment is a risk factor for crime among females and males both. However, several differences in that pattern were also observed. For example, there was a higher likelihood of crimes against persons among maltreated females compared with comparison females, but there was no such difference for males. In contrast, there was a significantly higher likelihood of convictions and incarcerations among maltreated males relative to comparison males, but this difference was not shown for females. Tests of gender interactions included in multivariate tests of crime outcomes were nonsignificant. Thus, findings hint at the possibility of gender differences in certain types of crimes, but further research is needed to determine whether this pattern is generalizable beyond the current sample. --- Conclusion: Limitations and Future Directions The current investigation adds to what is known about the association between child maltreatment and crime by examining a range of adult outcomes longitudinally, by attending to gender differences, and by focusing on how hypothesized covariates influence patterns shown in bivariate tests. Yet, there are several limitations that should be mentioned. As noted in earlier published reports of similarly structured analyses of the same data set, analyses do not attend to how maltreatment combines with other adversities to affect the outcomes in question (Middlebrooks & Audage, 2008). Moreover, analyses do not include variables to help explain "how" child maltreatment can increase the risk of later crime. Tests of theoretically guided hypotheses of developmental mechanisms are thus required. Moreover, child welfare involvement was used in this study as a proxy measure of child maltreatment, although it is known that child welfare records can underestimate the occurrence of abuse and neglect (T. I. Herrenkohl, 2011b). Last, findings are based on a sample from a particular geographic region and the sample itself is rather homogeneous with respect to race and ethnicity. Thus, findings may not generalize to diverse populations and results should therefore be interpreted with some caution. Nonetheless, this prospective, longitudinal investigation provides useful information for theory and practice-and it extends work already published in these important topics. As a next step in research on child maltreatment and crime, attention should be given to possible intervening factors and mechanisms that lead from early adversity to later adult crime. More attention should also be given to gender differences in this context, particularly given the apparent upswing, according to some sources, in the involvement of girls and young adult women in violence and other forms of antisocial behavior (Chesney-Lind & Belknap, 2004). --- Biographies Hyunzee Jung, PhD, MSW, is a research scientist at the Social Development Research Group in the School of Social Work, University of Washington. Her research includes the developmental impacts of child maltreatment and violence exposure with particular interests in prevention of antisocial behaviors and crimes in adolescence and adulthood. She also studies promoting factors and/or obstacles for desistance of crime and successful reintegration into society after release from incarceration. Todd I. Herrenkohl, PhD, MSW, is the co-director of the Three-Dimensional Learning (3DL) Partnership and professor in the School of Social Work at the University of Washington. His funded research focuses on the development and prevention of youth violence, consequences of family violence for children, and resilience in vulnerable youth and families. His publications span a number of interrelated areas in violence research, prevention and wellness, and positive youth development. As co-director of the newly established 3DL Partnership, an interdisciplinary, university-based center joining the fields of social work and education, he and his colleagues are seeking to raise the profile and practice of 3DL-social, emotional, and intellectual-helping educators and youth organizations prepare young people for success in school, work, and life. Those affiliated with the 3DL Partnership conduct community-driven research to better understand the influence of 3DL on young people's capacity for near-and long-term success in life and provide professional development and mentoring to help students, educators, and youth service providers integrate 3DL in their work with young people. In all activities of the Partnership, an emphasis is placed on sharing research findings and evaluation tools to improve practice and to influence policy at the local and national levels. one crime of a total of 36 survey items so as to examine the extent of criminal involvement. The 36 items consist of the 29 items used to scale crime outcome variables of this study in addition to 7 items that were excluded from the scaling. The seven items include "ever drunk in a public place"; "ever been loud, rowdy, or unruly in a public place"; and "ever bought, provided, or made available beer, wine, or liquor for someone under 21," and they were excluded due to too high a prevalence of such commitment. b Reciprocal (inverse) transformed variables were used for past-year crimes and counts of arrest and conviction. An inverse-transformed value of a variable is one over its original value..11.25 Note. Total sample size was reduced to 316 due to missing data on education level. A comparison of findings in models with and without education level showed no appreciable differences in the coefficients. OR = odds ratio; SES = socioeconomic status; OLS = ordinary least squares. a Variable for incarceration is binary. b Findings for reciprocal (inverse) transformed variables: An inverse-transformed value of a variable is one over its original value. Thus, higher values turn lower in number after transformation, and variable values become reverse ordered. As a result, an increase in a transformed variable indicates a decrease in terms of its original variable, so a positive association involving transformed outcome variables indicates an inverse association in terms of its original.

Bivariate analyses of adult crime and child maltreatment showed that individuals who had been maltreated as children, according to child welfare reports, subsequently committed more crime than others who had not been maltreated. Analyses of crimes by category-property, person, and society-provided further evidence of a link between child maltreatment and crime at the bivariate level. Tests of gender differences showed that crime generally is more prevalent among males, although females with a history of maltreatment were more likely than those in a no-maltreatment (comparison) group to report having had some prior involvement in crime. Surprisingly, multivariate analyses controlling for childhood socioeconomic status, gender, minority racial status, marital status, and education level showed that, with one exception (crimes against society), the significant association between child maltreatment and crime observed in bivariate tests was not maintained. Implications for future research are discussed.

INTRODUCTION Out of all the Organisation for Economic Co-operation and Development OECD countries, the Republic of Korea has the highest suicide rate (28.4 out of 100 000 people, based on 2009 data), and the highest rate of increase in the suicide rate [1]. In particular, suicide was the most frequent cause of death at the population level among the age group with work productivity and who are able to participate in economic activity. Suicide is not only a a public health problem, it is also a serious problem in the socioeconomic domain [2]. Given the unusually high suicide rate in Korea, relatively few studies examining the suicide rate in Korea have been performed. Research related to suicide has focused primarily on the national level [3][4][5][6] or individual level [7]. However, to understand the high suicide rate in Korea, it is important to understand the characteristics of the local communities in which the subjects of these studies resided. The local communities where individuals reside affect their quality of health based on the physical environment, access to healthy environments at home and in the workplace, availability of public and private services for the residents, along with the social, economic, and cultural characteristics, and regional ethical rule [8]. Within this context, studies that determine which of these characteristics affect the differences in interregional suicide rates would be a meaningful contribution for addressing the problem. However, there have been very few studies in Korea that have examined suicide rates at the regional level. It is widely accepted that suicide rates in general are influenced by the degree of urbanization and differ by sex; suicide rates are higher in rural areas than urban areas [6,9,10] and higher among males than females [11][12][13][14]. However, studies on suicide rates based on rural and urban areas mostly deal with changes in tendency over time [15], and many studies have been limited to only a few regions [9,10]. In addition, our review of the literature showed that a synthetic multilateral analysis of the connection between the characteristics of urban and rural areas and suicide rates at the national level has been very rare. Moreover, to our knowledge, no national studies have been performed that have considered both sex and age as factors influencing suicide rates. In this study we explained the factors that affect the differences in suicide rates among regions by stratifying the data according to urban versus rural residence, sex, and age, and its relationship to the multilateral regional indices. This method was used to narrow the gap in the regional differences in suicide rates, and provided basic data that should inform policies for decreasing the national suicide rate. --- METHODS --- I. Definition of Suicide and Application of Standardization This study used 3 years of source data on cause of death from 2006 to 2008 obtained from Statistics Korea. In order to calculate the suicide rate, the sum of the midyear population of the relevant regions over those three years was used as the denominator, and the number of suicide cases of the relevant regions over those three years was used as the numerator. We calculated the standardized suicide rate according to the direct age standardization method. --- II. Classification of Region To account for separated or merged cities, counties, and boroughs (si, gun, and gu), we divided all the regions of Korea into 248 cities, counties, and boroughs in order to establish the regionsto be used in our study. We classified the counties (gun) as rural areas (86 counties), and the cities (si) and boroughs (gu) as urban areas (162 cities and boroughs). Between the year 2005 and 2008, the regions that had changed administrative districts were the city of Cheonan and Jeju Island. In this study, Jeju Island was divided into the city of Jeju and the city of Seogwipo. The southeastern and northwestern boroughs of the city of Cheonan were merged into one city of Cheonan. --- III. Regional Characteristics Variables In order to calculate the relationship of indices to regional characteristics, we utilized the 2% sample source data and Almanac of District Financial Affairs of 2005 of the Ministry of Public Administration and Security. The regional characteristics were divided into four domains: public service, social integration, residential environment, and economic status. First, for public service we chose the ratio of the social welfare budget used for regional general accounting. Second, the relationship of the indices to social integration was calculated using the single household ratio, female householder ratio, and divorced or separated household ratio. Third, the relationship of the indices to the residential environment were calculated using the poor housing environment household ratio, ratio of households not in an apartment, and the excessively concentrated household ratio. Fourth, the study included economic status by analyzing the ratio of the population whose academic completion was less than high school, the ratio of households that are low income, and the ratio of households that do not own a vehicle [16]. --- IV. Statistical Analysis A. Actual conditions and regional differences We classified the subjects according to sex, age, and urban or rural residence, and ANOVA was performed for each group. Furthermore, the statistical significance of the differences between urban and rural areas was confirmed through a t-test. --- B. Multiple regression analysis on factors that affect suicide In order to understand the factors that affect the differences in regional suicide rates, multiple regression analysis was performed, and the subjects were stratified and analyzed according to ages less than 65 years and 65 years or above, urban and rural residence, and male and female. Independent variables were composed of the formerly-mentioned 10 variables concerning regional characteristics of the 4 domains. Before performing the multiple regression analysis, in order to confirm that each independent variable is in a linear relationship with log conversion value, we performed the Pearson correlation analysis for each independent variable and each quadratic term. As a result, we were able to find that each independent variable was in a linear relationship with the standardized suicide rate at a significance level of 0.05. --- RESULT --- I. Current Suicide Rate and Its Regional Differences Table 1 shows the differences of suicide rates by sex, lifecycle, and urban versus rural residence. The agestandardized suicide rate was shown to be 23.7 per 100 000 peoples; the male and female rates were 33.2 and 15.8 per 100 000, respectively. The suicide rate had also increased as the subjects increased in age (p <unk> 0.001). When comparing urban areas to rural areas, in males aged less than 19, there was no difference between the areas, but in males above 20 years old, the suicide rate in the rural areas was significantly higher than in the urban areas. In the case of females, there were no statistical differences between the aged 19 and below group and the 65 years or above group, but for the age group of those aged 20 to 64, the suicide rate in rural areas was statistically and significantly higher than urban areas. --- II. Multiple Regression Analysis of Factors that Affect Suicide Table 2 shows the average distribution of independent variables used in the regression analysis. From the regional general accounting data, the ratio of the social security budget was shown to be high in urban areas, and variables that showed the characteristics of the rest of the regions were all high in the rural areas (p <unk> 0.05). --- A. Age below 65 In the case of subjects aged less than 65 years old, the regression model showed an overall 56.1% suicide rate, the males' R square was high at 59.2% and the females' R square was low at 9.7% (Table 3). In terms of region, urban areas showed a very high R square of 60.4%, but rural areas had a very low R square. From all of the independent variables, lower social class, poor housing environment, and housing in a non-apartment had significant associations. In both male and female variables, lower social class was statistically significant. In urban areas for males, lower social class and poor housing environments were statistically significant. In urban areas for females, single household and no car were statistically significant. In the rural areas both males and females did not have statistically significant variables. --- B. Age group 65 or above In a multiple regression analysis based on the subjects who were in the 65and above age group, the total model R square was 0.260, males were 0.221, and females were 0.169. The R square of urban areas was 0.296, and the R square of rural areas was 0.306. Compared to the below 65 age group, the R square of males and urban areas was lower, whereas, R square of females and rural areas that showed an increase (Table 4). Overall, there was a very strongly positive association with the lower social class, and there was a very strongly negative association with the no car variable. Males were statistically significant in the lower social class, no car, and poor housing environment variables, whereas, females were statistically significant in overcrowding, lower education level, and no car variables. In the urban areas, in case of males, lower social class was statistically significant, whereas, for urban areas and females, lower education level was statistically significant. For the rural areas and males group, lower social class and no car were statistically significant. Finally, for the urban areas and females group, overcrowding, lower social class, and no car were statistically significant. --- DISCUSSION This is an ecological study on the factors that affect suicide rates based on the regional level, especially urban versus rural areas. However, due to the ecological fallacy, the characteristics of the relevant region's residents can be different from those of the victims of suicide. A limitation of this study was that the individual characteristics of victims of suicide were not analyzed. Nevertheless, because ecological studies have assisted in confirming the regions that need the public health support, and the studies are useful for influencing public health policies or plans [17,18]. Moreover, as we segmented the regions, the ecological fallacy showed a tendency to decrease [19], and this method is appropriate for understanding the effects of regional unit factors on suicide [20]. Through this study, rather than seeing regional factors that showed coherent relevance to the suicide rate of regions, we were able to confirm that the suicide rate can be considerably different according to urban or rural areas, and to sex. The suicide rates for males is more than twice as high than for females [12,[20][21][22]. Even in this study, the male suicide rate was twice as high as the female rate, and for the age group of 45 to 64, there was a three-fold difference. To explain these differences in suicide rates between the sexes, Suh [3] stated that although the suicide attempt rate is higher in females than in males, females tended to attempt suicide for the purpose of demonstration, whereas it has been reported that males attempt suicide with more certain methods. Furthermore, while females have greater resources to defend themselves from psychologically trauma, males receive greater psychological impact due to problems such as unemployment, retirement, and diseases [21,22]. We determined that the male suicide rate is higher than the female rate because there were also cases where the male victims of suicide had negative forms of behavior such as alcoholism, and because access to the instruments used for suicide is easier for males [12,23,24]. After comparing the subjects according to each age groups, the results showed that the suicide rate increased with age, and the suicide rate of those 65 and older was higher than any other age group. This result coincides with the existing studies [6,24,25], which have stated that the factors causing the elderly to commit suicide are due to physical diseases, being bereft of one's spouse, lack of income, and decrease in social activities, all of which are common in old age [26,27]. When comparing suicide rates in the age groups older than 20 in the rural and urban areas, every combination of age group and sex showed significance significantly higher rate in all rural areas except for the female group in 65 years or above. In discussing the reasons for the differences in suicide rates in rural and urban areas, Park et al. [28] stated that suicides using pesticides is the second most frequent method, especially because pesticides are poisonous and are easily accessible. Kim et al. [7] further claimed that because rural areas consist of an older population than urban areas, even when the age was standardized, the suicide rate in rural areas was higher. In addition, the fact that people have a bias against visiting psychiatric clinics for psychological symptoms such as depression is a problem, and the fact that there is a lack of awareness of psychological diseases can also be another reason the suicide rate of rural areas is higher [29]. Rural areas, lack emergency medical facilities and those that exist are difficult to access for many people, and it is predicted that these reasons can also play a role in raising the suicide rate in rural areas; thus, future research is required. According to the regression analysis, after having examined the relationship between the regional characteristics index and suicide rate, we found that the correlation between a region's social welfare expenditure level and the suicide rate was low. However, a study in the U.S. found that social welfare expenditures and suicide rates have a negative relationship [30,31]. Compared to the U.S., which is known for strong rural decentralization, Korea's social welfare policy has a very strong centralized authoritarian rule, which led us to assume that the relationship between the suicide rate and region's social welfare expenditures was not very significant. Park et al. [6] stated that, in comparison between countries, although social welfare expenditure level does not affect the absolute suicide rate, it does decrease the growth rate of suicide. In case of Korea, this implies that rather than regional level social welfare policies, national level policies can be more effective in decreasing the suicide rate, and it also implies that by consistently investing in social welfare policies, one can decrease the growth rate of suicide. Even then, the organization that actually carries out these social welfare policies is the local government; therefore, the role of local government cannot be overlooked. Social integration has been shown to have a close relationship with suicide through various studies ever since Durkheim first suggested it [13,14,29,32], and, in general, those with a spouse shows low suicide rate compared to people who live alone because they are single, divorced, or bereaved [13,14,32]. However, this study showed that none of the three variables that measure social integration are related to the suicide rate. This demonstrates that the substitute index of social integration is inadequate or that factors such as social solidarity and so on that were not part of this study played a larger role in the suicide rate, all of which are parts that should be considered in future research. It was shown that the residential environment and economic status of a region causes a clear effect overall, and showed a difference according to age group and regional differences. Looking at the population under 65 years old, poor housing environment and lower social class had major effects on the suicide rate in urban areas, but they did not have any relevance to the suicide rate in rural areas. This phenomenon can be explained related to relative deprivation. Currently, in Korea, compared to rural areas where the difference in the living environment is relatively low, the urban areas possess a huge difference in the living environment between the needy and the wealthy upper class, and there is growing anxiety regarding housing [33]. In this study, the fact that poor housing environment and lower social class showed a strong relationship with with the suicide rate strongly implies that slum areas in the city or poverty-stricken areas where the living environment is poor and where lower class people are concentrated are where the suicide rate is high. Considering this point, we presume that when developing an intervention program for prevention of suicide for urban populations, focusing first on an area with many poor urban people will hugely contribute to lowering the suicide rate. Studies done by Rezaeian et al. [19] and Rehkope et al. [34] support this point. Overall, females less than 65 years old showed significantly low R square compared to males, and according to research on characteristics of adult suicide [35], suicide of adult males has to do with financial problems, and of females is highly related to psychological problems such as depression. However, in this study, because it did not take into account individual factors such as psychological problems, the R square could have been low. There needs to be further research on this point. In populations 65 years and above, it appeared that the effect of the living environment disappeared and only the economic standard caused a significant effect on the suicide rate, and this is demonstrated to be similar in both urban and rural areas. In particular, there was almost no difference in regression model R square between urban and rural areas, and there was a relatively high R square even in females. This implies that, in order to reduce the suicide rate of the elderly population in Korea, economic support countermeasures that would solve the older population's poverty problem requires greater attention than any other serious problem. To summarize thus far, there were differences in suicide rates between urban and rural areas, males and females, and between groups less than 65 years old and those 65 years and above, but all these findings could be condensed into one generalization--that the regional residential environment and economic status have significant impacts on the regional suicide rate. In other words, policies that reduce the regional economic status gap can also lead to an overall decrease in the suicide rate. Nevertheless, in populations less than 65 years old, there was a very low R square of regression model, and this demonstrates that follow-up studies will be required considering other regional characteristics that could not be considered in this study. Such are the limitations of this study. First, the regional classification standard of this research lacks the quality needed to apply the distinction of urban versus rural areas. For example, in cities that are made up of urban-rural areas, the characteristics of both urban and rural areas are consolidated, but it is classified as a city in this research. However, the regional classification code that would enable us to overcome the abovementioned problem was not provided by Statistics Korea. Second, this study obtained suicide rate data according to the city, county, or borough (si, gun, or gu) using cause of mortality source data provided by Statistics Korea. However, there have been criticisms that out of the fact that the suicide statistical data presented by Statistics Korea is different from the suicide statistical data distributed by the National Police Agency. In particular, having systematic errors, not random errors, from the suicide statistics data of either urban areas or rural areas could have had an impact on this study's results. Third, this study was not able to consider factors like the region's social bond, network, mental disease (such as depression) prevalence rate, or accessibility of medical services (such as psychological counseling or emergency medical aid) that can impact the suicide rate. In particular, the fact that these factors were not included in the source data of this research could be the reason why there is higher R square of the regression model in rural areas than urban, and more in females than males. Despite these limitations, we were able to confirm that a region's living environment, economic standard, and so on, have significant effects on the regional suicide rate, and we were able to see that these effects are demonstrated differently according to sex, age, and rural versus urban residence. Therefore, in order to alleviate the high suicide rate in Korea and to reduce regional differences, multilateral intervention countermeasures that consider characteristics related to urban versus rural residence, sex, and age need to be prepared. Specifically, a suicide prevention campaign (based on regions concentrated with poverty-stricken classes) should be effective for the reduction of suicide in the non-elderly population in urban areas, and economic support among the elderly population should be helpful in reduction of their suicide rate. In conclusion, future research needs to include individual-level variables that were not included in this research, and comprehensive analysis that considers factors mentioned as the limitations. --- CONFLICT OF INTEREST The authors have no conflicts of interest with the material presented in this paper.

Objectives: Identify the characteristics related to the suicide rates in rural and urban areas of Korea and discover the factors that influence the suicide rate of the rural and urban areas. Methods: Using the data on causes of death from 2006 to 2008, the suicide rates were calculated and compared after age-standardization based on gender, age group and urbanicity. And, in order to understand the factors that influence suicide rate, total 10 local characteristics in four domains -public service, social integration, residential environment, and economic status -were selected for multiple regression analysis. Results: The suicide rates were higher in men than women, in rural areas than urban, and in older people than the younger. Generally, although there were variations according to age group and urbanicity, suicide rates were significantly related to residential environment and regional economic status but not related to regional welfare spending and social integration. In addition, the population over the age of 65 years, only regional economic status has significantly influence on their suicide rates. Conclusions: The influence of characteristics of regions on suicide rate is various by age-group, gender, and urbanicity. Therefore, in order to lower suicide rate and reduce the gap between regions, various approaches must be adopted by taking into account the socioeconomic characteristics of the regions.

Introduction Teachers are highly respected professionals in Finnish society. The MA-level qualification supports the general respect for the teaching profession, which is not a second choice for students, as it is in many other western countries. Although primary and special teacher education programs remain popular among university applicants [see Education Statistics Finland (VAKAVA), 2022], enrollment has decreased in recent years, and studies have demonstrated that an increasing number of teachers are considering changing their professional OPEN ACCESS EDITED BY Niina Meriläinen, Tampere University, Finland field early in their careers (Heikonen et al., 2017;Räsänen et al., 2020). Further in the article by TE we refer to the Finnish MA-level teacher education for primary school teachers. In this study, we examine how student teachers' perceptions of teacherhood build upon and on the question of who holds the power to define the "ideal teacher. " Our primary data consist of thematic interviews with 16 first-year student teachers attending a 5-year degree program in primary school TE at one medium-sized Finnish university. A small amount of additional data, gathered from written self-reflections of four of the interviewed students when they reached their fifth year, was also considered in the analysis. By examining student teachers' perceptions on teacherhood, we aim to identify themes that have powerful influence in defining the attributes and characteristics of the ideal teacher, according to the students' thinking. Based on previous studies, the search for the critical potential of TE-and thus the teaching profession-can be enhanced by making visible the process of teacher formation and by examining the actualization of the characteristics and norms associated with the profession. Through research, the definitions and discourses regarding teacherhood can be diversified, thus encouraging teachers to realize their autonomy and agency, with respect to critical societal issues as well, which have traditionally been excluded from the Finnish teaching profession. Societal and cultural changes, such as growing diversity of students, regional and school segregation, and increasing influence of socioeconomic background on learning outcomes transform the nature of teachers' work. From a societal point of view, recent concerns have included research findings on increasing inequalities, a decline in learning outcomes, greater segregation between residential areas and schools, and mental health challenges of children and young people [e.g., Bernelius and Kosunen, 2023;Finnish Ministry of Education and Culture, 2023;Juvonen and Toom, 2023;World Health Organization (WHO), 2023]. Problems in schools, teachers' heavy workload, and burnout are also frequently featured in the media, which raises concerns and triggers public discussion about how difficult it is to work as a teacher. Finnish universities, including those offering TE programs, have autonomy over their institutions and decisions concerning their curricula and how TE is organized. Legislation prescribes only certain frameworks for the qualifications of different professional groups (e.g., teachers in special education and primary school education). Formally, the contents of TE curricula play a key role in the educational system, equipping future teachers with the skills, attitudes, and knowledge needed in contemporary schools (see Husu and Toom, 2016). In reality, the process is much more complicated, and student teachers construct their perceptions of teacherhood from varied sources of information and also outside TE's sphere of influence, which might be potentially problematic. However, when systemic changes are needed at either the social or the individual level in the school environment, the focus first shifts to TE. Traditionally, TE has paid attention to the questions and disciplines of didactics, pedagogy, and psychology, but social science, especially sociology, has also been one of the subjects studied in TE. These traditions have roots in the history of schools, which for a long time emphasized "banking" rather than "problemposing" in education (Männistö et al., 2023), considering schools as institutions where pupils are socialized into the existing norms of the society, and teachers are authorities delivering information to new generations. In Finland, graduating student teachers are expected to become transformational agents who can critically reflect on and evaluate what types of changes are necessary in education and implement them (Toom and Husu, 2016). According to the Finnish Education Evaluation Centre (2018), the graduating students should be persuasive and creative innovators who are able and willing to develop their own work methods, as well as the school communities (Niemi et al., 2018). Traditional views on teachers as experts who transfer knowledge to new generations are no longer valid (see Simola et al., 2017), and TE is called for to support students in developing critical reflective views regarding teaching. Traditionally perceived in Finland as individualistic and personally experienced, the teaching profession is being extended to become more collaborative, and teachers are expected to develop their work with colleagues and other stakeholders (see Husu and Toom, 2010;Blömeke et al., 2015;Toom and Husu, 2016, p. 17-22). However, transforming teachers' and student teachers' perceptions and core assumptions regarding their profession is challenging and time consuming (e.g., Lindén, 2010;Lanas and Kiilakoski, 2013;Lanas and Hautala, 2015;Fornaciari, 2020). Furthermore, research on student teachers' perceptions of teacherhood has been relatively scarce (see Syrjäläinen et al., 2006b;Räihä, 2010;Säntti, 2010;Juutilainen et al., in peer review). Based on previous studies (e.g., Britzman, 2003;Furlong, 2013;Androusou and Tsafos, 2018;Fornaciari, 2020), TE might not have great influence on future teachers' core perceptions of their work. Instead, previous research has demonstrated that new teachers' perceptions might draw on tradition and cultural-historical phases of the Finnish teaching profession (e.g., Simola et al., 2017;Fornaciari, 2020) and normative ideas about the ideal characteristics of a "good" teacher or student teacher (e.g., Lanas and Kelchtermans, 2015;Juutilainen et al., 2023). In Finland, the unproblematized status of the school and the teacher in the national-cultural narrative has traditionally granted autonomy to teachers, allowing them to rely on their moral compass to guide their professional actions. Additionally, TE as an institution has been relied on to select and educate future teachers who are suitable for society's needs. Finnish success in international tests, such as PISA (Programme for International Student Assessment), has been considered as providing sufficient evidence that the school system in Finland functions as a whole, with TE as part of it (e.g., Husu and Toom, 2010, p. 2). 2 Cultural and societal framework of the study --- Good teacher competencies Society sets both explicit and implicit expectations for teachers; teachers' work is not only defined by the national curricula and current policy aims but also molded by the surrounding culture and norms. Theoretical analyses and empirical studies of teacher competencies and characteristics are abundant. The definition of a good teacher is full of ideals (Kostiainen and Rautiainen, 2011, p. 159). While it is possible to identify common elements across a wide range of studies, there is no agreed, empirically based articulation of a teacher's core competencies (e.g., Husu and Toom, 2016). According to Panti<unk> and Wubbels (2010), teachers' professional competence is comprehensively built on four dimensions: values and raising children; understanding and contributing to the development of the educational system; content knowledge, pedagogy, and curriculum; and selfevaluation and professional development. Teachers' work has been regarded in diverse ways at different times, with varying priorities and objectives, and teachers' professional actions reflect the understanding of human nature, knowledge, and learning of their generation. In Finnish society, the expectations for teachers have taken on various emphases in different decades. In the 1970s, good teaching skills were considered central in teacher training. In the 1980s, the role of the teacher as an expert was emphasized. In the 1990s, reflection and an investigative approach were highlighted. In the 21st century, the teacher has been perceived as a societal agent and ethical visionary, actively developing society (Aarnos and Meriläinen, 2007). In the Finnish context, teachers have always represented not only pedagogical expertise but also the so-called model citizenship, reflecting the educational ideology and the prevailing ethos of society at a particular time. Teachers were expected to demonstrate the integrity of their role in and out of school, to be good role models for their students, and to conform to cooperation, order, and discipline. Educators had to strive for good conduct in all respects. In fact, from a historical point of view Finnish primary school teachers are argued to be rather traditional than critical in their relationship with society. Schools and teachers in Finland have traditionally been perceived as preservers of the status quo rather than agents of change, and teacherhood is still associated with conservative norms and ideals (e.g., Lanas and Kiilakoski, 2013;Lanas and Kelchtermans, 2015;Simola, 2015;Fornaciari and Männistö, 2017;Juvonen and Toom, 2023). According to current professional thinking, the classroom teacher should have an understanding of the elements outside the classroom (e.g., curriculum level, school system, school and municipal policies) that guide their actions and influence their work, as well as a willingness to influence the social realities outside the classroom (see National Board of Education, 2004Education,, 2014;;Niemi et al., 2018; University of Jyväskylä Teacher education Curriculum, 2020). Toom and Hsu (2016, p. 20-22) considers teachers' societal competence in relation to the aims of TE, which involves strengthening the knowledge, skills, and competencies for teaching and education that a pluralistic and egalitarian society requires of teachers. In Finnish society, the increasing diversity of students' cultural, social, and economic backgrounds also emphasizes the importance of the ethical and moral nature of teaching (see also Biesta and Burbules, 2003). Contemporary research on schools and teachers, along with administrative documentation, advocates the development of a more active relationship with society (see National Board of Education, 2004Education,, 2014;;Niemi et al., 2018;University of Jyväskylä Teacher education Curriculum, 2020). The current generations of students enter TE in a new climate of social debate and with fresh expectations. Societal awareness and critical reflection on societal practices have also emerged as desired qualities among TE applicants (see Mankki and Räihä, 2019;Fornaciari, 2020). The portrait of an ideal teacher is actively produced in academia, such as in TE, and in administrative policy documents; it is also driven by other stakeholders, such as labor and business interests. In current project-based development efforts, the ideal teacherhood is often produced jointly by all these actors. --- Changing society, changing teacherhood? Finnish society is changing in the broader context of varying everyday realities of schools at national and regional levels. The growing diversity of students, the variety of lifestyles, and pluralism are changing the work of teachers in many ways, also in Finland, even though it lags comparative countries (in Northern Europe) in this development. The Finnish uniform culture, with its ethnic and cultural homogeneity, has been a distinctive feature of Finnish schools. To date, relatively little cultural competence and understanding of (among others) social or demographic changes and their impacts on the school environment have been required of Finnish teachers. As previously noted, the traditional image of the Finnish teaching profession is rather conservative, and Finnish TE has typically attracted fairly like-minded students with relatively similar backgrounds and expectations on the profession (see Syrjäläinen et al., 2006a;Räihä, 2010). However, accelerating cultural and social changes are slowly changing the nature of teachers' work, as well as the objectives and the general perspective of their work in Finland. From a societal point of view, the greatest challenges for Finnish schools in the future are related to how they will be able to implement the all-encompassing task of fostering equality of people with diverse backgrounds (e.g., immigrants, socioeconomical status, gender, region). Internationally, the Finnish school system has so far done quite well in terms of educational equality and uniformity (see Bernelius and Huilla, 2021). However, research has shown that among the OECD countries, Finland has the largest literacy gap between migrant and migrant background students and non-migrant students (Helakorpi et al., 2023). Not only do migrant students and students with migrant backgrounds show poorer academic performance, but they are also bullied more in school. Students with migrant backgrounds also have a greater risk of dropping out of school after comprehensive education (Souto, 2020, p. 317-329). Global goals of sustainability education also fail to translate into concrete actions by the time they reach everyday life in Finnish schools (see Mykrä, 2023). Furthermore, Lehtonen's (2023) study demonstrates that regarding gender and sex education, teacher training, teaching, and the textbooks used in schools are often still heteronormative in Finland, and teachers lack the tools and motivation to resist heteronormative starting points in their work. Indeed, many studies have identified the demand for a societal focus as a significant aspect of teacherhood, with an emphasis on understanding the needs of a changing society and actively contributing to its development (see Syrjäläinen et al., 2006a;Husu andToom, 2010, 2016;Lanas and Hautala, 2015;Husu and Toom, 2016;Clandinin and Husu, 2017;Fornaciari, 2020). Although the teaching profession in Finland is highly autonomous and there are no formal external evaluations of teachers' work, teacherhood is strongly influenced by different social, cultural, and historical ideals and norms (Britzman, 2003;Furlong, 2013;Lanas and Kelchtermans, 2015;Uitto et al., 2015;Fornaciari and Männistö, 2017;Androusou and Tsafos, 2018;Dugas, 2021). Hence it is reasonable to question whether and despite the contemporary TE objectives, administrative policies and guidance and the national primary curriculum have changed the actual practices in terms of school cultures or teachers' attitudes and societal thinking, among others. Culturally and historically shaped perceptions of teacherhood are socially constructed and reconstructed. Although education paradigms have changed and continue to evolve, perceptions of teacherhood are undergoing slow transformation (Vuorikoski and Räisänen, 2010;Simola, 2015;Fornaciari and Männistö, 2017). Teachers' defense mechanisms against the changes in their work have also been identified in studies regarding teachers' professional agency (see Säntti, 2010;Hökkä, 2012;Vähäsantanen, 2013;Fornaciari, 2020). --- Teacher education and student teachers' perceptions of teacherhood The current Finnish TE is research based, and its aim is to prepare teachers who will use contemporary research as the basis for their work and thus reform the field to meet the needs of society and children (Toom et al., 2010;Lanas and Kiilakoski, 2013). In addition to the knowledge of and skills in traditional school subjects, the professional skill development of today's teachers emphasizes mastery of the so-called generic skills, such as interaction, information processing, thinking and reflection, and digital technology skills. Thus, research on teaching and teacherhood also stresses the centrality of guiding students' learning processes, rather than merely transferring knowledge to them, and the role of the teacher as part of a collaborative, knowledge-creating community (Luukkainen, 2004, p. 16-17;Tynjälä, 2004, p. 175-188;Toom and Husu, 2016) The current TE and research rhetoric call for critical teacherhood with a comprehensive understanding of education (Rautiainen et al., 2014), but there is no consensus on how well contemporary TE actually instills critical societal elements in the educational thinking and teacherhood of future teachers (see Värri, 2007;Kinos et al., 2015;Lanas and Hautala, 2015;Nikkola and Harni, 2015;Fornaciari and Männistö, 2017). Perceptions of teacherhood refer to collectively internalized, culturally and socially constructed ideas about the nature of the teaching profession and the appropriate personality for the job (e.g., Lanas and Kelchtermans, 2015). Such perceptions are strongly influenced by individuals' own experiences, as well as the ways in which the people in their homes, immediate social surroundings, and wider social environment discuss and understand teachers and teacherhood (Alsup, 2006;Furlong, 2013;Lanas and Kelchtermans, 2015;Uitto et al., 2015;Androusou and Tsafos, 2018;Dugas, 2021). Almost all aspiring teachers have school experiences and around 13,000 h of classroom observations of the school administration and a teacher's daily duties are like. Teachers themselves are likely to have expectations of a personally fulfilling career, expectations that have begun to form in their years as students, observing and learning what teachers and school are like (Lortie, 1975; see also Britzman, 2003;Furlong, 2013). Indeed, socialization in teacherhood starts at an early stage, and studies show that teacher training may be viewed by the students as a formal, compulsory step on the way to a vocation whose tasks and ideal profile are defined outside higher education. Juvonen and Toom (2023, p. 121-127) describe this as a two-dimensional expectation setting for teacher work-teaching as a profession defined by society, on one hand, and teacher work perceived by teachers themselves, on the other hand. Cultural expectations of school and normality begin to form in our years as students, and similar to all the other people, teachers, as products of cultural socialization and through their actions, reflect what is viewed as culturally normal. Skills learned through observations and a strong motivation for entering the field of teaching may mean that student teachers are eager to complete their degree efficiently; to this end, adapting to TE, rather than pausing to criticize it, seems logical. Furthermore, Kuusisto and Rissanen's (2023) study showed that the majority of future teachers set instrumental goals for their work. Through the teaching profession, students sought to find meaning in their lives and to bring economic security to themselves and their families. For many students, the profession had prevalently pedagogical goals of growth and nurturing (see also Fornaciari and Rautiainen, 2020). This poses a challenge for TE, as student teachers have a level of experiential thinking that is difficult to contest in the TE education. The discrepancy between students' preconceptions and teacher conceptions aspired for in TE arises in relation to contemporary teacher perceptions, which have been outlined by official documentations by the Finnish Ministry of Education and Culture (2016) and rooted also in TE programs. However, TE departments in Finland have great autonomy in how they interpret and implement the official guidelines in their curriculum. It has also been argued that the TE institution as a place where previous thinking and attitudes about learning, the school's function, and teacherhood are challenged does not fully reflect reality, according to some studies (see Räihä, 2006;Syrjäläinen et al., 2006a;Lanas and Kelchtermans, 2015;Juvonen and Toom, 2023). In TE, the school as a societal structure is insufficiently reflected, although the superficial self-reflection of teachers is emphasized, and some studies have found that the overall impact of TE on the perceptions, attitudes, professional identity, and agency of future primary school teachers is relatively weak, and students' perceptions do not substantially change during their studies (e.g., Britzman, 2003;Alsup, 2006;Räihä, 2006;Husu and Toom, 2010;Furlong, 2013;Kallas et al., 2013;Lanas and Hautala, 2015;Androusou and Tsafos, 2018;Matikainen et al., 2018;Fornaciari, 2020;Fornaciari et al., 2023;Juvonen and Toom, 2023). As noted, contemporary perceptions of teacherhood are characterized by notions of the teacher as a multifaceted societal actor, an innovative expert, and a democratic developer of the school and working community (see Blömeke et al., 2015;Finnish Ministry of Education and Culture, 2016;Husu and Toom, 2016;Raiker and Rautiainen, 2019). Therefore, a central task and objective of TE is to train and enable active future professionals to critically analyze and improve their own work, further hone their expertise, raise their students as active citizens, reform education and their school, and thus, contribute to meeting the challenges of modern society (e.g., Toom and Husu, 2016; University of Jyväskylä Teacher education Curriculum, 2020; Metsäpelto et al., 2022;Juvonen and Toom, 2023). However, this kind of TE seems to be in the margins and mainly related to singular development projects instead of manifesting as mainstream TE. 3 Research design --- Data collection The primary data for this study comprise thematic interviews with 16 first-year student teachers attending a 5-year degree program in primary school TE offered at a Finnish university. The interviews were conducted between February and June 2014 in Finnish. The interviewees were between 18 and 27 years old, with a mean age of 20.5 years. The themes of the interviews focused on the students' experiences of studying in TE; what they perceived as important in their studies, how they experienced the learning environment and their peer group in TE, and how they perceived themselves as TE students. In addition, the interview themes covered the student's previous school experiences, their path to teacher education and perceptions of themselves as learners in school. Throughout the interview, the students were encouraged to talk freely about the themes, emphasizing issues that were relevant to them. All interviews were transcribed, which produced a total of 255 pages of transcribed text (Times New Roman, 12-point font size, 1.5 line spacing). The quotations that are cited here to illustrate the data were translated from Finnish to English by the second author, who also conducted the interviews. Additional data were gathered in the autumn of 2017, when the same students were in their fifth year of TE. Four of the students who were interviewed in 2014 wrote a reflective essay about their experiences in TE. They were asked to write freely about their experiences in TE, what they perceived as important in their studies for their future profession, and what they thought and felt about their approaching graduation and starting their teaching career. Each essay was approximately two pages in length. Despite the small amount of these additional data, they shed light on the socially and culturally constructed and shared ways of understanding teaching as reflected in the students' narratives. --- Master and counter narratives In this study, we based our analysis on a previous study that used the same data from 16 student teacher interviews, exploring student teachers' agency in teacher identity construction through master narratives and counter-narratives (Juutilainen et al., in peer review). In the previous study, narrative analysis was applied. Master and counter-narratives can reveal prevailing norms and alternative, sometimes even opposing means to narrate experiences and relationships (e.g., Hyvärinen, 2020;Lueg et al., 2020; see also Heikkilä et al., 2022). Master narratives are understood as culturally expected and accepted courses of events and actions, framing what is interpreted as "normal" or "typical" (Bamberg, 2004;Hyvärinen, 2020). Master narratives are always embedded in certain social and cultural contexts and can be contested and challenged through counter-narratives (Bruner, 1991;Bamberg, 2004;Hyvärinen, 2020). Based on the narrative inquiry, three narratives were configured (for detailed information, see Juutilainen et al., 2023): the master narrative of sustaining an internalized teacher identity, the counternarrative of transforming the teacher identity, and the counternarrative of questioning the teacher identity. The results of Juutilainen et al.'s (2023) study revealed that the most prevalent narrative in the student teachers' stories-the master narrative of sustained teacher identity-reflected an orientation to and engagement in those aspects of TE that corresponded to the students' preconceptions of teaching as "practice. " Here, the teacher's profession was understood mainly through teachers' practical actions undertaken with their pupils in the classroom. This master narrative seemed to represent a traditional teacher perception, which is more focused on preservation than on change and is strongly affected by the apprenticeship of observation (see Lortie, 1975). In other words, it involves observing teachers' work from a pupil's viewpoint and internalizing normative preconceptions of what it means to be a teacher based on childhood experiences and teacher role models, the impact of home discourses, and cultural images and expectations of teachers (see Knowles, 2003;Alsup, 2006;Lanas and Kelchtermans, 2015;Uitto et al., 2015). The counter-narratives in the study of Juutilainen et al., 2023 acquired their meanings in relation to the master narrative, opposing the established expectations of the latter. The counternarratives were also present in the data to a considerable yet smaller extent. The counter-narrative of transforming teacher identity illuminated a transformation from students' preconceptions of teaching, which were somewhat similar to the master narrative, to TE's institutional, culturally situated narrative of the contemporary teacher. Thus, the teacher perception in this narrative seemed to represent a kind of unquestioned model teacher perception of contemporary TE. The counter-narrative of questioning the teacher identity (Juutilainen et al., 2023) entailed questioning and a critical stance toward the normative societal master narratives of teaching and learning in school, extending across different contexts and times. This counter-narrative represented a teacher perception that entailed critical reflection on what is at the core of the teacher's profession. This kind of critical reflection and ability to evaluate and implement the changes that are needed in education is a goal of TE today (see Toom and Husu, 2016). However, this counter-narrative was found only in a few student teachers' storylines. --- Thematic analysis Based on Juutilainen et al.'s (2023) results about the narratives and how those illuminated student teachers' core perceptions of the teaching profession, we wanted to investigate what aspects had the most power in defining "the good teacher" for future professionals in Finland. Based on the prevalence of the master narrative in the data, it seemed that TE might not have the most powerful influence on students' perceptions; we started to wonder, then what or who had the power to define the ideal teacher? Consequently, we formulated our specific research questions: What is the foundation on which student teachers' perceptions of teacherhood are built, where is the "ideal teacher" defined, and by whom? Thus, we explored the data from the 16 student interviews using thematic analysis (Braun and Clarke, 2006), aiming to identify recurrent themes that seemed powerful in affecting student teachers' perceptions according to the student teacher narratives. Then, we proceeded to investigate these thematized aspects in relation to the narratives found in the previous study to see if different narratives would correspond to different themes of powerful influences. In this phase, we also included in our analysis the written essay data from the four students. Due to the small amount of this data, we did not aim to make any generalizations on how student teachers' perceptions evolved during TE. However, these four students, by chance, differed in their narrations in the first-year interviews in such a way that one of them employed mainly the master narrative, two applied mainly the counter-narrative of transformation, and one used the counternarrative of questioning in her storyline. Thus, we looked for themes influencing the teacher perceptions also from these written essays, as they offered us a glimpse into possible power relations that might affect students' teacher perceptions even more than the official aims of TE. The most significant aspect emerged from the essay of the student who had used the counter-narrative of questioning in her interview when she was in her first year of studies. At that time, she already described some unofficial power relations within the peer group and contested some norms of a typical student teacher; nevertheless, she was sure of wanting to become a teacher. However, in her written essay during her fifth year, it became evident that the contradictions among her peers and with respect to the typical student teacher norm had increased during her years of studies; concurrently, she started to have self-doubts, thinking that she was too "non-teacher-like. This observation provides an important insight into what might happen if unofficial power relations were not brought to light in TE. Thus, in the Results section, we consider this finding further regarding the counter-narrative of questioning. Through our thematic analysis, we found that the themes influencing student teachers' perceptions of the ideal teacher were the social norms of the "typical student teacher, " the student teachers' relationships with teacher educators, and the sociocultural environment of the peer group in TE. When these themes were observed concurrently with the master and counter-narratives in Juutilainen et al.'s ( 2023) study, we found that the effects of these themes differed between master and counter-narratives. Therefore, in the results of this study, we used the three narratives together as a framework to describe how the different powerful aspects influenced student teachers' perceptions (Table 1). --- Results --- The powerful influence of social norms of the "typical student teacher" In this research, it seemed that during the participants' TE studies, the critical teacher perception was confronted with the traditional one, which was apparently maintained through the master narrative among the "typical student teachers. " Based on our findings, we suggest that the social norms of typical student teachers have the most power and influence on student teachers' perceptions of the ideal teacher. Our findings suggest that teacherhood is principally framed by sociocultural norms and ideals, which may be reproduced among student teachers and guide their construction of professional thinking even more strongly than the explicit goals of TE. The implicit norms and informal power relations within the student teacher community seemed to influence the transformation of perceptions and the construction of professional agency. The master narrative in the student teachers' accounts reflected their orientation to and interest in those aspects of TE that corresponded to their internalized preconceptions of teaching as a practical job, emphasizing the implementation and reproduction of practices. The theme that seemed highly powerful in affecting the student teachers' perceptions comprised the social norms of the typical student teacher. These norms seemed to go beyond time and context since the student teachers referred to the "typical" expected characteristics or normative behaviors of future teachers, manifested already when they were pupils in school. Being active, well-behaved pupils, earning high grades, complying with the school norms, and following the teachers' instructions were perceived as characterizing future teachers' own school paths. I was always one of the front-row girls... Quite good and talented, I did not have to work too hard, but I still did because I wanted to get the highest grades. But I also got along with my classmates; I am social, too, and it has been a significant part of school life to have friends. Maybe I'm also kind of a leader type in a group, so I guided the back-row boys also to work, told them what to do, and so on. But I think I was that kind of pupil that teachers appreciated because I was curious and interested but in a good, moderate way, not like jumping on the walls for excitement. Maybe I was even a little too good, like, so we are the ones who are going to be teachers; have all teachers been like this? (L04). I think I have always been a kind of basic good pupil, probably the kind of typical future class teacher (K11). In TE, the social norms of the typical student teachers seemed apparent to the students. They described strong cohesion with their peers and feelings of "everyone being the same. " The typical characteristics and expected behaviors of the normative student teachers were talkativeness, being extroverts and social, and conscientious in their TE studies by aiming to accomplish what they believed was expected of them, striving to receive good grades, and Frontiers in Education 07 frontiersin.org qualifying as teachers. The social norms of the typical student teachers also included a kind of activeness, but it seemed that it meant participating eagerly in the tasks suggested by the teacher educators because the students seemed to allege that teacher educators had the authority to which they wanted to conform. Furthermore, normative activeness seemed oriented toward the tasks that involved social interaction and playful activities that could be put into practice with pupils. These social norms of typical student teachers seemed to have a powerful influence on student teachers' being and learning in TE. Conforming to the norms seemed to guarantee belonging to the peer group, having friends, and enjoying their time in TE. I belong to those who have power [in the learning group]. Because when I have an opinion, I say it out loud, and I have noticed that others listen to me. I can be myself in the group-maybe it's because most of the students here are like the same. So, you do not feel any different from them (L04). [The most important thing in TE] is my peer group. We are so close that we are almost like a little family. Also, I have a feeling that everyone here is the same. Well, not everyone, but there are so many congenial people here; it is funny. It has been funny to notice how similarly we think about things (K08). It was especially significant from the TE perspective that the norms of typical student teachers seemed to reinforce sustaining the traditional teacher perception. This was because the norms implicitly included orienting to and engaging in those areas of TE that were concordant with the students' traditional preconceptions of the teaching profession. For example, typical student teachers were considered active in participating in the "practical" activities, such as teaching practice or subject studies, that were deemed as a teacher's "real work. " On the contrary, lectures and what was perceived as more theoretical studies (e.g., the basic studies on education) were disliked. Therefore, to conform to the norm, students needed to engage in the practical activities and avoid theoretical studies. --- Relationships with teacher educators as powerful influence In the counter-narrative of transforming, which indicated student teachers' perceptions evolving from the traditional preconceptions to a teacher perception that was represented in contemporary TE, the most powerful influence seemed to come from their relationships with the teacher educators. Within this narrative, the students expressed their wish to learn new perspectives, engage in reflection, and transform their conceptions of teaching. They also described their admiration for their teacher educators, which, on one hand, might have enhanced their willingness to learn; on the other hand, it might have prevented them from critically reflecting on the cultural and institutional stories of contemporary TE. I really respect [teacher educators], and yeah, you could say that

In Finland, graduating teachers are expected to become "transformational agents" who are able to critically reflect upon and evaluate what types of changes are necessary in education and who can also implement the required changes. However, based on previous studies, teacher education seems to have little influence on future teachers' core perceptions of teacher's work. Instead, previous studies have demonstrated that new teachers' perceptions might draw on tradition and cultural-historical phases of the Finnish teacher profession, and normative ideas concerning the ideal characteristics of a "good" teacher or student teacher. In this study, we examine how student teachers' perceptions of teacherhood build upon and who has the power to define the "ideal teacher." Based on our study, we suggest that to understand how the perception of the ideal teacher is formed and how teacher education could better influence the transformation of these perceptions, we must consider the unofficial power relations among student teachers. These power relations seem to originate from the hegemonic discourse of the "typical student teacher," which contains and renews traditional perceptions of teaching and teachers as authorities and experts transmitting subject content knowledge and skills to pupils. This discourse seems to be renewed among student teachers and has more impact on students' perceptions than the official aims of teacher education. Hence, in our study, the unspoken sociocultural power relations come to light in different ways, in the peer relations between student teachers but also in the students' conceptions of the teacher educators. We suggest that by unraveling the unofficial power relations in the sociocultural context of teacher education and by focusing on supporting every student teacher's agency and critical reflection, it is possible to transform the perceptions about the ideal teacher.

traditional preconceptions of the teaching profession. For example, typical student teachers were considered active in participating in the "practical" activities, such as teaching practice or subject studies, that were deemed as a teacher's "real work. " On the contrary, lectures and what was perceived as more theoretical studies (e.g., the basic studies on education) were disliked. Therefore, to conform to the norm, students needed to engage in the practical activities and avoid theoretical studies. --- Relationships with teacher educators as powerful influence In the counter-narrative of transforming, which indicated student teachers' perceptions evolving from the traditional preconceptions to a teacher perception that was represented in contemporary TE, the most powerful influence seemed to come from their relationships with the teacher educators. Within this narrative, the students expressed their wish to learn new perspectives, engage in reflection, and transform their conceptions of teaching. They also described their admiration for their teacher educators, which, on one hand, might have enhanced their willingness to learn; on the other hand, it might have prevented them from critically reflecting on the cultural and institutional stories of contemporary TE. I really respect [teacher educators], and yeah, you could say that I kind of admire them. The way they lead the group is something I would like to do as well as a teacher. So, I kind of see them as models for myself. And I have not really seen anything from them yet that I would criticize, so it's also kind of scary because then I could be misled. Maybe I eagerly accept everything they say because I kind of admire them (N06). [The teacher educators] are important to me. If they were someone else, I do not know if I would be this excited because they show their own motivation, and I feel that I have never had these good teachers before (N01). TE and the discourses produced and maintained there are also bound to a specific time and culture, thus influencing the student teachers' socialization in the profession, either explicitly or implicitly (see Sitomaniemi-San, 2015;Lanas, 2017). Through critical reflection, student teachers can become aware of the channels of socialization in the teaching profession and experience more agency in relation to their profession and in defining their own sense of teacherhood (see Mezirow, 1995;Taylor, 2003;Leijen et al., 2020). Within the counter-narrative of transformation, it seemed that some of the social norms of the typical student teachers were applicable since student teachers described similar traits of being "good pupils" in their own school years, which seemed to have led them to TE. They expressed their feelings of belonging to their peer group and the kind of "sameness, " as described in the master narrative. However, some accounts indicated that within this narrative, student teachers did not necessarily seek to have close friends from their peer group but regarded them as mere colleagues in TE studies. Thus, it seemed that despite experiencing social cohesion in their peer group, they were not as dependent on their peers as within the master narrative. To me, peers represent, like the learning group. Like I do not want to have a best friend from them; I already have best friends in life... I want to see them as a group, and I can easily ask them about TE stuff. But I do not share more personal things with them, and I do not feel the need to (N06). Therefore, in this narrative, their relationships with teacher educators seemed to hold the most power in influencing students' perceptions. Nevertheless, student teachers seemed to experience enough identification with their peer group's social norms that they felt they belonged in the group. --- Sociocultural environment of the peer group in TE: contradictions and contesting the social norms The social norms for typical student teachers became even more evident since few student teachers described going against the norm. The counter-narrative of questioning illuminated a critical teacher perception, emphasizing engagement in questions such as a teacher's agency in alleviating social injustices (see also Hilferty, 2008;Lanas and Kiilakoski, 2013;Panti<unk>, 2015;Quinn and Carl, 2015;Matikainen et al., 2018;Magill, 2021). This kind of orientation to teacherhood can be perceived as suggesting the transformative agency that is expected from future teachers. However, this counter-narrative had minimal appearance, and it was constructed in relation to the master narrative and the traditional teacher perception through questioning and criticism. Resisting the master narrative of a typical student teacher appeared to span across different contexts and times since this counter-narrative included descriptions of resisting or questioning school norms in one's own school years as a pupil or acting against the normative, expected behavior described in the master narrative. R08: [I was] kind of a wild child, energetic and lively, did a lot of mean things, and like [adults saying], 'Is that kid ever going to become anything sensible' (...), not like a very 'good pupil'? (R08). I have always criticized teachers a lot. Both in the classroom and discussion in general. In my family, we have always talked a lot; we have been encouraged to tell our opinions. And in high school, I did that a lot; I feel that teachers do not look back and think of me with joy because I think I was always like, 'Why cannot we do this like this?' or 'Why do not pupils ever get to [write on] the board? Why do only teachers do?' (K10). Within this counter-narrative, there also appeared contesting and acting against the typical student teacher norms. Student teachers described feeling somehow different from their peers or noticing underlying contradictions. I have wondered, is it just that there happens to be people in my group who have all been really good in school and have always worked hard in school?... I have wondered, is everybody here like that, that they stress a lot about school? Because I want to think like, you cannot always do everything the way the teachers say; you should also think for yourself, so you do not do something that is useless... You need to question sometimes what the teachers say (K10). I have experienced my peer group as kind of contradictory. There are some cliques in the group, a few of them, which create even more boundaries there. Kind of like an invisible boundary. And nobody says anything about it out loud, but many probably notice it (R08). The counter-narrative of a critical teacher was based on a desire to understand the theoretical foundations of teaching, which were fundamentally different from the traditional emphasis on practice and content knowledge. Engagement in TE occurred through theoretical and critical examinations of educational issues. Issues such as ethics and values in education, the well-being of children and families, and social inequalities were identified as significant in TE. At the same time, the interest in these issues seemed to create boundaries between these student teachers and the typical ones. I feel that I am not on the same page with my peers. Perhaps I am too critical a thinker, questioning things and reality. Little girls who have grown up in a bubble do not necessarily understand the things that I think are important in education. These include issues like inequalities in school and segregation of social realities. Personally, I think it's absolutely essential that the teacher should remove or reduce those in education (R08). As we had a glimpse of this particular student teacher's further study path through the additional data collection, it is significant to note that in the description from the fifth year of studies, the narrative of questioning and critical teacher perception seemed to have led to an experience of being a "non-teacher" at the end of the studies. This can be a concern for TE if the experience of being a "non-teacher" causes people to leave the profession (see also Lanas, 2017). Diverse pupils with various needs require different teachers, and critical and transformative teacher agents are needed to meet societal and educational challenges, such as the needs of increasingly multilingual and culturally and socially resilient schools (see Panti<unk>, 2015;Husu and Toom, 2016;Matikainen et al., 2018;Magill, 2021;Juvonen and Toom, 2023). Diversity would thus be desirable in the future from the perspective of the renewal of the teaching profession. --- Discussion In this study, we have aimed to describe the socially and culturally constructed and shared ways of understanding teaching and its nature as reflected in TE students' speech. We have done this through teacher students' accounts of constructing teacherhood. Hence, even though we have not aimed to describe individual students, it cannot be avoided completely when illustrating the varying construction of teacherhood. Neither has it been our intention to generalize about the changes that TE does or does not bring to students' perceptions of teaching. We also recognize that other communities of practice and influential agents which are beyond our study focus (e.g., family, media, religion, political stance) are contributing to the teacher students' perceptions of teachers' work. However, in our research, we have been able to identify some of the ways in which students discuss and identify TE culture, the potential for change, and the challenges they face. Based on our study, we suggest that to understand how the perceptions of the ideal teacher are formed and how TE could better influence the transformation of these perceptions, we must consider the unofficial power relations among student teachers. These power relations seem to originate prevalently from the hegemonic discourse on the typical student teacher, which contains and might renew traditional perceptions of teaching and teachers as authorities and experts who transmit subject content knowledge and skills to pupils. This discourse seems to be renewed among and between student teachers and have more impact on students' perceptions than the official aims of TE. Thus, in our study, the unspoken sociocultural power relations come to light in different ways, not only in the peer relations among student teachers, but also in their conceptions of teacher educators. As mentioned above, the 2020s teachers are expected to become "change agents" who can critically reflect on and evaluate what types of changes are necessary in education and schools and also implement the required changes. Thus, TE is called for to support student teachers in developing critical reflective views about teaching and learning. This study's results suggest that it is important to support collaborative examination of and critical reflection on teacher perceptions in TE to enable future primary teachers to construct professional transformative and critical thinking. However, the research data in this study was collected in 2014 and 2017, and more current data are needed to examine how recent trends in Finnish education system and regarding teachers' role and expertise are reflected in today's student teachers' views. Nevertheless, the need for teachers' critically reflective societal orientation can be recognized already in the early 2000's educational administrative documentations (e.g., National Board of Education, 2004Education,, 2014;;Husu and Toom, 2016). The master narrative of our analysis appeared to propose social and cultural norms attached to being a typical future teacher. This may restrict student teachers' possible identities and professional agency construction to the targeted modern teacher figure. Furthermore, the traditional views of teachers as experts transferring content knowledge through practical work can be perceived as somewhat contradictory to the goals set for Finnish TE, for example, by the Finnish Ministry of Education and Culture (2016). Based on our study, we also make suggestions on how future teachers' perceptions about the ideal teacher could be better influenced in TE. Culturally and historically shaped conceptions of the teaching profession recur powerfully in the sociocultural environment where student teachers live. For this reason, TE must emphasize the problematization of traditional conceptions of the teaching profession, strongly and unanimously promote the somewhat incongruous (with respect to the traditional visions) conceptions about the modern teacher, and pay attention to the dismantling of student teachers' biases and preconceptions. We suggest that unraveling the unofficial power relations in the sociocultural context of TE and focusing on supporting every student teacher's agency and critical reflection will make it possible to transform the perceptions about the ideal teacher In this regard, to promote critical thinking and democracy education and challenge the TE culture in Finland, certain different experiments have been conducted in TE in recent years, 1,2 but in 1 For example, Critical Model of Integrative Teacher Education (CITE; see Nikkola et al., 2013) is one of the most long-term development projects implemented to break the traditional TE formula. This program aims to reach thinking beyond the traditional understanding of learning and teaching based on core subject certainty. The program is built on the idea that it is more important to understand the complexities of learning than to control them by didactic means. 2 The DERBY study group (see Hiljanen et al., 2021) is built on the idea that teacher training plays a major role in how schools and teachers (and society as a whole) should prepare for the social and cultural challenges of today's world, such as climate change, extremism, and populism, as well as their causes. the big picture, these aspirations still play a minor role. There are also plenty of theoretical models to support this work (see Kincheloe, 2012;Brookfield, 2017;Korthagen, 2017;Dugas, 2021Dugas, ). 10.3389/feduc.2023.1297055.1297055 Frontiers in Education 10 frontiersin.org --- Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- Ethics statement Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article. --- Author contributions AF: Writing -original draft. MJ: Writing -original draft. --- 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.

In Finland, graduating teachers are expected to become "transformational agents" who are able to critically reflect upon and evaluate what types of changes are necessary in education and who can also implement the required changes. However, based on previous studies, teacher education seems to have little influence on future teachers' core perceptions of teacher's work. Instead, previous studies have demonstrated that new teachers' perceptions might draw on tradition and cultural-historical phases of the Finnish teacher profession, and normative ideas concerning the ideal characteristics of a "good" teacher or student teacher. In this study, we examine how student teachers' perceptions of teacherhood build upon and who has the power to define the "ideal teacher." Based on our study, we suggest that to understand how the perception of the ideal teacher is formed and how teacher education could better influence the transformation of these perceptions, we must consider the unofficial power relations among student teachers. These power relations seem to originate from the hegemonic discourse of the "typical student teacher," which contains and renews traditional perceptions of teaching and teachers as authorities and experts transmitting subject content knowledge and skills to pupils. This discourse seems to be renewed among student teachers and has more impact on students' perceptions than the official aims of teacher education. Hence, in our study, the unspoken sociocultural power relations come to light in different ways, in the peer relations between student teachers but also in the students' conceptions of the teacher educators. We suggest that by unraveling the unofficial power relations in the sociocultural context of teacher education and by focusing on supporting every student teacher's agency and critical reflection, it is possible to transform the perceptions about the ideal teacher.

Background At the London Summit for Family Planning in 2012, participation was appreciated as a key principle in ensuring that the goal of providing family planning access to 120 million additional women and girls by 2020, is met [1]. Community members' views play an important role in shaping reproductive health practices [2]. As such, community-based participatory approaches leverage an understanding of the strengths and weaknesses among all the parties involved, as each party aims to solve a common problem, by combining knowledge and action for the social change needed to improve health and eliminate health disparities [3]. Research has shown the growing concern of the gap between evidence produced to improve health in communities [4], and the actual translation of this evidence into interventions and policies, especially among disempowered members of the communities [3]. Community participation, therefore, becomes a major contributor to knowledge generation and translation [3]. Participation is defined as the active involvement of affected populations in decision-making, implementation, management and evaluation of policies, programs and services [5]. Community dialogues are used as a participatory tool in the identification of rural health needs or to improve communication that encourages a common mutual understanding. Dialogues encourage the realization of perspectives and conditions of the other person or party, to identify and prioritize the needs of the community [6][7][8][9]. The dialogues aim to bring together parties that would not normally collaborate and assist them in aligning their thoughts on a particular issue [10]. A community dialogue forum allows the existing knowledge-base of each party to increase with consideration of the perspectives and views of others, and issues can be discussed and debated on in a neutral environment that allows a fair exchange of ideas [11]. Community dialogues have most commonly been used in HIV and AIDS prevention and mental healthcare programs [12][13][14][15]. In West Africa and other locations [8,16], community group interventions have been used to shape healthy sexual and reproductive health behaviours [17]. In assessing whether a community participation programme could increase the met needs for family planning and contraception in Zambian communities [18], the UPTAKE Project tested the feasibility of a community dialogue involving health care providers and community members [18]. In the context of the project, the methodology (intervention) through which healthcare providers and the community were to be engaged was referred to as "The Approach" [9,[18][19][20]. The Approach was developed through well-informed evidence from existing literature [20] and refined through the integration of community, healthcare provider, and other stakeholders' perspectives using qualitative research activities: focus group discussions (FGDs) and in-depth interviews during the formative phase of the Project [19,21]. It defined best practices that addressed four stages in the implementation of a participatory programme: (i) programme initiation, (ii) participant identification and recruitment, (iii) ensuring community and health system dialogue and collaboration [9], and (iv) ensuring sustainability and scale-up [18]. The feasibility testing of the approach focused on stage (ii) and (iii), which involved participant identification and recruitment and ensuring community and health system dialogue and collaboration. The Approach developed a rationale and hypothesized pathways that aimed to reduce the unmet need for contraception within a human rights framework (project Theory of Change, ToC) [9,18,22,23]. The community dialogue methodology was structured around the project ToC, in a more simplified version, to encourage community and health system dialogue and collaboration in identifying possible causal pathways, as well as the requirements and assumptions that needed to be filled to achieve change. In other words, a simplified ToC framework served as a participatory tool to engage both community and health care providers to discuss and define possible causal pathways toward an overall outcome or desired change, which was to address the unmet need for family planning and contraception. They would then collaborate to implement, monitor and evaluate activities for each causal pathway. The community dialogue approach was designed to assess the acceptability and feasibility of bringing together healthcare providers and the community to participate in discussions on improving Quality of Care, QoC in family planning and contraception provision. Early in the formative phase of the UPTAKE Project, QoC was identified as a key intermediate outcome that could lead to increased met needs for family planning and contraception [9,18,20,24]. This was based on the assumption that quality services that respond to the needs of the users and potential users were a requirement for increased demand and utilization of services [25]. Further, considerations were integrated into the Approach following the feasibility testing and finalization of the formative phase research [18]. This paper reports on the feasibility testing of the community dialogue, which aimed to facilitate dialogue between the health care providers and community members, to increase the uptake of family planning and contraceptive services in Zambia. --- Methods Establishing the feasibility of the community dialogue was undertaken in two ways: by conducting the community dialogue and evaluating it. Key stages of the dialogue (Additional file 2: Annexe 2), with representations from the community and health providers, were undertaken. An evaluation of the community dialogue through observations using a standardized feasibility testing ticklist (Additional file 1: Annexe 1) for all observers took place during the dialogue. Also, the feasibility testing evaluation included focus group discussions, FGDs with three groups of stakeholders who had participated in the community dialogue (health care providers only, community members only and a mixed group of health care providers and community members). The observations and discussions evaluated the operational and cultural feasibility of the dialogue, with focus on the following areas: perceived acceptability, demand or estimated use of the Approach, implementation or the extent or likelihood and manner in which it could be implemented as planned or proposed, practicality for deliverability based on resources, time, commitment, etc., adaptation or whether it was necessary to change contents of the proposed approach and finally, integration or the level of system change needed to integrate the proposal into existing settings [9]. --- Recruitment of participants The invitees for the community dialogue were a combination of people from a minimum of three main categories; community members, health care providers, and other stakeholders in family planning and contraception. All three were considered influencers of family planning and contraception decision-making, community participation and representation (Table 1). The recruitment of participants was facilitated by a local district medical officer, who engaged the district nursing officer. The nursing officer facilitated the recruitment of health system representatives: nurses, clinical officers and other family planning and contraception practitioners. The officer also recruited the community (volunteer) health systems representative groups such as the Safe Motherhood Action Groups (SMAGs), the Neighborhood Health Committees (NHCs), and the family planning and contraception users and the adolescents among other community members. Apart from the health care providers and community members, other stakeholders in family planning and contraception were invited by the UPTAKE Project research team. These included the Non-Governmental Organizations (NGOs), the education sector representatives through the District Education Board Secretary (DEBS) and the District Commissioner (DC) -who unfortunately was unable to attend the meeting. In total, of the 30 people invited: 21 managed to attend the dialogue, meeting the 70% minimum requirement that was agreed upon by the project team. Of the 21 attendees, seven were male and 14 were female. --- Evaluation of the community dialogue approach-through observations and FGDs Observations Non-participant observations were used as a data collection method for the evaluation [26], where people who were not participants of the community dialogue were selected to observe the entire session. The observations provided a broad overview of the setting, as well as the entire community dialogue process. The observers carried out guided observations while the community dialogue was taking place using a standardized feasibility testing tick-list (see Additional file 1: Annexe 1). The observers included a project team member, a health system representative and a community member to ensure that diverse views were captured. The health system and community representatives were taking part in the project for the first time while the project team member was more aware of the objectives of the community dialogue activity. This was done to control the observer effect [26]. The three different types of observers controlled any selectivity that could occur if only one (type) of an observer was considered [26]. Observations were also triangulated with the other data collection methods, such as the FGDs. --- Focus-group discussions Following the community dialogue session, three FGDs were conducted to hear from the participants about their views on the entire community dialogue implementation process. The facilitators used a pre-defined guide to structure the discussion. The FGDs explored the following themes: representation in the community dialogue, orientation and ground rules, participation in the community dialogue, the dialogue on family planning and contraception and QoC and the technical, schedule, and cultural feasibility of the community dialogue approach. The FGDs, as a form of participatory evaluation, allowed the participants to air their views on each of the themes. The community dialogue participants were split into three groups for the FGDs: the community member group, the health care provider group, and a mixed group with both the health care providers and the community members. The groups were split to ensure ease of discussion among the group members and they were given the freedom to be in any group provided it was the right category. Each of the focus groups had 5-8 participants. Not all the participants of the dialogue were part of the discussions as they opted not to, or had to leave and attend to their work. --- Data analysis FGDs were audio-recorded with participants' permission, transcribed verbatim, and translated where interviews were done in the local languages. NVivo (Version 10, QSR International), was used to organize and manage the data while thematic analysis [27] was used to analyse the data. The data was read and re-read for familiarity. A code-list, mainly consisting of pre-determined, broad themes was developed based on the key areas in the feasibility testing tick-list (Additional file 1: Annexe 1). New emerging structural and analytical themes were iteratively added to the initial code-list, as data analysis progressed. The data were coded separately by two coders but routinely discussed, to address any coding biases and to enhance inter-coder reliability [19]. Participant observations were noted during the dialogue by project team members and this enabled the triangulation of findings from the FGDs. The three observers' findings from the community dialogue tick-list (Additional file 1: Annexe 1) were also read, aggregated and triangulated with the other community dialogue findings. --- Ethical considerations The process of informed consent was fully adhered to. The informed consent components were discussed with the group, and individual written consent was obtained from each of the participants by members of the UP-TAKE Zambia team, the Principal Investigator, Research Assistant, Data Manager or the other Facilitators. All participants were over 18 years. The entire study, including the feasibility testing, was reviewed by the WHO technical and ethics review boards (A65896). Local ethical clearance was obtained from the University of Zambia Biomedical Research Ethics Committee (UNZABREC) and permissions to work within the Zambian health system was sought from the Ministry of Health. --- Key findings This section highlights the community dialogue implementation process. Thereafter, results according to the participant observations and from the FGDs are presented under the following headings: recruitment and identification (attendance), orientation and ground rules, participation in the community dialogue, the dialogue of FP/C, and QoC, technical, schedule and cultural feasibility. The community dialogue process The community dialogue was conducted at a location in a suburban district of the Lusaka, outside the project intervention district. The entire dialogue took 125 min, with a 20-min break. The dialogue sessions were divided among three facilitators who were project staff members, according to 3 sections: 1) Orientation, 2) Establishing ground rules, 3) refining the ToC approach (Additional file 2: Annexe 2). --- Agendas for community dialogue meeting The first presenter gave a detailed background to the project, its goals, and the aims of the community dialogue. This activity lasted 20 min. The participants were then asked to suggest some ground rules that they felt would guide community dialogue. The ground rules session took 15 min. The ground rules for the dialogue included: having respect for other people's opinions, speaking loudly, setting mobile phones to vibrate or be silent, raising hands if they wanted a chance to speak, not having any side meetings, participating actively, staying on topic during the discussions, acknowledging that all the participants in the room were equal, confidentiality-no one's opinion would be revealed after the meeting ended or any time thereafter. Reference was made to the ground rules throughout the dialogue. This was then followed by an FGD with the community dialogue participants to get their views on the entire dialogue process, and how it could be improved. After setting the ground rules, the first facilitator presented the simplified ToC to the participants. This part aimed to show the participants how the discussions would lead to the overall outcome, which was to reduce the unmet need for family planning. To explain further how the ToC was going to be used, a simple dry-run was done. A discussion, led by the second facilitator, was introduced to identify the assumptions and causal pathways to improved QoC in family planning and contraception provision. The intermediate outcomes were then discussed, with activities and assumptions for each outcome. Some of the intermediate outcomes included: having qualified health workers, the availability of preferred methods at the health facilities, having more respect for clients and having more equipped family planning areas. This activity took 60 min. Once the causal pathways, activities and assumptions had been identified, the third facilitator led a discussion on identifying the most feasible and acceptable pathways with regards to acceptability, demand, implementation, practicality, adaptation and integration of the pathways. This criterion was based entirely on each participant's opinion and participants were encouraged to speak freely on the 'best' pathways that could achieve more than one intermediate outcome. This activity took 90 min. After the discussions using the ToC participatorytool had been concluded, the first facilitator wound down the discussion with a summary of the community dialogue activity, concluded and thanked the participants for their active contributions throughout the discussions. --- Observations and focus-group discussion results --- Recruitment and identification of dialogue participants During the FGDs, while some health care providers felt that there was adequate representation in the community dialogue, the community members mentioned that the dialogues required more representative participants to produce even more relevant results. For example, there was a need for political leaders to also be represented. An adolescent said: "We were not represented properly because were outnumbered, others were more [than us], but we were just a few of us (...)" --- [Community focus group discussion, Adolescent] The community members also mentioned a need for representation from the churches and other faith-based organizations since it was recognized that they played an important role in shaping reproductive health behaviours. The community members also stated that the Community Health Workers were well represented, but that the pharmacists were needed to bring out more information on the vastly experienced stock-outs of family planning and contraception supplies. "(...) I think to be specific, we should have some representatives from churches, yes, and from the political wing, the stakeholders they should have called them because they are part of it (the discussion on family planning and contraception) as well." [Healthcare provider focus group discussion, Healthcare Provider] From the observations, it was noted that the adolescents' turn-out was less than the intended number (2 out of 3). A bigger proportion of community members did not attend., while almost all the health care providers invited attended the meeting. --- Orientation and ground rules The participants felt that ground rules were appropriate since they all took part in creating them. Participants reported that they were able to remind themselves and each other to follow the rules because they were displayed throughout the discussion. Participants appreciated the importance of the rules in maintaining organization and order throughout the dialogue. A participant had this to say: They (ground rules) came from the participants, it was not imposed on the participants, but it's the participants that came up with those rules." [Mixed focus group discussion, Healthcare Provider]. One of the young people, among the community members, on the other hand, felt that the rules should have been explained in more detail for him to understand what they meant. It was assumed that all the rules were understood because they came from the participants. An adolescent said: "I did not understand the first one, the one that says speak through the chair, and do you speak alone or...?" [Community focus group discussion, Adolescent]. --- Participation in the community dialogue During the dialogue, there was a consensus among the participants that English was suitable for the articulation of ideas by participants, whether they were from the health sector or not. However, some community members during the FGDs mentioned they could have expressed themselves better in the local language despite agreeing to use English during the dialogue session. Other members of the community felt as if the discussion was specialized or technical, especially when the health care providers spoke. The use of technical language and abbreviations during the dialogue was discussed during the FGDs. With regards to the presentations during the dialogue, community members indicated that where some acronyms they did not understand, hence on some occasions, they could not answer appropriately. ".. the language; it is not everyone that has been to school or up to grade12, at least there was supposed to be a mix up of language with English because some of us work in the community and we use local languages. So somehow to some of us, some words were big (complicated or unfamiliar jargon)." [Community focus group discussion, Community Member]. During the FGDs, young people also mentioned that they felt English was the most appropriate language to use. However, some terminologies and acronyms were complicated for them but they felt too shy to ask. "Like the term 'integration', that term yes was not clear." [Community focus group discussion, Adolescent]. A community member, who sat next to a young person during the dialogue also felt that the youth were unable to ask what the terms meant in the larger group. It was much easier for them to inquire from their neighbours in the meeting and not through the moderator. "Oh yeah, okay they (terminologies) were coming from us participants and some community health workers because those are normal terminologies, but it might have been different from teachers, those are not like, this man (name mentioned) am sure he is very aware of them, but there are community workers who are from teaching maybe like my son here, the adolescent, he is not familiar with those terminologies." [Healthcare provider focus group discussion, Healthcare provider]. From the observations and interviews, community members participated well in the community dialogues despite being outnumbered by the health care providers in the meeting. Overall, both the community members and the health care providers, as well as other stakeholders, reported during the FGDs that they felt free to speak their minds and participate as this was reinforced by one of their ground rules (having to no wrong answers). One health care provider had this to say: "I feel there were no barriers because people were able to express whatever they wanted to say and no one was opposing even when the answer that one gives or opinion that one gives was not opposed...". [Mixed focus group discussion, Healthcare provider]. A community member also said: "Actually, it (the dialogue) was something that was good, it is important once in a while to meet together with the community and the health providers because, for health providers, there is nothing that we can do without the community, cause or anything sensitization and other things we depend on the community so the community should be given information on everything that is there in the health facility. So we are represented, it's a link actually between the community and the health Centre, and so these representatives are important to us and the health providers because they are the ones who speak to us and whatever we want from the community we ask these people to speak for us." [Community focus group discussion, Community Members]. It was observed that the adolescents also expressed themselves by bringing out issues that affected their access to family planning and contraception information and services. However, they were not entirely free to speak and required active encouragement from the facilitators. This was attributed to their discomfort speaking out in a public forum and feeling outnumbered by the adults. --- Dialogue on family planning and contraception and QoC Despite the feeling that the health care providers were more familiar with the topics being discussed, the community members felt able to express their views on the subject of QoC in family planning and contraception. A healthcare provider said: "I think it was okay, we have interacted freely, openly and we have understood each other's views, and from this, I think we are picking a leaf for forward (to move forward) in life". [Healthcare provider focus group discussion, Healthcare providers]. FGD participants agreed that access to family planning and contraception information and services was vital. They agreed that this was an area that needed to be deliberated so that overall unmet need could be reduced. The participants also mentioned the benefits of family planning and contraception and that there was more work to do regarding sensitizing the community about the different options they had. They made specific reference to the need for more 'appropriate' information and services among the youth. "I would concur with her (fellow participants) because of the unwanted pregnancies mostly, and they end up to have unsafe abortions, so if the services are given to these adolescents, I think it will prevent the abortions and unwanted pregnancies among the youth." [Healthcare provider focus group discussion, Healthcare provider]. Conversely, an education sector representative expressed reservations, especially regarding the dissemination of all family planning and contraception information with the youth. The representative felt adolescents were too young and that this information needed to be altered to make it more age-appropriate. Without such censoring, the information was seen to increase the rates of promiscuity among the youth. Despite such dissent, all the participants agreed that the dialogue allowed them to learn from each other, and they agreed that they had different viewpoints concerning QoC-health care providers viewed quality from the supply side while community members viewed it from the demand side. For example, the lack of certain services such as the Intra-Uterine Device was attributed to staff shortages and not negligence on the health care providers' part. This was discussed during the dialogue. "I would say it was good because there were some divergent views before we could come to agree because we were also given opportunity to argue, and try to raise some concerns, challenges that we need, and also what the community is complaining, but at last we agreed to say we have to work together, we need to prioritize our systems and working so that both of us benefit." [Community focus group discussion, Community Member]. From the observations, some strong differences in opinion about QoC were noted between the community members and the health care providers. During the FGD discussion, participants concluded that they were looking at QoC, but from different perspectives-the supply side and the demand side. "(...) yes I think this was a very good discussion, this one has helped since we have people from the district office: education, it will help them plan, how can we get out there to the children, how can we reach them with this information and we also heard their blocks/obstacles and all this. So we didn't know as health providers that we also have a limit. We thought it was easy for us to go and talk about sexuality openly in their schools. So I think it was a very good thing that at least even as health workers will know how we are going to take it when we meet a child who is ours and will not behave like a parent but as a health service provider(...)" [Mixed focus group, Healthcare provider]. When asked about their view on the importance of the discussion on QoC, all the participants reported that they agreed on both the definition and the key constitutes of QoC. They could explain what they thought should constitute QoC even though a single definition was still a challenge to achieve among the various stakeholders invited. A young person felt he expressed his fellow young peoples' views-that the healthcare provider needed to be more welcoming at health care centres. "It was useful such that it kind opened up on how the people in the health centres talk to the adolescent when they come to ask for help from them like if you want to ask for a condom, they shouldn't go like" as young as you are" and all." [Community focus group discussion, Adolescent]. A health care provider said; "I think we did agree on what Quality of Care is as a community and the health care providers and that's the more reason why we came up with those terms, yes we were very free to express ourselves and even after expressing ourselves although seemingly we were putting the health provider in a squeeze position but no it was so nice that at least both parties were able to understand, where each one of us is coming from and then at the end of the day we fully realized how important and the stressful conditions that this other person is in." [Mixed focus group discussion, Healthcare providers]. --- Schedule feasibility It was observed that most of the participants found it difficult to get acquainted with the topics being discussed. As the participants got more familiar with the dialogue topics, and what was needed of them, the meeting became more interactive. Some community members in the FGDs noted the need for more time to be allocated to the discussions. A need for more time was requested, to provide the participants with more room to express all their opinions and ideas. It was reported that since participants were from different locations, each one of them needed to be actively given a chance to take part in the dialogue. The time limitation was attributed to the pace of the richness of the discussion. Participants felt that the activity was much clearer towards the end of the allocated time for the discussion. This is when they felt even more encouraged to express their opinions. "The duration of the meeting was... we needed to be here for two days or so." [Community focus group discussion, Community Member]. On the other hand, a few community members felt the time allocated to the dialogue was sufficient. However, certain participants (healthcare providers) had too much time to speak compared to the others and that there needed to have been some control in the time allowed to speak. "Yes, I think it was ok except that other people dominated the floor, and I feel other people would have also benefited to make their views known but some people took most of the time." [Community focus group discussion, Community Member]. Interestingly, the health breaks between sessions were appreciated, as it was noted that they allowed participants to refresh themselves. --- Cultural feasibility Though mentioned briefly, all the participants felt the community dialogue approach was culturally sound. This is because it allowed them to address a common problem; reducing problems associated with unmet need for family planning and contraception. A community member further added that there was a need for more representation from the community to further determine the cultural acceptability of the Approach. In other words, if more representatives from different sectors were invited to share their views, then the cultural acceptability would be clearer. They said: "The approach was quite okay like we are saying, we know society is dynamic and we move with time and trends that we have previewed at that particular time, but am sure like we heard from the young man, he said he could not come so easily because he was amongst the elders, because our tradition says that they are certain things that we can easily mention in the public, others we cannot. Although in this forum, it wasn't coming out like hinting so much on our tradition. [Community focus group discussion, Community Member]. However, others still felt that the approach dealt with an issue that was seen to potentially be problematic to discuss if certain members of the dialogue were present or had more representation. "I feel it [the approach] cannot be applied especially in the religious context, for instance, if the girls are introduced to using family planning, it is like you are telling them to start engaging in sex. Whereas religious in the bible the bible says children not to start engaging [in sex] until they get married. So if you give them contraceptives, it is like you are telling them to go ahead and have sex." [Community and Healthcare Provider HCP]. Technical feasibility: the use of visual aids during the community dialogue In the FGDs, participants mentioned the usefulness of the aids used during the dialogue: the flip chart, the one-pager documents with information of QoC and the unmet need for family planning and contraception, and the Power-Point presentations, especially during the discussion on the different pathways, activities and assumptions. (...) because we were able to get everything they were teaching there (able to use the visual aids). [Community Member focus group discussion, community member]. The participants also felt that the aids used were able to open up their minds to the broader project context, and give them even better ideas about what would or would not work in the Zambian context. Community members and health care providers were able to understand more about what the aim of the dialogue session was. "I am talking in terms of how the program started because we were using PowerPoint we were able to see the definition, we would start by introducing the background of the project itself, we learnt that the project is running in three countries so we were able to understand (...)." [Healthcare provider focus group discussion, Healthcare providers]. --- Discussion This paper aimed to document the feasibility of a community dialogue approach bringing together health care providers and the community to reduce the unmet needs for family planning and contraception in Zambia. Factors that influenced the implementation of the community dialogue during the community dialogue and subsequent evaluation through FGDs are highlighted in the discussion. --- Positive attributes of the community dialogue The participants generally agreed that family planning and contraception were important issues that needed to be discussed, despite coming from different backgrounds. They understood that key barriers to the provision of family planning and contraception services, as well as uptake in the community needed to be explored and addressed. Such success has been reported in other dialogues in family planning, suicide and HIV prevention as they aim to achieve a common understanding of the problem [12,15,28]. The dialogue ensured a shared understanding of the problem and the steps that needed to be taken for that problem to be solved. Participants mentioned that they learned more than they knew about family planning and contraception before the dialogue, a finding similar to Tesfaye in Ethiopia on curbing HIV using community dialogues who found that this was a key driver of implementation [13]. Adding to the evidence in Zambia on participatory interventions in family planning and contraception, this study suggests the feasibility of the Approach and the possibility of the success of such a complex-designed intervention in the Zambian context [2,20]. Divergence in the categories of people invited enriched the meeting as it facilitated increased representation from the community and from the health sector too, similar to what was found in South Africa [9]. The dialogue approach facilitated the engagement of the community and health care providers as it was viewed as feasible, despite cultural influences that shape family planning and contraception outcomes. The use of a community dialogue forum or platform for the different stakeholders allowed a deeper understanding of the other participants' views, who they previously blamed for hurdles in service provision. However, a need to be proactively aware of the power dynamics [20]-especially where the healthcare providers were more conversant with the subjects under discussion was noted. A more inclusive approach to sharing time on the floor to air opinions is suggested. Regarding orientation and ground rules, the process was appreciated as this triggered and ensured ownership of the rules by the participants. Since the participants took part in the development of the rules, share in feelings of the rules being imposed on them by outsiders (facilitators). The rules were thus acceptable and were adhered to. --- Considerations for refining the approach Adequate representation ensured that divergent and varied viewpoints were considered and in the discussions, and for a new shared understanding to be developed. The importance of representation from a wide range of stakeholders was stressed in other community dialogues however, this could only be addressed after an evaluation of the dialogue, and suggestions for more stakeholders were made [9,12,13]. A consideration for refining the approach was the engagement of the religious and community leaders in the dialogue. Also, considering that all the health system participants attended the meeting compared to the community members, inviting more community members could actively increase representation. Besides, the adolescents also felt that they were outnumbered by the adults. Another consideration for the success of other such dialogues involving the youth would be to conduct separate dialogues for the young people, but still have them represented in the larger dialogue sessions. This would be a key response to the unbalanced power relations between the younger and older participants. A need to gain more insights from the actual users of family planning and contraception services was mentioned. In this case, the participants were selected and invited into the discussion as'representatives' from the community but not really as 'users'. Therefore, the user perspectives were missing in the discussion. During the preparations, efforts were made to identify various categories of stakeholders, and more potential participants were suggested during the dialogue, amplifying the importance of the feasibility testing itself. Allowing more time for the discussions was suggested as participants were more eager to express their views as they got more familiar with the topic. For more meaningful dialogue and understanding of the shared problem, there was a need for more time to discuss the causal pathways to change. This is similar to Tesfaye's finding in Ethiopia [13], though this study had over 60 participants, which is over twice the number of participants invited to the feasibility testing. This points out the need to be balanced in the total number of participants invited to the dialogue and to be mindful of the time taken for the overall dialogue [9]. The language used required more consideration, as some participants may not have been as eloquent as was thought with one language. The consideration of using clear and direct language was made during the discussion on ground rules. Much as the team thought the language was addressed, there was still a need to address terminologies and to continuously assess the ease of use of one language during the discussion. Crankshaw et al. (2019) in South Africa found that bilingual notetakers during the dialogue process were useful in facilitating language complexities [9]. Also, the use of multilingual facilitators could have addressed the language barriers encountered. A study to facilitate dialogue in HIV revealed that language was considered before the meeting, and all the facilitators were multilingual, according to the community targeted [13]. Active usage of more than one language proved useful. The facilitators of the community dialogue meeting needed more training on using the ToC tool to facilitate the meeting. This would reinforce the importance of creating the space for dialogue, ensuring the respectful expression of diverging views, and to fully understand the desired outputs of the intervention. --- Limitations and strengths One of the limitations of this feasibility testing is that it was a one-off meeting, and some of the other components of the Approach were not tested during this meeting. Also, some of the issues, such as the cultural feasibility of the approach, could have been explored further in subsequent meetings. However, the feasibility testing (community dialogue) stage of the intervention was a vital stage in the development of the Approach and valuable information was obtained from the evaluation. Regarding the methodology, some observations may have brought out some subjective findings [26]. This was addressed by selecting three different types of observers [29] to clarify any observer biases. These findings were also triangulated with the findings from the FGDs [29]. Finally, while the feasibility testing was nested in a participatory approach that aimed to bring together healthcare providers and the community members, this refinement stage of the development of the intervention achieved the "the edge effect," as coined by Burton and Keagan (1999) [30]. This means the community benefited from the knowledge and contact facilitated by the research project by meeting, interacting and sharing information for mutual growth and benefit to all members of the community. --- Conclusion The participants of the feasibility testing accepted the community dialogue approach. The participants were able to deliberate solutions to a shared problem and they had enriched views due to the diversity of representation during the dialogue. Despite coming from different backgrounds and having different viewpoints, this platform allowed them to agree on the importance of and have a shared understanding of the problem-high unmet need for family planning and contraception. Participants suggested solutions that were acceptable to all the participants despite their differences, and dissenting views were also allowed and considered. It is important to note, however, that certain factors need to be taken into consideration to yield more rich discussions. Great emphasis on language of choice is stressed and discussions would benefit from multilingual facilitators. A need to identify and prioritize views from more marginalized persons such as the adolescents, in this case, would prove essential too. --- Availability of data and materials The data are not publicly available as it contains information that could compromise research participant privacy/consent.

Background: Community dialogues have been used in participatory approaches in various health prevention and awareness programs, including family planning interventions, to increase understanding and alignment of particular issues from different peoples' perspectives. The main objective of this paper is to document the feasibility of a community dialogue approach, which aimed to promote dialogue between healthcare providers and community members. The feasibility testing was part of formative-phase research needed to design an intervention, with the ultimate goal of increasing the uptake of family planning and contraception. The community dialogue intervention generated discussions on key approaches to improve family planning and contraception provision and uptake. Methods: Key stages of the community dialogue were undertaken, with representation from healthcare providers and community members. Participants included frontline and managerial health care providers, community health workers, family planning and contraception users, the youth, other stakeholders from the education sector, and civil society. How the dialogue was implemented (operational feasibility) as well as the cultural feasibility of the community dialogue content was evaluated through participant observations during the dialogue, using a standardised feasibility testing tick-list, and through focus group discussions with the stakeholders who participated in the community dialogue.

and Keagan (1999) [30]. This means the community benefited from the knowledge and contact facilitated by the research project by meeting, interacting and sharing information for mutual growth and benefit to all members of the community. --- Conclusion The participants of the feasibility testing accepted the community dialogue approach. The participants were able to deliberate solutions to a shared problem and they had enriched views due to the diversity of representation during the dialogue. Despite coming from different backgrounds and having different viewpoints, this platform allowed them to agree on the importance of and have a shared understanding of the problem-high unmet need for family planning and contraception. Participants suggested solutions that were acceptable to all the participants despite their differences, and dissenting views were also allowed and considered. It is important to note, however, that certain factors need to be taken into consideration to yield more rich discussions. Great emphasis on language of choice is stressed and discussions would benefit from multilingual facilitators. A need to identify and prioritize views from more marginalized persons such as the adolescents, in this case, would prove essential too. --- Availability of data and materials The data are not publicly available as it contains information that could compromise research participant privacy/consent. However, some anonymized aspects of the datasets may be available upon request and with permission of the Department of Sexual and Reproductive Health and Research, World Health Organization. Note that data sharing is subject to WHO data sharing policies and data use agreements with the participating research centers. --- Supplementary information Supplementary information accompanies this paper at https://doi.org/10. 1186/s12913-020-05589-5. Additional file 1: Annexe 1. Feasibility Testing Tick-list. Additional file 2: Annexe 2. Feasibility Testing Agenda. Abbreviations DC: District Commissioner; DEBS: District Education Board Secretary; FGDs: Focus Group Discussions; NGOs: Non-Governmental Organizations; QoC: Quality of Care; SMAGS: Safe Motherhood Action Groups; ToC: Theory of Change; WHO: World Health Organization --- Authors' contributions The study conception and design was done by PS, JC and TN as well as the other principal investigators on the project from Kenya and South Africa. MM, TN and AS contributed towards data collection, MM and AS analyzed the data and MM drafted the manuscript. TN AS, JMZ, JC and PS contributed towards the revision of the manuscript. All authors read and approved the final manuscript. --- Ethics approval and consent to participate Written informed consent was administered and voluntary participation was adhered to. The entire study was reviewed by the WHO technical and ethics review boards (A65896) and local ethical clearance for the study, including the feasibility testing was obtained from the University of Zambia Biomedical Research Ethics Committee (UNZABREC) and permissions to work within the Zambian health system was sought from the Ministry of Health. --- Consent for publication Not applicable. --- Competing interests The authors declare that they have no competing interests. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Community dialogues have been used in participatory approaches in various health prevention and awareness programs, including family planning interventions, to increase understanding and alignment of particular issues from different peoples' perspectives. The main objective of this paper is to document the feasibility of a community dialogue approach, which aimed to promote dialogue between healthcare providers and community members. The feasibility testing was part of formative-phase research needed to design an intervention, with the ultimate goal of increasing the uptake of family planning and contraception. The community dialogue intervention generated discussions on key approaches to improve family planning and contraception provision and uptake. Methods: Key stages of the community dialogue were undertaken, with representation from healthcare providers and community members. Participants included frontline and managerial health care providers, community health workers, family planning and contraception users, the youth, other stakeholders from the education sector, and civil society. How the dialogue was implemented (operational feasibility) as well as the cultural feasibility of the community dialogue content was evaluated through participant observations during the dialogue, using a standardised feasibility testing tick-list, and through focus group discussions with the stakeholders who participated in the community dialogue.

Introduction Much of the initial excitement surrounding the Internet revolved around its impact on space (see Benedikt, 2000;Castells, 2000). Social commentators at the time spoke of "a world of digital sensation" [1], "free from the constraints of geography" [2]. Negroponte (1995) predicted a future in which people would "socialize in digital neighborhoods in which physical space [was] irrelevant" [3]. Friendships in this new environment were expected to emerge through a confluence of interests rather than proximity (Baym, 2015). The famous "No more there" commercial run by MCI in 1994(No More There, 1994) captured the zeitgeist when it imagined the Internet dismantling the social barriers of distance. While the Internet's broader impact is unquestionable, the suggested effect on physical space was never fully realized. Physical space still matters as much as it ever did (Massey, 2005). After all, the rise of social networking sites has seen people's online connections resemble their off-line, spatially bound, networks rather than the more spatially dispersed interest-based sociability of chat rooms or MUDs (boyd and Ellison, 2007). Many digital applications are now specifically designed to connect people to their physical surroundings and shift content as people move through space (Wilken and Goggin, 2015). The 'power of the Internet' has accordingly been harnessed "to facilitate connections between people based on geographic proximity" [4]. The GPS functionality of smartphones means that digital information can now be tethered to specific locations, just as it can be accessed on the move. For Silva (2006) this intermingling of physical world environments with digital space has produced what she refers to as 'hybrid space.' As Saker and Evans (2016b) suggest, this 'hybrid space'"[gives] rise to new embodied experiences and social connections in place" [5]. Yik Yak, which was a popular location-based social application, was a recent example of this potential. Launched in 2013 by a pair of college graduates (Shontell, 2015), Yik Yak quickly became somewhat of a phenomenon with young people (Hess, 2015). The founders raised well over $US60 million in venture capital funding and earned a valuation of over $US400 million within a year of the application's creation (Shontell, 2015). Based on the design of earlier location-based applications like Whisper and Secret, Yik Yak allowed users to anonymously publish and read short posts (though the application made a slight shift towards optional persistent identities in 2016). At the same time, Yik Yak represented a different type of anonymity than sites like 4chan because of its engagement with physical proximity. The posts, or "yaks" as they were commonly called, people could see are determined by their physical location. In denser areas, only posts made within a radius one and half miles were available. In less dense areas, the radius could range up to 10 miles. In October 2014, the application was updated to incorporate a "peek" function. This feature allowed users to "peek" into other locations by choosing from a list of (typically) college campuses or placing a pin on a map and seeing nearby "yaks." After the data collection for this study was completed, Yik Yak also added a "base camp" from which people can post to regardless of their location and optional avatars. Yik Yak closed in April 2017 after going through multiple design interations. The application shut down in part because of the many controversies surrounding Yik Yak's combination of anonymity and location-based sociability. Originally, the application was nearly completely anonymous, only requiring a phone number and not requiring persistent pseudonyms or allowing people to post pictures. As discussed below, that design led to initial popularity but also outcries about sexism, bullying, and racism. The designers then switched to more persistent pseudonymous identities and enabled people to post pictures, but the switch was not popular and not enough to save the application. Consequently, despite initial popularity and excitement from venture capital, the application became extinct in 2017. The analysis in this paper reports on the usage of the application from November 2014 to March 2015. At that point, the application was fully anonymous (at least to end users) and required no pseudonyms or even an e-mail address to register. As we detail in our discussion, however, the analysis in this article will hopefully be useful regardless of application. After all, Yik Yak was only one of many anonymous sites online and one of many social applications that use location. Consequently, the data detailed below will shed light more broadly on practices of location-based, anonymous sociability. Yik Yak has been the topic of much debate. For the most part, discussions have revolved around the anonymity the application affords its users and the controversy surrounding cyberbullying, racism, and generally unpleasant discussion threads (Dewey, 2014;Mahler, 2015;Stone and Kingkade, 2014). We contend that the focus on the occasionally antisocial effects of concealing one's identity has overshadowed Yik Yak's function as a tool to contextualize and approach a specific locality, a tool that displays data tied to the mobility of the user. As we show through our data analysis, Yik Yak often worked as an exemplar of how the networked connections of locative mobile media could affect how people engaged with physical space and how they understood the shifting spatial dynamics as they moved from one place to another. Drawing on six months of ethnographic research and interviews with 18 Yik Yak users, the chief aim of this paper is to examine how people use location-based social applications to shape their sense of locality and how the mobility of the body changes the flow of digital information. We also contend with how the anonymity of Yik Yak combined with location-based sociability enabled unique usage patterns. While the literature review and discussion focuses predominantly on Yik Yak's role as a form of locative media, we also examine how anonymity shapes how people communicated place through the application. To situate our argument, the ensuing literature review provides a detailed analysis of location-based mobile applications, paying particular attention to the relationship between mobile social media and place. We begin with an examination of early mobile social networks before moving on to more recent examples of locative applications and linking this research to the mobilities turn. We then discuss the methodological approach underpinning this research before detailing our data analysis and concluding with a discussion of why Yik Yak represents unique ways in which mobile social media can impact how people engage with place. The main contribution of this article is to both build on existing research on location-based social media and provide an exploratory, original contribution by analyzing how issues of space and mobility interact with anonymity to shape experiences of the physical world. Importantly, while our analysis focuses on the now defunct Yik Yak, our findings extend past this specific application to provide further insight on the social impacts of locative media. As we discuss, information accessed through the Internet is increasingly shaped by physical location, requiring exploratory research into how digital information becomes a new type of "lens" through which people engage with their surroundings (Dourish and Bell, 2011). --- Locative media and place Mobile phones were often viewed as negating the importance of space and place. With landlines, location was key. After all, phones were tied to locations, not people (Wellman, 2002). In contrast, mobile phones made it possible to communicate while on the move, negating the importance of being located at a specific site to receive a call. The ability to coordinate while mobile meant coordination and communication were no longer as spatially bound (Katz and Aakhus, 2002;Licoppe, 2004;Ling, 2004), just as it meant people could partially detach themselves from their physical surroundings to communicate with distant others, a phenomenon referred to as "telecocooning" (Habuchi, 2005) or "absent presence" (Gergen, 2002). Essentially, the mobility of mobile phones often made the importance of physical surroundings less significant than the connections made with distant others. Even as mobile voice calls and texting became dominant forms of communication, examples did exist of how mobile phones could connect, rather than detach, people to their surrounding space. A notable example of such a service is the mobile social network Dodgeball (Humphreys, 2007). Active between 2003 and 2009, Dodgeball enabled users to compile a list of friends and then broadcast their location to those friends through a single text message. Humphreys' (2010) research on Dodgeball identified a process she refers to as 'parochialization'. Parochialization, a term she developed from the work of Lofland (1998), occurs when individuals experience urban environments as being more welcoming when they know similar others are present in the location. In other words, these individuals felt more connected to a place when they knew other Dodgeball users were similarly frequenting that environment. Put differently, these individuals used the digital data of the text message to enact an altered relationship with their physical space. Mobile social networks have since been superseded by location-based social networks (LBSNs) that utilize advanced locative capabilities and Internet connectivity of smartphones. While there have been many prominent examples of such applications, including Google Latitude, Gowalla, and Whrrl, Foursquare was the most successful LBSN (Frith, 2012). Following its launch in 2009, Foursquare gained over 50 million users before moving its location-sharing functions to a separate application called Swarm in late 2014. As a result of its popularity, Foursquare has been the subject of much research. The application has been examined in the context of modifying approaches to mobility (Frith, 2013), sociability (Bertel, 2013;Cramer, et al., 2011;Silva and Frith, 2010;Frith, 2014;Licoppe, 2014), place (Frith, 2015;Humphreys and Liao, 2013;Ozkul, 2013), and gamification (Frith, 2013;Saker and Evans, 2016b). A body of work has similarly coalesced around Internet-enabled, locative mobile media as a more general category (Silva and Frith, 2012;Farman, 2012;Frith, 2015;Wilken and Goggin, 2015). Studies have shown that the constant connectivity locative applications enable can produce an enduring sense of co-presence between known users (Ling and Horst, 2011;Rainie and Wellman, 2012), provide new opportunities for coordinating social meetings (Campbell and Kwak, 2011;Wilken, 2008) and deepen placebased connections (Humphreys and Liao, 2013). The focus on locative application and their effect on space and place has more recently extended to other areas such as memory (Frith and Kalin, 2016;Kalin and Frith, 2016;Ozkul and Gauntlett, 2013;Saker and Evans, 2016a), temporality (Saker and Evans, 2016a), and the use of location as a modality of identity (Schwartz and Halegoua, 2015). While the popularity of early locative applications might have waned somewhat (Frith, 2015), the inscription of place and movement through locative media has not. Over time the use of location has been mainstreamed into many other types of social media. People embed location in Instagram photos (Hjorth and Pink, 2014), share location on Facebook (Bertel, 2013;Wilken, 2014), use location to find people on dating applications like Grindr (Licoppe, et al., 2016), and organize search results on location-based review applications like Google Places and Yelp (Barreneche and Wilken, 2015;Wilken, 2014). As Frith (2015) has argued, to understand location-based mobile applications, and indeed hybrid space (Silva, 2006), one must both appreciate the information accessed through the application and how physical space influences that information. Or to put it differently, location-based mobile media of various types can become a "lens through which the spatialities of urban space can be viewed" [6]. Yik Yak, however, was different from the locative applications detailed above. It was not a social network (people do not have "friends") or a spatial search application to sort through location-based reviews. Instead, it was more like an anonymous Twitter (though people do not "follow" other users) that is spatially bound through the location awareness of the smartphone. Perhaps unsurprisingly, given that computer-mediated anonymity has long been associated with antisocial behavior (Christopherson, 2007;Moore, et al., 2012), Yik Yak's popularity was accompanied by significant controversy stemming from the negative aspects of anonymity (Hess, 2015). These controversies in turn dictated much of the interest that surrounded the application. Reports about Yik Yak linked it to the spreading of rumors, bullying, and anonymous threats (Kulp, 2014). Notable cases of racism, and sexism at universities led to calls for the application to be banned (Callendar, 2014;Stone and Kingkade, 2014), with some universities actually prohibiting its use on campus (Orenstein, 2015;Rose, 2015). Anonymity is not, however, by default a bad thing (Spears and Lea, 1994). In contrast to the overall push online away from anonymous communication, "[some] scholars have questioned these design approaches, suggesting that anonymous contributions and ephemeral participation online can be desirable" [7]. As boyd (2012) has posited, anonymity can enable people to exert power over their identity choices and the ways they communicate online. Likewise, multiple social researchers have shown that individuals can use anonymity to strategically accomplish goals, and that many of these goals exhibit prosocial rather than antisocial behavior (Hogan, 2013;Lampe and Resnick, 2004;Leavitt, 2015;Qian and Scott, 2007). The argument that anonymity does not necessarily contribute to an explosion in antisocial behavior was also echoed in one of the few empirical studies of Yik Yak content. Black, et al. (2016) performed a content analysis of Yik Yak and found that inflammatory posts were not very common and only.3 percent of posts contained an individual's first or last name. That result was partially echoed in a content analysis by Saveski, et al. (2016) that found that Yik Yak did not feature a significantly higher number of inflammatory posts than non-anonymous Twitter. However, in an analysis of Yik Yak's design features, Li and Literat (2017) argued three featuresanonymity, hyperlocality, and the voting function -"can turn the app into fertile ground for vitriol, particularly in the sociocultural context of the college campus." The voting function was present in the iteration of the application we studied, and people could upvote or downvote posts. When a post reached -5, it disappeared from the feed. Otherwise, people got "Yakarma" that totaled the cumulative number of upvotes on their posts. We return to these studies in the discussion section in which we situate our findings within existing research on the social impacts of Yik Yak. Anonymity is only half of the design that made Yik Yak interesting and unique. The other half, location awareness, is just as important for understanding how people use the application and how it fits within the growing literature on mobile social media. While the application is different from other locative applications, existing research on location-based mobile media and place nonetheless provides valuable analysis for how people employ mobile interfaces to engage with their physical surroundings. Building on that literature, this paper argues that Yik Yak represented a tool people could use to communicate about place, a tool they used to interact with their surroundings in relatively novel ways. With this in mind, the article uses Yik Yak to specifically examine how similar applications could contribute to new forms of spatial engagement. --- Methods Our qualitative work focused on one specific city that we describe in more detail later in this section. After receiving IRB approval, we checked Yik Yak multiple times a day from October 2014 to March 2015 and took notes each day on the different behaviors observed from users. Screenshots of user practices were similarly captured throughout this period and then returned to later during data analysis. We made the choice of screenshots to capture inductively. Following the tenets of grounded theory (Glaser and Strauss, 1967), we did not begin our observation with pre-determined research questions and we did not read existing Yik Yak research before beginning our data analysis. Instead, we captured a variety of interactions in our observational period and used those observations to shape our initial interviews. After three months of observation, we began recruiting interview participants. We waited three months to allow sufficient time to establish a base of inductive knowledge concerning how people use the application and what areas should be covered in our exploratory interviews. Our recruitment strategy involved posting details of the project to the city's subReddit, posting to Yik Yak (we asked people to use the instant messaging application to reach us), and speaking to known students. In sum, four participants were recruited through Reddit, nine participants were recruited through Yik Yak (they contacted us through the messaging application Kik), three participants were referred to us by other participants, and two participants were former students of one of the researchers. In total 18 Yik Yak users were interviewed, with interviews lasting between 40-90 minutes, resulting in 21 total hours of interview data. Except for one interviewee who was 36 years old, participants were between 18-23 years old. Participants included 10 female users and eight male users. 16 of the 18 participants were enrolled in university at the time of the interview. These demographics are reflective of Yik Yak's largely college-age user population (Hess, 2015). The coding of our ethnographic notes and interview data were guided by the naturalistic grounded theory techniques described by Charmaz (2006). This process began by using a constant comparative method (Huberman and Miles, 1994). In so doing, categories were able to emerge organically from the data without pre-determined research questions. We also used early ethnographic observations to develop a rough interview script. Subsequent interviews were accordingly semi-structured. This approach meant that interviews could branch off in different directions if interesting issues emerged. As with our ethnographic data, interview data were coded early and often. The approach enabled categories to emerge naturally from the material, which meant we could identify areas to be addressed in more detail during later interviews. Later in the coding process, we began grouping concepts into categories to thematically segment off sections of data that related to a more cohesive picture of different aspects of Yik Yak usage. For the purposes of this article, we report on the group of categories that concerned data pertaining to issues of place and mobility. The grouping of our organic categories will hopefully help further theory relating to how the use of locative social media influences perception of space and place. Finally, to break slightly with research tradition, we want to explain our research site in some detail. We do so because one of our main points is that the city in which the data was collected significantly shaped our data because Yik Yak is intricately tied to mobility. If someone travels five miles, they see a totally different Yik Yak feed shaped by the local population of users, a point we cover in more detail in our data analysis. So to provide more context, the site of our research is a mid-sized college city (around 130,000 people) with two public universities totaling 45,000 students. The city is located in a seven million person metropolitan area in a conservative state in the United States, but the city is significantly more progressive than the surrounding cities in the metro area and especially the rural areas just outside the metro area. As we show in the next section, much of the interview data includes direct quotes that detailed city names. In the interest of anonymity, these names have been changed so that "City A" now refers to the city in which the research was performed. Other cities are referred to as "City B," "City C," and so on. The same naming convention was used for the universities mentioned in participant quotes. The names of cities and universities have also been blacked out in the accompanying screenshots. --- Data analysis The data reported in this study combines quotes from our interviews and screenshots from our ethnographic work.on the locational aspects of Yik Yak. We do not go into detail on issues related to the application such as anonymity, privacy, and identity because they are not as relevant to the central argument of this paper. The five categories we cover are as follows: (1) The relational nature of location; (2) The social dynamics of proximity; (3) Racism and proximity; (4) Temporality and proximity; and, (5) Locationbased exploration. --- The relational nature of location A common type of post we observed was the self-referential post about Yik Yak. These posts contrasted Yik Yak based on the location in which it was used. After all, the feed a person sees is determined by their location, and for the participants interviewed as well as many of the anonymous users observed, Yik Yak was a different social tool in City A than elsewhere (see Figure 1). These extracts reveal how the connection to place can be strengthened through the use of Yik Yak. The descriptions are all relational and related to corporeal mobility: City A's feed is better than City B's feed. Importantly, such discussions extended past the dynamics of the Yik Yak feed. Participants were not simply differentiating between feeds in these examples; more importantly, they were often differentiating between places and addressing how the movement of their body altered the feed they received. The use of Yik Yak enabled participants to get a feel for a locality, rather than simply a feel for the Yik Yak community. So, in the first quote, the participant went on to criticize the entire town for being too fraternityfocused. The participant in the last quote did the same in her criticisms of City D for being racist. In this vein, the feed became a proxy for the place as a whole and the mobile screen became an interface through which one could view the surrounding space. In other cases the relational nature of Yik Yak feeds was more finely grained. Some posters differentiated between feeds in different parts of City A (it only takes about 20 minutes to drive from one side of City A to the other) (see Figure 2). They acknowledged how the digital information altered with even relatively small movements of their body and smartphone. In addition, people frequently posted to differentiate between the Yik Yak feeds near the city's two main university campuses (which are only about two miles apart). In this instance, Yik Yak was used to communicate about different parts of a relatively small city. More often than not these posts revolved around the frequency of "yaks" in different locations. Multiple people explained that they could tell how many college students lived nearby just by physical moving to a different location and accessing the Yik Yak feed. In some cases, posters even encouraged a playful form of competition to see which parts of the city could share the most on the application. --- The social dynamics of proximity The majority of the Yik Yak content we observed would likely be unsurprising to anyone who has spent significant time with college students. People posted frequently about sex, drugs and alcohol; they complained about classes, traffic, and parking; they asked about the location of parties. Most of the content was fairly mundane, but our interview data suggested that the value participants took from the content was related to the location-based nature of the application. For example, we witnessed frequent questions about the proper age to lose one's virginity, questions about other people's number of sexual partners, questions from women asking if other women faked orgasms, questions from males asking about other males' penis size, and questions about relationship issues (see Figure 3 for an example of a relationship question). Multiple interview participants had either asked relationship or sexual questions on Yik Yak, and when we probed as to why they used the application instead of looking the information up online (we were specifically discussing posts about appropriate ages to lose one's virginity), one participant explained that, "I just didn't want to do that. I don't care all that much, but I wanted to know, and I'd rather ask other college students I might know or something than just find some random page online. I trust it more." The quote above is representative of much of the interview data. What made Yik Yak interesting for our participants was not just the content, but more importantly the content combined with the physical proximity. A complaint about traffic, for example, might not be interesting in itself. However, when another user immediately recognized the traffic being discussed it became what one participant described as a "bonding experience." The traffic post, the complaint about a math class, or the brag about a sexual encounter became a window into the community, a new way to anonymously discuss a place. The quote below highlights this point: "I look at Yik Yak as a way to kind of get the pulse of City A. I can see what's going on that weekend or hear about the stupid things people did or something happening on campus. It's just cool. I feel like it helps me know City A better." The "pulse" of the city captures the overall feelings our participants expressed about Yik Yak. Abstractly, the feed became a way to glimpse into what was going on, to feel a connection to the similar experiences of other nearby students. Of course, the "pulse" was not always positive, as the next section examines. --- Racism and proximity One of the criticisms of Yik Yak in the popular press has been the high frequency of racist and sexist posts on college campuses. In alignment with these criticisms, City A's Yik Yak did occasionally feature sexist, homophobic, and racist material (see Figure 4). For the most part, the "downvoting" and reporting systems kept the majority of overtly offensive posts from staying on Yik Yak for a long time. However, one participant stopped using the application from late November until early February specifically because of racist posts that were not always downvoted. She explained the problem was worse when she was down by her mother's house in City E, but City A also featured too much racist content, particularly surrounding the death of Mike Brown and the "I can't breathe" protests related to the murder of Eric Garner. As she put it, "Way too much of that nonsense wasn't getting downvoted. Some of it even ended up with upvotes, and I don't want to see that. I get Mike Brown. I mean, he might have done something to deserve it. But the "I can't breathe thing"? Seriously? There was a video. I bet those assholes wouldn't be making jokes about that if they weren't anonymous. I know that stuff happens, but it just bothered me to know people I go to school with can be so ignorant." The racism and bullying that takes place on Yik Yak are commonly linked to the dangers of anonymity. However, the last sentence of the quote above, which was shared in similar terms by two other interview participants, demonstrates how the locative aspects of Yik Yak can make the offensive content feel more hurtful. Unlike a random online comment section or message board, participants who watched a racist post get "upvoted" on Yik Yak were aware that the views being expressed were posted by people nearby, people they may interact with on a daily basis. As one participant explained, a racist post on Yik Yak does not have the distance of a random racist remark online, but instead feels more like seeing racist graffiti on campus. For the two African American students we interviewed, proximity to such posts made them more personal and made them slightly more wary of the place as a whole. --- The temporality of proximity College towns are unique places. City A has 130,000 full time residents, and an extra 40,000 students during the school year. The city is a noticeably different environment when school is not in session. Essentially, as the trajectories of bodies that make up a place pour out of the city, the city becomes a different place: restaurants change their hours, traffic decreases, and bars become much less crowded. These changes also made their way to the city's Yik Yak feed. With no exaggeration, at points over the Holiday break the feed slowed to a crawl. After college students left the city, the number of posts decreased by more than half. Functionally, City A's Yik Yak feed reflected the temporal rhythms of the city. As soon as the students returned, college life became vibrant again and so did the Yik Yak feed. Likewise, when the students left for break, the city and feed emptied out (see Figure 5). In some cases, posts became both temporally and spatially self-referential. Many posts resonated with the sentiment of the screenshot below, expressing a connection to City A's Yik Yak community while also complaining about the period in which the user would be out of touch (see Figure 6). The majority of these posts also link to earlier categories and featured complaints about the Yik Yak feed "back home," contrasting City A to whatever city the user will be heading to for break. For the participants who stayed behind, the Yik Yak feed became representative of the overall slowdown in the city's social life and the outward flow of students. Those who continued to use the application often posted complaints about how the feed was dead and that no one was throwing parties or heading to the bar. As the quote below suggests, the feed became a representation of City A as a place, with many posters explicitly linking the dearth of Yik Yak posts with the lack of students wandering the campus: "Honestly, I couldn't wait for the Yakkers to start posting again. I knew I was going straight to the bar as soon as I saw Yik Yak pick up. I knew it won't be dead." --- Location-based exploration Location-based services are well documented as enabling people to explore their surrounding environment. In a similar vein, for many of our participants Yik Yak functioned as a tool of spatial exploration. In these instance, participants explained that they had gone to a campus event or a new restaurant because they saw people posting about it on Yik Yak. The feed in those cases became a way of discovering new places, of connecting with parts of the city or university life that likely would have remained hidden without the application. Unsurprisingly, the types of exploration that frequently occurred focused on parties. Indeed, a significant number of people posted information about parties, either letting people know about the parties they were throwing or identifying parties they were attending (see Figure 7). While these posts focused on connecting with places in the city and impacting the mobility choices of users, they also often intended to foster interpersonal connections. In fact, a number of the Yik Yak posts we observed were written specifically to facilitate meeting up with new people (see Figure 8). The reasons for meeting up varied. Late at night on the weekend, people posted looking for sex (these rarely got positive responses), people posted looking to buy or sell drugs, and people posted explicitly looking to meet new people in social situations. For example, individuals would share party information and ask other users if anyone wanted to show up together. Likewise, people would offer to buy someone a drink at the bar. If successful, people would then share their Kik usernames and proceed from there. Multiple interview participants used Yik Yak to discover both new people and new places. One woman organized an informal "finals stress" bar meet up through Yik Yak during finals week. She noted that she was encouraged by how the application burgeoned her sense of connection to City A, and she made at least one lasting friend through the experience. Another participant explained that he and his friends had engaged in a social experiment in which they posted that they were throwing a party and then shared address information through Kik. He told us that more than 30 Yik Yak users showed up and that the party was an opportunity to connect with people they would likely have never met without the application. Ultimately, participants' use of Yik Yak extended past engaging with a representation of their surrounding space; the Yik Yak feed also encouraged them to go out into the city and make mobility choices to explore new places or make new social connections through the application. As we discuss in the next section, this type of exploration is an exemplar of how location-based mobile applications can contribute to the formation of hybrid spaces. --- Discussion Yik Yak was a popular anonymous sharing application that had historical antecedents in the various anonymous "college message board" sites like College ACB or Juicy Campus (Press and Tripodi, 2014). Beyond the anonymity, however, what makes Yik Yak unique is its embrace of locative media and more specifically its use of proximity. Indeed, the feed people engage with literally changes as they move through physical space. Different physical locations deliver significantly different social content. What was appealing about Yik Yak for the participants in this study was its unique combination of anonymity and proximity. Participants were well aware of other anonymous sites they could use online, but they chose Yik Yak because of the place-based connections it facilitated. Participants were cognizant that other posters likely lived nearby, went to the same university and experienced the same traffic, the same bars and so on. Saker's (2016) study of Foursquare and a process he terms "localisation" is useful here. "Localisation" occurs when individuals engage with embedded locative information to momentarily assume a "local" subjectivity within an unfamiliar environment. Our participants similarly found value in the knowledge that available Yik Yak posts pertained to a locality that they too deemed "local," just as this practice deepened their connection to a specific place. The effect of the Yik Yak feed on localisation was then governed by the content of the feeds. The mention of a known traffic incident, for instance, could serve as bonding experience, just as the implicit proximity of a racist post could make it feel more personal and jarring. The affordance of proximity also contributed to a relational understanding of what Yik Yak represents as a social media artifact. To the people we observed and the participants we interviewed, Yik Yak is neither monolithic nor static. The application is different back home visiting parents than it is when accessed from a college town. As multiple participants explained, they only liked using Yik Yak in City A when the population consisted of mostly more liberal college students. In this vein, Yik Yak functions as barometer of place. Even a trip 20 minutes away may lead to a feed filled with high school students, fraternity posts, or racist content. For the participants we interviewed, their feed was a proxy for their physical environment. Participants did not simply feel Yik Yak was filled with those people; more importantly they felt their physical space was filled with those people. These types of perceived differences in content are prime examples of what Farman (2014) refers to as the "site specificity" of locative media. He defines site specificity as "the emphasis on the unique qualities of a particular location that cannot be transferred onto another place" [8]. While Farman's work examines storytelling and historical sites, we argue here that the concept of site specificity can be productively extended to applications like Yik Yak. The feed one accesses in a particular environment is germane to that milieu, just as the site-specificity of the application delivers posts based on location. Put differently, mobilities in content correlate with mobilities in space. For someone to analyze Yik Yak, they must understand not only available posts but also the place in which the posts are accessed. In other words, what must be acknowledged is the importance of the specificity of location in the context of the application. In addition, our findings regarding the importance of physical location were also present in Black, et al.'s (2016) quantitative study of Yik Yak content, which found that the largest category of post focused on local features of a place. The site-specificity explored by Farman is one part of a larger push towards what Silva ( 2006) calls hybrid space. As explained earlier, hybrid space has been a key concept for the subfield of locative media studies, and crucial to the concept is the argument that the digital, social, and physical have

HOME ABOUT LOGIN REGISTER SEARCH CURRENT ARCHIVES ANNOUNCEMENTS SUBMISSIONS Home > Volume 22, Number 10 -2 October 2017 > Frith Yik Yak was a location-based social application that allowed users to anonymously create, read, and respond to posts made within a few mile radius. This paper reports on six months of ethnographic work and interviews performed with 18 Yik Yak users. We argue that one of Yik Yak's primary functions was to communicate about place and to find new ways to connect abstractly with the local social situation. The data detailed in this article contributes to the growing literature on the spatial and social impacts of locative media. Contents 1. Introduction 2. Locative media and place 3. Methods 4. Data analysis 5. Discussion 6. Limitations and future research 7. Conclusion

8]. While Farman's work examines storytelling and historical sites, we argue here that the concept of site specificity can be productively extended to applications like Yik Yak. The feed one accesses in a particular environment is germane to that milieu, just as the site-specificity of the application delivers posts based on location. Put differently, mobilities in content correlate with mobilities in space. For someone to analyze Yik Yak, they must understand not only available posts but also the place in which the posts are accessed. In other words, what must be acknowledged is the importance of the specificity of location in the context of the application. In addition, our findings regarding the importance of physical location were also present in Black, et al.'s (2016) quantitative study of Yik Yak content, which found that the largest category of post focused on local features of a place. The site-specificity explored by Farman is one part of a larger push towards what Silva ( 2006) calls hybrid space. As explained earlier, hybrid space has been a key concept for the subfield of locative media studies, and crucial to the concept is the argument that the digital, social, and physical have merged in new ways. Describing hybrid space, Frith (2015) writes that Hybrid space conceptualizes what happens as the Internet leaves the desktop and moves out into the physical world. Importantly, however, hybrid spaces are not just places affected by the location-based information of the mobile Internet; hybrid space are also spaces that show how physical place shapes the meaning of the mobile Internet. [9] Hybrid space, alongside related concepts like Code/Space (Kitchin and Dodge, 2011) and Augmented Reality (Manovich, 2006), explores the idea that the digital and physical are no longer conceptually separate. The information one accesses through a location-based application essentially becomes a marker of a physical space, a new way of learning about and engaging with that space. Different digital and locative affordances accordingly have the potential to mobilize different hybrid spaces that can then constellate different physical, social and spatial possibilities. As our data suggest, Yik Yak functions as a sort of hybridized "pulse" of the city. The application's socially and spatially generated feed is akin to what Dourish and Bell (2011) describe as a "lens" through which to view surrounding spatiality. In alignment with studies that have examined other locative mobile media, Yik Yak serves as 'an exploratory tool for discovering new places to experience' [10]. Echoing Humphreys' (Humphreys, 2010;Humphreys and Liao, 2013) notion of "parochialization", this practice made a place mentioned or a party discussed seem more inviting, just as it extended this concept beyond physicality to people. In the same way mobile social networks can make unfamiliar environments feel more familiar (Humphreys, 2010), it is our contention that by establishing a communal point of connection Yik Yak can equally make "unknown others" feel in some way known. This was especially the case for participants who went out of their way to organize meet ups with other users that they had not met before. Additionally, our research demonstrates that the hybrid space of Yik Yak can influence how participants cohesively comprehend their surroundings. For many of our participants, their feed came to represent the type of place they felt City A was. It became a way to aggregately communicate about place. More than the interpersonal communication of location-sharing applications or the review-based nature of location-based search applications, Yik Yak represented a more total representation of a place. The "rhythm" of the feed followed the temporality of college life: parties on the weekends, sexual posts late at night, complaints about midterms, stress over finals, and posts about leaving for break. Once again, our qualitative finding was echoed in Black, et al.'s (2016) quantitative analysis, which found common categoires of posts to include fairly typical university topics such as sex and dating, drugs and alcohol, and partying. The mundanity of posts, however, enabled some people to form a sense of connection to place built through the Yik Yak feed. They were able to tap into their local community by viewing the scroll of posts made by those collocated within a few miles of their location. The space, in that sense, became hybrid: the digital information impacted one's sense of connection to place, just as one's place impacted the value of the digital information. This type of hybridity, the ability to connect to and communicate about place through location-based social applications, represents a significant shift in how people use their mobile devices to both communicate with others and engage differently with the physical world. In addition, the location-based nature of Yik Yak also played a role in shaping issues of racism and cyber bullying. As participants told us, when racism was present in the feed, it felt more personal because the viewer knew it was expressed by nearby people. Our findings suggest the impact of antisocial content combined with locative media is an important area of study, but we also found that content was fairly infrequent, once again echoing the quantitative findings of Black, et al. (2016). We did find negative, offensive content, but in our study at least, Yik Yak was not the "fertile ground" for vitriol Li and Literat (2017) predicted. For one thing, the voting function actually worked to get rid of the majority of inflammatory posts, which contradicts Li and Literat's (2017) prediction that voting would make antisocial content worse. We did find that, in a few instances, the voting function (combined with anonymity and hyperlocalism) made negative content more personal, but at least in our site of study, the voting worked as a community enforcement tool to prohibit the majority of antisocial posts. We also did not find posts that mentioned people by name, possibly because of the downvoting function combined with Yik Yak's automatic filters. Of course, even one example of racist, sexist, homophobic, or bullying content -and we found more than one exampleis one too many. We mention our data in the context of Black, et al.'s (2016) analysis merely as a counterpoint that something unique about Yik Yak turned it into a site defined mainly by antisociality. As a final note, while this study looked at what is a now defunct mobile application, the theory of localization and site specificity built upon in this paper remains just as relevant to other location-based social applications. After all, while Yik Yak has folded, there are a variety of apps that offer similar functionality and combine anonymity with locative media (Gangwar, 2017). We have shown how Yik Yak represents a digitally mediated "lens" through which people can tap into the various social trajectories that make up a place. Massey (2005) defined space as a collection of trajectories, some more permanent, some ephemeral. Real-time, location-based social feeds are a way to gain insight into some of those trajectories, to track the temporal rhythms of flows as the feed slows or speeds up depending upon the assemblages of identities within a space at a give time. As location information becomes even more inextricably tied into the digital information accessed while mobile, we will likely see an explosion of platforms used to tap into the shifting trajectories of place. --- Limitations and future research This study explored one city's Yik Yak community through ethnographic and interview work. The focus on qualitative research and a single place means the results found in this study are not generalizable to other areas in which Yik Yak was used. In fact, the lack of generalizability was one of the main points of our argument: what Yik Yak is as a social tool depends greatly on where it is used. Consequently, future qualitative studies should expand upon this research by performing comparative analyses of different cities to analyze how different groups use the application. In addition, quantitative research can build off this study by using survey work or discourse analysis to examine different Yik Yak feeds and explore how Yik Yak fosters spatial connections in more generalizable terms. Quantitative work that analyzes a much larger corpus of Yik Yak data in separate locations will be particularly useful for further exploring the issues addressed in this article. Finally, the design of the application has changed somewhat since the data was collected and analyzed. The application now contains slightly more persistent pseudonymous identities and further capabilities, such as photo sharing. Ideally, however, the analysis provided in this paper extends past individual design features to capture a deeper pictures of the potential intersections of anonymity and location-based sociability. --- Conclusion Yik Yak was a mobile application that combined one of the oldest strands of Internet research: (1) the social effects of anonymity, with one of the newer strands; and, (2) the social shifts of locative media. The key argument of this paper is that Yik Yak was a mobile application people used to communicate and comprehend place, among other things. The application therefore had the potential to impact how users engaged with their surroundings, doing so in some more literal ways by encouraging people to find new places or make new social connections within the local community. But equally importantly, applications like Yik Yak encourage spatial connection in more abstract ways as well, functioning as a "lens" through which people felt they could understand the "pulse" of the city. Of course, the same proximity that in some cases made people feel more connected could also exacerbate the negative content found on the application. The posts, whether good or bad, whether social or antisocial, had a more significant impact on the people we interviewed because they were locationbased, because they came specifically from people collocated within a certain radius. In this sense, the physical space and digital information merged into a hybrid space in which the location influenced the Yik Yak feed, but the digital content also impacted how one felt about the location. As this article has shown, how we understand future social, mobile applications will increasingly have to take into account physical location. Location-based services are growing and will continue to develop in new directions. The growth underlines why applications like Yik Yak are important for understanding the ways people's physical location and mobility increasingly shape the digital, social information they receive. These types of locative applications provide both opportunity for novel types of computer-mediated sociability and raise concerns Internet studies scholars are uniquely suited to address.

HOME ABOUT LOGIN REGISTER SEARCH CURRENT ARCHIVES ANNOUNCEMENTS SUBMISSIONS Home > Volume 22, Number 10 -2 October 2017 > Frith Yik Yak was a location-based social application that allowed users to anonymously create, read, and respond to posts made within a few mile radius. This paper reports on six months of ethnographic work and interviews performed with 18 Yik Yak users. We argue that one of Yik Yak's primary functions was to communicate about place and to find new ways to connect abstractly with the local social situation. The data detailed in this article contributes to the growing literature on the spatial and social impacts of locative media. Contents 1. Introduction 2. Locative media and place 3. Methods 4. Data analysis 5. Discussion 6. Limitations and future research 7. Conclusion

Introduction Information and communication technology (ICT) use was necessary to stay socially connected and capable of receiving many health and social services during the COVID-19 pandemic shutdowns. ICT access was particularly important for older adults who were under the most stringent isolation protocols (Llorente-Barroso et al., 2021). While early reports had optimistic projections of older adults' adoption and ownership of ICT over the years, especially during the course of the pandemic (Kakulla, 2021;Faverio, 2022), many studies warned that such growth often only represented a shift from "have nots" to "haves" (Freeman et al., 2022). In other words, the mere possession of ICT devices is not enough to guarantee meaningful digital access and engagement. Compared to younger adults, older adults tend to have overall lower digital literacy and less success in efficiently achieving their goals and accurately addressing their needs as a result of internet usage (Van Deursen, 2020). It is crucial to treat older adults not as a monolithic group of technologically-incompetent users. Older adults possess a wide range of digital skills and engage with ICT in varying ways (Van Deursen and Helsper, 2015a;Hänninen et al., 2020). However, the digital divide between older and younger adults in infrastructural access and digital literacy still remains (Smith, 2014;Hecker et al., 2021;Perrin and Atske, 2021). The 2022 Pew Research Center survey found that 86% of those ages 30-64 owned broadband access at home compared to 61% of those ages 65 and older (Faverio, 2022). Among the older adults who are connected, despite the subset of older adults who are proficient in technology use, compared to the younger population, the overall older population is at lower odds of integrating internet use into everyday activities and uses the internet in more limited ways owing to lower literacy, inability to see the benefits of online engagement, and, sometimes, genuine disinterests in using the internet (Quan-Haase et al., 2018). Some older adults reported being overwhelmed by the variety of ICT functions and struggling with a lack of clear instructions and adequate support, which resulted in an inability to expand usage and increasing frustration with learning new things (Vaportzis et al., 2017;Harris et al., 2022). As a result of rapid digitalization and persistent issues related to the digital divide, some older adults had to give up on certain activity engagements as these activities became no longer available offline (Reneland-Forsman, 2018). The digital divide became even more visible as the US service organizations transitioned overnight to remote service delivery in March 2020. Many older adults faced obstacles and steep learning curves. Although the pandemic has pushed many older adults to use ICT to some extent to communicate with social networks and keep up with information, many functions and applications of ICT remain poorly utilized and understood. Reports on older adults' digital engagement during the pandemic have found significantly less ICT usage among older adults to manage daily activities and access health services (Lam et al., 2020;Kakulla, 2021;Perrin and Atske, 2021). In the same 2021 AARP Tech Trends report that highlighted older adults' new tech purchases during the pandemic, more than half of the surveyed older adults (n = 2,271) reported needing additional support with their purchased devices and almost 40 percent of them lacked digital confidence (Kakulla, 2021). Meanwhile, socio-demographic factors also impact older adults' internet usage. Declining internet usage has been associated with growing age and those above age 75 are less likely to access the internet than those from the younger group of older adults (65-74) (Smith, 2014;Crouch and Gordon, 2019;Sixsmith et al., 2022). Studies have also found that adults with higher educational status in early life were more likely to engage in internet use in later life (Leukel et al., 2021). In addition, ICT adoption patterns are also influenced by an individuals' physical and cognitive capability. Visual and hearing impairment and memory loss in older adults are associated with decreased usage of the internet (Gell et al., 2015;Choi et al., 2020;Lam et al., 2020). All the existing studies and reports have underlined the need to implement appropriate and adequate tech support and training for older adults. Previous researchers have explored older adults' ICT learning technology support needs and learning preferences. Recognizing a wide range of skill levels and needs across individuals, studies identified a demand for personalized support that fulfills a broad range of interests (Barnard et al., 2013;Hunsaker et al., 2019;Schlomann et al., 2022). Older adults with sufficient internet skills may not need tech support or emphasize getting the support that expands their ICT abilities to engage in a broader range of digital activities (Quan-Haase et al., 2018;Hunsaker et al., 2019). To older users who are more dependent on others' support, the availability and immediacy of help is a critical matter (Hunsaker et al., 2019). While formal technology support and training is also identified as one of the technical support sources among older adults, due to concerns related to cost and accessibility, many reported getting help from informal sources such as their families and friends who are known as "warm experts" (Lafontaine and Sawchuk, 2015;Hunsaker et al., 2019;Hänninen et al., 2020). Introduced by sociologist Bakardjieva (2005), the term warm expert refers to more technologically experienced individuals who are in a tech novice's close social network, who help inexperienced tech users to solve their technical problems and contribute to their learning process. To older adults, 'warm experts' typically are their close personal networks, such as families, friends, peers, and social service providers, who are able to offer personalized support in a timely manner (Olsson and Viscovi, 2018;Hänninen et al., 2020;Hunsaker et al., 2020;Nordin et al., 2021). Moreover, as indicated by Quan-Haase et al.'s (2018) study, tech support might not be desired by all older adults with limited skills and experiences, as some place more value on offline engagements and perceive the tech learning process as a waste of time and effort. Regarding device preferences, some older adults find it easier to use tablets than mobile phones or laptops, as tablets provide larger screens than regular phones but allow more flexibility than computers (Chan et al., 2016). Likewise, smart (i.e., internet capable) TVs have been identified as appropriate and effective learning tools for older adults because TVs provide a familiar and easy-to-use interface for the older population, helping to minimize technology resistance and anxiety (Santana-Mancilla and Anido-Rifón, 2017; Andreadis et al., 2021;Wang and Wu, 2021). As shown, past research has well demonstrated older adults' heterogenous digital engagement patterns, infrastructural access and narratives on preferences in adoption. However, there is insufficient research that extensively and empirically interrogates older adults' experiences with an existing tech support service. While many studies interrogating older adults' support needs took place before the COVID-19 crisis, the arrival of the pandemic has changed the techno-social environments for many as the integration of ICT use into everyday life has become more necessary than ever. Meanwhile, throughout the pandemic, the importance of technology support services for older adults has been highlighted as health and community-based organizations pivoted to virtual service delivery and programming. Numerous efforts have been made by both the public and private sectors to support older ICT learners. Nevertheless, the effectiveness of these initiatives has not been examined for the most part. In this study, we have an opportunity to examine older adults' real-life experiences and behaviors with regard to tech support usage during the pandemic in a small sample. This study takes advantage of a setting where material access problems were solved (as people were provided free devices and broadband connection) and available training and tech support services were provided, to ask what are the further barriers and facilitators to older adults' effective usage of ICT during the pandemic and beyond? In this study we evaluate the effectiveness of ICT support through the meaningful access framework. In the past decade, the digital inclusion/exclusion framework had gradually moved from a broad discussion of the differences in physical access to a nuanced recognition of differences in attitudes, types of engagement, skill levels, and the tangible outcomes as result of ICT usage (Witte and Mannon, 2010;Van Deursen and Helsper, 2015b). This framework conceptualizes three levels of digital divide. The first level concerns disparities in infrastructural access; the second level focuses on gaps in skill levels, digital literacy and uses; and the third level assesses the differences in the impact generated by internet use (Van Deursen and Dijk, 2014;Van Deursen and Helsper, 2015b). Translating such theoretical framework to the policy work focusing on ICT and older adults, the Brookdale Center for Healthy Aging identified four essential components that constitute meaningful digital access for older adults: a usable device, adequate broadband internet service, the education to foster skills, and ongoing technical support to ensure one's capability to navigate the internet independently to meet one's needs (González-Rivera and Finkelstein, 2021). Consistent with the framework for digital inclusion, Brookdale's meaningful access concerns not only the basic infrastructural capabilities or possession of basic skills to go online but also one's capacity to make use of the internet independently and benefit from everyday digital engagement. Therefore, successful education and tech support should result in knowledge about the usefulness of ICT including its specific functions and platforms that fuel motivation, and effective performance of online activities that ensure meaningful access and realize the intended benefits of ICT for older adults (González-Rivera and Finkelstein, 2021). We partnered with a large organization serving older adults in New York City which had launched an ICT enhancement initiative for its clients in response to the COVID-19 pandemic. The specific group receiving these devices included all the residents of one independent living apartment building for older adults; participants from a chronic disease self-management program; clients of mental health clinic; participants from a palliative care program; and participants from several senior centers (voluntary recreation and meal sites for older adults living in the community). All of them were connected to a variety of resources and stably housed. Following the COVID-19 lockdown, this organization provided groups of their clients ICT devices, including laptops, tablets, and TV set top boxes that connected to the internet (i.e., smart TVs). Clients did not have their own choice of device; different devices were available in different settings. However, in all instances, this initiative included installation assistance, user manuals, free unlimited broadband, and ongoing technology training and support services provided by two tech support organizations who were experienced in working with older adults. Additionally, clients were able to receive support from the service organization's staff members whom they knew well, which facilitated self-paced learning. We evaluated the impact of this effort and explored older adults' experiences with ICT support services. Given the combination of removal of infrastructural barriers (devices, set up, connection all provided) and provision of training and ongoing support, this initiative offered a useful opportunity to investigate older adults' engagement with ICT devices and the efficacy of ICT technology support. This study aimed to: (1) better understand the technology competence, use, and barriers of older tech service recipients who participated in this program; (2) provide guidance about the impact of various components including the use of specific devices, connectivity, training, and support services; (3) evaluate the strengths and weaknesses of the organization's tech access programs; (4) ultimately, present evidence useful for the future creation and expansion of technology services for older adults. We attempt to address gaps in the current literature by exploring not only older adults' interactions with internet-connected devices but also, specifically, their experiences with ICT support services. --- Materials and methods --- Service program specifics The organization distributed internet-capable devices and broadband access to five groups of program participants. The specific details of the programs are presented below: • Wired a senior residence for wifi and provided residents with a laptop and tech support services. Tech support services included initial device installation, lessons, and ongoing remote services provided by the company's staff specializing in services for older adults to support participants' tech use whenever problems arise. Services were provided in English, Russian, and Hebrew. • Provided tablets and tech support services to participants in three of the organization's service programs: mental health, chronic disease self-management, and palliative care.Tech support services were the same as for people in the residence. • Distributed TV set top adapters for internet connection to senior center participants to enable access to various interactive virtual programming, including fitness classes, peer networking, and professional development sessions. Tech support was offered by the provider of the adapters, and included installation and ongoing tech support through a helpline. --- Data collection procedures This evaluation utilized a survey research design. Because of the patient confidentiality regulations at the studied research site, our researchers were not allowed to recruit participants directly but through the support of the service organization's staff members. While the number of participants reached during the recruitment process was unknown, a total of 35 older adults reached out to our researchers via a given contact number and were interviewed. Additionally, we communicated with the two tech services providers, program leads and the sponsoring organization's site staff directly, which supplemented the data collection effort. The program evaluation protocol was approved by the City University of New York Institutional Review Board. To maintain client confidentiality, we used a passive recruitment strategy. Data collection took place primarily between January 2022 and March 2022. Based on clients' demographic information provided by the older adult's organization and within the linguistic capacity of our research team, we sent flyers in English, Russian, and Spanish to the five respective program leads, who then distributed the recruitment flyer to all program participants who had received devices. Interested clients called a number provided on the flyer to schedule 30-minute interviews by phone. Prior to the interview, respondents provided verbal informed consent and were guaranteed anonymity and confidentiality of their information. Interview data were recorded in Qualtrics survey software. Non-English speakers had the option to be interviewed in Spanish or Russian, but all interviews were conducted in English. Respondents were compensated for their time with $20 gift cards. --- Data collection instrument The questionnaire was organized into six domains: demographics, self-assessed wellness, social connection, technology use, technology support, and technology attitudes. In addition to providing personal baseline information, including health status and familiarity with computers, respondents were asked to: • Assess change in contact and feelings of closeness with their social networks compared to before COVID-19, change in using technology to connect with social networks since COVID-19. • Rate the frequency and ease of use of internet-connected devices (tablets, TV boxes). • Describe the assistance and support provided by the tech providers, when relevant. • Describe their experiences with the devices, as well as the impact those devices have had on their daily lives. • Assess their level of skill and confidence in conducting various online activities. • Assess their satisfaction with participating in the program and importance of an internet connection during the pandemic. • Assess loneliness using the 3-item version of the UCLA Loneliness Scale (Russell, 1996), a commonly used measure for older adults. The UCLA Scale demonstrated high internal consistency in this sample (Cronbach's alpha = 0.88). The majority of questionnaire items used categorical or Likerttype scale responses. However, each section also included openended questions, including items specific to experiences with the laptop, tablet, and TV set-top devices, as well as the initial installation, training, ongoing support, and barriers to/facilitators of device utilization to allow for a greater depth of information. --- Findings Description of the sample We recruited a diverse sample of participants with regard to age, race/ethnicity, and physical and mental health conditions. Almost half of the participants (16) were between 70 and 79 years old, and 8 participants were 80 years of age or older [see Table 1]. More than half of the participants were Black/African Americans and Latinx. Since the sponsoring organization serves low-income older adults, participants were low-income. However, no one was precariously or unstably housed as the organization provides housing and/or housing support. A majority of participants (n = 22) reported trouble using their hands due to arthritis. Nearly half (n = 14) reported trouble seeing even with glasses or contact lenses, and 7 had difficulty hearing even if using a hearing aid. No one reported severe cognitive declines while a few (n = 8) reported having somewhat poor memory. A majority of participants reported that their daily activities had either been severely restricted (n = 2) or somewhat restricted (n = 19) by their physical health. In terms of mental health, while most participants reported overall good mental wellbeing, two reported that their mental health had severely affected their ability to perform daily activities. Despite repeated attempts and substantial effort by the organization's program staff, no clients from the palliative care program answered the survey. Program staff provided their perspectives on the reasons for this lack of response, which are incorporated into findings and practical implications. --- Resolved infrastructural access barrier leads to a degree of ICT adoption Overall, most participants already had or attained some proficiency through the technology support programs for at least some ICT functions. Those individuals shared rather positive attitudes toward ICT use and reported that using the internet was very important during the pandemic (n = 30) and that their experiences with ICT devices and support services were good or very good (n = 31). One person shared that, "It's unbelievable what that monster can do. I can't live without it. It's the center of my life." Free devices and the internet are shown to be one of the facilitators for participants to adopt ICT. One person stated: "I take full advantage of it. It was given to me as a gift and it would be selfish not to use it." Another participant who previously did not have a device expressed her joy upon receiving her tablet: "I always wanted one. And [the organization's name] gave me one!" Although this participant still struggled to use most of the device functions, the participant learned how to send emails and use zoom to take guitar classes. As the first-level of the digital divide was solved through free devices and broadband, some individuals who were initially hesitant about using devices became more open to the idea of ICT use. One person shared: "I stopped using it at the beginning. But then I thought, they took all this energy to give me this thing, I'll give it another try...I've been very happy with the online offerings. It has enhanced my life a lot." To some, it was the combination of the free devices and the impact of COVID-19 that made them appreciate the ICT utilization: "Before covid, it was better. We would go to the theater, museums, and concerts. Now, the world is more narrow. But the computer helps expand it." These findings are consistent with several studies, suggesting strongly that the belief that most older adults lack the ability and desire to learn ICTs is simply not accurate (Vaportzis et al., 2017;Sixsmith et al., 2022). Older adults are capable of improving their life through ICT usage with appropriate support (Francis et al., 2019). The design of this tech-enhancement program-eliminating basic infrastructural barriers-supports the explanation that much non-use of ICT by older adults stems from a lack of infrastructural access rather than a lack of interest. At the same time, material access issues, such as concerns with the cost of devices and the internet, affect many digitally marginalized communities regardless of age. --- Health characteristics in dialog with tech usage While past research revealed a significant association between physical and mental health challenges and reduced technology use among the older population (Smith, 2014), we found a more complicated relationship between health and tech use after the access barriers were removed [see Table 2]. There were a total of 8 infrequent users/non-users among the 35 people surveyed who reported no or very infrequent use of their devices. Interestingly, while the prevalence of respondents reporting either difficulty seeing, hearing, or using their hands was high among participants (41, 21, and 65%, respectively), they were NOT overrepresented in the group who did not adopt devices. Such a non-associative relationship between tech use and health conditions further shows that once the access barriers are solved, the impact of health-related barriers is mitigated. Nevertheless, although self-reported difficulty seeing, hearing, and using one's hands did not hinder adoption, it does appear that there are states of disability, physical or mental, beyond which interest in or capacity for ICT is not present. Among the 8 infrequent users/non-users, there were 3 respondents who reported bad/very bad physical and/or emotional health. Half of them were very challenged during the tech enhancement program period, including one reporting having had suicidal thoughts, another who "lost" the use of device immediately and could find no help, and another who reported being unable to read and, therefore, unable to use the device1. The finding that some people find ICT adoption out of reach due to their health is further supported by our unsuccessful attempt to reach clients from the organization's palliative care program. While a 2016 systematic review of ICT usage in palliative care pointed to the potential of ICT in aiding decision-making, the particular research field is small (Ostherr et al., 2016), with a sharp focus on ICT adoption from care providers' perspectives than patients' (Portz et al., 2020;Mills et al., 2021). Echoing many others, this research calls for more future research to continue exploring questions pertinent to adoption patterns among older palliative care patients. --- Utilization of tech support services is related to degree of ICT competency The 35 people we surveyed were categorized into three groups based on their responses to questions about their technology use before the new devices were distributed and their responses to questions about functions, frequency, and ease of use of the new devices. People (n = 10) who already had ICT competence (most also already owned at least one device before the program) and then added use of the new device were categorized as "experienced." Those (n = 17) who had little/no previous experience with ICT and gained the competence and confidence to do several functions on their new device and did so at least weekly were categorized as "new users." Those who reported less than weekly use and no specific functions used (n = 8) were categorized as "infrequent users/non-users." About one-third of the respondents (n = 10) already had experience using an internet-connected device (desktop computer, tablet, laptop) before they received their new devices as part of the program. Not surprisingly, this group uniformly found the new devices easy/very easy to use. They were also the group that was the most likely to request and successfully receive training and technical assistance from the tech support companies. These respondents were typically happy to receive a new device and often reported using it differently than their existing one. They often described the tech support service as "available" and "helpful." Many called tech support for troubleshooting whenever they encountered problems. One participant took advantage of the training class to expand their tech skills: "I already know how to use a computer. Also, [the organization's name] gave me very good computer classes." Another participant successfully acquired skills to set up and use their new tablet by contacting technology support services and even offered assistance to their peers: "[The name of the technology service] girls were very helpful. I taught myself based on what they said. Then I helped others, about 30 to 40 people in the building! I'd go house to house." Almost half the participants were the agency's intended target for the ICT distribution and training program: older adults who did not have access to devices and the internet at the start of the pandemic and gained it through this initiative. Sixteen of the people interviewed who reported no previous experience with ICT were pleased with their tech-learning experiences. However, in contrast to the "experienced" group who benefited most from the tech support programs, most "new users" did not seek further support from the formal tech support program following the initial start up session. Of those who did, several reported that the tech support program was not helpful. As one participant summarized succinctly, "It's all very simple to understand. We needed private Self-rated quality-of-life tutors. How do you give computers to people who never used them without any basic education? Those who already owned computers benefited. Others, of course not." Most of the time, among the new users, consistent with previous research (Lafontaine and Sawchuk, 2015;Hunsaker et al., 2019;Hänninen et al., 2020), warm experts, including families, peers, and the organization's social service staff, were the preferred sources of technical support. Although everyone we surveyed was aware of the existence of the professional tech support services, most reported not requesting any assistance from tech support. One participant shared the story of having their daughter contact the tech support for help. --- Inability to apply learned skills to expanded usage While most respondents learned to use their devices, for many, the functions they used regularly were somewhat limited, and centered on the core functions the organization needed them to master in order to maintain the continuity of services during the COVID-19 lockdowns. As shown in Table 3, the majority of the laptop and tablet recipients reported that they could do a suite of functions well or very well. These tasks included sending/receiving email, online shopping (though a significant minority -43% report not doing this at all), reading online publications, accessing educational and recreational sites (like senior centers), playing games, watching TV online, receiving video calls, communicating with a case manager or service provider, and taking classes online. The online functions that were less frequently endorsed included: online banking, accessing benefits information, accessing social media sites, participating in chats or blogs, and using telehealth services. There was a sizable minority who reported only using their device to interact with the service provider, like answering Zoom calls from the organization's workers and participating in online classes offered by the organization. A few could do some online tasks, such as watching TV online and accessing zoom, but were unable to do other things like reading newspapers online and playing games. This suggests that many people mastered what they were explicitly taught, but are less inclined to venture further into the options/opportunities their devices provide or transfer the learned skills to perform other activities. This is consistent with our previous research that for people for whom ICT is new, it is not always evident what the device is useful for, even when some skills are gained (González-Rivera and Finkelstein, 2021). --- Discussion: moving forward In examining older adults' experiences with an existing tech support service during the pandemic, the majority of the findings of this study are consistent with past findings on older adults' heterogenous internet use and engagement in the pre-pandemic era. The results of our study once again show that older adults possess a range of tech skills and needs that require different levels of training and support based on an individual's skills and needs (Hunsaker et al., 2019;Schlomann et al., 2022). Importantly, this study found that those with previous tech experiences and a degree of digital literacy benefited most from the tech support service. New users with limited tech experiences continue to prefer "warm experts" as their instructors. Some past studies ascribed the inability to participate in formal tech service support and training to a lack of availability, immediacy, affordability, and accessibility (Hunsaker et al., 2019;Hänninen et al., 2020). However, in this research, although all the participants were aware of the readily available professional tech support staff who offered free support, the new ICT users still more frequently sought support from families, friends, and their regular support providers who may not be the tech-teaching experts. A possible explanation could be that those with more tech knowledge are better at recognizing and articulating the specific problem they have encountered and the particular support they need (Hunsaker et al., 2019). Meanwhile, new learners may prefer informal learning environments and obtaining help from those they have close relationships with, which helps relieve tech novices' stress and fear while learning new things (Lafontaine and Sawchuk, 2015). The uneven utilization of ICT functions and applications may partly be the result of being taught "how to do this" without understanding "what this is good for." In this specific program, the organization offered the devices and training in an emergency situation with the goal of continuing to keep older adults connected to their services during the pandemic. The people in this program learned the computer functions they were explicitly taught. Many of our informants did not recognize the implications for other uses from what they were taught. While such forms of tech support could be effective and appropriate in addressing older service recipients' immediate needs during a time of crisis, it remains crucial for future tech support programs to create learning tools that allow older adults to translate learned skills to a broader range of online activities based on their needs and goals (Quan-Haase et al., 2018). Our previous analysis of the New York City census re access to technology found predictors of internet access among older adults included younger ages, higher levels of formal education, higher income, and living with others (González-Rivera and Finkelstein, 2021). Other studies report that people in poorer physical, emotional, and cognitive health are less likely to adopt ICT (Crouch and Gordon, 2019;Leukel et al., 2021;Sixsmith et al., 2022). Among our informants, ICT adoption was not associated with younger age, higher education, and health conditions. While many of these participants were low-income and racial and ethnic minorities, all were clients of a large aging services organization and, therefore, were connected to a variety of resources and stably housed. Therefore, we understand this finding as supporting the idea that material access barriers and socioeconomic disadvantages may drive much of the lower uptake of ICT among older adults in the overall population in New York City. Moreover, despite the infrastructure and technical support provided, some participants did not use any ICT and others used it in limited ways. Those who reported very limited usage and knowledge of ICT devices were in overall good health and were not miserable. To quote one participant: "I meditate and pray every day. I read spiritual material, do puzzles, keep myself busy and I don't feel lonely. I draw and do math. I got the tablet in the mail, but don't know how to use it." Even during a time of crisis when technological competency was regarded as a determinant of quality of life, consistent with the previous findings before the pandemic, older participants did not let their tech skill levels impact their social involvement and exhibited a high level of autonomy in deciding the ways to live their lives (Quan-Haase et al., 2016, 2018). --- Tech support design and policy recommendations Our findings have implications for program and policy. First, "purpose built" training may not optimize all the possible ways to access the many functions and range of online experiences enabled by these devices. It is important to incorporate tech education into the tech support services that can keep older people updated on the wide range of existing and emerging online services they could benefit from. As many existing studies have pointed out, the perceived usefulness of the internet is one of the motivators for internet use among older adults (Yap et al., 2022). Therefore, tech support training should start by understanding an individual's interests and needs and build from there to help them identify ways ICT could help them meet these needs. Tech training and support staff for older adults need to be trained in incorporating such an educational component into their regular tech support services. In this case, even when an older client calls for help for one specific issue or skill, while assisting the targeted issue, the supporting staff should intuitively guide them through the various other options that one learned skill could be used for and applied to. Second, service organizations should include assessment of ICT competency, use, and access into their standard intake protocols. We recognize that customization is difficult to implement in an institution or an organization serving a large number of clients or during times of crisis such as the onset of the COVID-19 pandemic. Therefore, we suggest that tech support services can consider ways to prospectively assess people's technology access and computer competence on intake and with periodic updates, like other components of a care plan. Third, we encourage tech support services to also offer available training and resources to clients' social service providers to give them the necessary skills and tools to help older adults navigate ICT devices and ICT learning experiences. In terms of policy, we call for training for home healthcare workers to provide tech support and teaching skills. Additional funding would be required to pay workers with these new skills, which would cause a necessary and desirable increase in their wages. Further funding should also go to older adult centers, public libraries, religious institutions, and other community-based programs to develop or bring in adequate programs to help older members of their communities get the skills and support they need to become internet users. Fourth, as suggested by the narratives of some participants who claimed that internet use was just unnecessary and non-usage from Frontiers in Psychology 09 frontiersin.org mouth by the organization's service staff. Therefore, the number of participants reached remains unknown and the recruitment might have been biased toward individuals who had more success with their devices. It is reasonable to assume that those who did not utilize the tech devices or services were less inclined to participate. Secondly, since the participants had no choice of what device they were offered, we were not able to compare their preferences between devices. Third, the sample is rather small in this research. Future research may benefit from a larger research sample, which can generate more statistically meaningful findings. Despite these limitations, this study provides unique insight into older adults' experiences with ICT during the pandemic. A key strength of the research is the diversity of the research sample, which encompasses a broad range of experiences by race, ethnicity, age, educational background, and health characteristics. Importantly, this study uniquely focused on older adults' technology support and training services during the pandemic. The research findings serve as additional evidence for future tech support and training design for older adults during the ongoing COVID-19 crisis and beyond. --- Data availability statement The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors. --- the participants with extreme health challenges (including those from the palliative care), some from the current cohort of older adults may just prefer an offline lifestyle or do not have the capacity to learn and utilize a new skill. Therefore, information and social interaction must continue through multiple modalities for older adults and, we would argue, for populations of all ages with all kinds of ICT access barriers. --- Limitations and strengths This study is not without limitations. First, any recipient of the tech service programs in our partner organization was eligible to participate in the research. However, due to patient confidentiality guidelines at the studied service organization, our researchers were not allowed to recruit participants directly but through word of --- Ethics statement The studies involving human participants were reviewed and approved by the CUNY Hunter College Institutional Review Board. The patients/participants provided their written informed consent to participate in this study. --- Author contributions All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication. --- 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

Introduction: Although Information and Communication Technology (ICT) has great potential to help older adults cope with challenges associated with aging, the intended benefits of ICT are not always realized in this population due to access barriers and low digital literacy. During the COVID-19 pandemic, numerous tech support initiatives for older adults got underway. However, evaluation of the effectiveness of these initiatives is less common. This research partnered with a large, multi-service organization in New York City that gave some groups of their clients ICT devices, unlimited broadband, and access to technology training in response to COVID-19 lockdowns. This study investigates older adults' experiences with ICT and ICT support services to better inform the existing and emerging tech support for older adults during and beyond the pandemic. Methods: Data were obtained from interviewer-administered surveys of 35 older adult recipients of ICT devices, connectivity, and training in New York City. The average age was 74 years (range = 55-90 years). The group was diverse regarding race/ethnicity (Black 29%, Latino 19%, White 43%). All had low incomes. Surveys consisted of multiple-choice items and open-ended responses.The study found that one size does not fit all when it comes to ICT training and support for older adults. While connection to devices and services and tech support led to a degree of ICT adoption, the newly learned skills did not always lead to expanded device usage. The readily available tech support training and support do not guarantee service utilization, as success with tech services is related to one's pre-existing ICT competence.: The study concludes that customized training based on individuals' skills rather than age is needed. Tech support training should start by understanding an individual's interests and incorporate tech education to help users identify a wide range of existing and emerging online services that can meet Frontiers in Psychology 01 frontiersin.org Finkelstein et al. 10.3389/fpsyg.2023.1129512 their needs. Service organizations should consider including an assessment of ICT access, use, and skills into their standard intake protocols to ensure effective service delivery.

participants with extreme health challenges (including those from the palliative care), some from the current cohort of older adults may just prefer an offline lifestyle or do not have the capacity to learn and utilize a new skill. Therefore, information and social interaction must continue through multiple modalities for older adults and, we would argue, for populations of all ages with all kinds of ICT access barriers. --- Limitations and strengths This study is not without limitations. First, any recipient of the tech service programs in our partner organization was eligible to participate in the research. However, due to patient confidentiality guidelines at the studied service organization, our researchers were not allowed to recruit participants directly but through word of --- Ethics statement The studies involving human participants were reviewed and approved by the CUNY Hunter College Institutional Review Board. The patients/participants provided their written informed consent to participate in this study. --- Author contributions All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication. --- 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.

Introduction: Although Information and Communication Technology (ICT) has great potential to help older adults cope with challenges associated with aging, the intended benefits of ICT are not always realized in this population due to access barriers and low digital literacy. During the COVID-19 pandemic, numerous tech support initiatives for older adults got underway. However, evaluation of the effectiveness of these initiatives is less common. This research partnered with a large, multi-service organization in New York City that gave some groups of their clients ICT devices, unlimited broadband, and access to technology training in response to COVID-19 lockdowns. This study investigates older adults' experiences with ICT and ICT support services to better inform the existing and emerging tech support for older adults during and beyond the pandemic. Methods: Data were obtained from interviewer-administered surveys of 35 older adult recipients of ICT devices, connectivity, and training in New York City. The average age was 74 years (range = 55-90 years). The group was diverse regarding race/ethnicity (Black 29%, Latino 19%, White 43%). All had low incomes. Surveys consisted of multiple-choice items and open-ended responses.The study found that one size does not fit all when it comes to ICT training and support for older adults. While connection to devices and services and tech support led to a degree of ICT adoption, the newly learned skills did not always lead to expanded device usage. The readily available tech support training and support do not guarantee service utilization, as success with tech services is related to one's pre-existing ICT competence.: The study concludes that customized training based on individuals' skills rather than age is needed. Tech support training should start by understanding an individual's interests and incorporate tech education to help users identify a wide range of existing and emerging online services that can meet Frontiers in Psychology 01 frontiersin.org Finkelstein et al. 10.3389/fpsyg.2023.1129512 their needs. Service organizations should consider including an assessment of ICT access, use, and skills into their standard intake protocols to ensure effective service delivery.

Introduction Turkey is a country with a high risk of disasters, especially earthquakes, due to its geographical and geological structure. First degree earthquake fault lines spread to almost all parts of the country. Such a situation constantly keeps the possibility of encountering an earthquake disaster on the agenda. Unfortunately, it is very difficult to say that despite the radically changed disaster policies and new management mechanisms created after the 1999 Marmara earthquake, social awareness was created in terms of earthquake preparedness. The losses of life and property experienced in the earthquake disasters on February 6 and then on February 20, 2023, horribly reveal how unprepared we are on these matters. More than fifty thousand deaths (WHO, 2023), destruction of hundreds of thousands of residences and workplaces, millions of people becoming homeless (UN-IOM, 2023), and economic losses that will require long years and high costs to compensate are considered as the prominent consequences of the earthquake called "the disaster of the century". In addition to the damage caused by the earthquake in the physical structure, The damage it caused in the social structure should not be forgotten. Anxiety, restlessness, worry, fear, isolation, tension, posttraumatic stress disorders, sleeping and socialization difficulties are just a few of the social and psychological problems caused by the earthquake (Bozkurt, 2023;Tang, Deng, Glik, Dong, and Zhang, 2017). All these negative symptoms can affect different segments of society in different ways. Particularly vulnerable and fragile groups such as children, disabled people, families of disabled people, elderly people, women, and immigrants are much more affected by the process and face more difficult conditions in terms of sustaining their lives. Conditions that are already very challenging for the general population become even more difficult for these groups, and their vulnerability is literally multiplied. At this point, social work practices provide guidance and advocacy activities to increase the resilience of earthquake-affected citizens and vulnerable groups against disasters, to help them hold on to life, and to meet their basic needs. It is known that social work practices will make significant contributions to social change and improvement. The needs of earthquake victims and vulnerable groups are identified through the practices carried out by social workers at the individual (micro) and groups (mezzo) levels (Tapan, 2023;Mullally, 1997, pp. 108-134;Pohjola, 2011, p. 12) and appropriate solution mechanisms. Improvement processes are accelerated. In this context, efforts are made to heal social damage through social work intervention such as psychosocial support, education, group work, needs assessment, guidance and advocacy. The basic function of social work in this sense is formulated as acting as a bridge between people damaged by the earthquake and the resources, facilitating the interaction of earthquake victims with each other and with the society, providing guidance and support to social policy makers, and helping to create financial resources for all activities (Tapan, 2023;Pincus and Minahan, 1973, pp. 15-33). Hatay is the province most affected by the earthquakes that occurred on February 6, 2023, andFebruary 20, 2023. More than half of the deaths in these earthquakes occurred in Hatay. On the other hand, hundreds of thousands of Syrian immigrants lived in crowded conditions in old buildings that were relatively earthquake-proof in Hatay. This situation led to both an increase in casualties in Hatay and the formation of vulnerable groups that were disproportionately affected by the earthquake disaster due to the immigrant population presence. (Bozkurt, 2023;Dal Zilio and Ampuero, 2023;Hussain, Kalayc<unk>o<unk>lu, Milliner, etc. 2023). In this study, the effectiveness of social work policies implemented immediately after the February 2023 earthquake disaster in Hatay is evaluated. The evaluation was carried out using the interview method, one of the qualitative research techniques. Interviews were conducted with 30 experts and professionals who carried out social work activities in Hatay after the earthquake, and these interviews were supplemented by field observations. For the research, approval was obtained from the Hatay Mustafa Kemal University Social and Human Sciences Scientific Research and Publication Ethics Board on June 12th, 2023, protocol number 18, as well as the necessary permissions from the Hatay Governorship. The information security of the participants was ensured and their postearthquake sensitivities were taken into special consideration. No participant was coerced into being interviewed, and all regulations regarding the protection of personal information were strictly followed. The study consists of conceptual framework and literature, methodology, demographic characteristics, findings regarding earthquake experience within the scope of research findings, findings regarding the activity process in the earthquake zone, findings regarding expectations and predictions for the future, and discussion and conclusion sections. It is hoped that the results of this study will be a source of academic studies, especially in the fields of social work and disaster, and will help policy makers and decision makers on the subject. --- Literature Review and Conceptual Framework Social Work and Application Areas in Disasters Disasters are events that can affect the normal flow of life in many ways. Whether natural or humancaused, disasters are important phenomena that cause many negativities in social life or have the potential to deepen existing negativities and risks (Kad<unk>o<unk>lu, 2020). As Tomanbay states, disasters are events that can disrupt both social balance and the internal and social balance of individuals (Tomanbay, 2000, p. 125). Since disasters occur in unexpected and sudden situations, they are also described as crisis periods. For this reason, disaster management is often handled in coordination with crisis management. Can (2020) criticizes these definitions from the perspective of disaster sociology. He states that the definitions originate from physical sciences rather than social sciences, that nature is held responsible for the damages that occur in the definition of disaster, whereas when the human factor is excluded, it is not possible for nature to produce a disaster in its own course, and that a holistic approach focusing on the before, during and after the disaster is required. Based on these criticisms, Can defines disaster as follows: "Disaster is a disaster that occurs suddenly or over time in places where human communities live, either by the ordinary movement of nature or by direct or indirect human intervention; "It is a social phenomenon that causes great damage and losses in physical, economic, psychological and many other aspects and has important social consequences in terms of its effects" (Can, 2020, p.20). The extent to which a society or community is affected by a disaster depends on how resilient it is. This resilience is directly related to vulnerabilities. Resilience and vulnerability are two important key concepts of disasters that are related but conceptually different. There is an inverse proportion between resilience and fragility. More broadly, as resilience increases, vulnerability decreases; as fragility increases, resilience decreases. The concepts of resilience and fragility manifest themselves in many different aspects such as the individual, family, community and society. However, it is often not known who/what is how resilient and how fragile on this scale that varies from individual to society. This situation becomes more visible in the event of a sudden disaster. According to another approach, vulnerability occurs at two levels: social and individual. The situation caused by factors such as poverty, limited educational opportunities, lack of support from society and public institutions, and the health, psychological and social effects of the disaster in the long term expresses fragility at the individual level. It is pointed out that fragility increases at the social level in case of inadequacy or poor management of social service provider institutions for disasters, which ties to the demographic, historical and cultural fabric of society (Akbaş, 2020, p.336).Resilience is related to a society's current economic, social, physical, institutional, social and psychological preparedness level for disasters. In this context, it is evaluated that a disaster management perspective that extends over a long period of time during and after the disaster, including preventive measures starting before the disaster, will increase resilience. It is emphasized that creating a resilient society and culture of resistance is among the functions of social policy (Akbaş, 2020, p.337). Social work also comes into play at this point and covers the practices carried out to bring an individual, family, society or community to a more resilient position or situation, starting from the pre-disaster period. As Ceyhan (2023, p.780) states, social work has an extremely important role including the preparation processes before and after disasters, reducing disaster-related risks, and practices that will increase the resilience of the society against a possible disaster. In other words, social work refers to practices, services and approaches that pursue a strategy to reduce the effects of disasters, starting from before the disaster, continuing during the disaster, and afterward, in line with possible scenarios. These applications and services encompass psychosocial support, economic and material support, legal support, and more in all shapes and sizes. In short, social work takes an approach that ensures preparation before highly destructive disasters, especially earthquakes and fires, training fully equipped and well-trained teams, and working in coordination with each other (<unk>zçelik, 2020). Social work practices can be activated both by the state and in cooperation with nongovernmental organizations and some voluntary foundations in the region experiencing the disaster. One of the most important institutions that provide services before and after disasters on a state basis is the Ministry of Family and Social Work. Although in some cases the recovery process in the local area develops spontaneously, it may not always be sufficient. Moreover, when some coordination problems arise, this may cause more harm than good. In this case, when the resources of the affected communities in the region where the disaster occurs are not sufficient, some social support mechanisms get involved. The most important of these is social service provider institutions in the context of non-governmental organizations. In Türkiye, the Red Crescent is the leader of social work in disasters as a nongovernmental organization (NGO) (<unk>zçelik, 2020, pp. 52-53). Apart from this, many independent, national and international non-governmental organizations that are not affiliated with local governments or the state implement social service practices. After disasters, some interventions become necessary, as mentioned above. Perhaps, the most significant of these is providing psychosocial support. Durimg the post-disaster phase, psychosocial support is provided to individuals, families, or groups to help them cope with the disaster and crisis situation. For this reason, psychosocial support after a disaster is a necessity. The reason is that when this cannot be achieved, the risk situation may increase and reach advanced levels in a negative sense (Kök, 2023, p. 9). According to another evaluation, psychosocial support is a set of multidisciplinary services that includes eliminating the incompatibilities and disorders that may arise after a disaster, increasing the well-being of the individual and society, increasing the resistance to disasters that may occur in the future, and supporting recovery processes. After earthquakes and other disasters, psychosocial support services are provided through public institutions, non-governmental organizations, expert volunteer initiatives and experts within local government organizations. Psychosocial support is critical for disaster victims to hold on to life against problems such as depression, loneliness, alienation, isolation, anomie, and stress caused by disasters. As a matter of fact, the reciting of the adhan after the earthquake was perceived as a support to hold on to life for earthquake victims who thought that life had ended (Bayhan, 2020, p.300-302). On the other hand, an application that is at least as important as psychosocial support is financial aid, which is usually provided for once and helps overcome the crisis situation, giving individuals the opportunity to focus on other problems. Other supports include providing legal counselling by offering necessary guidance in order to prevent possible loss of rights. On the other hand, after highly destructive disasters such as earthquakes, health consultancy and necessary guidance and assistance in this regard also cover extremely important application areas. --- Social Work Practices for Disadvantaged/At-Risk Groups in Disasters The destruction experienced in disaster situations -especially earthquakes -creates special need groups or makes the situation of those who already have special needs more critical (Tomanbay, 2000, p. 125). It can be said that during disasters, especially those with special needs, or in other words, disadvantaged/risky groups need some social work practices more. Because these groups consist of individuals who have experienced the disaster like everyone else and who, independently of this, have some special needs or needs that differ from those of other segments of the society (Kök, 2023, p. 9). For this reason, there may be a situation of double victimization or double disadvantage, which is of primary importance in social work practices in disasters. The most important issue in the relationship between fragility and disasters is that social conditions determine fragility. Definitions and usage of vulnerable groups may vary depending on geographical regions, organizations and academic research. The term vulnerability is frequently used in social policy, public health and humanitarian work to describe specific groups and produce solutions for their needs. Although disadvantaged groups are defined in different ways for different reasons, evaluations are made that they are more special, vulnerable and fragile than other segments of society due to their qualities. In this context, the disabled, the elderly, immigrants and refugees, children, women, and because of all these processes, the poor are defined as disadvantaged groups (Demir, 2020, p.268-270). Various social policies are being developed to protect vulnerable groups during earthquakes and meet their needs. These policies aim to support vulnerable groups before, during and after the disaster. Disaster experiences can cause anxiety, lethargy, stress, material and moral losses, displacement or various health problems in individuals. While all of these are experienced by many disaster victims, their devastating effects can be more profound, especially for those who are considered as marginalized or disadvantaged. For this reason, the advocacy of social work practices in this field come to the fore (Ceyhan, 2023, p. 780). Considering that material losses can be compensated over time, it is of primary importance to focus on the moral losses of individuals and intervene in emerging behavioral or personality disorders. Because if no intervention is made at this point, this situation may lead to other negative effects in the future, such as sleep disorders, post-traumatic stress disorder, and cardiovascular system disorders. For this reason, the most important support to be given after a disaster is considered psychosocial support. Psychosocial support given to disaster victims does not only cover the first moments of the disaster. However, it rather requires long-term case management and a holistic approach. In fact, at this point, other state institutions or nongovernmental organizations can be activated by inter-institutional cooperation when necessary (Aykut and Soner Aykut, 2020, pp. 60-62). --- The Role of Social Work in Disaster and Crisis Management Natural disasters are events that are likely to occur whenever and wherever humanity exists. Disaster management is defined as the set of activities that start before the disaster and continue during and after the disaster in order to eliminate the possible damages that may occur after natural disasters and reduce their effects. One of the most important components of disaster management is the social service interventions carried out by social workers. Social workers are experts who have the necessary equipment and knowledge to reduce and prevent disaster risk. In addition to taking on protectivepreventive, rehabilitative and educational roles due to disasters, professionals also play a very active role in disasters with effective case management, planning and consultancy services. By making a plan specific to each individual's needs and situation, social workers can manage disaster-related cases very effectively and take actions to prevent possible crises (Ceyhan, 2023, p. 780-781;Kamrujjaman et al., 2018;Naturale, 2007). On the other hand, social workers can also take on an advocacy role after disasters for the purpose of facilitating disaster and crisis management and raising awareness. In this regard, for example, Tapan (2023, p. 20) aimed to make a socio-political contribution after the disaster by taking on an advocacy role as both a disaster survivor and a social worker after the February 6 earthquakes. As it is known, Türkiye is a geography prone to natural disasters such as earthquakes, floods, landslides, and fires. In particular, the fact that the continent it is located on is relatively young shows that it is more prone to seismographic movements, that is, earthquakes. The earthquakes experienced on February 6 are the two biggest examples of this in the last century. Social service practices are of particular importance in geographies where such large earthquakes occur. Because, as Kök (2023, p. 9) states, the larger the geography where the disaster occurs, the more difficult it is to coordinate social service practices after the disaster. Thus, it is very important to plan post-disaster social service practices very well in such large geographies. In this context, the first step that needs to be taken is to identify possible crises in advance and plan measures for them. Social services act as a crucial reference point for minimizing the problems caused by disasters, both before and after they strike. However, in order to achieve this, it is necessary to create an organizational order and ensure crisis management (Kök, 2023). Crisis management in disasters covers all interventions and services provided bef fore, during and after the disaster. This is simply called integrated disaster management (Altun, 2016, p. 184). Tapan (2023, p. 25) offered several suggestions regarding disaster and crisis management after the recent February 6 earthquakes. These can be summarized as follows: First of all, the withdrawal of disadvantaged groups to safe areas, the equal distribution of resources to the clients, the uninterrupted provision of services by ensuring the cooperation of non-governmental and public organizations, and the provision of consultancy regarding grief and therapy processes to disaster victims who have lost their relatives. In addition to all these, medical social work practices are also extremely important. Within the scope of medical social work, on-site interventions are provided in a health institution in the region where the disaster occurs, or, if there is no such opportunity, in field hospitals established. Social workers fulfill key roles in macro, meso and micro sense in hospitals and health institutions through case management, advocacy roles and various interventions (Karaa<unk>aç, 2023(Karaa<unk>aç,, p. 1163)). --- Problems Encountered by Social Workers in Disasters Research on the impact of social workers during disasters is among the understudied topics (Kranke et al., 2020). However, there are very few studies on how professionals cope with the stress of being exposed to disasters (Cronin, Ryan, & Brier, 2007, p. 370;Naturale, 2007). Being a social service provider in disasters sometimes creates certain areas of struggle. These can be grouped under several headings: The first of these is the level of emotional and psychological impact of disasters on social workers. Secondly, the social worker becomes physically tired or worn out. Thirdly, the social worker is also a supportive victim. The last one is the lack of adequate planning and coordination in disaster situations. All of these are also critical important factors that can lead to wear and tear, called secondary trauma. Adding to the previous point, while social workers possess considerable training and dedication, some emotional and psychological aspects of being human can inevitably challenge even the most skilled professional. In recent years, studies have begun to explore this phenomenon, and the concept of 'compassion fatigue' has emerged to aptly describe this experience. In recent years, studies have begun to be carried out on this subject, and the concept of "compassion fatigue" has come to explain this expression. As stated by Türk and Kaya (20203), compassion fatigue occurs when social workers listen to clients and establish empathy and intense bonding with their losses, pain, and difficulties they face. As a result, the social worker's energy may be depleted, resulting in a condition called compassion fatigue. For example, in a study researchers conducted with social service workers after the February 6 earthquakes, they examined the effect of practitioners' compassion fatigue on their psychological resilience and found that the secondary traumas experienced significantly negatively affected the psychological state of the employees (Türk and Kaya, 2023, pp. 86-87). Compassion fatigue or secondary traumas refer to social workers experiencing the same types of symptoms experienced by traumatized clients. Distress effects such as insomnia, nightmares, stomach aches, headaches, fatigue, memory loss, and sadness are examples of a few of the physical, cognitive, emotional, and behavioral domains of the secondary traumatic stress experience (Naturale, 2007). The second problem faced by social service providers is also related to the first problem mentioned above. Particularly due to compassion fatigue or secondary traumas, the service provider may occasionally neglect their own needs. This brings about physical exhaustion as well as emotional exhaustion (Türk and Kaya, 2023, p.86). AFAD has prepared a guide for emergency and disaster workers on this subject and stated what employees should pay attention to. The guide recommends, employees should allocate time for themselves to rest, not forget to take care of their own needs while taking care of those who ask for help, pay attention to nutrition and sleep, etc. (AFAD, 2023). Thirdly, one of the problems faced by employees is that social workers and managers in disaster environments are also affected by the disaster and the increase in disaster-related needs (Cronin, et al., 2007, p. 378). This situation emerged more clearly with the February 6 earthquakes, and social service workers experienced mental, physical and emotional fatigue due to the fact that they had to serve as disaster victims themselves. However, it can be said that there are not enough studies on this subject. The last one is that the planning and programs between institutions, individuals or institutions and individuals are not framed well enough. Lack of coordination here can negatively affect both the psychology and working conditions of social workers. For this reason, the coordinated and rotating work of social service workers is very important and functional. In a study conducted on this subject within the scope of the Covid-19 disaster, <unk>ahin Taş<unk>n and Bürüngüz (2021) interviewed social workers who worked in medical social work departments in institutions, municipalities and hospitals affiliated with the Ministry of Family and Social work in Istanbul, and as a result of the study, coordination between institutions was determined. They stated that employees made risky decisions using their own initiative due to reasons such as lack of resources and lack of a flow procedure on what to do in case of a possible disaster. Considering all these together, during disasters, it is essential for social workers to both cooperate with their teams and practice personal care in order to work most effectively on behalf of their clients (Kranke, et al., 2020). --- Hatay Case Study on Social Work Practices in Disasters Research Method, Research Process and Research Field Qualitative case study method was used in the study examining the effectiveness of social work practices in Hatay, an earthquake region. This method is used to understand and evaluate the facts through the experiences and opinions of the participants (Creswell, 2015). Within the scope of qualitative research, the interview technique has the feature of facilitating the acquisition of rich data (Y<unk>ld<unk>r<unk>m and <unk>imşek, 2016). The interview technique has some advantages compared to other research techniques. The advantageous aspects include providing the opportunity to better understand the thoughts, experiences and approaches of the participants, to continue the interview more flexibly and fluently, and to provide guidance when necessary (Merriam, 2009). Researchers should take into account the positive and negative aspects of each technique when choosing a method and shape the research within this framework (Punch, 2005). In this research, the interview technique, one of the qualitative research methods, was preferred. Semi-structured interview forms were prepared to evaluate the effectiveness of social work practices after the earthquake. In Hatay, the province most affected by the earthquake in Turkey, tent cities and container cities where earthquake victims stayed were visited, and the activities and practices of social service workers working in these areas were observed on-site. The interviews were generally held in a conversational environment in front of tents or containers. No social service worker was forced to interview and only those who were willing were interviewed. The questions in the interview form, where the participants were not interrupted, were directed as part of the conversation. Personal identification information was handled in accordance with all relevant data privacy regulations, ensuring complete anonymity for participants. In this study, where the effects of social work practices during the earthquake were investigated, Hatay Province was choosem as the field. This choice was influenced by the fact that Hatay, which has enough cultural and architectural knowledge to host many different civilizations historically, is also the city that suffered the most destruction in the earthquake and is accessible to researchers for observation and interviews. --- Demographic Features Within the scope of the research, interviews were held with 30 people who were experts and experienced in their fields and who worked in Hatay during the earthquake. The participants were reached through personal contacts and snowball sampling method. 16 of the participants in the research were women and 14 were men. Each interview lasted an average of 40-50 minutes, and all interviews were deciphered by the researcher. Data continued to be collected until saturation was achieved. All participants are university graduates and have at least a bachelor's degree. The age range varies from 24 to 42. When the participants were asked about their professions, 19 people answered as Social Worker, 6 people as Psychologist, 2 as Psychological Counsellor, 2 as Sociologist and 1 as Rehabilitation Specialist. Professional experience periods vary between 1 year and 12 years. Duty periods in the earthquake zone vary between 2 weeks and 7 months. While 5 of the nterviewed participants stated that they were from Hatay, the remaining 25 people expressed that they came from different provinces of Türkiye on assignment or as volunteers. 10 of the participants work in nongovernmental organizations and 20 people work in various public institutions. The following questions were asked in general during the interviews: How did you decide to come to the Hatay? Can you tell us about the first sight and feelings you encountered when you came to Hatay, the earthquake zone? Could you separately evaluate the difficulties and conveniences experienced while operating in the earthquake zone? Although the general answer to the questions about what field they worked in the earthquake zone was psychosocial support, they declared that they tried to help in every aspect needed in the field. They put forward opinions that, in addition to psychosocial support, they tried to take part in needs assessment, advocacy, guidance, education, hygiene provision, access to resources support, coordination, communication, and all kinds of social service activities imaginable. Frankly, field observations during the interviews also support this claim. The table includes gender, age, profession, professional experience, length of duty in the earthquake region, provinces of origin, mission area in the earthquake region, and working organization (NGO/Governmental). In the parentheses after the participant statements, the participant code (P1, P2,), gender (F/M) and age categories are given. --- Research Findings --- Findings Regarding Earthquake Experience In the interview form developed to investigate social service activities in Hatay during the February 6 earthquake, the activities related to the earthquake experience consist of questions about the participants' opinions before the activity. In this context, the participants' reasons for choosing Hatay among the eleven provinces considered to be earthquake regions, their first impressions about the effects of the earthquake and the parts it affected the most, and their opinions about the reasons for the extreme destruction caused by the earthquake were investigated. The common point of the topics researched in this section is that the participants provide information about the working environment they encounter before they even start the activity. Such an approach also explains the field climate that affects the opinions of social workers. During the earthquake, the intervention of people who are experts in their fields, knowledgeable, equipped and experienced in every field is extremely important. It is known that such interventions make significant contributions to the reduction of risks and losses in earthquakes and to the recovery and normalization processes. On the other hand, it is evaluated that the profession, especially that of those working in the field of social work, has extremely high feelings of empathy and compassion and is very related to human love and spirituality. As a matter of fact, social workers who heard about the earthquake disaster that took place on February 6, 2023, took immediate action, and tried to support the earthquake victims in every field where they were needed. A small portion of the social workers interviewed did not leave the earthquake zone while they were already living in Hatay and took it upon themselves to immediately participate in the process and contribute. A large number of them came from different provinces of Türkiye and tried to take part in every possible activity of social service. When asked why they chose to work in the Hatay region during the earthquake, the interviewees stated that they turned to the region with the most destruction out of a sense of professional and humanitarian responsibility. I was working in Hatay before the earthquake. I was in a position to easily go to another province. I chose to stay in Hatay. The magnitude of the disaster here was enormous. I could not leave the city where I was born and raised. I chose to stay in Hatay because it has moral advantages and to get social support from my family. My wife and family relatives live in Hatay. This is the land where I was born and raised, I grew up here, I received education from the schools of this place, I blended in with the people of this place, and in my opinion, this place needed the service the most in the period after the earthquake (P18, F, 29). Driven by a desire to help I wanted to help the relatives of our citizens who lost their lives in the earthquake and our injured citizens, and everyone who experienced that pain there, and I had friends in the Hatay region, I received information from them about what was happening and the situations in which I could help, and I decided to go (P16, F, 25). When I chose the department, I studied the PDR department in order to heal people, to support people who are in a difficult situation and in a difficult mood, to be with them and to accompany them on that journey. Again, the institution I work at serves this very well. We work with disadvantaged groups. When the earthquake happened, I tried to empathize with the people there directly. No matter what, I go and do my best; For example, carry a napkin? Feeling like doing even that would be good for me, my friend, and I volunteered (P13, F, 27). Participants took action immediately after the earthquake, yet they stated that they had serious difficulties in transportation to the Hatay region, that transportation was extremely difficult, and that the difficulty of transportation in these conditions competing against time disrupted their support activities. When they reached the region, they stated that they were shocked by the scene they encountered, that despite all their experience (a significant percentage of the interviewees stated that they had worked in pandemics, floods and regional earthquakes), they had never encountered such a disaster before and observed that there was no stone left unturned in the city. While we were going by plane, Hatay Airport was closed, so we landed at Gaziantep Airport and from there we took the shuttle to Hatay. For these reasons, it was a long, tiring and stressful journey. There were cracks in the roads, and the roads were closed in some places. There was an extraordinary crowd. Vehicles bringing aid supplies, ambulances, funeral vehicles and every kind of vehicle you can think of were on the roads. The road trip, which was supposed to take two hours, took about ten hours, and this tested our patience very much (P26, M, 31). We arrived late at night and the sight we saw on our way to our duty area in the morning horrified us because there was no building that was not destroyed, we realized that 100% of the city was destroyed and it was worse than what was seen on the screens, it made us feel helpless. I felt great sadness and fear, everyone needed help, it was dark everywhere and it was raining (P9, F, 43). All the buildings around me were destroyed, voices calling for help were coming from the houses and I felt a great sadness, I felt helpless and powerless because I couldn't do anything (P3, M, 28). The late arrival of aid and the increasing number of deaths every day caused me deep anxiety (P30, F, 25). Participants gave similar answers to questions about the causes of the earthquake, making sense of the material and moral losses experienced, and the segments most affected by the earthquake. It has been seen that there is almost a consensus that earthquake is a geological natural event, unpredictable and unpreventable, but if the necessary precautions are taken, the loss of life and material losses can be reduced and social damage can be minimized. It was a long-awaited earthquake anyway, Hatay is a 1st degree earthquake zone, after all, but I never thought it would be this destructive and cause loss of life. Of course, I believe in fate, but believing in fate does not prevent me from taking precautions (P5, F, 36). Hatay is a region known to have been destroyed seven times in history. I am surprised that we live in a geography full of fault lines and are so unprepared and confused for an earthquake. I prefer to approach natural disasters as a whole. How prepared were we? If the buildings had been built to withstand severe earthquakes, would we have suffered so many losses (K29, F, 35)? I think an earthquake is a natural disaster, but such a loss of life and property is imprudence. P11, M, 26). Earthquake is a natural disaster. Earthquakes cannot be prevented, but precautions can be taken by foreseeing what will happen afterwards. I attribute the material and moral losses mostly to lack of precaution, and I feel sad (P22, M, 33). On the other hand, it was stated that the entire population of the region, especially the most vulnerable groups, was affected by the earthquake. Children, disabled people and families with disabled individuals, women, immigrants, and poor citizens had to deeply experience all kinds of negativities of the earthquake. They stated that especially children would not be able to recover from the earthquake disaster and the shock of losing their homes and relatives due to the earthquake for a long time, so they made the gratest effort in this field as social workers. I think the group most affected by the earthquake is children. Because they are defenseless and in need of protection. They follow the path their families have drawn for them (P16, F, 25). Families of disabled people and chronic patients are the ones most affected by the earthquake. They suffer a lot because they cannot escape easily during an earthquake and have difficulty finding medical supplies after the earthquake (P25, F, 28). Disabled and elderly individuals and their relatives are the groups most affected by the earthquake. While providing home care services is challenging even under normal conditions, this becomes almost impossible when the most basic needs are not met (P4, M, 27). Children are most affected by earthquakes. Such traumatic events experienced during psychosocial development stages can cause permanent problems in adulthood (P21, F, 26). --- Findings Regarding Activities, Difficulties and Inadequacies in the Earthquake Region In this section, where the activities carried out in the earthquake zone were investigated, the participants were asked questions about in which area they carried out their activities and for how long, the difficulties, facilities and inadequacies experienced in this process. In addition, they were asked to convey, with their field experiences, the factors required to make social service activities in the earthquake zone more effective and efficient. Social work practices in natural disasters such as earthquakes primarily aim to meet the urgent needs of the society and provide support. In this context, the most common types of social service practices in the disaster literature are disaster shelters, psychosocial support, meeting basic needs, community education, family reunification, support for the disabled, and legal consultancy services. Disaster shelters are established during or after the earthquake, and social service workers in these places provide shelter, basic needs and psychosocial support to the victims. Psychosocial support includes support services provided to help people affected by the earthquake cope with posttraumatic stress. This practice may include counseling, group therapy or support groups. Meeting the basic needs of earthquake victims such as food, water, clothing and medical aid is also considered a type of social service activity. Social workers identify these needs and provide access to help. Community education includes informing individuals about earthquake preparedness and emergency plans. This application is an important social service application in terms of helping people learn how to be prepared for an earthquake. Family reunification is a social service practice that provides assistance in reuniting and communicating with family members who were separated during an earthquake, thus minimizing social damage. Within the scope of support for the disabled, disabled individuals are provided with assistance for their special needs and their integration with society is supported. Legal consultancy is a type of social service practice that includes assistance and consultancy services regarding the legal rights

Hatay, one of the provinces most affected by the major earthquakes that occurred on February 6, 2023, was the area most impacted by the event. Immediately following the disaster, to recover from the effects of the earthquake and alleviate its negative impacts, social workers flocked to the region and implemented many social service practices. Social work practices are of critical importance in terms of accelerating the healing processes for the people of the region. In the study, the activities of social workers were evaluated using a case study approach. The aim is to reveal the effectiveness of social work practices from the perspective of social workers working in the earthquake response. Such an approach both supports and guides policy makers and decision makers in establishing new living conditions in the region and reveals the issues that need to be taken into account for future activities. Within the scope of the research, interviews with 30 social workers were analyzed. The results demonstrated that social work practices are extremely important in eliminating social damage in the post-earthquake period; however, human resources should be developed and increased in terms of quality and quantity, and financial and physical resources should be provided for social work practices.

disaster literature are disaster shelters, psychosocial support, meeting basic needs, community education, family reunification, support for the disabled, and legal consultancy services. Disaster shelters are established during or after the earthquake, and social service workers in these places provide shelter, basic needs and psychosocial support to the victims. Psychosocial support includes support services provided to help people affected by the earthquake cope with posttraumatic stress. This practice may include counseling, group therapy or support groups. Meeting the basic needs of earthquake victims such as food, water, clothing and medical aid is also considered a type of social service activity. Social workers identify these needs and provide access to help. Community education includes informing individuals about earthquake preparedness and emergency plans. This application is an important social service application in terms of helping people learn how to be prepared for an earthquake. Family reunification is a social service practice that provides assistance in reuniting and communicating with family members who were separated during an earthquake, thus minimizing social damage. Within the scope of support for the disabled, disabled individuals are provided with assistance for their special needs and their integration with society is supported. Legal consultancy is a type of social service practice that includes assistance and consultancy services regarding the legal rights and insurance claims of earthquake victims. Social work professionals adapt, increase or decrease their practices according to local conditions and needs. The Ministry of Family and Social Work stated that they reached more than 3 million citizens in the earthquake zone with many social service practices such as psychosocial support, psychological first aid and coordination of in-kind aid, and that they showed that the state stands by its citizens, and that they carried out social service activities in the field with more than 12 thousand personnel. It was also emphasized that among these personnel there were social workers who worked devotedly in the field, even though they were earthquake victims themselves (Ministry of Family and Social Services, 2023a). The Ministry also prepares social service projects for earthquake-affected citizens who have gone abroad temporarily, and within the scope of the projects, psychologists, psychological counselors, social workers, and child development experts provide family seminars, psychosocial trainings, and historical-cultural trips, separately for adults and children. Within the scope of the projects stated that improvement activities will be organized. In addition, it is also stated that with the project, which aims to reduce the negative effects of the earthquake on citizens, Turkish families residing in Germany and whose relatives come from the earthquake area will be informed about how to approach their relatives affected by the earthquake and what they should pay attention to (Ministry of Family and Social Services, 2023b). During the earthquake disaster in Hatay, social service experts and employees declared that they contributed to many social service activities. Education, rehabilitation, consultancy, guidance, needs assessment and access to services, especially the psychosocial support services mentioned above, are among the leading activities. The issue frequently mentioned in the interviews with the participants was that the social service personnel operating in the earthquake zone were involved in almost every issue and every social service practice and that they made an effort for this. I worked in the psychosocial support team in the earthquake zone for 1 week in Antakya, 1 month in K<unk>r<unk>khan, and 3-4 months in the Hassa region. Home visits,individual interviews,psychoeducation and other trainings,activities,children's activities,sports,culture,etc. I worked in all activities (P10,M,34). I worked in the Children's Services Unit, Women's Services Unit,and Socioeconomic Support Units (P22,M,33). I worked for weeks in the field of household screening and social activities for children in the container city where we were assigned as the Ministry (P29,F,35). We worked with both children and families. For example, tents were set up in Antakya. We were going to those tents and doing activities with the children, but we also tried to reach the children who could not reach them and set up tents with them and support those children. We played games and did activities, and apart from that, we reached the families by visiting the villages and neighborhoods of Samanda<unk>. We asked about their needs and tried to help in terms of psychosocial support (P8, F, 43). We were assigned to the villages and neighborhoods of the provinces or districts to which we we had ben assigned, and also to container cities. We worked in children's areas, we worked in elderly areas, we helped people with disabilities, home care, individuals in need of socioeconomic support, families and even people trying to reach tents and other shelter needs. We had to not only work in one field but also work outside our own field. Because our employees were affected by the situation at some point, we tried to provide psychosocial support to them (P15, F, 27). A number of difficulties have been encountered in social work practices in the earthquake zone. Such challenges are inherent in disaster and the social work profession. Access difficulties, emergency coordination, resource shortage, mental problems, communication problems and housing problems stand out as the most frequently encountered difficulties. During earthquakes, infrastructure may be damaged and road and communication networks may be interrupted. This makes it difficult for social service teams to reach affected areas and provide assistance. Since earthquakes often require the participation and intervention of more than one organization, they can lead to lack of coordination and conflicting relief efforts. Earthquakes can require a large number of resources quickly. Social work teams face challenges in the field with inadequate funding or understaffing. On the other hand, earthquakes can cause traumatic events and psychological problems may be common among affected individuals. Social workers also have to deal with such situations. Damage to the communication infrastructure makes it difficult to find missing people and convey requests for help. Many people may become homeless during earthquakes. In such cases, social service teams may have to intervene with rapid planning and implementation to meet temporary shelter and settlement needs. To overcome all these challenges, good preparation, quick response and effective coordination are important. In this context, social service teams during earthquakes are of critical importance for the well-being of society. Most of the difficulties expressed were also confirmed by social service workers operating in the Hatay region. As difficulties there was a major organizational problem. Inter-institutional communication was not possible because their phones did not have reception. Since everyone came from outside, they did not know the environment or the staff (P12, F, 38). We visited households in the village in Antakya, but they could not go to the unvisited villages due to bad roads (P5, F, 36). It was very tiring for us to work with a small number of people in the units due to the concentration of applicants to work in the earthquake zone and our colleagues being on administrative leave or passing away. It became very difficult for those of us who were directly exposed to the earthquake to provide psychosocial support. We were sleep deprived, we were sleeping little, we were working all the time, so we were very tired, but frankly, we did not feel so tired because we saw people in those conditions (P29, F, 35). I was staying in a tent city with foreign nationals in the earthquake zone. I had difficulty communicating with adults. Because we don't speak the same language. There was no problem with the children either, they were just too crowded, maybe we can say this as a problem (P7, M, 32). During the activities, we had difficulties in directing them to other government institutions. There was a bit of a coordination problem. Lack of living spaces, people's general psychology, dirty air due to demolition, difficulties in accessing basic services, difficulties experienced in the field (P14, M, 25). In order for social service activities to be effective and efficient in the earthquake zone, factors such as preparation and planning, cooperation and coordination, human resources, communication, resources, public participation, training and capacity development, psychosocial support, and rapid response come to the fore. Detailed preparation and planning must be made for effective service delivery before, during and after the earthquake. Emergency plans, training, drills and scenario development are important at this stage. Effective cooperation and coordination should be ensured between different institutions, non-governmental organizations, local governments and other stakeholders. This factor is vital as it allows services to be provided without conflict. Competent and sufficient human resources such as social workers, psychologists, psychiatrists and guidance specialists must be available. These professionals significantly accelerate the healing process through the provision of psychosocial support during crisis periods. Personnel who can communicate effectively with the public and have crisis communication training are required. It is critical to inform and guide the public. Physical resources such as equipment, materials, financial resources and accommodation facilities are extremely important in supporting the effectiveness of service delivery. Community involvement and feedback help tailor services to meet needs. Social work professionals and other crisis management personnel should be regularly trained and kept up to date. The psychosocial needs of earthquake victims should be focused on and emotional support should be provided. It is vital to act quickly and in a coordinated manner immediately after an earthquake to have the potential to minimize loss of life and damage. In the interviews, social service workers operating in the Hatay region also put forward opinions that these factors would significantly increase the effectiveness and efficiency level of social work practices. More human resources are required. Individuals working in the field (like me) should be supported in training and many issues (P24, F, 29). I think we need more Social Workers and Psychologists and concrete activities that will revive hope in people (P18, F, 29). As an employee in the earthquake zone, I also need psychosocial support and I request that support be provided in this regard (P2, M, 32). Institutions such as family social work, Afad and Red Crescent need to work in cooperation and coordination (P10, M, 34). --- Findings Regarding Expectations and Predictions for the Future Although the expectations and predictions of social workers about the future after the earthquake are different, it is possible to reach certain conclusions based on common points. First of all, after the earthquake, there is an increase in the psychosocial and basic needs of the society, and social workers are expected to work harder to meet these increasing needs. Secondly, social workers' crisis management skills become even more important. As earthquakes and other natural disasters increase in frequency, experts' skills in emergency response improve and become more efficient. Thirdly, social workers are expected to focus on education and awareness activities to increase society's preparedness for disasters. Fourthly, the importance of closer cooperation and coordination with other institutions, local governments and non-governmental organizations for post-earthquake service delivery is understood. Fifthly social workers can improve service delivery by using technologies such as communication and data analytics more effectively. Sixthly it should not be forgotten that social workers working in post-earthquake services may themselves be under stress. Therefore, it is important for them to be well and get support. Finally, post-earthquake societies have long-term recovery and reconstruction needs. Social workers also play an active role in this process. These insights reflect the challenges and opportunities social workers may face to more effectively respond to the needs of post-earthquake communities. On the other hand, the predictions and expectations for the general society that experienced the earthquake are hopeful that the situation will improve day by day, the wounds will be healed and the material and moral, economic, psychological and social damages will be compensated over time. I hope that more effective and effective work will be carried out in the future. More effective psychosocial support should be provided by taking into account the psychology of the personnel working in the field (P18, F, 29). As far as I understand, the process will not work any faster than this. But my hope is that a city can be built that will not cause such destruction again (K1, K, 24). I hope that our state will heal the wounds quickly and we will get back on our feet (P22, M, 33). I think that those traumas, those damages, those psychological injuries are not things that will go away easily, we need to give great support as a society, we need to heal the wounds of those people before building a house, buying a car (P8, F, 27). I think people there always need social support. I think part-time assignments from here should be done a little more intensively. Appointed personnel must receive training on how to treat individuals affected by disaster (K15, K, 27). I do not know how other ministries and other institutions of the state will work professionally. However, our ministry stated that it will continue psychosocial support. My personal expectation is that in a very short time, people's important needs such as basic shelter, basic security, basic clothing, eating and drinking, and access to food, as well as strengthening and finally access to social services, will be met... I hope my expectations will come true in a very short time (K29, K, 35). In the next period, I hope earthquakeresistant buildings will be built and those in need will not be victimized, especially the demographic structure in Hatay was an example for our whole country, I hope it does not change (P27, M, 42). Participants working in the field of social work in Hatay had a significant change in their lives before and after the earthquake, they began to value their loved ones much more, they tended to live life minimally, they realized that making others unhappy for financial reasons causes suffering that affects the whole society. This experience heightened their sensitivity and instilled a sense of caution towards natural disasters and their impact. They stated that it is necessary to be more sensitive and cautious about this issue. I learned to live life minimally. Because I still feel the nothingness of having such a bond with matter when even the breath, we take does not belong to us (P12, F, 38). Material possessions lost their importance and enjoying the moment became important (P14, M, 25). After the earthquake, I learned how valuable my loved ones and the life I live are (P26, M, 31). I changed, my environment changed, it deeply shook my perspective on life (P4, M,27). I did not have much experience with the suffering before the earthquake, and I experienced the psychological difficulties of working in disasters (P16, F, 25). Nothing is the same anymore, we lost our home and many of our relatives, and we still experience post-traumatic stress symptoms (P5, F, 36). --- Discussion Social service in disasters encompasses a range of activities, including providing emergency shelter, food assistance, and mental health counseling to individuals and groups affected by disasters. In the literature, it is seen that international studies on disaster and social service activities are more intense than national studies. It is noted that these studies, which mainly focus on social service activities carried out during and after disasters such as earthquakes, fires, hurricanes and finally pandemics, are generally compatible with the findings of this research on social service activities carried out during the February 6 Hatay earthquake. In the Wenchuan earthquake that occurred in China, Huang, Zhou, and Wei (2011) particularly highlighted the healing dimension of social work activities. Frankly, the findings of this research conducted in Hatay point to the same direction. They stated that the medical support, social support and psychosocial activities provided by social service workers aim to improve the physical and mental health of earthquake victims and thus increase their motivation for life. During the Marmara Earthquake, qualified social workers were needed to provide aid and support services in the field. These experts give hope to disaster victims and help them look to the future more optimistically. Hope motivates disaster victims and supports them in achieving their goals, especially in such periods (Javadian, 2007;<unk>biş and Kesgin, 2014). In his study, Zakour (2008) emphasized the importance of social service workers in creating resources for social work activities in disasters and making these resources accessible to disaster victims. The study carried out in Hatay, the earthquake region, spent weeks and months of household screening, needs assessment and meeting the identified needs for the same purposes. Similar findings emerged in the study conducted by Wong (2018), which touched upon the importance of social service workers during disasters. In their article, Artan and <unk>zkan (2020) focused on the importance of social work and the roles of social workers in disasters and reached similar findings. Another study addressing social work activities at the individual, group and community levels with disaster and post-disaster dimensions was conducted by Alstone, Hazeleger and Hargreaves (2019). The findings of the study are similar to the findings of this study conducted in Hatay, but the activities in Hatay were organized as a whole rather than separately at micro, mezzo and macro levels. The situations of vulnerable groups with unique and special needs were of course considered and support activities were continued within special programs. Studies by Ayd<unk>n (2012) and Altun (2016), focusing on the situation of vulnerable groups in disasters, also reached similar findings and highlighted the importance of social service interventions for risk groups. Tuncay (2004), who made significant contributions to the literature with his book titled "Social Service in Disasters, Social Work Practices Realized After the 1999 Marmara and Bolu-Düzce Earthquakes", revealed the nature and characteristics of the social services activated during the earthquake and the difficulties experienced by social service workers during disasters. The findings highlighted in the work are almost the same as the findings in this study conducted in Hatay. As social service intervention, primarily psychosocial support, need identification, access to resources, education, rehabilitation, taking into account the special needs of vulnerable groups, and household screening are the prominent social service intervention areas in both studies. On the other hand, the difficulties experienced by social workers in the earthquake zone such as inadequacy of human resources, inadequacy of space to carry out activities, working for excessive hours, and as a result of all these, the inability to maintain their own well-being stand out as common findings of field studies. After the disaster, it is extremely important for social service workers who will serve in the regions affected by the disaster to be protected from the psychological effects of the disaster and to be able to continue their professional work effectively (Tuncay, 2004;<unk>biş and Kesgin 2016). In order to continue their work effectively, rescue personnel must be well prepared, otherwise emotional trauma renders them ineffective (Waeckerle, 1991;<unk>biş and Kesgin 2016). As a matter of fact, in this study conducted in Hatay, a significant portion of social service workers in the earthquake area stated that they experienced difficulties in protecting their mental health and that they especially needed psychosocial support. Similar findings emerged in Aktaş's (2003) study, in which he investigated how social work intervention would be in crisis situations, the steps of intervention, and the interventions to be carried out at the social level. In a study comparing the Van and Marmara earthquakes in terms of social service activities, it is evaluated that the special needs of vulnerable groups (especially children, women and disabled people) were not adequately addressed and the desired level of psychosocial support was not reached (Altun, 2016;Tapan, 2023). This situation is partially compatible with this research. The reason the incident is still fresh in Hatay in this this sense, social support services are continuing uninterruptedly. In his research on the actors involved in disaster management and their roles in terms of social service activities, <unk>zçelik (2020) examined the social service activities carried out by central government organizations (ASHB, AFAD, K<unk>z<unk>lay, UMKE etc.), local governments and nongovernmental organizations in the field. The findings that all these institutions tried to support disaster victims as much as possible in a coordinated manner during the disaster are fully compatible with the findings of this research. On the other hand, <unk>biş and Kesgin (2014) touched upon the relationship between social work and medical rescue in their research and discussed the social service practices of the Ministry of Family and Social Services in crisis intervention in case of disaster. Findings have been reached that the implementation objectives of the Ministry and the activities carried out in Hatay are compatible. As a matter of fact, the conclusions that the Ministry entered the earthquake area with as much personnel and resources as possible and did not hesitate to make any sacrifices in supporting the earthquake victims were confirmed by social workers operating in Hatay. It was reported that there was a serious lack or inadequacy of coordination after the Marmara earthquake (Karataş, 2000;Tapan, 2023). This reveals that similar results were obtained with this study conducted in Hatay and that it is compatible with the literature. --- Conclusion Earthquakes are one of the leading disasters that have the effect of radically changing human life. The earthquake disaster that occurred in Hatay on February 6, 2023 affected the lives of all people living in the region, causing wounds that are difficult to heal and damage that is difficult to compensate. In such incidents, social work practices are of critical importance in minimizing social damage and accelerating healing and normalization activities. In fact from the first moment the earthquake was learned, the Ministry of Family and Social Work, local administrations, non-governmental organizations and volunteer initiatives flocked to the region to provide support in the field of social work and assigned their experts and experienced officials on the subject. It is extremely valuable to make social service activities operational in the region immediately after the earthquake disaster and to carry out these activities with trained, knowledgeable and experienced staff. Because such an initiative reveals the value given to people in the region, the steps taken to reduce suffering, and the belief that the people of the region are not alone in the healing processes. On the other hand, evaluations carried out in line with the opinions and suggestions of social service experts and studies operating in the earthquake region will increase the accuracy of the steps to be taken and the policies to be produced in the field. As a result of the field interviews conducted with experts who are practitioners in the field of social work in the earthquake affected region of Hatay, many conclusions have been drawn that will guide decision makers on this issue. During the earthquake, there were opinions that there were serious difficulties in transportation to the earthquake area, that transportation delayed arrival to the site, that access to the region could not be achieved during the very valuable hours called golden hours, and it was emphasized that alternative transportation routes should be provided to the region. It was found that there was a lack of coordination between institutions providing social services, which significantly reduced the effectiveness and efficiency of services. The environment of chaos and turmoil created by the lack of coordination has also made it difficult for earthquake-affected citizens to have access to basic needs. On the other hand, the principle of equal and fair access to humanitarian aid has been disrupted by the lack of coordination. At the point of making sense of the causes of the earthquake and earthquake losses, social workers point out that the earthquake is a natural event and therefore cannot be prevented or predicted. However, they have a consensus that the loss of life and property can be minimized with effective measures to be taken and deterrent measures and controls to be implemented. It has been stated that if the ground surveys are scientific, the construction quality is high and durable, the damage caused by the earthquake will be much more limited. On the other hand, social work practitioners showed vulnerable groups as the segments most affected by the earthquake. It has been stated that especially children, the disabled, women, the poor and immigrants are already vulnerable, and their grievances has increased with the earthquake. It is possible to talk about a consensus among social workers that for social service activities in the disaster area to be more effective and efficient, a serious preparation process, sufficient human resources in terms of quality and quantity, sufficient financing, and physical space to carry out the activities, and social support are required. The fact that the earthquake occurred in more than one province at the same time and in a very wide geography caused inadequacies, especially in terms of human resources, and therefore a decrease in the quality of social service practices. On the other hand, the problems experienced in shelter and accommodation areas in the early days of the earthquake were significantly resolved during the process. First tent cities and then container cities played an important role in this field. It is possible to state that there is a generally optimistic approach regarding future expectations and predictions. A very significant part of the social service workers who contributed to the research put forward expectations that, as the state and society, healing processes will be carried out quickly, wounds will be healed, and a new life will be achieved with new hopes. At this point, on the one hand, physical structuring will be emphasized and solid housing and living spaces will be built and on the other hand, the psychological and social damages of the society will be repaired with other social service activities, especially the psychosocial supports.

Hatay, one of the provinces most affected by the major earthquakes that occurred on February 6, 2023, was the area most impacted by the event. Immediately following the disaster, to recover from the effects of the earthquake and alleviate its negative impacts, social workers flocked to the region and implemented many social service practices. Social work practices are of critical importance in terms of accelerating the healing processes for the people of the region. In the study, the activities of social workers were evaluated using a case study approach. The aim is to reveal the effectiveness of social work practices from the perspective of social workers working in the earthquake response. Such an approach both supports and guides policy makers and decision makers in establishing new living conditions in the region and reveals the issues that need to be taken into account for future activities. Within the scope of the research, interviews with 30 social workers were analyzed. The results demonstrated that social work practices are extremely important in eliminating social damage in the post-earthquake period; however, human resources should be developed and increased in terms of quality and quantity, and financial and physical resources should be provided for social work practices.

The current study is a literature review to analyze the parents' burden in deciding to vaccinate their children against COVID-19, during the pandemic while utilizing Ulrich Beck's risk society term. The definition, perception, and experience of risk in society are all important and developing topics of risk studies in the social sciences. According to Beck's idea of risk society, risk is a human construct that takes many forms due to technological advancement and global influence. Parents are primarily responsible for protecting their children against risks that have been amplified or otherwise attenuated. The COVID-19 pandemic has increased parental obligations by making the heightened risk a reality. These responsibilities include preventing contamination and vaccinating children. As the vaccines are promptly developed for a new disease, it is also seen to be risky. The study concludes that the COVID-19 vaccine decision is a recent and significant parental responsibility because of the risk society, which attributes the protection of individuals against primarily human-made and global threats. Moreover, opinions toward vaccination rely on several variables, including confidence in institutions, the health concerns associated with vaccination, and the influence of the virus on young children. <unk>al<unk>şmam<unk>z, Ulrich Beck'in risk toplumu teriminden yararlanarak, pandemi s<unk>ras<unk>nda ebeveynlerin çocuklar<unk> için COVID-19 aş<unk>s<unk>n<unk> seçerken yaşad<unk>klar<unk> yükü analiz etmek ve anlamak amac<unk>yla gerçekleştirilen bir literatür taramas<unk>d<unk>r. Toplumda riskin tan<unk>m<unk>, alg<unk>s<unk> ve deneyimi, sosyal bilimlerdeki risk çal<unk>şmalar<unk>nda önemli ve gelişmekte olan konulard<unk>r. Beck'in risk toplumu konseptine göre risk, teknolojik ilerleme ve globalleşme sonucu insan yap<unk>s<unk> olan ve pek çok çeşidi bulunan bir yap<unk>dad<unk>r. Ebeveynler, çocuklar<unk>n<unk> artt<unk>r<unk>lan (abart<unk>lan) veya azalt<unk>lm<unk>ş risklere karş<unk> korumaktan birincil derecede sorumludur. COVID-19 salg<unk>n<unk> art<unk>r<unk>lan riski gerçe<unk>e dönüştürerek ebeveyn yükümlülüklerini art<unk>rm<unk>şt<unk>r. Bu sorumluluklar aras<unk>nda bulaş<unk>s<unk>n<unk>n önlenmesi ve çocuklar<unk>n aş<unk>lanmas<unk> yer almaktad<unk>r. Yeni bir hastal<unk>k için h<unk>zl<unk> geliştirilen bir aş<unk> oldu<unk>u için aş<unk>n<unk>n da riskli oldu<unk>u görülmektedir. <unk>al<unk>şman<unk>n sonuçlar<unk>na göre, COVID-19 aş<unk> karar<unk>, bireylerin insan yap<unk>m<unk> ve global risklere karş<unk> korunmas<unk> yükümlülü<unk>ünü bireylere b<unk>rakan risk toplumu çerçevesinde, ebeveynlere yeni ve önemli bir sorumluk getirmektedir. Ayr<unk>ca aş<unk>lamaya yönelik kararlar, kurumlara duyulan güven, virüsün ve aş<unk>n<unk>n küçük çocuklar üzerindeki etkisi gibi sa<unk>l<unk>kla ilgili kayg<unk>lar dahil olmak üzere bir dizi de<unk>işkene dayanmaktad<unk>r. --- Introduction This study aims to examine the burden of the pandemic on parents, through their decision to vaccinate1 their children, based on theories on risk such as social amplification of risk framework (SARF), psychometric paradigm, cultural theory, and governmentality of risk and focusing on the risk society concept of Ulrich Beck (1992). COVID-19 is a recent issue that poses significant risks, the full effects of which are still being analyzed. It has tremendously impacted social, personal, and family life. As a health concern, COVID-19 is associated with care work, contamination, lockdowns, and precautions. All of these regulations and obligations have also affected family life, relationships, and the responsibilities of parents towards their children and society. Therefore, even though the vaccine is primarily a health issue, it also has sociological aspects that must be carefully considered. Our study aims to investigate the sociological aspects of COVID-19 and the concept of taking risks associated with its vaccine. COVID-19 has revived the debate about vaccines combined with new risks and concerns about the vaccine. While sociological studies on risk are relatively few, the risk is calculated numerically via quantitative studies. Considering the relevant areas, it can be understood that parenting and vaccine, parenting and COVID-19, and parenting and COVID-19 vaccine have been studied in various regions. However, parenting and the COVID-19 vaccine have not been studied with the framework of "risk". Our research aims to examine how parents make decisions about administering the COVID-19 vaccine to their children, taking into account both the perceived risk and the social and cultural factors that may influence their decision-making processes. The vaccine is a significant issue argued through parenthood obligations and state intervention since the vaccine is applied through the childhood phase. Even though vaccine rejection contains a significant study area, COVID vaccine rejection is a relatively new issue, and the issue is argued with terms such as "vaccine hesitancy" and "vaccine acceptance" instead of rejection; thus, there is not any study on vaccine rejection and covid or parents' COVID vaccine rejection. However, there are studies with significant content, number, and variety of research on the vaccine decisions of parents to analyze the parents' position and situation considering COVID vaccine and risks. The study starts with an inquiry into the definition of risk and argumentations regarding risk in the social sciences to provide a sociological framework for the construction of risk. It focuses on the basic understanding of risk in social sciences and how the term risk society can be understood considering these historical backgrounds of the risk theory. Additionally, the main theories on risk and society are elaborated with a basic interest in the "risk society" term of Ulrich Beck. Supported by this theoretical variety, our basic theory, risk society, can be understood and analyzed better from a wider sociological perspective. Depending on this theoretical base on risk, research is conducted on parents' decision on vaccinating their children's COVID-19 vaccine. Therefore, the relationship and analysis of COVID-19 and parenting can be comprehended considering the obligation of parents to the risk society. --- Risk in Social Sciences Risk can be considered a vague idea and can also be used to identify distinct groups of people who are more susceptible to dangers. (Füredi, 2007: 27) Short defines risk also stating the positive dimension of risks. According to that, even, if the risk is more specifically the chance or probability of a hazard's negative effects, the idea of risk does not need to have such a limited scope or negative meaning. A more impartial definition plainly says that risk is the potential of a possible event. There is a lot of research on the advantages of risk and uncertainty in people's lives (Short, 1984: 711). Füredi (2007: 27-28) discusses how risk profiles are determined and calculated and suggests that children who are considered to be at risk often exhibit a specific lifestyle. Furthermore, social workers may examine the background of parents to assess whether their children are at risk. The numerous risk factors that impact individuals can constrain their choices and prospects for the future. Some situations, encounters, and experiences are also classified as being at risk. The introduction of the concept of "at-risk" creates a division from the conventional connection between human behavior and the probability of particular risks. People have risk profiles related both to who they are and what they do and it is created by specialists from many fields. They think this knowledge can be helpful. Risk factor analyses extract the behaviors that are characteristic of persons who are most likely to be at risk. The risk factors that receive the most attention in the field of health promotion include stress, obesity, and smoking. To be at risk also indicates that the threats one faces are independent. Even Beck's statement on how risk is human-made (even the major and grand projects and problems such as nuclear bombs, and global warming) and each individual is considered to be responsible for each risk (Beck, 1992: 7), Füredi remarks that external risk exists and they are independent and completely separate from the actor and is not only the result of any particular action. As a result, the best course of action is to completely avoid a risk once it is recognized that it exists in and of itself and requires little to no human participation (Füredi, 2007: 27-28). While defining risk, Füredi also points to specific characteristics of the risk concept in the Modern World and points out that risk is referred to as the possibility of damage, injury, illness, death, or another unfortunate event associated with a danger is referred to as risk. In general, the concept of "hazard" refers to a threat to individuals and their values. Hazards go beyond the obvious dangers like hurricanes, poison, germs, and toxic waste. Variously, things like peanuts, tampons, cars, and birth control pills, to mention a few, have been depicted as dangers. (Füredi, 1997: 25). Beck also remarks on the increasing risks on family life, work life, ecological balance, social ties and due to scientific innovations and reflexive modernity (Beck, 1992: 13) Along with all of these, the modern period is often presented as an age of disaster, of global conflicts, genocides, and ethnic cleansings, catastrophes of industrial and rural transformation, disasters of technological arrogance, and environmental calamities (Füredi, 1997: 19-20). Beck also claims that risk is different in the modern world compared to premodern times stating that the idea of risk is closely intertwined with the concept of reflexive modernization and that risk may be characterized as a systematic method for dealing with the dangers and insecurity that modernity itself presents and generates. Thus, risks can be defined as the outcomes of modernization's globalization and its alarming force (Beck, 1991:21). To sum up, both Beck and Füredi agree that the risk, at present, is the responsibility of the individuals. Misfortune and accidents are not accepted as explanations and excuses for risks and danger, but as the responsibility of individuals (Füredi, 2007: 10;Beck, 1992: 46). Füredi adds that today's society has a difficult time comprehending misfortune and hardship, since people's problems are increasingly considered to be the result of reckless or malicious behavior. Our society has a difficult time accepting the possibility that we might occasionally experience negative events. Public health authorities frequently assert that most injuries suffered by people are preventable and that it is irresponsible to attribute such an incidence to an accident; thus, advocates for health promotion and safety specialists reject the word accident. (Füredi, 1997: 10). Research on risk has been mainly studies based on more quantitative study areas until recent decades. However, risk has been recognized also as a social issue. Understanding, defining, and analyzing the risk, perceptions of risk, sociological structure, and the process of producing risk can be summarized as the basic concerns of social sciences concerning risk studies. Basic theorists and theories on qualitative studies on risk studies in social sciences can be listed as Mary Douglas and Cultural Theory, Foucault and governmentality of risk, Slovic and psychometric approach, and Ulrich Beck and concept of risk society which is the main theory of this research questioning the relationship of risk and vaccine decision of parents considering risk. Wilkinson states that sociologists' evaluations of the risks we face seem to have a major impact on how they conceptualize the social development of "risk consciousness" and its political implications for the potential futures that lie ahead. (Wilkinson, 2002: 7) Thus, the definition, perception, and focus of risk theories vary due to specific concerns and attention. Therefore, Wilkinson adds that the sociological field that has grown up around the study of risk is primarily concerned with explaining how our perceptions of health risks and technological dangers are produced culturally, and also their role in the formation of a new ethical and political foundation for a society that, based on which expert you believe, has increased the threat of a major environmental catastrophe as a result of accidental side effects of its design. (Wilkinson, 2002: 7) --- Social Amplification of Risk Framework (SARF) A significant contribution to risk perception studies is the social amplification of risk framework (SARF). This framework focuses primarily on how individuals perceive and evaluate risks concerning content, threat, approximation, and risk warning. According to SARF, risk can be amplified in a society when certain risks and events that specialists deem to be low-risk become a special focus of worry and political activity. Nevertheless, society pays relatively lesser attention to risk attenuation than to other threats that experts deem to be more important. Smoking, car accidents, and naturally occurring radon gas are examples of significant risks that may be subjected to social attenuation of risk perceptions. (Kasperson, Kasperson, Pidgeon, and Slovic, 2003: 13-14) Media has a significant effect on our risk evaluation and our tendency to amplify certain risks over others. Wilkinson states that our first, and occasionally only, exposure to subjects like the dangers of emerging genetic technology and the potential of an ecological catastrophe is when we read the news and watch television (Wilkinson, 2002: 115) besides social media in the present. Concepts of amplified-attenuated risk are also significant difficulties when it comes to parenting. In her research concentrating on the burden of motherhood, Villalobos also explores parental behavior and how it relates to the idea of risk. In her study, she also makes mention of how parents worry about amplified risks, such as a nuclear bombing, and even make lifealtering decisions to shield their family from it. She uses the example of a family she interviewed as an example who decide not to move somewhere 3 hours away to NYC due to their concerns about a nuclear bombing assault on NYC (Villalobos, 2014: 35). Slovic (1987) proposes a psychometric approach to research risk perception within people. Developing a taxonomy for hazards he aims to comprehend and foresee reactions to the risks assessing perceived risk. He argues that people's intense sensitivity to some dangers, their disinterest in others, and the differences between these emotions and professional views may all be explained by a taxonomy approach and he proposes the use of the psychometric paradigm to ensure a taxonomic scheme. --- The Psychometric Paradigm According to this view, people evaluate the intended amount of regulation for each risk as well as the desired level of riskiness for various hazards using quantitative methods according to the psychometric paradigm. The risk perception of individuals depends on their 'heuristics', frames of perception. These judgments of individuals are then connected to judgments about other characteristics which can be listed as; firstly, the hazard's status concerning characteristics that have been postulated to account for risk attitudes and perceptions (for example, voluntariness, despair, knowledge, and predictability). Secondly, the gains that each hazard provides to society. Additionally, the number of deaths induced by the hazard in an ordinary year, and finally, the number of deaths caused by the hazard in a disastrous year (Slovic, 1987: 281). Thus, the psychometric paradigm comprises a theoretical framework based on the idea that risk is a concept that is subjectively interpreted by people who may be influenced by a range of psychological, social, institutional, and cultural factors. The paradigm relies on the premise that many of these factors and their connections can be measured and modeled with the right survey instrument design to shed light on how communities and individuals respond to the dangers they encounter (Slovic, 2000, xxiii). The psychometric paradigm is criticized for being more quantitative on risk analysis and having a lighter focus on the broader social, cultural, and historical contexts in which such heuristics are developed and function (Lupton, 2006: 2) compared to the theories in social sciences and risk society term of Beck. --- Cultural Theory Douglas, in her early works, defined the view on notions of purity and contamination as culturally particular and serves to build and uphold beliefs about self and Others of the society. Thus, things are considered contaminating and polluting and therefore hazardous due to the threat it poses to social order. Her "cultural risk" understanding is also generated depending on her these theoretical findings on purity and contamination (Tulloch, 2008: 142;Lupton, 2006: 2-3). Douglas and Wildavsky have developed a cultural theory where they explain the cultural aspect of risk. Cultural theory developed by Mary Douglas and Aaron Wildavsky is also known for their functional structuralist assessment of how organizations and societies react culturally to risk using a "group-grid" model. The group refers to the physical barrier that people have constructed to segregate themselves from the external world. Grid refers to all the additional social classifications and power relationships that they utilize to control how individuals relate with one another (Douglas and Wildavsky, 1983: 138). High-group and highgrid firms put their reliance on institutions and are hierarchical in structure, adhering closely to group norms and risk-taking behaviors. Low-group and low-grid organizations, in contrast, value individualism and a self-regulatory approach to risk (Lupton, 2006: 2-3). Douglas also focuses on social solidarity and risk relationship. Wilkinson adds that Douglas's explanation of the rise in environmental disaster risk in Western societies is not due to an increase in danger but rather to the breakdown of social solidarity among marginalized groups, which encourages them to use ecological catastrophe as a strategy for preserving their preferred way of life (Wilkinson, 2002: 104-107). Even the focus of Cultural Theory on risk has different aspects from risk society theory, their emphasis on the changing characters and dynamics of risk-taking behavior and the impact of social solidarity contributes to theoretical studies of social science on risk defining and analyzing risk behaviors of different parts of society considering group relationship and bonding. Cultural Theory is a sociological framework that seeks to explain how different cultural beliefs and values shape our understanding and responses to risk. Unlike the psychometric paradigm, which focuses on individual perception of risk, Cultural Theory emphasizes the importance of shared cultural norms and values in shaping our understanding and responses to risk. In contrast to the Social Amplification of Risk Framework (SARF), which emphasizes the role of media and social networks in amplifying and shaping risk perception, Cultural Theory emphasizes the role of cultural symbols and narratives in shaping our understanding and response to risk. Cultural Theory proposes that different societies and groups hold different cultural biases, which can lead to diverse perceptions and responses to risks. Finally, Cultural Theory is different from Beck and Füredi's ideas in that it emphasizes the importance of culture and its role in shaping our responses to risk. While Beck and Füredi emphasize the responsibility of individuals for managing risk, Cultural Theory suggests that cultural biases and values play a significant role in shaping individual and collective responses to risk. --- Governmentality of Risk Michel Foucault's ideas on a new type of governance in modernity are the base of discussions in the literature on governmentality and risk. Governmentality is described by Foucault as an assembly composed of the institutions, practices, assessments and reflections, figures, and strategies that permit the exercise of this very particular yet complicated type of power. (Foucault 1991, 102). Furthermore, risk, based on Foucault's analysis of governmentality and risk, is defined as a capacity to identify hazards and acquire the art of governing relationships of power. (Foucault 1991, 90) Thus, following Foucault's theory of governmentality, risk is the management and control of uncertainties and potential dangers in society. The concept of risk is a key component of Foucault's theory of governmentality because it offers a way to comprehend how contemporary forms of power and government function and how they affect and control the behavior of individuals and populations (Lupton, 2006: 5). Some authors on governmentality have called attention to the growing emphasis on individual responsibility for preventing and controlling risks in modern neo-liberalism, the political ideology that currently rules Anglophone countries. They have identified a new prudentialism that is currently pervasive in governmental discourses and tactics, which shifts away from traditional ideas of social insurance as a form of risk allocation in favor of an emphasis on individuals minimizing risk (Lupton, 2006: 5). The risk society theory of Beck (1992) also remarks the growing responsibility of individuals on risk instead of institutions. Beck states that as risks of modern life are accepted as human-made and even their accelerating number and variety, individuals are thought to be responsible for their protection and safety. Furthermore, in five basic categories, Zin classifies risk and governmentality studies. The first group studies how institutions govern risk problems and how governance methods transform. Secondly, general concepts and their effect on problem interpretations and the composition of "at risk" groups, such as youth or children are examined. Furthermore, some scholars inquire about different groups' techniques for reacting to these discursive representations, such as the denial of the label "risky group". Certain scholars view studies on governmentality as a response to the risk society approach's insufficient explanatory power because it primarily emphasizes statistical and insurance risk-calculation methods. As a new meta-narrative that is directly tied to the societal level, the danger is seen by other authors as a final perspective (Zinn, 2004: 12-13). The concept of governmentality of risk refers to how governments and other forms of power attempt to manage, control, and govern risks. It is concerned with how risk is perceived, assessed, and managed by various actors in society, including the government, the private sector, and individuals. The governmentality of risk is based on the idea that risk is not just a natural phenomenon, but is socially constructed and that different actors may have different interests, values, and beliefs about risk. On the other hand, the risk society and the various theoretical frameworks we have discussed, including cultural theory, SARF, Beck's and Füredi's ideas, and the psychometric paradigm, all focus on how risks are perceived and managed by individuals and society as a whole. They are concerned with understanding how people make sense of and respond to risks, and how risk perception and management are shaped by social, cultural, and political factors. In summary, while the governmentality of risk focuses on how risk is managed by those in positions of power, the other theoretical frameworks focus on how individuals and society as a whole perceive and respond to risk. --- Risk Society Risk society theory has preferred to focus primarily on macro-structural factors that could be affecting what they believe to be the emergence of risk-avoiding in late modern societies. Thus, Beck and Giddens have contributed an understanding of reflexive modernity containing a critical overview focusing on risk and "risk society". They begin by defining the classical modern worldview as rational and controlling. Beck argues that the demand to make human living conditions controllable by instrumental rationality, manufacturable, available, and (individually and legally) accountable is enforced on industrial society, civil social order, and particularly the welfare state and the insurance state. However, in risk society, the unanticipated consequences of this need for control lead to a state that was previously thought to be overcoming the realm of uncertainty and ambivalence, or, to say it another way, alienation. So now, this also forms the basis of a society's comprehensive self-criticism (Beck, 1994: 10). Therefore, modernity aimed to calculate and control anything but failed due to increasing uncertainty and changing nature of nature, society, and risk. Beck adds that it may be demonstrated that political decision-making processes are not suited to comprehend or legitimate this return of uncertainty and uncontrollability. This holds not only for organizational forms and measures but also for ethical and legal principles and categories, such as responsibility, guilt, and the polluter-pays principle. Similarly, to this, indeed, social science concepts and techniques fall short if presented with the size and complexity of the facts that must be communicated and comprehended (Beck, 1994: 10). Therefore, reflexive modernity concept is based on the idea that late modernity is described by a critique of modernity's processes, which are no longer merely seen as producing goods (like wealth and employment) but are rather seen to produce many of the dangers and risks from which we feel threatened both as environmental crises and social challenges as global warming, new viruses and high unemployment and dissolution of family bonding. Thus, while government, industry, and science are emphasized as the primary generators of risk in late modernity (Lupton, 2006: 3-5) the individuals are held responsible for the survival of these risks since the risks are considered human-made, and people live in a more individualistic life. Beck defines reflexive modernity as the potential for creative self-destruction over the course of a whole era, namely the industrial society. According to this view, not of the revolution or the crisis, instead the success of Western modernism, is the subject of this creative destruction. (Beck, 1994: 2) Giddens's description of risk in the modern world also adds a remarkable contribution to the issue. He starts explaining characteristics of risk firstly as globalization of risk in the context of density: nuclear war, for instance, may threaten human existence. Additionally, now, the spread of dependent events that impact everyone, or at least a significant part of the global population, such as shifts in the international labor market, is known as the globalization of risk. Furthermore, the inflow of human knowledge into the physical environment poses a risk because it has been developed or socialized. Besides, the creation of institutionalized risk environments that influence billions of people's chances of surviving, such as the financial markets. Comprehension of risk as risk is another characteristic of risk in the modern world. Thus, religious or magical knowledge cannot convert dangerous gaps in knowledge into objective truths. Moreover, there is a widespread knowledge of risk and many of the threats we all confront are well-known to large populations. Finally, we are aware of the limitations of expertise since no expert system can be completely informed about the effects of applying expert principles." (Giddens, 1991: 124-125). Beck also defines a risk society as having a class society with stronger borders where, to that extent, risks seem to strengthen, not abolish, the class society. Poverty attracts an unfortunate abundance of risks. By contrast wealthy (in income, power, or education) can purchase safety and freedom from risk (Beck, 1992: 35) This is a class-specific distribution of risk. However, risks display an equalizing effect within their scope and among those affected by them considering the pollution all around the World and other chemical and biological global dangers (Beck, 1992: 36). Comparing Fordist work regime and risk regime, Beck concludes that, in contrast to the Fordist regime, which standardized work, the risk regime entails individualizing it. Therefore, the risk regime is distinctive in that it categorically excludes, after a time of adaptation, any eventual return of the old assurances of standardized employment, standardized life histories, an outmoded welfare state, and national economic and labor policies. (Beck, 2000: 70) Family structure also is affected by the risks of the modern world. Economic challenges due to temporary job positions make families vulnerable economically. (Beck: 1992: 142) Furthermore, increasing numbers of divorced families also make marital and family support fragile, besides responsibilities on families as a result of individualization of life and risks. (Beck 1992: 112;Beck, and Beck-Gernsheim, 2004: 30). To sum up, Beck argues that today's risks result from individual choices. Therefore, they rely on a framework that is both scientific and social (Beck, 1992: 155) Thus, the use of technology nowadays generates and creates risk. We are frightened about global risks that are assumed to be created by individuals. Beck states that dangers of annihilation predicated on human decisions shatter the natural character of civilization (Beck, 2002: 99) Therefore, even risks and issues like diseases or earthquakes, which were once entirely attributed to Divine will or to the structure of the universe, are now regarded to have been caused by humans employing biological weapons or causing devastating natural disasters. In addition, individuals are expected to take personal precautions against risks rather than governments. Thus, we are living in a risk society where, currently, risks come in far more varieties and are increasingly readily dispersed globally. The concepts related to risk perception, management, and communication have been relevant in the context of the COVID-19 pandemic and vaccination campaigns. Understanding the factors that influence people's decisions to get vaccinated or not, as well as how they perceive the risks associated with the virus and the vaccine, is crucial for effective public health communication. The ideas of Beck, Füredi, and SARF can help explain why some individuals may have different risk perceptions and behaviors than others. For example, Beck's risk society perspective highlights how modern society has created new risks that were previously unknown or less prominent, such as the risks associated with pandemics or new technologies like vaccines. Füredi's emphasis on individual responsibility can help explain why some individuals may be hesitant to get vaccinated or may engage in behaviors that increase their risk of exposure to the virus. The psychometric paradigm can help us understand how people's beliefs, values, and emotions shape their risk perceptions and behaviors, including their attitudes toward vaccination. Cultural theory offers a different approach to understanding risk perception, emphasizing the role of cultural values and beliefs in shaping how individuals and groups perceive and respond to risk. This approach can help explain why some cultural groups may be more or less likely to get vaccinated, or why some parents may have different attitudes towards vaccination for their children. Finally, the concept of governmentality of risk highlights how governments and other institutions manage and govern risks, including through policies related to vaccination campaigns. Understanding the role of government and other institutions in managing risk can help us evaluate the effectiveness of vaccination campaigns and other public health interventions. Overall, all of these concepts and theories can help us understand why some individuals and groups may have different attitudes towards vaccination and risk management, and how effective public health communication can be developed to encourage vaccine uptake and protect public health. --- COVID-19 Vaccine Decision and Parenting Based on the culture, region, and significant historical events, parenting has various aspects, obligations, and requirements. In the modern world defined by Ulrich Beck as risk society due to reflexive modernity, hence parental responsibilities and family interactions may also need to be revisited in perspective of these conditions. As previously argued risks have increased and become more widespread as a result of social, technological, and economic changes that have affected nearly every aspect of life, including food, health, energy, social interactions, and communication. Risks are perceived as human-made, and individuals are held accountable for their development and mitigation rather than governmental entities and organizations. Families have been undermined by the high divorce and unemployment rates of modern life, yet they still have a greater obligation to protect their members from these external threats (Beck, 1992: 142). Parents are the adults who must protect both their children and themselves. Parents feel more vulnerable and frightened than ever as a result of the hazards and risks associated with high complexity and diversity as well as the decreased support from the government and social groups. Before making any decisions about minor or significant issues, they should first recognize and categorize risks as attenuated and amplified, and take precautions against each risk. According to Villalobos (2014), parents are more concerned about amplified risks like nuclear catastrophes than attenuated certain risks, even if we are still in danger from more common, attenuated, and definite dangers like car accidents (Kasperson et al., 2003: 14-15). However, amplified risks such as pandemics, biological war, alien invasion, or nuclear accidents may be perceived as higher priorities due to a variety of factors, including media coverage of these issues and the fact that, even though their likelihood of occurring is low, their damage would be extremely severe. Additionally, some other amplified risks such as global warming, ecological order imbalances, and food and water pollution play a larger role in our daily decisions and concerns. This means that determining and evaluating risks is an intricate and complicated issue. Furthermore, with the development and spread of COVID-19 and the declaration of the coronavirus as a pandemic by the WHO on March 11, 2020, we may conclude that an amplified danger has become an attenuated risk.2 Therefore, parents also have various duties, responsibilities, priorities, and concerns specific to the pandemic. Parents need to be aware of, analyze, and comprehend the pandemic conditions, risks, and safety measures. Even though they should be abiding by regulations and laws and taking the data supported by science into consideration, they continue to struggle with understanding the validity of the data. Trust in experts, governments, and other authorities is not taken for granted in risk society. As Giddens points out, people are aware of the experts' knowledge and comprehension gaps about risks, even within their fields of expertise (Giddens, 1991: 130). Parents should protect themselves, their children, and family from the virus as well as the negative effects of the recently developed and utilized medicine and vaccine against the virus because it is a widespread disease and a rapidly spreading, contagious virus. Additionally, they must safeguard society by isolating and immunizing (vaccinating) themselves and their children with these new vaccines as well as by avoiding touch and contingency. These may appear to have opposing goals and responsibilities. Considering that parents are the decision-makers and subscribers of their child's health care, it is important to take into account how one's personal beliefs, values, and lifestyle may affect a person's ability to comprehend and think in the factuality of the information being provided and, subsequently, influence choices concerning childhood vaccines. (Ruggiero, Wong, Sweeney, Avola, Auger, Macaluso, Reidy, 2021: 509). --- A General Understanding of Vaccine Decisions of Parents Parents make and follow up on decisions regarding vaccines for their kids differently everywhere around the world. According to a systematic review by Galanis, Vraka, Siskou, Konstantakopoulou, Katsiroumpa, and Kaitelidou (2022: 1-3), which includes 44 studies in 18 countries and 317,055 parents, 60.1% of parents desire to vaccinate their children overall, compared to 22.9% of parents who refuse to do so and 25.8% of unsure parents. Evans, Klas, Mikocka-Walus, German, Rogers, Ling,... Westrupp (2021: 1) note that parents are quite cautious about their children's safety while making vaccine decisions. Age, career, and the parent's place of residence are general characteristics that

Parenting in risk society: vaccine decision of parents for their children during covid-19 pandemics.